Assembly Health Committee

Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Good afternoon and welcome to the Assembly Health Committee's hearing on Tuesday, June 30th. Before we begin, I want to make sure everyone understands our committee procedures to ensure we maintain order and run a fair and efficient hearing with the goal of hearing as much from the public within the limits of our time. We seek to protect the rights of all who participate in the legislative process so that we can have effective deliberation on the critical issues facing California. The rules of conduct by members of the public include no engaging in conduct that disrupts, disturbs, or otherwise impedes the orderly conduct of this hearing, engaging in personal attacks of members of this committee, authors, staff, or other witnesses, talking or loud noises from the audience. Please be aware that violations of these rules may subject you to removal or other enforcement processes. If you are providing witness testimony at this hearing, all witnesses will be testifying in person. Main support and opposition will be allowed two main witnesses for a maximum of two minutes each. As a reminder, primary witnesses in support must be those accompanying the author or who otherwise have registered a support position with the committee. And the primary witnesses in opposition must have their opposition registered with the committee per the instructions on our website. All other supports and opposition can be stated at the standing mic when called upon to simply state your name, affiliation, and position. All testimony comments are limited to the bills at hand. I would like to note we have a few interpreters who are providing American Sign Language interpretation for those attending today's hearing in support of SB 331 by Menjivar, the Let California Kids Hear Act. And I would just pause for a second and ask if the interpreter is in a location where those who need that interpretation are able to see unobstructed. Assuming that they are and do not need to be relocated, as I'm looking out in the public hearing right now, I will continue on. I also ask that everyone in the audience help ensure the interpretation remains visible and accessible by avoiding disruptions, such as blocking the interpreter or obstructing the view of participants who are relying on the interpretation. For consent, the following bills have been proposed for consent at today's hearing. Any member of the committee may remove the bill from consent calendar. Item number 14, SB 1447. author is the senate health committee with a motion of due pass to appropriations with that we do have our first uh member or senator who is able to present we will begin with as a subcommittee with file item one sb 331 by menjavar Whenever you are ready, Senator, thank you.

Hi, my name is Marie, and I've been coming to Sacramento since first grade. Some of my fellow advocates here today have been coming here since they were babies and toddlers. Year after year, we've come back asking for the same exact thing, equal access to sound. Although I was born with hearing, I lost some of it after an illness. Before my fourth birthday, my preschool teacher told my mom, Marie isn't the same confident little girl who walked into this classroom in September. She's removing herself from circle time and crying. She's losing language skills she once had. Something isn't right. The day I got hearing aids changed my life. I danced around the house because I could hear my feet tapping on the floor. I was happy again. My parents carried guilt because, for months, I hadn't fully heard them say, I love you, or the bedtime stories they read to my brother and me. One night, they found themselves at a support group in L.A. They were quickly humbled as mom after mom shared devastating financial decisions their families had to make. The first three moms quit their jobs So their kids could qualify for Medi-Cal The fourth said I've got five kids Our family isn't going down He go without Then my mom learned that kids were showing up At centers at age five unable to say their own names because they had never heard them That was the moment our advocacy journey began I know what access to hearing aids has made possible in my life. Without them, I would not have had the same opportunities as my peers to learn to speak, attend mainstream school, and hear and connect with my peers and families. This bill will help 8,000 children. It'll provide access for 8,000 children's hearing aids. While some families choose different ways to communicate, a child's access to sound should never be dictated by their family's health plan. One of the first pictures of me in Sacramento was in front of the California for All sign outside of the governor's office, wearing an oversized turquoise backpack. Vote to let California kids hear and include deaf and hard of hearing in California for all.

Thank you so much, Maria. It's such an inspiration to see you here. Thank you so much, Senator. Assemblymember Bonta and the Health Committee, thank you so much for this opportunity. My name is Dylan Chan. I'm a professor of pediatric otolaryngology at UC San Francisco. Our team at the Children's Hospitals in San Francisco and Oakland take care of about 2,000 children who are deaf and hard of hearing every year, and we've published nearly 100 articles on pediatric hearing health access outcomes and disparities. 1,000 children are born in California deaf and hard of hearing every single year. For these children, hearing aids are an absolute medical necessity. There is overwhelming evidence that failure to provide appropriate intervention for deaf and hard of hearing children causes permanent speech, language, cognitive, educational, and social-emotional deficits. Because of this, pediatric hearing loss is considered a developmental emergency where every month without sound confers increased risk for permanent developmental delays. Despite this, only 14 percent of California children in large group plans have coverage for hearing aids. A pair of hearing aids costs six thousand dollars every few years. In our clinics, we see hardworking families who delay necessary treatment because they

Good afternoon, Chair and members of the committee. My name is Sarah Bochter and I was a student at Galileo High School now incoming freshman at Cal Poly Slow and a volunteer with the American Heart Association I like to start off by saying thank you for the opportunity to speak today in support of Senate Bill 869 and the importance of providing clear icons on menus to identify standard beverage menu items with high levels of added sugar. As a high school student, and like many of us, I'm busy, burnt out, and I like to alleviate some of that stress by hanging out with my friends and ordering smoothies or coffee after school or over the weekend, sometimes both. When I order, I'm not sitting there Googling nutrition facts, scanning QR codes, or giving staff an extra task of giving me calorie information. I look at the menu, pick whatever sounds the most appetizing, and keep it moving. And to be honest, I'm ordering enough to satisfy my craving, which is about a medium, and if I'm really feeling it, I'll get the large. It wasn't until learning about this bill in school and seeing examples of nutrition information and drinks that I realized just how much added sugar was in my usual drink. I was shocked and I had no idea that I was starting my day with almost all the sugar I should be having for an entire day. If that information had been right there on the menu when I had ordered, I would have made a different choice or at the very least I would be more mindful about the rest of the sugar I eat that day. I also know that my peers want this information and want to be more cautious of their sugar consumption as well. I learned through further research that too much added sugar is linked to serious health issues like heart disease, type 2 diabetes, and obesity. As a first-generation person going to school in my family, I have high expectations of myself. I hope to become a cardiologist in the future for a multitude of reasons. My biggest reasons, however, is to help the future. As a cardiologist, I'd rather have fewer patients coming in or at the very least older patients for natural reasons than have multiple patients coming in as young children and young adults for diseases that shouldn't be their burden to carry so early on in life. I like to think that you all want that for our children as well. Thank you. Icons are easy to see and understand. My own mother, who has had to learn English on her own, oh, didn't have the easiest time asking for sugar and content in drinks, and it's not realistic. We respectfully ask for your aye vote on SB 869 so that not only young people like me, but all Californians can start our days informed and end our days as healthy as possible. Thank you.

Good afternoon, Madam Chair and members of the committee. Thank you for taking the time to hear about such an important issue today. My name is Christine Falibel, and I lead state government affairs for the American Diabetes Association. I'm here today to speak in support of Senate Bill 869. For too long, we've asked people to make better choices without giving them the tools or the truth that they need to actually do that. Sugary beverages are one of the clearest examples of this gap. They're marketed as refreshing, energizing, and even healthy. But what's often missing is simple, honest transparency about how these drinks impact our bodies, especially for communities already facing higher rates of chronic conditions like type 2 diabetes and obesity. That's where Senate Bill 869 comes in. This bill is not about taking choices away. It's about making those choices real and transparent. Currently, there are no mandates for restaurants to label added sugar, the most detrimental sugar to our health and well-being, even though the dietary guidelines for Americans recommend limiting added sugar to less than 50 grams per day for most adults. Transparency levels the playing field. It replaces confusion with clarity and empowers people to make decisions that align with their health goals We know that small daily choices add up A single beverage may not seem like much but over time it can significantly impact someone health trajectory Studies show that adding just one 12 ounce sugary drink daily increases the risk for developing type two diabetes by 26%. Liquid sugar without any fiber is especially dangerous for insulin resistance, weight gain, and health complications. Senate Bill 869 is a step toward respect for consumers, for families and for communities. It acknowledges that people can make good decisions when they're given honest information. We support Senate Bill 869 and ask for your aye vote. Thank you very much.

And I will. I'll turn it over to one of my witnesses. I'm sorry. Oh, is there a technical witness here? You're bringing up a technical witness? Yes. Yes, Sarah Sorcher, Center for Science and the Public Interest. I'd be happy to answer any questions you have about QR codes. Is there anything specific you want me to talk about? I was just wondering why they wouldn't be used in trying to find out a solution for this or to make sure the public's aware. Thank you. Yeah, I think the issue is that consumers are already really struggling with a food environment that is stacked against them when it comes to health. So we did a study in 2021 showing that, for example, most small-sized beverages exceed the daily value for added sugars. So it's a very distorted environment. And the problem with the QR codes is that they sort of hide the information about what you're getting behind this technical device that a number of consumers don't have access to. We know the elderly. We know children. We know people in rural areas may not be able to use a smartphone to inform purchasing decisions. And so it just puts in additional barriers to accessing the information, and that's the concern. What we've seen from the studies also is that really to be effective, the warning labels need to be conspicuous. They need to be clear. they need to be accessible and QR codes just don't provide that. Thank you because when I go and try to do the menu thing, I never know what I'm ordering. So anyway, thank you for clarifying. Yes. Yeah.

I can only speak for myself. I'm not whipping out my phone. I'm not looking, trying to look through a bunch of different things. Many of these QR codes will take you to the nutritional information, which I agree that CRA has worked. And you can find that if you dig deep enough. But the information that oftentimes they will reveal is the total amount of sugar, not the added amount of sugar. There is a difference, and there is a difference in terms of the impacts to your health. And so you can go and you can look and you can see if you are savvy enough to have a phone or go on their website. Many of them will have the total amount of sugar, but this is really focused on added sugars because that is what has been linked to diabetes, heart disease, Alzheimer's, obesity. And, you know, this is a very simple bill, but like I said, it can have significant impacts not on one's health, but also on our health care system in general. Think about the amount of money that we are spending to treat these preventable conditions that end up being very chronic, long-term conditions that we can treat by allowing people to have better choices when they're purchasing drinks, which we all do every single day.

Well, I want to thank you, committee chair and your committee again for working with us with this bill. I want to thank you all for the conversations today. I love your suggestion. I would love to not have to do legislation and to have, you know, the people in our restaurants to really work as partners with their consumers to ensure that what they are taking in is as healthy or at least allow them to have the information. As you stated, I wanted California to be the first in the nation to do this, but unfortunately we're not because New York has already done this, and without a QR code. And they have been able to adjust so that their residents can have that transparency and make those decisions for themselves. We passed an allergen bill last year, which was extremely important. over twice as many people in California have diabetes or are pre-diabetic as those who have actual food allergens. And so, yes, it was important, but this is also extremely important because of not only who it impacts, but as was stated, our kids are just drinking up these sugary drinks, and so it's also about who will be impacted in the future. And with that, I respectfully ask for an aye vote at the appropriate time on SB 869. Thank you.

