BILL ANALYSIS Ó
SB 191
Page 1
Date of Hearing: June 18, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 191 (Padilla) - As Introduced: February 7, 2013
SENATE VOTE : 33-1
SUBJECT : Emergency medical services.
SUMMARY : Deletes the January 1, 2014 sunset date and makes
permanent existing law: 1) authorizing county Boards of
Supervisors to elect to levy an additional $2 for every $10
fine, penalty, or forfeiture imposed or collected by the courts
for all criminal offenses, including violations of the Alcoholic
Beverage Control Act and Vehicle Code for purposes of the Maddy
Emergency Medical Services (EMS) Fund; 2) requiring 15% of the
collected assessments to be utilized for all pediatric trauma
centers throughout the county, as specified; and, 3) requiring
costs of administering money deposited into the fund pursuant to
such assessments to be reimbursed in an amount that does not
exceed the actual administrative costs or 10% of the money
collected, whichever amount is lower.
EXISTING LAW :
1)Establishes the Maddy EMS Fund, which permits each county to
establish an EMS fund, upon adoption of a resolution by the
Board of Supervisors. Requires the fund to be administered by
each county, except that a county electing to have the state
administer its medically indigent services program may elect
to have its Maddy EMS Fund administered by the state.
2)Permits the following of the Maddy EMS Fund: a) up to 10% may
be used to reimburse costs of administering the fund; b) a
reserve of up to 15% of the amount in the portions of the fund
reimbursable to physicians and surgeons, and hospitals, as
specified; and, any amount that is distributed for other EMS
purposes, as specified.
3)Requires that the amount in the Maddy EMS Fund, reduced by the
amounts specified in 2) above, to be utilized to reimburse
physicians and surgeons and hospitals for patients who do not
make payment for EMS and for other EMS purposes, as determined
by each county according to the following schedule:
SB 191
Page 2
a) Fifty-eight percent of the fund to be distributed to
physicians and surgeons for emergency services provided by
all physicians and surgeons, except those physicians and
surgeons employed by county hospitals, in general acute
care hospitals that provide basic, comprehensive, or
standby emergency services up to the time the patient is
stabilized, as specified;
b) Twenty-five percent of the fund to be distributed only
to hospitals providing disproportionate trauma and
emergency medical care services;
c) Seventeen percent of the fund to be distributed for
other EMS purposes, as determined by each county, including
but not limited to, the funding of regional poison control
centers.
4)Requires, in each county, an additional penalty to be levied,
in the amount of $7 for every $10 or fraction thereof, upon
every fine, penalty, or forfeiture imposed and collected by
the courts for criminal offenses, including all offenses
involving a violation of the Vehicle Code or any local
ordinances adopted pursuant to the Vehicle Code, except
parking offenses, as specified. Requires, if established by a
county Board of Supervisors, the money to be placed in one or
more funds, including the Courthouse Construction Fund, the
Criminal Justice Facilities Construction Fund, the Automated
Fingerprint Identification Fund, the Forensic Laboratory Fund,
the Maddy EMS Fund, or the DNA Identification Fund.
5)Allows, for purposes of supporting EMS pursuant to the Maddy
EMS Fund, in addition to the penalties specified in 4) above,
the county Board of Supervisors to elect to levy an additional
penalty in the amount of $2 for every $10, or part of $10,
upon every fine, penalty, or forfeiture imposed and collected
by the courts for all criminal offenses, including violations
relating to the control of alcoholic beverages, as specified,
and all offenses involving a violation of the Vehicle Code or
a local ordinance adopted pursuant to the Vehicle Code.
Requires that 15% of the funds to be utilized to provide
funding for all pediatric trauma centers throughout the
county, both publicly and privately owned and operated, as
specified.
SB 191
Page 3
6)Requires each county establishing a Maddy EMS Fund, on January
1, 1989, and on each April thereafter, to report to the
Legislature on the implementation and status of the EMS Fund.