Good afternoon again. I am presenting SB 950, which will ensure timely access to FDA-approved medically necessary treatments for Californians with early-onset Alzheimer's disease. I want to thank the committee staff for working with our office, and I accept the committee amendments, which remove the explicit parameters around the coverage. Alzheimer's disease is a chronic and irreversible neurological condition that affects over 7 million people nationally with 12% residing here in California. Alzheimer's disease, while often thought of as a condition of aging, reflects broader disparities in our public health care system. Women, those with lower income, communities of color face disproportionate elevated risk, higher diagnostic rates, and poorer outcomes once living with the disease. For many years, little could be done to slow or stop the disease once it was diagnosed, but that reality began to change with the development of an FDA approval of medications that meaningfully slow the clinical decline of early Alzheimer's disease. These innovative medical breakthroughs that remove the plaques responsible for the disease progression finally provide families precious time, hope, and memories they deserve. These treatments are generally covered by Medicare, Medi-Cal, and CalPERS, which together covers a significant share of Californians living with Alzheimer's. However, coverage is less consistent in the commercial market where enrollees can be subject to plan-by-plan determinations and utilization management. As identified in the Jiburb analysis, coverage of both disease-modifying and symptomatic treatments is not universal across commercial plans. SB 950 reaffirms our goal to have universal and equitable access to these treatments when medically necessary. Timely and easy access is important, especially because there are no FDA-approved disease-modifying therapies for later-stage Alzheimer's. One extra denial, one more phone call, one failed medication, one extra month of waiting for a decision can be a huge barrier in the difference between receiving life-changing treatment and losing that opportunity altogether. altogether. SB 950 specifically ensures that all enrollees on commercial plans regulated by the state can access medically necessary FDA-approved treatments for Alzheimer's disease. It prohibits inappropriate rerouting of medically necessary treatment, preserves utilization management and prior authorization process, and establishes Alzheimer's as an exigent circumstance to ensure the expeditious coverage determination process. SB 950 help alleviates pressure from our families, caregivers, and healthcare system while navigating a very complex and time-sensitive disease. Alzheimer is a fourth leading cause of death in California, and families deserve clarity, consistency, and timely care. Today, I am joined by Andrew Mendoza with the Alzheimer's Association and Andrew Cope an advocate who will share his personal experience with Alzheimer disease Thank you Andrew Mendoza on behalf of the Alzheimer Association proud sponsor of 950 Thank you Madam Chair members of the committee and staff for your work to advance this important measure. We appreciate what Senator Weber Pearson prioritizing early intervention strategies to improve brain health. SB 950 clarifies existing law to ensure that people living with Alzheimer's disease have coverage for the treatment plan that their doctor deems medically necessary. And it streamlines access by removing unnecessary barriers to care. The disease-modifying treatments approved by the FDA present a paradigm shift for those contending with an Alzheimer's diagnosis. These therapies and lifestyle interventions provide proactive measures to delay cognitive and functional decline. California recognized the importance of providing coverage for biomarker testing, which helps many assess the risk for Alzheimer's disease. These developments encourage early detection and diagnoses. Treatment is the natural next step for an early intervention strategy. Unfortunately, issues in our health care delivery system often delay someone from receiving a diagnosis from primary care and the lack of specialist delay confirmation. They very well could exit their eligibility window for treatment during that time. Moreover, co-occurring conditions, the lack of infusion sites and qualified providers, or the costs incurred from the necessary tests in addition to lacking insurance coverage can all be prohibitive for someone seeking access to care. Most people with Alzheimer's disease are over 65 and on Medicare, which minimizes the affected population to those with early onset or diagnosed prior to 65, which represents less than 1% of those with Alzheimer's disease in California. However, the access that SB 950 would provide can make a meaningful difference in the lives of individuals contending with the diagnoses at a young age as it affords time to create plans and cherish family. This bill is an important measure for ushering in a new era for the treatment of Alzheimer's disease, and we appreciate Senator Weber Pearson for meeting the moment and closing the gap in coverage that would otherwise be a significant consequence if left unaddressed. Thank you for your consideration. I'm respectfully asking for your aye vote at the appropriate time, and I will now turn it over to our advocate, Andrew Cope, to share his experience receiving in the diagnoses of early-onset Alzheimer's disease. Thank you. You'll have two minutes.

I'm 56 years old, and I'm from Menlo Park, California. As Andrew mentioned, I'm here today because I'm also living with Alzheimer's disease. My journey began when a genetic test revealed I had the double APOE4 genotype, which, if you're unfamiliar, has the highest incidence of Alzheimer's and the highest incidence of early onset. That test sent me on a year-long journey that started with my primary care physician, and then I waited six months to get an appointment with a neurologist, and then I waited an additional three months to get the PET scan, which revealed my diagnosis. It was a year of anxiety, worry, uncertainty. I had no idea how much quality time I have left with my wife and two children. However, as has been mentioned here, I'm an incredibly lucky person to be born when I was. Medical research right now is making life-changing progress for people like me. There's now a very simple blood test that reveals the pathology for Alzheimer's, and as is mentioned, there are two therapies, two infusion therapies that are approved, that have proven to slow the progression of the disease. And there are clinical trials, one of which I'm going to be joining, that are pushing the progress even further. So it's giving people like me true optimism and hope. These treatments that we referenced, they've been shown to reduce the plaque progression growth in the brain by as much as 30%. So I ask each one of you to sort of take a moment and imagine somebody important to you, whether it's a family member or a very close friend. and maybe they have a diagnosis like mine, and now you tell them that you going to be able to give them months years or maybe a decade of life to live and plan That absolutely priceless I here as a volunteer because this disease face is changing in real time and more and more people are going to look like me that are living with this disease, and I feel it's my responsibility to do something positive for anybody else who is facing this disease and to the millions of people who never had the chance. Everybody in this room right now has a chance to make a difference in this pivotal moment. You can do it for me. You can do it for people that are important to you. You can do it for all of California. So I really urge you to pass SB 950 and be on the right side of history on this one. Thank you for your time and thank you for your consideration. Very much appreciated. Thank you. Others in the hearing room who would like to register support, please come forward. I'm Howard Posner, a volunteer advocate with the Alzheimer's Association. I support the bill. Good afternoon. My name is Lisa Bishop. I'm a volunteer advocate with the Alzheimer's Association, and I support SB 950. Hello. Kylie Ashioka, also a volunteer advocate with the Alzheimer's Association, in support. Hi, Veronica Meech with the Alzheimer's Association, in support of SB 950. Lynette Blumhart, volunteer advocate with the Alzheimer's Association. I'm here in support of SB 950. Floyd Stickerson, board member, Northern California Alzheimer's Association, in support. Good afternoon. Darby Kernan, on behalf of Leading Age California, in support. Good afternoon. Sandra Poole, on behalf of Western Center on Law and Poverty, in support. Jennifer Snyder on behalf of the California Life Sciences in support. Alex Kahn with the California Chronic Care Coalition in support. Jessica Hay with AFSCME California in support. Thank you. Are there any primary witnesses in opposition? Please come forward. You'll have two minutes each. Thank you. Thank you, Cassidy Heckman on behalf of the California Association of Health Plans. I want to start by thanking the author, her staff, and the sponsor for continued conversations on this bill. Regrettably, we are still opposed to it today. As outlined in our letter, one of our primary concerns is the ban on step therapy. While the bill states that if the FDA has approved one or more types of treatment for Alzheimer's disease that a health plan does not have to cover all types of treatment without step therapy. It specifies this as conditional on a plan covering at least one anti-amyloid without step therapy. We appreciate the intent behind this language, however, there are currently only two anti-amyloids that are FDA approved, both brand name, and they cost between $26,000 and $32,000. We believe this language will limit plans from offering enrollees a therapeutically equivalent and more affordable alternative when they eventually come to market. Additionally, we are concerned about the requirement that health plans cover all FDA approved drugs for the treatment of Alzheimer's disease and dementia. As the analysis notes, health plans already cover all medically necessary drugs, including anti-amyloids. However, we have concerns the language can unintentionally prevent plans from updating their formularies as new data emerges and from designing products that are both affordable and appropriate. Finally, we are concerned with the recent amendment that requires anti-amyloids and other Alzheimer's drugs to be treated as exigent circumstances A 24 review is an incredibly short timeline for an entire class of drugs specifically ones like anti that are new to market and are required to be used under strict guidelines and supervision For these reasons we remain respectfully opposed Thank you Good afternoon Chair and members Matt Aiken with the Association of California Life and Health Insurance Companies, also in respectful opposition to SB 950. I just want to first say we sincerely appreciate the author's intent and goal of improving care for individuals living with Alzheimer's and dementia. I'd like to align my comments with my colleague and briefly highlight one additional concern we do have with the bill. As my colleague noted, the bill would significantly limit plans' ability to use step therapy for FDA-approved Alzheimer's treatments, requiring that at least one anti-amyloid therapy be available without it. We are concerned that the efficacy of these drugs has not been strongly proven. As Chabrup noted, there is some evidence that disease-modifying medications are effective at slowing cognitive decline, but the effects generally fell below minimum clinically important difference thresholds. Shaburb also noted that there is not enough research to determine whether amyloid plaque reduction improves health outcomes. Given the evolving clinical evidence and the potential for side effects with some of these medications, we believe plans should maintain the ability to apply evidence-based utilization management tools, such as step therapy. For these reasons, we respectfully oppose the bill, but we'd like to sincerely thank the author and sponsors for their engagement so far, and we do look forward to future conversations if it moves forward today. Thank you. Thank you. Any others in the hearing room who would like to offer opposition? Seeing none, I will bring it back to committee for any comments or questions. Assemblymember Stephanie and then Patel. Thank you. I just want to thank the senator for bringing this forward. I had a dad pass away. My dad just passed away April 29th of this year after suffering from Lewy body dementia for eight and a half years. and I was just saying to my daughter the other day that I wish I had been able to do more at the early stages in 2016 and 2017 and the suffering that my family went through, that he went through, the healthcare, the hurdles, it's traumatic and with all due respect to the opposition, I think these are just the same tired arguments we hear about what we need to be doing for Alzheimer's and dementia. And I want to thank the Alzheimer's Association and the witness for bravely sharing your story. When I told my daughter, I wish there was more I can do, I'm glad I get to be here today and vote aye on your bill. So thank you. Assembly member Patel. Thank you, Senator, for bringing this bill forward. It's very important we have our patients have access to lifesaving therapeutics. and anything that can improve quality of life is certainly worth looking into. I do have one question, specifically from what the OPPO brought up about the designation as an exigent condition. Can you address concerns around that? Yes, we're making it exigent circumstance because these medications have a limited eligibility window. They're only available for people that are in the early stage of Alzheimer's. something that was mentioned in the presentation is that this is specifically also targeting the insured population that is living with early onset. So that's diagnosed younger than 65, but the treatments are available for people that are in the early stage before they move into the mild to moderate aspects of Alzheimer's disease when they're going to need either more assistance with their activities of daily living or they will need higher levels of care at a long-term care facility. So essentially, that is why we're making that circumstance exigent instead of the normal. Thank you for explaining that. That's something I didn't have quite a good grasp on understanding. therapeutics, a follow-up question, maybe even two. So these therapeutics are such that they have to be used at the very early stages. Are they then able to continue to be used for the duration of the condition? That is something that we are still finding out. Essentially, there is a subcutaneous maintenance dose for Lakembi, which is one of the anti-amyloid therapies. So that would continue on. There is a notion that you'll be able to stop Consunla at a certain point, but I don't think that we're there yet to say that for sure. but they are not essentially to carry over to those other stages. Those other stages are where the symptomatic medications are generally used. Okay, thank you for that explanation. Yeah, so I think, I'm sorry, think of these medications on the very, very front end to try to prevent the progression. Once you get to a certain point, the medications are used to treat the symptoms. And so that's also one of the reasons why we're not going with the step therapy because of step therapy will make you do the symptom treatment first fail before you can do this, but you really need this first if you're able to be diagnosed at the early stage. So it's almost like treating two different kinds of diseases or disease profiles. Yeah, it's targeting different things. This is targeting the formation of the amyloid plaques versus the other medications that target the symptoms of Alzheimer's. Thank you for that. I'd like to move the bill. Thank you, Assemblymember Patel. A second by Stephanie. Senator, I want to thank you for bringing forward this measure. And again, I want to thank as well, thank the testimony provided. this is certainly something that I feel very personally having two members of my family who suffered from Alzheimer's and dementia and were taken from us too long. I think to Assemblymember Stephanie's point and very loving commentary when people have dementia and Alzheimer's they are with us for a very, very long time often. but physically so. And we have to recognize that we are dealing with people who are not able to be their full selves. And that creates other kind of, quite frankly, health concerns and puts people into acute healthcare needs and creates much more cost to the consumer, the family, and to our overall healthcare system. I think you've put forward a very strong argument for why we need to make sure that we are treating this particular opportunity for effective delivery of care sooner and to classify it with exigent circumstance. That was a very helpful explanation with that. Senator, would you like to close? Yes. Once again, I want to thank you, Chair and the committee. I really want to thank the sponsors, the Alzheimer's Association, but my witness in particular for coming and being so vulnerable and sharing your story. I want to acknowledge Assemblymember Stefani. Thank you so much. And I'm sorry for your loss. I didn't know, but thank you for sharing that because it highlights how widespread these conditions are and how they impact families and communities. And, you know, the treatments that we're talking about today, unfortunately, we're not there with the cure. So this is not going to cure, but it can provide something incredibly meaningful that may have otherwise not felt possible. More time a better quality of life newfound memories with loved ones that can be passed down for generations Those things are invaluable. And as we look ahead, these medical discoveries are just the beginning. We know that we have ongoing research and innovation to move us closer to expanding access, improving lives, and one day achieving a future that is free from Alzheimer's disease. And with that, I respectfully ask for an aye vote on SB 950. Thank you. Thank you. We have a motion and a second. Please call the roll. The motion is due passes amended to the Appropriations Committee. Bonta? Aye. Bonta, aye. Sanchez? Addis? Aguiar-Curry? Ahrens? Coloza? Carrillo? Aye. Carrillo, aye. Jeff Gonzalez? Jeff Gonzalez, aye. Mark Gonzalez, Johnson, Johnson, I, Patel, Patel, I, Patterson, Rodriguez, Chiavo, Chiavo, I, Sharp Collins, Stephanie, Stephanie, I. That measures on call, Senator. We are going to pause from the rest of your slate of bills to move to item number two, SB 490 by Umberg, regarding alcohol and drug programs. Thank you, Senator, whenever you're ready. Thank you, Madam Chair, and a special thank you to Senator Weber Pearson for your accommodation. Very much appreciate that. Madam Chair and members, I'm here to present SB490. Thank you to you personally, Madam Chair, and also to Logan Hess for your continuing help with Umberg bills. We'll be accepting the committee's amendments. I'm happy to present SB 490, which will establish timelines for the Department of Health Care Services, DHCS, to investigate allegations of licensed treatment at unlicensed sober living homes. If DHCS cannot meet the timelines, SB 490 would authorize counties to request approval to conduct site visits and enforce compliance with existing state licensing requirements. The challenge of unlicensed sober living homes is particularly acute in Orange County, but it is a statewide phenomenon. and is a statewide concern, and it's a concern because DHCS doesn't, frankly, have the resources to be able to do the kinds of site inspections that we would hope or audits. A recent state audit revealed significant shortcomings in DHCS's oversight of unlicensed treatment facilities. The audit found that DHCS has not consistently investigated allegations of unlicensed facilities providing or advertising treatment services. So there are many examples. There are many examples where there's been a complaint, an initial take a look-see, and no follow-up. Per the recommendation of the state auditor's report, SB 490 institutes a timeline to assign a complaint to an analyst within 10 days, complete investigations within 120 days, issue violation notices within 10 days of completing the investigation, and conduct mandatory follow-up site visits to ensure unlawful services have been stopped. If this is the gravamen of the bill, if DHCS fails to meet these timelines, then counties can work with DHCS to enforce licensure laws and protect public health and safety. With me testifying in support of the bill are Anaheim City Council Member Kristen Moss who is also Founder and Director of the National Patient Brokering and Prevention Initiative I sorry I got that confused Founder and Director of the National Patient Brokering Prevention Initiative, Sequoia Thyssen. So thank you very much. Back to you, Madam Chair. Thank you, Senator. We each have two minutes. Thank you. Good afternoon, Chair Bonta and committee members. I'm Kristen Maas, City Council Member for the City of Anaheim. On behalf of Anaheim, thank you for this important opportunity to offer input on the topic for our city and all of California. Like other cities, Anaheim provides a frontline perspective on this issue. Recovery treatment in many forms plays a vital role in our city as it does across our state. The challenge of substance abuse disorder brings real impacts on people, families, and neighborhoods. Anaheim is supportive of community care facilities. We estimate our city is home to more than 150 facilities of many varieties. We share a belief that recovery is most effective in the right setting and with the best help possible. But we also know that there are challenges. As a city, we are limited in our ability to regulate treatment facilities or group homes. That makes California's role and your consideration of this proposed legislation so important. Recovery is only as strong as the support someone receives. There are many great operators whose work changes lives. But we also know of horror stories, stories of billing exploitation, client cycling, disruptive operations, unlicensed treatment, and ultimately failed recovery. Undermining recovery in one case undermines treatment and supportive recovery as a whole. What is being proposed is enhanced oversight in a reasonable, incremental way. SB 490 embraces the state auditor's recommendations for investigating unlicensed treatment. It would bring partnership with counties to do site visits and ensure licensing. This would allow the state to leverage local support and to better respond to violations, ensure compliance, and to protect the health and safety of those in treatment. The proposal would strengthen state oversight backed by local governments. It is critical for all of us to ensure that recovery meets the highest standards, brings better outcomes, and supports healthier communities. Thank you for your consideration on this proposal. On behalf of the City of Anaheim, I extend our city's appreciation for your support of enhanced recovery outcomes and a stronger treatment system. Thank you. Thank you so much. You'll have two minutes as well. Thank you. My name is Sequoia Thiessen. I'm the founder and director of the National Patient Brokering Prevention Initiative and a UC Berkeley student. I support SB 490 because, from my perspective as both a survivor and someone who works on this issue every day, California's oversight of fraudulent and unlicensed treatment centers has not kept pace with the reality on the ground. I founded this organization because after surviving this industry and then researching it, I realized that exploitation is not the exception. It has unfortunately become the norm. When people are entering treatment, they are in their most vulnerable. These become more than licensing violations because they create environments where serious harm can go unchecked. When oversight fails, there are serious consequences. I have witnessed patients including myself be subjected to conditions akin to human trafficking Because of the lack of oversight there is immeasurable exploitation going on here in California including kidnapping rape coercion and both labor and sex exploitation The people exploiting this system count on enforcement gaps and delays. They want to delay these consequences so that they can continue commodifying people's health and sobriety. SB 490 also