Requires the report to cover the preceding fiscal year, and to
include: total amount of fines and forfeitures collected, as
specified; amount of penalty assessment funds collected; fund
balance and the amount of moneys disbursed under the program
to physicians and surgeons, for hospitals, and for other EMS
purposes, and the amount of money disbursed for actual
administrative costs; the number of claims paid, as specified;
the amount of moneys available to be disbursed to physicians
and surgeons, as specified; and, the amount of moneys
available to be disbursed to hospitals.
7)Establishes eligibility requirements for the reimbursements of
claims submitted by physicians and surgeons.
8)Establishes the California Health Benefit Exchange pursuant to
the federal Patient Protection and Affordable Care Act (ACA)
which authorizes states to establish health benefit exchanges
for individuals and small businesses to compare health
insurance products and purchase policies from among four
categories: Bronze, Silver, Gold, and Platinum, and for some
purchasers, to obtain subsidies and tax credits.
FISCAL EFFECT : None
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, Californians,
regardless of geographic location, income, or ethnicity
continue to face either increased emergency room wait time,
being rerouted to other hospitals, or both. Additionally,
pediatric trauma care is still not widely available in
California. There are only 14 pediatric trauma care centers
in our state of 38 million people. Too often, pediatric
trauma patients must be transported by helicopter to trauma
centers and the time that elapses during transport can impact
survival and recovery rates. In 2006, legislation was signed
into law authorizing counties to supplement their local Maddy
EMS Fund by collecting an additional $2 penalty on every $10
assessment on certain criminal and vehicle code violations,
and 15% of these funds is allocated for pediatric trauma care.
This is the only source of funding for pediatric trauma care.
This bill removes the sunset date of these assessments to
SB 191
Page 4
continue to fund pediatric trauma services.
2)BACKGROUND .
a) Maddy EMS Fund . In 1987, the Legislature approved the
establishment of the Maddy EMS Fund, and although counties
are not required to establish EMS Funds, there are
currently 50 counties that have done so. The Legislature
intended the EMS Funds to reimburse physicians, hospitals,
and other providers of emergency services, specifically to
patients who do not have health insurance coverage for
emergency services and care, cannot afford to pay for those
services, and for whom payment will not be made through any
private coverage or by any program funded in whole or in
part by the federal government, as specified.
Counties have several sources of revenue for their EMS Funds:
Maddy revenues, derived from county penalty assessments on
various criminal offenses and motor vehicle violations;
traffic violator school fees; and, revenues from taxes on
tobacco products deposited in the State's Cigarette and
Tobacco Products Surtax Fund, including the EMS
Appropriation.
Current law requires courts to collect the fines, penalties,
and forfeitures for various criminal offenses, motor
vehicle and traffic violations. Currently, the total
penalty assessment is $7 for every $10 of fines and
forfeitures, a portion of which goes to the Maddy EMS Fund.
Courts collect the penalty assessments and forward them to
counties.
In 1988, voters passed the Tobacco Tax and Health Protection
Act of 1988 (Proposition 99) through the initiative
process. Proposition 99 imposes taxes on the distribution
of cigarettes and other tobacco products. The state
collects these taxes for deposit in the State's Cigarette
and Tobacco Products Surtax Fund to fund a variety of
programs, including the California Healthcare for Indigents
Program (CHIP) and Rural Health Services (RHS) program,
which allocate funds to counties for indigent care. Since
2000, the Legislature has appropriated money from CHIP and
RHS funds to provide counties with revenues which are
restricted to reimbursement of uncompensated emergency room
care by private physicians. This annual appropriation is
SB 191
Page 5
referred to as the EMS Appropriation.
SB 1773 (Alarcon), Chapter 841, Statutes of 2006, further
authorized county Boards of Supervisors to levy an
additional penalty in the amount of $2 for every $10, or
part of $10 for criminal offenses, violations relating to
the Vehicle Code and alcohol beverages. Under SB 1773, 15%
of the funds collected must be utilized to fund pediatric
trauma centers (referred to as Richie's Fund) through the
county, both publicly and privately owned and operated.
The expenditure of money is limited to reimbursement to
physicians and surgeons, and to hospitals for patients who
do not make payment for emergency care services in
hospitals up to the point of stabilization, or to hospitals
for expanding the services provided to pediatric trauma
patients at trauma centers, other hospitals providing care
to pediatric trauma patients, or at pediatric trauma
centers, including the purchase of equipment. The
remaining 75% in these funds are distributed in accordance
with the percentages specified in Existing Law 3) above.
SB 1773 was set to originally sunset in 2009, but was
extended to January 1, 2014 under SB 1236 (Padilla),
Chapter 60, Statutes of 2008. This bill deletes that
January 1, 2014 sunset date and makes the assessments
permanent.
b) Trauma Centers . A 2002 California HealthCare Foundation
study indicates that California's trauma centers provide
the highest levels of emergency care to the most critically
ill and injured patients, maintaining the highest level of
service in terms of specialized medical personnel,
including panels of on-call specialist physicians. Under
state law, hospitals with trauma centers also must maintain
emergency departments. The California Emergency Medical
Services Authority (EMSA) establishes the standards for
trauma systems. EMSA reviews and approves trauma care
plans developed by local emergency services agencies, and
local agencies are responsible for the designation of
trauma centers based on an approved plan. Focus groups of
experts report growing concerns with the state's lack of a
coordinated trauma care system and with inadequate funding
for existing trauma centers, which care for large numbers
of uninsured and underinsured patients.
Trauma Center designations include levels I-IV and Level I
SB 191
Page 6
and II Pediatric. Level I and II trauma centers have
similar personnel, services, and resource requirements with
the greatest difference being that Level I Centers are
research and teaching facilities. Level I and Level II
Pediatric Trauma Centers focus specifically on pediatric
trauma patients, Level I Pediatric Trauma Centers require
some additional pediatric specialties and are research and
teaching facilities. Level III and IV trauma centers
generally provide initial stabilization of trauma patients
with the greatest difference being surgical capabilities at
the Level III facilities. Currently, there are 74 trauma
centers and 15 pediatric trauma centers.
c) ACA . On March 23, 2010, President Obama signed the ACA
(Public Law 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152).
Among other provisions, the new law requires most U.S.
citizens and legal residents to have health insurance;
creates state-based American Health Benefit Exchanges
through which individuals can purchase coverage, with
premium and cost sharing credits, as specified, and creates
separate exchanges through which small businesses can
purchase coverage. According to estimates, the ACA will
extend health coverage to approximately 4-6 million
Californians. Starting in 2014, new health coverage
options will be available in the private health insurance
market and in the Exchange. As part of ACA implementation,
there are many new requirements on health insurers and
plans such as elimination of preexisting conditions
requirements, limitations on enrollee cost sharing,
guaranteed issue of plans and policies, and restrictions on
the factors health plans and insurers can use to determine
premium rates. Additionally, the Exchange will create
better information and more competition in the insurance
market.
3)SUPPORT . The California Chapter of the American College of
Emergency Physicians indicates that allowing the funding
assessments to sunset would result in the loss of
approximately $50 million for the emergency care safety net at
a time when drastically more funding is needed. The Maddy EMS
Fund is intended to mitigate the losses for treating the
uninsured, particularly in rural and urban emergency
departments. Although the Maddy EMS Fund only reimburses
pennies on the dollar to the cost of providing care to the
SB 191
Page 7
uninsured, it remains a critical source of funding to ensure
patients have access to high quality emergency care.
Eliminating the Maddy EMS Fund would lead to a reduction in
emergency physician staffing.
County Boards of Supervisors, including, Los Angeles, Del Norte,
Humboldt, Alameda, Lassen, and San Diego state that retaining
the availability of Richie's Funds is critical to maintaining
the fragile trauma and emergency care system of these counties
and continue to serve the emergency medical care needs of
adults and children.
4)OPPOSITION . The Automobile Club of Southern California states
that penalty assessments are levied against Vehicle Code
moving violations, as well as certain Penal Code violations.
According to the Uniform Bail and Penalty Schedule published
by the Judicial Council of California, current penalty
assessments are in excess of about 380% of the base fine.