acknowledges that many fraudulent rehab actors own more than one facility, and they often move patients between facilities to avoid oversight and accountability. In practice, this mirrors human trafficking because patients are brought from all over the United States and being coerced with housing, food, and medical care to generate income for these unlicensed facilities. It is not uncommon for patients to be brokered across 50-plus facility over a number of years. This bill will help close an important gap within collaboration and trust building as well. One of the main reasons victims struggle to come forward in this industry is because they are typically coming from backgrounds that have fractured trust with the state. This bill tells patients that you care about the conditions they are subjected to while in treatment and that their reports will not go uninvestigated. Thank you. Thank you for that testimony. We will hear from anybody else in the hearing room who would like to offer support for the measure. Good afternoon. Sylvia Solis Shaw here on behalf of the City of Beverly Hills in support. Thank you. Cassidy Heckman on behalf of the California Association of Health Plans in support. Good afternoon, Olivia Herrera, intern at Stone Advocacy, on behalf of the California District Attorneys Association, in support. Thank you. Good afternoon, Kendra Bagley, on behalf of the City of Carlsbad and the City of Thousand Oaks, in support. Stephanie Watkins, on behalf of the Association of California Life and Health Insurance Companies, also in support. Thank you. Are there any primary witnesses in opposition? Thank you. Thanks, you all have two minutes. Thank you, Chair and members for the opportunity to speak to you today. My name is Amar Asshid, the Director of Legislative Affairs for the County Behavior Health Directors Association of California, representing the leaders of the public behavior health agencies that serve the mental health and substance use disorder needs of California's Medi-Cal uninsured and underinsured populations. CBHDA respectfully stands in opposition to SB 490. SB 490, as is in print, instructs the Department of Health Care Services and potentially county behavior health agencies to investigate sober living homes providing unlicensed substance use disorder treatment, an activity those centers should not be engaged in and one that the department already has jurisdiction to investigate. The issue that the author discusses are rooted in private sober living facilities which advertise detoxification services or other unlicensed residential SUD treatment and are not contracted or under the jurisdiction of County Behavioral Health in any way. SB 490's proposed timeline for DHCS to complete investigations for facilities engaged in unlicensed residential SUD treatment in conjunction with the proposed option for County Behavioral Health Department to instead perform the function of investigating those private entities in which they have no jurisdiction over represents a significant liability risk and a potential unfunded workload increase for county behavioral health agencies. It's for that reason that we thank the committee for the proposed amendments in the analysis, which take the bill to a more appropriate step in assisting in the aims to ensuring that the investigations of these entities engaged in inappropriate unlicensed SUD treatment are happening in a thorough and timely manner through DHCS, the appropriate jurisdiction and oversight authority of these facilities. However, with these proposed amendments, there still seem to be a number of technical concerns, which will result in unnecessary burdens to some of the counties that we hope to continue to engage in discussion with the author's office on in order to mitigate for. And it is for those reasons that CBHDA at this time respectfully opposes SB 490. I thank the chair and members for the time today. Thank you. Any others in the hearing room with position of opposition to the bill seeing none, I will bring it back to the committee for any comments or questions. Assembly member Patel. Thank you for bringing this bill forward. Certainly it's an important thing to take on these unlicensed behavioral health, mental health clinics, especially for behavioral or substance abuse disorders. I want to ask if you could address some of the concerns raised by the opposition here from our county behavioral health folks. I think that's correct. In an ideal world, there would be adequate resources, adequate capacity at DHCS to be able to timely investigate abuses. But that's not the world in which we live. And so as a consequence, cities and counties, some counties, but particular cities and neighborhoods have said, we need to do something about this. And if DHCS doesn't have the capacity, where do we turn? I understand that counties don't want an additional workload. And indeed, they don't have to do anything. We're simply telling them, hey, here's what's going on. Please investigate. Please take action. So if they don't want to, they don't have to. There's no mandate in this bill. There's no consequence. There's no penalty. But in order to address the violations and the challenges that exist, we need to do something. And it's a good matter of public policy that we basically empower localities to actually do site visits and investigate. But as a practical reality, if DHCS stops it, they can stop it. In other words, they can stop any investigation. They can stop any further process with respect to the sober living homes. Okay. Thank you for that. Seeing Assemblymember Schiavo. I want to thank you for this bill. If there's no one with eyes on situations and if there's no one checking, then there are literally no checks on what people are doing. And especially, you know, when you're talking about people who are in a vulnerable state and in a really difficult time in their life where they could be taken advantage of, it's really unconscionable. And there's been some terrible horror stories about what is happening in some of these centers. And so, you know, unfortunately, until we get to the point where we as a state can fund the kind of oversight and investigation that needs to be done, And I think that we should certainly not stand in the way of localities being able to, you know, look into the sober living facilities themselves. So I happy to support it today happy to move the bill and would love to be added as a co if you have me All right Thank you very much Thank you What she said So right Thank you What she said as your close, Senator? That's my close. Yeah, that's my close. Appreciate it. Thank you, Madam Chair. With that, I think we have a motion. Assembly member? Yeah, one follow-up. I do, after processing this a little more, seeing that this is not a mandate and it's an option for localities to pursue investigation. I do feel like it's okay, and I would like to add on as a co-author as well. Thank you. Thank you very much. Thank you. Can you also second that one? And I will second it. Thank you. Senator has already closed. Please call the roll. The motion is due pass as amended to the Appropriations Committee. Bonta? Aye. Bonta, aye. Sanchez, Addis, Aguirre-Curry, Ahrens, Coloza. Carrillo. Carrillo, aye. Jeff Gonzalez. Jeff Gonzalez, aye. Mark Gonzalez. Johnson. Johnson, aye. Patel. Patel, aye. Patterson. Rodriguez. Chiavo. Chiavo, aye. Sharp Collins. Stephanie. That measure's on call. Thank you so much, Senator. Thank you, Madam Chair. Thank you, Assemblymember Chiavo. Thank you, Assemblymember Patel, and all the other members. Thank you. Thank you. We're going to move back to our file item number nine, SB 1037 by Weber Pearson for one of three bills that she still has to be heard. Go ahead. Item number nine, SB 1037. Thank you. Thank you, Madam Chair. I want to thank you and your staff for the work on this bill. I accept the amendments described in the analysis and that are reflected in the mock-up. The focus of this bill, SB 1037, is affordability of state-regulated commercial health insurance. This bill with the amendments requires health plans and ensures to demonstrate where the premium rate growth meets the cost growth target established by OCA. If the rate growth will exceed the cost target, the plan must indicate why and what steps it will take to address it and reconcile this with any relevant analysis published by OCA. SB 1037 codifies the federal definition from the Affordable Care Act of, quote, unreasonable rate increase, end quote, which is a determination state regulators are currently authorized to declare when reviewing health insurance rate. This bill also requires regulators to consider specific revenue indicators when determining if a rate increase is unreasonable, but not in a way that conflicts with the financial solvency of the plan. With the amendments, this bill will require regulations in consultation with OCA to be re-evaluated as a part of the rate review process if the insurer's rate meets the ACA affordability standard benchmarked for an individual and for a family of four with household income at 200, 400, and 600 percent of the federal poverty level. The findings of the evaluation will be reported as required under existing law at a public meeting on health insurance rates. With the loss of federal enhanced premium tax credits, many covered Californian enrollees have experienced an average of a 97% increase in monthly health care insurance premiums. As predicted almost 400 Californians canceled or terminated their covered California coverage Cancellations were highest among middle Californians and people of color Those who are still covered have moved to higher deductible plans with lower premiums, but a higher cost sharing when services are needed. This will aim to add health insurance rate reviews and affordability focus. With me today to testify are Caitlin Van Dyne from Health Access California and Benjamin Eckert from NUHW. Thank you. Thank you. You'll each have two minutes. Good afternoon, Madam Chair and members. Katie Van Dyne for Health Access California. We're strongly in support of SB 1037 as amended that will evaluate the impact of proposed rate increases on affordability. and detail how health plans will show the benefits of the Office of Healthcare Affordability cost growth targets in their rates. The most common question we get about the Office of Healthcare Affordability is, when will my health care costs be less because of OCA? And in fact, the UC Labor Center says that if we had these targets three years ago, premiums for family coverage would have been $5,800 less over those three years. The bill requires that the health plans and insurers explain in the rate review process how the OCA targets will be affecting health care costs. They are asking consumers and employers to pay. And as the senator noted, we'll see if they're going to meet those targets, and if not, what proactive steps are being taken, and what are those cost drivers leading to those increases. SB 1037 will help us ensure the savings and the cost curve targets are realized in consumer premiums. And to evaluate how affordable rates are, under this bill, the departments will consult with OCA and look at that through an affordability standard and look at that based on different Californians' incomes. We think this is a really important measure and really appreciate this in this bill. And with that, I respectfully ask for your aye vote on SB 1037. Thank you. Thanks. Good afternoon, Chair and members. My name is Benjamin Eichert, and I'm the Public Policy Director for the National Union of Healthcare Workers here in strong support of SB 1037. NUHW represents frontline caregivers across California, including 4,500 mental health clinicians at Kaiser Permanente, and we often hear how unaffordable care has become for the patients our members serve. SB 1037 sharpens what plans must show in rate review, including how OCA's cost growth targets reach the premiums people pay, and it adds something new. If a plan will miss the target, it has to tell regulators, explain what's driving the higher costs and what it's doing to fix it. We strongly support OCA's all-in approach. We also support measuring whether rates are truly affordable year over year as a share of people's income. The piece we most want to speak to is letting regulators weigh excessive financial capacity. The analysis before you shows excess reserves at full service plans topped $94 billion in 2024. These reserves are largely funded by California consumers who have paid the increasing rates, whether individually or as businesses burdened with higher premiums. They've also been paid by workers who did not get a wage increase because instead that money was diverted to maintain increasingly costly health care benefits. When a tax-exempt plan sits on such large reserves and still wants a rate increase, regulators should be able to ask, are the rates too high or should that money be going into care? Often the answer is both. We're grateful to the author for advancing this important issue. For the patients our members serve, I respectfully ask for your aye vote. Thank you. Any others in the hearing room who would like to offer support for the measure? Megan Loper on behalf of the California Hospital Association in support Thank you Are there any primary witnesses in opposition Thank you. biggest challenges facing Californians today. It's why health plans support policies that address the underlying drivers of health care costs and oppose proposals that make coverage more expensive. The reality is that premiums are not set arbitrarily. They are certified by actuaries, reviewed by state regulators, subject to public scrutiny and can be deemed unreasonable. Health plans are already required to spend the vast majority of premium dollars on medical care with access funds returned to consumers through rebates. California has some of the strongest consumer protections and transparency requirements in the country. The issue we're facing is not a lack of oversight. The issue is that the underlying costs of care continue to rise. Hospital costs have increased by more than 265 percent over the last five years, and pharmaceutical costs have risen by more than 70 percent. In addition to these pressures, the legislature had just approved and the governor signed a new MCO tax that places a $1.5 billion tax on commercial coverage. Given that action, it's difficult to reconcile the affordability goals of SB 1037 with the reality that health insurance will now bear additional costs. SB 1037 adds new regulatory requirements without addressing the factors that are actually driving premiums higher. Health pens want to be part of the solution, but meaningful affordability gains will come from... members Stephanie Watkins on behalf of the Association of California Life and Health Insurance companies regrettably here in opposition to the bill today we do appreciate the early conversations that we had with the author the sponsor and staff unfortunately as my colleague mentioned we share the legislature's goal of ensuring all Californians have access to comprehensive affordable healthcare unfortunately as drafted SB 1037 introduces a new and subjective rate review process more specifically while we understand the desire to de-link existing definition of unreasonable rate increases from the Federal Affordability Care Act in order to reflect California's specific market. The framework proposed in this bill creates significant implementation challenges. As it's currently drafted, 1037 introduces numerous new terms that have a potential to make the process not only confusing, but potentially inconsistent across regulatory bodies. We're concerned that the lack of certainty regarding compliance will lead to significant regulatory confusion as well as increased cost to the system. The bill also appears to combine the function of the Office of Healthcare Affordability Application Healthcare Cost Targets with DMHC and CDI's rate review process, which are fundamentally distinct. Additionally, while we appreciate the interest of considering affordability and the analysis that references the actual premium impact, we are confused about whether or not there are true deficiencies within the current process. If the argument is that there are there is additional information necessary to determine something to be unreasonable or reasonable we certainly want to have those conversations going forward but if this isn't an exercise in looking at affordability disconnected from the actual functional rate inputs that create a reasonable or unreasonable rate we're not sure that actually benefits the consumer rather than just adds additional cost to the system. So for those reasons, we remain opposed to the bill, but certainly do look forward to continuing conversations if it moves forward today. Thank you. Thank you. Are there others in the hearing room who would like to offer opposition to this measure? Seeing none, Assemblyman Ruschiavo. I want to thank the author for this bill. I think, you know, as was stated, and this is something that I saw for workers for many, many years, that they will go to the bargaining table. And after COVID, I mean, there are some unions, hotel workers, for example, who got zero wage increases because everything went to health care. And so it's something that we don't think about all the time about the downward pressure on wages that health care actually has. But because health benefits are taking up so much of the money that is on the table, it's a huge, huge detriment and is one of the biggest costs that is really keeping workers behind in the state and in the nation. And, you know, as the impacts of H.R. 1 are felt and the cuts to our health care and subsidies have disappeared, we know that people are really struggling. You know, some people in my district have talked about paying more for their health insurance than they do for their mortgage. and so I think having daylight on this and having more transparency for us to inform us as policymakers to be able to make decisions that make sense and how we best can support folks and policies that need to be changed I think is really critical for the work that we do and really grateful for your leadership on this and happy to move the bill. Thank you. We have a motion? Seconded by Patel. Senator, I want to thank you also for bringing forward this bill. I did just want to have you address the opposition's concerns around the kind of conflation, if you will, between the rate review process and the impact of cost targets, which are outlined as something that is pretty seminal to this measure. Thank you, Madam Chair. and hospitals to see the benefits of all that, the slowing of the increases in costs. We want to make sure that all of those benefits are realized on the rate side so that if we're seeing that the health plan isn't going to meet the cost growth target or there's going to be big increases in rates, we now have this data on cost drivers at OCA to be able to reconcile and check against and see what are the actual drivers of what is being proposed on the rate side I know I heard from the opposition arguments around well the rate regulation is looking forward It looking at proposed rates whereas the Office of Health Care Affordability is looking backwards We looking at spending from the previous years and then doing enforcement over the next couple of years after the actual enforceable year I think we can do both, and it's important that we can do both so that we can see moving forward what are the cost drivers, but also are looking backward with the data we have from the previous years to inform all of those decisions. and what we can do to try to actually see those benefits and bring down the rising cost of care for Californians. Thank you. Senator, would you like to close? I want to thank you and your committee staff once again. You know, eight out of ten Californians say that health care affordability is a top priority. This bill and my next two bills will be specifically addressing that You know, we can all agree that health insurance is extremely expensive And health insurance premium growth is surpassing medium household income and cost of living SB 1037 connects the work of OCA with regulatory reviews of health insurance premium rates And respectfully asks for an aye vote on this bill Thank you. We have a motion and a second. Please call the roll. The motion is due pass as amended to the Appropriations Committee. Bonta? Aye. Bonta, aye. Sanchez? Addis? Aguirre-Curri? Aarons? Coloza? Carrillo? Aye. Carrillo, aye. Jeff Gonzalez? No. Jeff Gonzalez, no. Mark Gonzalez? Johnson? Johnson, no. Patel? Aye. Patel, aye. Patterson? Patterson, no. Rodriguez, Chiavo, Chiavo I, Sharp Collins, Stephanie. That measures on call, Senator. Thank you. We're going to move on now to item number 10, SB 1094 by Weber Pearson. Okay. Thank you. Thank you, Chair, committee members, committee staff, for all of your work on this bill. I will be accepting amendments to require plans and insurers to notify providers about this bill and that beginning January 1st, 2027, their patients who are on a reference biologic will be eligible for pharmacy substitution of biosimilars on the formularies, listing the patients and the possible substitutions. It also lengthens the period of another required notice to patients and providers about formulary change to 60 days in advance from 30 days and adding more details to the notice, including which of the provider's patients will be affected and the expected cost sharing, as well as provider options to keep their patient on the reference product if necessary. We'll also prohibit a PBM, health plan or insurer or affiliated entity from requiring utilization of only a biosimilar product in which the entity has direct or indirect financial interest when other biosimilars may be available. So as I stated in the last bill, health care affordability is one of the top concerns of Californians. Over half Californians report health care costs rising faster than their incomes, and 60% report that they or a family member has skipped medical care due to cost. One of the underlying factors in this rising cost of health care is the cost of prescription drugs, which has increased by 72% since 2017. Biological products are particularly expensive Costing hundreds to thousands of dollars per injection These are critical treatments But their high price tags are putting a real strain On patients and our healthcare system in general Fortunately lower alternative like generics and biosimilars offer the same clinical results as their brand counterparts Over a past decade, studies have consistently shown that switching from a reference product to a biosimilar is not associated with any clinically significant difference in safety, efficacy, or immunogenicity. Despite having many safe, effective, lower-cost alternative available, we are not using them to their full potential. This bill offers two practical ways to encourage biosimilar use to bring down cost and inject more competition into a system that brand name pharmaceutical manufacturers have controlled for a very long time. First, it allows pharmacists to substitute a lower cost biosimilar for a biologic when appropriate unless a prescriber indicates otherwise by adding do not substitute to the prescription. Second, it allows health plans to require patients to try a generic or biosimilar unless the prescriber indicates otherwise by adding do not substitute to the prescription. The plan is required to provide 60-day advance notice to the patient and provider with the amendments that we're taking in this committee. This bill only allows health plans to require a patient to try a biosimilar when the net cost of the plan of the biosimilar is lower than the reference product and the patient's cost sharing is the same or lower than the reference product. This bill also requires health plans to report on the impact of this policy on premiums and cost sharing. Sharing, according to the California Orchard Purve analysis, this bill is estimated to generate savings for patients in our health system, including $4 million in cost savings for patients who switched to a biosimilar and $90 million in savings in the form of reduced premiums for employers, enrollees, and Medi-Cal. At the core, this bill is about affordability, safety, access, which are key components for adherence with any treatment. It's about making sure Californians can get the care they need without having to choose between their health and their financial stability. Today, speaking in support is Nick Luisos from the California Association of Health Plans and Dr. Bering, a pharmacist doctor with Western Health Advantage. Respectfully ask for your aye vote. Thank you. We'll each have two minutes. Great. Thank you, Chair and members. Nick Luizos on behalf of the California Association of Health Plans urging you to support SB 1094 and thank Dr. Weber Pearson for her leadership on this critical affordability issue. Policymakers have rightly declared affordability an issue and a top priority. This is why our association is actively working to promote policies like SB 1094 to drive down spending while expanding access to FDA approved drugs that are safe, effective, and thus make health care more affordable and accessible for all Californians. The author already went over the data about the unsustainable increase in list prices by the drug manufacturers, and we cannot sustain that trajectory unless bold policy moves are made. The independent analysis of this bill indicates offsets to premiums and savings to consumer at the counter, and the author went over those numbers already. But the bill achieves these savings by simply updating outdated statutes to reflect modern science. It aligns California with FDA clinical evolution and Medicare policy, allowing for the automatic substitution of safe, effective, and lower-cost biosimilars. This is a common sense update to expand access to life-saving medications without compromising safety. Existing law, unfortunately, illogically places barriers in this regard and prevents substitution that save people money. So this bill is carefully crafted It includes robust consumer protections notification requirements and reporting requirements And this is why you see a broad and diverse coalition of supporters for this bill We need more solutions like this to lower the cost of care for all Californians, and we respectfully urge your high vote. Thank you. Thank you. You'll have two minutes. Hi, everyone. I'm Dr. Kieran Firing. I am a chief pharmacy officer for Western Health Advantage. I'm here to support SB 1094 and thank Dr. Weber Pearson for the opportunity to be here today. As a pharmacist with more than two decades of experiencing and managing medication access and affordability, I have seen firsthand the positive impact biosimilars can have for patients and the healthcare system. SB 1094 would allow pharmacists to substitute FDA-approved biosimilars unless the prescriber indicates otherwise, helping patients access safe, effective, and lower-cost treatments while preserving physician oversight. At Western Health Advantage, we recently transitioned our population of patients using Stelara to a FDA-approved biosimilar. Through proactive physician engagement, patient education, and pharmacist-led care coordination, we achieved an exceptionally successful conversion with no member abrasion, no disruption in care, and continued positive clinical outcomes for our patients. Our experience demonstrates what evidence has already shown. Biosimilars are safe, effective, and can reduce unnecessary healthcare spending while maintaining high-quality patient care. SB 1094 provides pharmacists an important tool to help Californians access these therapies more effectively and affordably. For these reasons, I respectfully ask for your support in SB 1094. Thank you for your time and consideration. Thank you. Any others in the room who would like to offer support for the measure, please come forward with your name, affiliation, and position on the bill. Good afternoon, Chair and Members. Matt Akin on behalf of the Association of California Life and health insurance companies in strong support. Madam Chair and members, John Winger on behalf of America's Health Insurance Plans in support. Madam Chair and members, Dennis Klaus Romero with CPCA Advocates in support. Kate Van Dyne with Health Access California in support and adding on for SEIU California. Thank you. Natalie Peeta on behalf of the California Academy of Family Physicians in support. Madam Chair and members, Andres Ramirez with Blue Shield of California in support. Chair and members, Allison Ramey on behalf of the Pharmaceutical Care Management Association in support. Alexis Rodriguez for the California Chamber of Commerce in support. Thank you. Thank you, Chair and members. David Gonzalez on behalf of America's Vision Groups in support. Mandy Isaacsley on behalf of CBS Health in support. Michelle Rivas with the California Pharmacists Association with the amendments in full support. Thank you. Thank you. Are there any primary witnesses in opposition? We'll have two minutes. Thank you. Thank you, Madam Chair. Tim Madden, representing the California Rheumatology Alliance. We currently have an opposed unless amended position, but I want to make it clear it's on the bill, it's in print. We're in the process of reviewing the amendments that the senator just outlined, hoping to get through those quickly. But I did want to start with our appreciation to the senator and her staff for her time and listening to our concerns. I think she's been overly generous in listening to me talk her ear off about our concerns. And I do believe the amendments that she describes do get at some of the concerns that we have expressed. Maybe not in the exact same fashion, but I do believe that they are intended to address some of our concerns. So I'm looking forward to working through those with our folks to see where we land. We do have one concern that was not addressed in the amendments, and it has to do with the situation where a multi-switch is occurring. So this is when a patient is moving from a reference product, a brand name product, over to a biosimilar. And then once that switch is made, a subsequent switch is made to a different biosimilar. And we've also seen situations where they've been switched to a third biosimilar. So we're concerned with that for two main reasons. One, if there is an adverse reaction to that, the physician is left with not really understanding which of those biosimilars cause that reaction. Probably more importantly, my folks have expressed concerns with as you take more and different biosimilars, you develop antibodies against all of them. And there are some concerns that once you develop those antibodies, it actually inhibits your ability to go back onto the brand name product that you might have been stable on to begin with. But we have been talking to the senator about that. We are talking about getting into more details in July, and we look forward to having those conversations and available to answer any questions. Thank you. Are there any in the hearing room who would like to offer an opposition position? Gilbert Lurie here with Biocom with an opposed unless amended position also. Thanks. Jennifer Snyder on behalf of the Biotechnology Innovation Organization. opposed and less amended position as well. Mapback representing the osteopathic physicians and Amgen. Like Mr. Madden said, both our opposition positions are based on the bill in print. We're looking forward to looking at the amendments, and we'll go from there. Thank you, Senator. Kasha Hunt with Political Solutions on behalf of the California dermatologists. We actually are not in opposition anymore. We had an opposed and less amended position but are now moved to neutral, based on the senator's amendments. So thank you to the center for all our work. Thank you. I'll bring it back to the committee now for any questions. We'll go Gonzalez and then to Patel. Thank you, Madam Chair. You know, I was in opposition for this bill that was in print. I don't know if you're aware, I have a son with special needs, cerebral palsy. So looking at this from the lens of a dad and an advocate and the challenges of the different meds and then the biosimilars and how's that work, it really put me in a position of opposition because we've experienced so many challenges. But after speaking to some folks on your team and then outside of that team, we learned a little bit more and have moved to a place of support. So I want to thank you for the constant communication, the clarity in the amendments. I believe there's still a little bit more work to be done, but I think that can be done as we move this forward. So thank you. Thank you so much for that. I want to thank my supporters, but also those who have been in opposition. The notification requirements the ability to allow providers at the end of the day to determine whether or not the switch is appropriate has been very important to me and I know many in the opposition Because when you're talking about these particular drugs, they're so specialized that at times it takes people a while to get to a place where they are stable, and you don't want to mess that up. Now, not everyone takes that same long course, but there are some patients that do. And that's why in this bill, there are much stronger notification requirements than you have for any other medications, including interchangeable biosimilars, which can be switched right now without provider notification in advance. And so we had the 30-day before, and now we've amended it to 60-day. And it's not just a basic notification, because I get those notifications all the time that there's some new drug on a formulary. but I have no idea which one of my patients is on what health plan or remember who's on which medication. And so this one actually informs the provider of the formulary change and the patients that are there that could be impacted by this. And so if they look and they see, oh, you know, this patient, we've had a hard, long road to get them stable. They need to stay on this medication. They have that ability to then go into that patient's chart, write a new prescription and say do not substitute, and that will be honored by the pharmacist. Assemblymember Patel. Thank you, Senator, for bringing this bill forward, and thank you for your willingness to have conversation with me even up to the last minute and make sure I understand the intent of this bill. As someone who worked on biologics in my past career, I'm very sensitive to understanding the difference between biosimilars and interchangeables that are FDA-approved as interchangeables. I wanted to just reflect on that as you clarified just now that even the interchangeables, while designated as essentially interchangeable through studies, those don't have any kind of noticing requirements. And that is very interesting to me as we think about protecting patients and their changes to their prescriptions. I do have a couple questions for you to help me understand this bill more fully. Please bear with me. Will this bill allow substitution of a prescribed biologic with any biosimilar? And what are the studies behind the biosimilars being essentially interchangeable? I know that you had cited some in the committee analysis that also described that there are studies that show that they are in practice fairly interchangeable. And are there any concerns around that? So I will let my pharmacist talk about when they choose which actual biosimilar, because there is a book that they use similar to generics. But I will briefly touch on the difference between biosimilar versus interchangeable and that designation. And then we'll also let my other witness, Nick, talk about it too. But interchangeability is a legal definition. It's not necessarily a scientific one. It was defined as a part of the ACA. And even though recently the federal government has essentially said, and I'll read a statement from the FDA, all biological products are approved only after they meet FDA's rigorous approval standards so healthcare professionals and patients can be confident in the safety and effectiveness of a biosimilar product, whether or not it has been approved as an interchangeable biosimilar, just as it would be for the reference product. And so over time what you seen is that in order to get that designation as an interchangeable the number of studies have been completely whittled down And it really mainly just an application process at this point The FDA can't change it because it was a part of the ACA, and so it has to be changed through Congress. And we all know how quickly Washington, D.C. moves. And so because of that, the FDA has basically stated whether you're interchangeable or biosimilar, if you are FDA approved, you are basically the same as the reference product. And there is very little difference, if any, between the interchangeable and biosimilar. But I will let my pharmacist talk about how they choose it. And then Nick can jump on if there's anything else he wants to say about the difference between interchangeability and just basic biosimilars. So thank you for that. Great question. We get these questions all the time. So I'm sure you're familiar with brand and generic medications. This is the most analogic conversion that you can have is there's brand products, there's generic products. Although the generic is identical in terms of the chemicals, the excipients or maybe the powders or the colors are different. That's the difference between a brand and a generic. In a biosimilar, just as Dr. Weber Pearson stated, it is identical in the make and product. What's different with biosimilars is it is a protein. And although it is as close as humanly possible, there could be a little bit of a nuance. And that's seen even with generics. So we see this today with different types of generic and brand products. The bill today, what is asking is not that we would be able to change the type of biosimilar. It would be a one-to-one product. So we're not requesting to have the drug be a different type of mechanism of action. It would be an identical biosimilar to the reference product.