This means that for every $10 or fraction of the base fine,
about $38 is added, with a share going to the state and
counties. It states that when penalty assessments were
originally established in the 1950's, they were used to fund
drivers' training in public schools, and over time these
assessment have increased exponentially and today fund a
plethora of programs largely unrelated to traffic safety, and
funding emergency services through assessments places a
disproportionate burden upon the motoring public.
5)RELATED LEGISLATION . SB 535 (Nielsen) increases the
membership of the EMS Commission from 18 to 20 members. SB
535 is awaiting referral in the Assembly.
6)PREVIOUS LEGISLATION .
a) SB 1236 extends from January 1, 2009 to January 1, 2014,
existing provisions allowing a county Board of Supervisors
to levy additional penalties on criminal offenses, for
purposes of the Maddy EMS Fund, and allocate 15% of the
funds collected to pediatric trauma centers, as specified.
b) SB 1773 authorizes a county Board of Supervisors, until
January 1, 2009, to elect to levy an additional $2 for
every $10 in base funds for purposes of supporting EMS, and
requires the additional assessment to be deposited in local
Maddy EMS Funds, with 15% to be directed to pediatric
SB 191
Page 8
trauma services and authorizes up to 10% to be used for
administrative expenses.
7)POLICY COMMENT . The Maddy EMS Fund was established to provide
reimbursement of claims for emergency services provided by
physicians and surgeons and hospitals to patients who do not
have health insurance coverage for emergency services and
cannot afford to pay for those services, and for whom payment
will not be made through any private coverage or public
program, as specified. Additionally, although counties are
required to report to the Legislature the status of their
Maddy EMS Fund, including the amount of fines/assessments
collected, and amount of moneys disbursed, there is no one
entity that oversees counties' administration of their Maddy
EMS Fund. As evidenced by the reports submitted to the
Legislature last year and this year, some counties continue to
have significant balances in their Maddy EMS Fund revenues.
With the implementation of the ACA, it is expected that the
number of uninsured patients who access emergency care
services would be lower, and could result in fewer claims
being submitted for Maddy EMS Fund reimbursements. Although
this bill is only extending the sunset date of one of the
assessments utilized to fund the Maddy EMS Fund, as California
rolls out implementation of the ACA, it may be more prudent to
extend the sunset date of this bill until December 31, 2020 ,
instead of making these assessments permanent. This extension
will allow the Legislature to evaluate the continued need for
the Maddy EMS Fund assessments, including an examination of
the types of claims submitted for reimbursement, and how
counties are utilizing these funds in light of the ACA
implementation.
REGISTERED SUPPORT / OPPOSITION :
Support
American College of Emergency Physicians, California Chapter
(cosponsor)
California Medical Association (cosponsor)
Alameda County Board of Supervisors
Butte County Board of Supervisors
California Association of Public Hospitals and Health Systems
California Center for Rural Policy at Humboldt State University
California District of the American Academy of Pediatrics
SB 191
Page 9
California Fire Chiefs Association
California Hospital Association
California Nurses Association
California Pan-Ethnic Health Network
California School Nurses Association
California State Association of Counties
California State Council of Emergency Nurses Association
City Ambulance of Eureka, Fortuna, Garberville
Coachella Valley Association of Governments
Contra Costa County Board of Supervisors
Del Norte Ambulance
Del Norte County Board of Supervisors
Emergency Medical Services Administrators Association
Health Officers Association of California
Hospital Corporation of America
Humboldt County Board of Supervisors
Lake County Health Services Department
Lassen County Administrative Services
League of California Cities
Local Health Plans of California
Los Angeles County Board of Supervisors
Marin County Board of Supervisors
Merced County Board of Supervisors
National Nurses United
North Coast Emergency Medical Services
Paramedics Plus
Rural County Representatives of California
San Bernardino County Board of Supervisors
San Diego County
San Fernando Valley Dental Society
San Joaquin County Board of Supervisors
San Luis Obispo Board of Supervisors
Santa Barbara County
Santa Clara County Board of Supervisors
Sonoma County Board of Supervisors
Stanislaus County Board of Supervisors
Urban Counties Caucus
Yolo County Board of Supervisors
Opposition
Automobile Club of Southern California
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097
SB 191
Page 10