Yeah, of course, the assumption would be that it wouldn't be a different active target or something like that for treating that condition, that it would be an actual biosimilar. So I understand that. I just want to make sure that sometimes as we have excipients and pressed powders or pressed pills, things like that, in the way a biologic is created, there may be differences in cell lines, media cultures, et cetera, that could make that formulation slightly different and could react with the patient's body in treatment slightly differently. And when a physician finally has a patient on a treatment of care that seems to be working, we want to make sure, as you have done in your bill, that you've put in the provisions that if you have a do not substitute, it is not to be substituted. And it also will not be substituted, as I understand, upon renewal of that prescription until a prescribing physician actively asks or makes that change themselves. Is that correct?

So once that initial prescription has been completed and you need to do a refill and you put do not substitute, that is exactly what will happen.

Thank you for that clarification. That's important to know as well. And then is this a positive like when a physician gets notified that there are biosimilars available and you declared that the patient names would actually be listed out when you get a notification from a pharmacist in your bill is that do you have to give positive affirmation that yes it is okay Are you checking a box Yes okay to prescribe Or is it a notification and then you have to say no actually we want to keep them on this biosimilar or this original?

So this is 60 days before from the insurance company. And then the provider would need to go in and say, do not substitute, write a prescription that says, do not substitute. And is there a course of action for the patient to say if the physician did not make that notification, something happened, they didn't receive it, and then the patient wanted to go back to their original, their reference product.

Thank you. I do – oh, go ahead.

Okay. Thank you. We have had quite a few conversations, and I've gotten information from your staff on this. I do appreciate that you continue to work with opposition as we move this bill forward, but I am happy to support it today, and I look forward to seeing where it finally lands in its language. Thank you. Assemblymember Stephanie.

actually requiring that savings to be passed on to consumers. Thank you so much for that question. That was one of my initial very hard conversations with the health plans about ensuring that the cost would go back down to the actual consumers, and I will let the health plans give their answer. But it's easier said than done. That's what I'll say. And because of that, that is why in the bill they are required to give that report that basically lets us know where those savings come from. But I will turn it over to the fans to explain the complexity of that. Yeah, thank you,

Through the chair and to the health plans, I do know and I understand that this bill does require reporting on whether cost sharing and premiums are reduced, but reporting isn't the same as requiring savings being shared. It's just not. And I don't understand why you would oppose any language that would force you to pass those savings on. It does require report to DMHC and CDI on the percentage of substitutions, but this bill does not require that you pass those cost savings on. It's just data reporting. And that's fine. We can get the reporting, but without requiring you to actually pass that on to the consumers, it leaves me a little skeptical of not the author of the bill, but of your intention on whether or not you would be willing to accept language in the bill that would force you to actually pass it on, not just report that you've saved millions of dollars, but that you're passing those dollars on to the very patients

Yeah, no, thank you, Senator. So the bill only allows for substitution if it's going to be the it's a lower cost product. And if the consumer is going to see the same or lower share of cost at the pharmacy counter. and so um that those are the parameters around when the substitution would actually take place um and so you know with respect to the complexities um we already have a copay cap um an existing law for prescription drugs so um a person is not required to pay over a certain amount according to statute and i wish i had the statute in front of me and i can tell you that amount so um you know with respect to you know whether you know each and every time a person's going to see savings at the counter that is most likely to occur. In fact, our health plans that switched people off of Humira onto the biosimilars version of the drug, a lot of our plans are actually offering zero share of cost for those folks. So people are seeing direct benefits at the pharmacy counter with respect to biosimilars.

so biosimilars are very um uh well they're defined in both federal and state law i don't know if dr byring you had any you know comment to that effect on what we're talking about i mean biosimilars basically have to be or in essence have to be the same i mean as as the as the biologic so i'm not exactly sure um you know uh how to respond to that other than that so i'll i'll defer to

I have no clue when something I prescribe is going to be switched without my permission. I just write a prescription and then somebody comes to me and says, oh, I have an issue with this medication. And I look and I'm like, this is not what I prescribe. but because laws allow for brand names to be switched to generics without providers having the ability to say anything, then yes, you do have one or two patients depending on the drug or whatever that has a different type of side effect. We don't give, unfortunately, that right to doctors or patients up front for anything else. Now, like I said at the beginning or during my talk, this is actually implementing a process of notification that we don't have for any other medications that we're prescribing this time. Brand name, generic, or interchangeable. So I understand the concern about a patient being stable and why would we not allow for the patients to be able to say, I want to stay on this drug. I believe Nick kind of answered that, that they can say that with the work of the pharmacist, but also the providers very early on can say, I want this patient to stay on this medication and not be switched over, which we do not give providers the opportunity to do for any other class of medication at this time. Thank you.

Assembly Member Addis.

what? Yeah. For, yeah, on average, if you spread it out, but, um, the trip analysis, sorry, just the majority of people. So the Medi-Cal, the CalPERS, the individual, the small group, the large group, if you have those plans and you don't use this medication, you potentially save between one and six dollars so right for someone like that and i think many people on the dais may be one of those people i don know everyone uh insurance or health and health situation but what would we see what would we see in terms of saving that one to six dollars if this I mean that would that would that would be a part of the rate review process so when plans plans need to go through regulatory process for premiums and rates and their actuaries submit information to the Department of Managed Health Care about their costs and the Department of manage health care has the ability to stamp a rate as unreasonable if their actuaries disagree with the plant actuaries. So that would be a part of the whole data collection and review process at the DMHC. And again, I think the reporting requirement in this bill shines even greater focus on that and will probably be valuable to that process. But I mean, when I get my insurance

Review Program. So if you are switched, but you can only be switched if it's a lower cost drug, and that will likely, perhaps not 100% of the time, will result in a lower out-of-pocket cost for you. So you will see it at the pharmacy counter. So not in the insurance premiums when you go to the yeah i mean there's so many factors that go into your premium um unfortunately you know this bill i'll be honest this bill in and of itself while it offsets premium growth it's not going to lower premiums because there are so many headwinds with respect to affordability and costs including you know the recent tax that was signed by the governor yesterday um you've got and you know we stated it in our our uh testimony a massive increase in the cost of drugs in drug spending over the last several years. Hospital costs are going up. All those things factor into your premium. So I'll just leave it at that.

It's part of the overall development of the rates. Okay, so it won't lower premiums.

Well, I wouldn't necessarily say it won't lower premiums. it may not allow for premiums to go up as much as they would without it.

That's correct. Especially with all of the items that were just mentioned.

your premiums would have gone up by $100. But because of biosimilars and maybe some other things, it's only going up $20. You can see that that's a change. Now your premiums are still going up, but they're not going up as much as they would had something like this not been in place. That's number one. Number two, I think the other thing that I was mentioning is that for individuals who who are on these medications, their out-of-pocket expense will go down because they cannot be switched to anything that would make it go up. So it has to be either the same or lower. So that's why he was stating that for some people who are paying out-of-pocket right now, they go in what they've seen in other states or for other entities that have already established something like this is that people now have like a zero out-of-pocket expense. And so that is a real savings for that particular patient who's used to paying a significant amount of money out of pocket for these medications. And they'll see that. Thank you, Senator,

With the pharmacy.

I appreciate the report, those pieces, but if we're talking about changing care for people,

Well, I will say that the senator just responded that one thing that would be changing are the out-of-pocket costs. And I think that that's an important thing for us to focus on.

Yeah, thank you for that. Yeah, a couple items. I just – it is a complicated system. I think if you look at – what I do know is, according to the TRIBURP analysis, without this bill, premiums are going to go up between $1 and $6. Is that correct?

or at minimum, we won't save the one to $6, but it gets so complicated. I have this colon cancer bill that we have had opportunity to talk about every year and it could be maybe this blood test is cheaper to use than maybe a colonoscopy but maybe it increases access More people get a screening as a result, so healthcare costs actually go up. Does that mean we turn it down? It's just so complicated to look at it like that. But what I do know because of the CHIP-RUP analysis, which we use every single piece of legislation, is that there's an impact with this bill of helping people $1 to $6. Now, as you said, there are a lot of headwinds potentially that will increase health care costs, and so they don't actually come down. But there's systemic issues in the health care system that I think everybody is concerned about up here. But I do have some questions about the opposition, Mr. Madden, or soft opposition or figuring out how to get to neutral position. You had mentioned something about biosimilars potentially causing – like you'll be resistant now to that biosimilar, and as a result, all those classes, right, all the interchangeables and everything.

Or is that – so you understand what I'm saying? Is the biosimilar an issue in this case where it's more likely to cause people to be immune from receiving the benefits of that drug than the biologic?

No, that's great. That's a great illustration. And so your concern really relies upon that kind of example, right? Not so much because the physician can write, you know, do not substitute on there, right? And then that will be some kind of education, I'm sure, to the providers. But I guess what I – so they've addressed a big portion of your bill, correct – or your concerns, right, with the do not substitute?

So that's kind of a scenario that we see. You're right. They could mark do not substitute. That would avoid this multi-switching situation. But for some patients, our folks might be open to that switch occurring. Yeah. Well, you know, I supported this bill last week and intend to support it today as well. You know, that is an interesting dynamic there that I think, you know, maybe we can have it addressed or not. But that said, you know, and I know in this particular practice, you know, actually, if you're blessed enough to have a friend who's a doctor, you know, they get to hear all your problems like a therapist or something. And so my friend was saying, hey, look, Joe, you got to you have an autoimmune. It'll take you forever to figure out what it is, you know, and so, you know, throw that one out the door for now. Right. So I know it's a very hard thing to get to the point where, you know, you know, especially what you're going to prescribe. Right. So I understand the concerns around that. And and I'm glad that you expressed it in a way that I can understand it. And I'm sure. Dr. Weber Pearson is taking note of that, but I like the amendments that that have been taken even since last week. And I think this is a good really a small step, you know, in addressing affordability crisis. But also if there's in most cases that aren't quite as complicated as that, you know, I think this is going to be a benefit to the system. And OK, sure. Yeah. Yeah. And I just want to also mention in the center might be getting teed up to say this as well, because this has been one of the things that we've talked about quite a bit, is that I do think the language in the health and safety code, the amendments, there is a possibility that that would not be allowed. So that's that's part of the conversation that we agreed to just continue to talk through. So I think it's less clear on the B&P code side in terms of the pharmacist. But nonetheless, we've been having very open conversations about this. Well, I appreciate both your approach on this, being able to work together to come out with a better product. And obviously, if you comment at your closing or whatnot, but I appreciate your work on this and looking forward to supporting it today. I think you raising a very important concern Assemblymember Patterson and my understanding is that the changes that we would seek are actually in the BMP code

So I want to just clarify that what the opposition is referring to as far as the switching, that is with interchangeable biosimilars, not with biosimilars. And I've already stated that interchangeable biosimilars have a very different regulatory pattern. It is not addressed in this bill. We are continuing conversations to ensure that when we're talking about biosimilars, which cannot do this, that we are making sure that there wouldn't be switch. But right now, we're talking about a switch from the reference product to one biosimilar, not from a biosimilar to another biosimilar. So the situation that his client or the physician that he works with is referring to is the fact that interchangeable biosimilars have been changed or switched multiple times. But that has nothing to do with this bill or biosimilars.

I think you have it but I just want to point out that the bill does expand the ability to switch to biosimilars that are not interchangeable. So it actually increases our concern because we're talking about biosimilars, and we believe the interchangeable status has value and it means something. So these other two biosimilars in the Humira family have not been tested to be interchangeable with Humira.

I have several. Okay, Mike. such the jokes to you uh thank you madam chair for allowing me a second bite at this apple so with this concern that's brought forward um i'm wondering whether but it sounds like maybe this is something that would have need to have been done in bmp i think that there are always opportunities to amend legislation and this is something i think that the senator is willing to make sure it gets addressed as we will continue to look into this as um we've been having

Thank you for that. And I look forward to seeing how it lands finally when it comes back to the floor. But this raises some very interesting things to think about going forward. Thank you. Thank you.

Yes. Really want to thank the chair and this committee for all of the amendments and this very lengthy discussion that we've had today over this extremely important bill. And maybe we should rephrase how we talk about the cost around this bill. Instead of focusing on the savings of costs, recognize that this is not going to be a driver of increased health care costs. The vast majority of bills or a lot of the bills that we pass in this space are actually adding cost. Whether it's a good thing or not, every test, every extra coverage that we do is adding cost. This is not a driver that increases health care cost. And that is extremely important when we talk about the issue of affordability. It allows for physicians to still determine which medications their patients will be on at the same time finally doing something within our health care system that will not drive cost up. And for that reason, respectfully ask for your aye vote on SB 1094. Thank you.

Patterson, Sanchez, Secretary, please call the roll. The motion is due pass as amended to the Appropriations Committee.

Sanchez?

Sanchez, aye.

Aye.

Aguirre-Curri, Ahrens, Coloza, Carrillo, Jeff Gonzalez, Mark Gonzalez, Johnson.

Johnson, aye.

Aye.

Patterson?

Rodriguez?

Yes, thank you. Well, I appreciate the deep engagement on this subject from you and the committee staff. It is very technical, these changes and improvements to the system. But I think what it's important to keep in mind our North Star, which is that we want people to have confidence in the care court system and to have it work for them. And I really appreciate what Assemblymember Addis said about hearing so much from family members and moms, because that's also my experience is that there are so many families that are desperate for the state, the county, somebody to help them. And they're looking and using the pathways that we have, and they are finding that they are dead ends. And so figuring out how we can have our processes work more together, protecting civil rights, of course, as being a core tenant, but also making sure that we are helping people who need help. And so I think the state and the care court system and the counties could do a lot better. And people are currently falling through the cracks. As my witness was talking about her daughter, who we very well could see right here in Sacramento. And we see people, we all come to the Capitol every single week, and we see people who desperately need help. And so creating systems where the help can be accessed with appropriate safeguards is the goal. And this bill does help us move in that direction. So with that, I respectfully ask for your aye vote. Thank you.

Good afternoon Sharon members SB 526 authorizes community health centers with affiliate clinics to utilize the CDPH fast licensing process when opening a new health center relocating an existing one, or changing management. Licensing a new affiliate community health center is a complicated and time-consuming process, even for health centers with good history. To address this problem, legislation passed in 2010 requiring CDPH to develop a clinic-affiliate expedited licensure process to consolidate paperwork and ensure a seamless transition of operations to more quickly process these applications and limit disruption to healthcare access. This expedited licensing process has been critical to expanding healthcare capacity and access. Although this expedited process exists, a discrepancy in the law prohibits community health centers licensed before 2010 when this expedited process was established from utilizing it even if they have served the community for longer than the 16 years the process was established. This issue is highlighted in my district by its effect on Planned Parenthood Pasadena and San Gabriel Valley, which has provided vital health care service for more than 90 years. PPSG plans to open a new flagship health center and headquarters to replace the oldest health center in Pasadena with an improved facility and central administrative office hub. Establishing a new PPSG flagship health center will address growing service demands while also accounting for continued impacts from the Eaton Fire that left the administrative office uninhabitable and forced over 100 employees to use temporary workspaces. spaces. Although all Planned Parenthoods meet every requirement to establish a new flagship health center through the fast-tracked affiliate change of location pathway, it cannot pursue this licensing process because the original health center was established before the creation of the fast-tracked process. SB 526 cuts administrative red tape and ensures that health clinics throughout the state can begin serving more patients faster. To testify in support of the bill and help answer technical questions I'm joined by Angela Pontus from Planned Parenthood Affiliates of California and at the appropriate time I ask for your aye vote. Thanks so much you'll have two minutes. Thank you chair and members Angela

Are there others in the hearing room that would like to offer a position of support?

Are there any primary witnesses in opposition? Seeing none, are there any in the hearing room who would like to register opposition? Seeing none, I will bring it back to committee. We have a motion by Addis and a second by Patel. Seeing no other comments from committee, I as well do not have any. I want to thank you, Senator, for bringing forward this measure and to always making sure that we have an opportunity to provide additional care, particularly for those seeking reproductive care in this moment when we know that our system is incredibly attenuated because of the federal requirements and mandates that are being passed down from Washington DC. With that, would you like to close?

Thank you. We have a motion and a second. Please call the roll. The motion is due pass to Appropriations Committee. Bonta? Aye. Bonta, aye. Sanchez? Sanchez, no. Addis? Aye. Addis, aye. Aguirre-Curri? Ahrens? Coloza? Carrillo? Jeff Gonzalez? Mark Gonzalez? Johnson? Patel? Patel, aye. Patterson? Rodriguez? Rodriguez, aye. Chiavo? Sharp-Collins? Stephanie? That measure's on call. Thank you. Thank you. Thank you. We are waiting on Senators Allen and Reyes in the committee hearing room. Thank you. Once you hit your seat. We will start with the consent calendar for add-ons. On consent, Sanchez. Sanchez, aye. Aguirre-Curri. Aguirre-Curri, aye. Aarons. Aye. Aarons, aye. Coloza. Carrillo. Jeff Gonzalez. Aye. Jeff Gonzalez, aye. Mark Gonzalez. Johnson Rodriguez Rodriguez I on consent Chiavo Chiavo I sharp Collins that is now out we start at the top of the agenda moving to item number one SB 331 We lifting the call on Minjavar bill The motion is due passed to the Appropriations Committee Bonta? Aye. Bonta, aye. Sanchez? Aye. Sanchez, aye. Addis? Aye. Addis, aye. Aguirre-Curri? Aguirre-Curri, aye. Ahrens? Aye. Ahrens, aye. Coloza? Carrillo? Jeff Gonzalez? Aye. Jeff Gonzalez, aye. Mark Gonzalez? Johnson? Patel? Patel, aye. Patterson. Rodriguez. Rodriguez, aye. Chiavo. Chiavo, aye. Sharp Collins. Stephanie. That measure is now out. Item number two, SB 490 by Umberg. We are lifting the call. Sanchez. Aye. Sanchez, aye. Addis. Aye. Addis, aye. Aguiar-Curry. Aye. Aguiar-Curry, aye. Aarons. Aarons, aye. Colosa. Mark Gonzalez. Patterson. Rodriguez. Rodriguez, aye. Sharp Collins. Stephanie. That bill's now out. We'll move on to item number three, SB 526 for add-ons. Oh, sorry, lifting the call. Aguiar Curry. Aguiar Curry, aye. Aarons. Aarons, aye. Coloza, Carrillo, Carrillo, I, Mark Gonzalez, Johnson, Patterson, Chiavo, Chiavo, I, Sharp Collins, Stephanie. That measure is still on call. Item number four, SB608 by Menjavar, lifting the call. Bonta, I, Bonta, I, Sanchez, Sanchez, no, Addis, Addis, I, Aguirre Curry, Aguirre Curry, Aye, Ahrens, Aye, Ahrens, Aye, Colosa, Carrillo, Aye, Carrillo, Aye, Jeff Gonzalez, Jeff Gonzalez, No, Mark Gonzalez, Johnson, Patel, Patel, Aye, Patterson, Rodriguez, Rodriguez, Aye, Chiavo, Chiavo, Aye, Sharp Collins, Stephanie, That measure is still on call. Item number five, SB 869 by Weber Pearson for add-ons. Oh, sorry, lifting the call. Sanchez. Addis. Addis, aye. Coloza. Mark Gonzalez. Patterson. Rodriguez. Item five, SB 869. Rodriguez aye. Sharp Collins That measure is still on call. Item number 6 SB 950 by Weber Pearson. We are lifting the call Sanchez. Aye. Sanchez aye. Addis. Aye. Addis aye. Aguirre-Curray. Aguirre-Curray Aye. Ahrens. Ahrens. Aye. Colosa. Mark Gonzalez. Patterson. Rodriguez. Rodriguez. Aye. Sharp Collins. That measures out. Item number seven, SB 971. We have a motion and a second. The motion is due pass as amended. Bonta. Aye. Bonta. Aye Sanchez Aye Sanchez Aye Addis Aye Addis aye Aguirre Aguirre aye Ahrens Aye Ahrens aye Colosa Carrillo. Aye. Carrillo, aye. Jeff Gonzalez. Aye. Jeff Gonzalez, aye. Mark Gonzalez. Johnson. Patel. Aye. Patel, aye. Patterson. Rodriguez. Aye. Rodriguez, aye. Chiavo. Chiavo, aye. Sharp Collins. Stephanie. Aye. That measures out. Item number 8, SB 1016 by Blake Spear. Lifting the call. Aguiar Curry. Aguiar Curry, aye. Ahrens. Ahrens, aye. Colosa. Carrillo. Carrillo, aye. Mark Gonzalez. Johnson. Patterson. Chiavo. Chiavo, aye. Sharp Collins. Stephanie. that measures now out item number nine sb 1037 by weber pearson lifting the call sanchez sanchez no addis addis i agar curry agar curry i aarons aarons i coloza Mark Gonzalez Rodriguez Rodriguez I Sharp Collins Stephanie That measure is still on call Item number 11 SB 1199 by Weber Pearson Oh sorry Item number 10 SB 1094 10 SB 1094 by Weber Pearson for lifting the call Aguiar Curry. Ahrens. Ahrens, aye. Colosa. Carrillo. Carrillo, aye. Jeff Gonzalez. Jeff Gonzalez, aye. Mark Gonzalez. Rodriguez. Chiavo. Chiavo, aye. Sharp Collins. That measures out. Item number 11, SB 1199. by Weber Pearson lifting the call Sanchez Sanchez not voting Aguirre curry Aguirre curry aye Ahrens Ahrens aye Colosa Carrillo Carrillo aye Jeff Gonzales Jeff Gonzalez, I. Mark Gonzalez, Johnson, Rodriguez, Rodriguez, I. Chiavo, Chiavo, I. Sharp Collins. That bill is now out, and we have done all of the business that we could possibly do and are still waiting on our senators, Alan and Reyes, to hear the last items. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. All right, we're going to move on to item number 13, SB 1271 by Reyes, regarding midwifery workforce data availability to be a clinical preceptorship i will say senator allen sb 1244 will be heard as the last bill of the committee and we are all in love with senator reyes bill senator please be good whenever you're ready

You'll each have two minutes.

Good afternoon, Madam Chair and members. My name is Simona Spiegel, and I am here today in support of SB 1271. I a PhD candidate in medical anthropology at the University of Notre Dame where I research midwifery training and the movement for birth justice in California I also a student midwife and a medical doula serving families in the Bay Area For the past five years I worked alongside midwives as a researcher and now as a student midwife. I've interviewed and spoken with dozens of students and practicing midwives across California about their experiences in midwifery training. One issue has come up again and again, finding clinical placements and preceptors. I've experienced this challenge myself and traveled four hours round trip from Berkeley to apprentice with a midwife in Santa Cruz for a year. Even in the Bay Area, where there is one of the highest concentrations of licensed midwives in the state, finding a preceptor is difficult. I've spoken with students who have delayed their education, traveled long distances, or completed their clinical training out of state because they couldn't find placements in California. Those experiences point to a larger problem. Right now, the state doesn't have key data on how many preceptors there are or how to support potential preceptors in taking on students. SB 1271 would give California a clearer picture on how many preceptors there are and how to support them. and what it would take to support them in training the next generation of midwives. We can't strengthen California's midwifery workforce without understanding the training pipeline. Let's keep California a leading voice in birth care. I respectfully ask for your aye vote on SB 1271. Thank you. Thank you.

Yuli Smith, licensed midwife and proud preceptor representing Around Birth Collective, co-sponsor of this bill. Thank you.

Good evening, Chair and members. Karen Stout here on behalf of the California Nurse Midwives Association in support. Thank you.

Any in the hearing room who would like to register opposition? Seeing none, I will bring it back to the committee. We already have a motion and a second. Senator, I want to thank you for bringing forward a very thoughtful measure as somebody who used midwives to be able to deliver my beautiful three babies. I'm very thankful for you. With that, can you please call the roll?

Thank you, Senator. Please call the roll. The motion is due pass to appropriations. Bonta? Aye. Bonta, aye. Sanchez? Aye. Sanchez, I. Addis. Addis, I. Aguirre-Curri. Aguirre-Curri, I. Aarons. Coloza. Coloza, I. Carrillo. Carrillo, I. Jeff Gonzalez. Jeff Gonzalez, I. Mark Gonzalez. Mark Gonzalez, I. Johnson. Patel. Patel, I. Patterson. Rodriguez. Rodriguez, I. Chiavo. Chiavo, I. Sharp Collins. Sharp Collins, I. Stephanie. That measure is out. Thank you, Senator. Moving on to item number 12, SB 12. 1244 by Allen regarding public agency benefits intermediary compensation disclosure act Moved by Gonzalez seconded by Addis Senator

Thanks. You'll each have two minutes.

Wonderful testimony, no bias at all.

Are there others in the hearing room who would like to register support for this measure? Katie Van Dyne with Health Access California in support Thank you Evening Beth Monowski with SCO California in support Sarah Ducat on behalf of the rural county representatives of California the California State Association of Counties and the urban counties of California in support. Thank you. Are there any in the hearing room that would like to offer primary opposition? Please come forward. Thank you. You'll each have two minutes.

Thank you. You'll have two minutes.

Thank you. Any others in the hearing room who would like to register opposition? Seeing none, I will bring it back to committee for any comments or questions. Assemblymember Patel.

No other comments on this side? Senator, I want to thank you for bringing forward this measure. I did just want to have you address the issues raised around basically adopting the ERISA structure to be able to move forward this bill and why you've chosen not to do that.

And when it comes to common ground, when you're right, health care is very much evolving. You know, PBMs, I think, were off most of our radar a couple of years ago. But the Consolidated Appropriations Act, again, amended this year, just in 2026, did account for that and did add new forms of compensation that need to be disclosed as models are changing. So those requirements are very much addressed in federal compliance. And so we're asking for the ability to comply. If you look at our letter, it is pages and pages of red that are additions that this bill is adding that is in excess of ERISA, which we do frankly want to caution about, though this bill doesn't contain some language around fiduciary requirements. there is an active litigation model where the employer as the fiduciary is ultimately held responsible for actively monitoring broker disclosures and compensation for every element of their plan. So when you have all of these layers of reporting that as was addressed, some HR representatives may be overworked and underpaid and not fully understand they will be litigated to that standard though of addressing it. And is some of that probably shifting policy in the right direction for we want employers to understand the components of their health care and what they're paying for and what they're asking employees to pay for. But doing so needs to be in a way that it is going to be clearly identified information that is actionable and accurate, because ultimately, if California's introduction of these requirements into what's currently been a federal framework is to be implemented, we've seen this model and want to make sure that the information is correct. So there are federal requirements that vendors disclose to agents what they're paying. And then of course, an agent can turn around and say, exactly, here it is. This is exactly what we're paid. We provide that in a way that's clear. There's forms to do so. But it's not a small thing to say you're adding these additional criteria because there isn't then an understanding that the employer will be responsible for what's being reported to them. And the language does say that they need to understand what's being reported. Perhaps, Senator, in your closing, you could respond to that.

Could I ask that my witness had one short response relating to litigation? Please press your button.

Thank you. Okay. We have a motion and a second on your bill.

Thank you, Senator. We have a motion and a second. Please call the roll. The motion is due pass to Appropriations Committee. Bonta. Aye. Bonta, aye. Sanchez. Addis. Aye. Addis, aye. Aguirre-Curri. Aguirre-Curri, aye. Ahrens. Aye. Ahrens, aye. Coloza. Aye. Coloza, aye. Carrillo. Aye. Carrillo, aye. Jeff Gonzalez. Aye. Mark Gonzalez. Mark Gonzalez, aye. Patel. Patel, aye. Patterson. Rodriguez. Rodriguez, aye. Chiavo. Chiavo, aye. Sharp Collins. Sharp Collins, aye. Stephanie. Thank you, members. Thank you very much. That measures out. Thank you. Thank you. All right. For the members who need to add on, we only have add-ons left, right? Okay. All right. We are going to start with the consent calendar for add-ons. Colosa. Aye. Colosa, aye. Carrillo. Mark Gonzalez. Mark Gonzalez, aye. Sharp Collins. Sharp Collins, aye. The consent calendar is still out. We'll start at the top. Any committee members who wish to register a vote should get into the committee hearing room right now. We are only going to do this once. Item number one, SB331 by Menjivar. For add-ons. Colosa. Colosa, aye. Carrillo. Mark Gonzalez. Mark Gonzalez, aye. Patterson Patterson, aye Sharp Collins Sharp Collins, aye Stephanie Measure still out Item number 2, SB490 by Umberg for add-ons Colosa Colosa, aye Mark Gonzalez Mark Gonzalez, aye Patterson Patterson aye Sharp Collins Sharp Collins aye Stephanie Measure still out Item number three SB 526 by Perez Lifting the call. Colosa. Colosa, aye. Mark Gonzalez. Mark Gonzalez, aye. Patterson. Patterson, no. Sharp Collins. Sharp Collins, aye. Stephanie. Stephanie, aye. That measure's now out. Item number four, SB 626. 608 by Menjavar, lifting the call. Coloza. Coloza, aye. Mark Gonzalez. Mark Gonzalez, aye. Patterson. Patterson, no. Sharp Collins. Sharp Collins, aye. Stephanie. Stephanie, aye. That's out. That measures out. Item number five, SB 869 by Weber Pearson, lifting the call. Coloza. Mark Gonzalez. Mark Gonzalez, aye. Patterson. Patterson, no. Sharp Collins. Sharp Collins, aye. That measures out item number five by item number six by SB 950 by Weber Pearson for add-ons. Colosa Colosa I Mark Gonzalez Mark Gonzalez I Patterson Patterson I Sharp Collins Sharp Collins I Measure still out Item number 7 SB 971 by Choi for add-ons Colosa Colosa I Mark Gonzalez Mark Gonzalez I Patterson Patterson I Sharp Collins Sharp Collins I Stephanie Stephanie, I. That measure is still out. Item number 8, SB 1016 by Blake Spear for add-ons. Colosa. Colosa, I. Mark Gonzalez. Mark Gonzalez, I. Patterson. Patterson, I. Sharp Collins. Sharp Collins, I. Stephanie. Stephanie, I. That measure is still out. Item number 9, SB 1037 by Weber Pearson lifting the call. Coloza. Coloza, I. Mark Gonzalez. Mark Gonzalez, I. Sharp Collins. Sharp Collins, I. Stephanie. Stephanie, I. That measure is now out. Item number nine, SB 1037 by, sorry, item number 10, SB 1094 by Weber Pearson for add-ons. Coloza. Coloza, I. Mark Gonzalez. Mark Gonzalez, I. Sharp Collins. sharp collins i that measure still out item number 11 sb 1199 by weber pearson for add-ons coloza coloza i mark gonzalez mark gonzalez i sharp collins sharp collins i measure still out item number 12 by sb 1244 by Allen for add Stephanie Stephanie aye Measure still out. Item number 13, SB 1271 by Reyes for add-ons. Aaron's. Aye. Aaron's, aye. Patterson. Patterson, aye. Stephanie. Stephanie, aye. that measure's still out catherine I need a couple more to vote on. Which one? Adding on to item one, SB331, Stephanie. Stephanie, aye. Adding on to item 2, SB 490 Umberg, Stephanie? Stephanie, aye. Okay. And with that, we are adjourning our hearing. Thank you. Thank you.