BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 941|
|Office of Senate Floor Analyses | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 941
Author: Wood (D)
Amended: 8/18/15 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 6/24/15
AYES: Hernandez, Nguyen, Mitchell, Monning, Nielsen, Pan,
Roth, Wolk
NO VOTE RECORDED: Hall
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 77-0, 5/11/15 - See last page for vote
SUBJECT: Clinics: licensure and regulation: exemption
SOURCE: California Rural Indian Health Board
DIGEST: This bill exempts from licensure and regulation by the
Department of Public Health any clinic operated by a federally
recognized Indian tribe under a contract with the United States
pursuant to the Indian Self-Determination and Education
Assistance Act, regardless of the location of the clinic.
ANALYSIS:
Existing federal law:
1)Establishes the Indian Health Service (IHS), which is charged
with providing federal health services to American Indians and
Alaska Natives who are members of 566 federally recognized
Tribes across the United States.
AB 941
Page 2
2)Establishes the Indian Self-Determination and Education
Assistance Act (ISDEAA), which was enacted to ensure
"effective and meaningful participation by the Indian people
in the planning, conduct, and administration" of federal
services and programs provided to members of Tribes, including
health care. Under ISDEAA, Tribes have the option to exercise
their sovereignty by either assuming from IHS the
administration and operation of providing health care
themselves (through contracts), or to continue to receive
health care through the IHS-administered, direct-care health
system.
3)Specifies areas in which tribes are permitted to contract with
IHS to provide health care services under ISDEAA, known as
"contract health service delivery areas." California is a
contract health service delivery area, except for the
following 20 excluded counties: Alameda, Contra Costa, Los
Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo,
Santa Clara, Kern, Merced, Monterey, Napa, San Benito, San
Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and
Ventura.
Existing state law:
1)Exempts various types of clinics from licensure and regulation
by the Department of Public Health (DPH), including clinics
operated by a federally recognized Indian tribe or tribal
organization, as defined, that are located on land recognized
as tribal land by the federal government. Among the other
types of clinics exempt from licensure by DPH are the
following:
a) Any establishment that is owned and operated as a clinic
by one or more licensed health care practitioners and used
as an office for the practice of their profession, with the
exception of surgical clinics and specialty clinics;
b) Clinics operated as outpatient departments of hospitals;
c) A clinic operated by, or affiliated with, any
institution of learning that teaches a recognized healing
art and is approved by the state board or commission vested
with responsibility for regulation of the practice of that
AB 941
Page 3
healing art;
d) An intermittent clinic that is open for no more than 20
hours per week, and that is operated by a licensed primary
care clinic; and,
e) Student health centers operated by public institutions
of higher education.
2)Exempts a health care practitioner that is licensed in any
other state, and who is employed by a tribal health program,
from any requirement to be licensed in California with respect
to acts authorized under the person's license in another
state, where the tribal health program performs services under
the ISDEAA.
3)Establishes within the Department of Health Care Services the
Indian Health Program, which is charged to improve the health
status of American Indians living in urban, rural, and
reservation or rancheria communities throughout California.
This bill exempts from licensure and regulation by DPH any
clinic conducted, maintained, or operated by a federally
recognized Indian tribe or tribal organization, as defined in
federal law, under a contract with the United States pursuant to
ISDEAA, as specified, regardless of the location of the clinic,
except that if the clinic chooses to apply to DPH for a license,
then DPH retains the authority to regulate that clinic.
Comments
1)Author's statement. According to the author, many Native
American tribes operate their own health programs for their
members on the reservation, but often times many tribal
members live off the reservation. Due to the geographic nature
of the North Coast, many members off the reservation have a
difficult time accessing health care. In order to better serve
these members, tribal groups have opened new tribal health
clinics off the reservation to expand health care services to
their tribal members. However, opening a tribal clinic off the
reservation is a very burdensome process. One cumbersome
application in the process is the state facility license
within DPH, which is known to be time-consuming, costly, and
includes duplicative paperwork. Tribal clinics are already
AB 941
Page 4
required to be licensed under the federal government and IHS,
which already cover the same requirements that DPH's state
facility license seeks to regulate. By streamlining the
facility licensing process, tribal clinics would be able to
focus more time to providing quality health care to tribal and
non-tribal members off the reservation.
2)Background on ISDEAA and tribal health services in California.
In 1975, the ISDEAA was signed into law. The ISDEAA reaffirmed
congressional support of the nation-to-nation relationship
between the United States and each Tribal nation. The ISDEAA
was enacted to ensure "effective and meaningful participation
by the Indian people in the planning, conduct, and
administration" of federal services and programs provided to
the Tribes and their members. Under the ISDEAA, Tribes and
Tribal Organizations have the option to either (a) administer
programs and services the IHS would otherwise provide
(referred to as Title I Self-Determination Contracting) or (b)
assume control over health care programs and services that the
IHS would otherwise provide (referred to as Title V
Self-Governance Compacting). These options are not exclusive;
Tribes may choose to combine them based on their individual
needs and circumstances.
According to IHS, California is home to the largest population
of American Indians/Alaska Natives in the country. According
to the 2010 Census, California's Indian population was
362,801. California is home to 107 federally recognized
tribes. The California Rural Indian Health Board (CRIHB), the
sponsor of this bill, reports that there are approximately 34
clinics operated by tribal health programs in California: 13
of these clinics are off tribal land and are currently
licensed by DPH, while 21 clinics are either on tribal land or
meet one of the other licensure exemptions (for example,
affiliation with an institution of higher education that
offers a health profession education program). All of these
tribal health programs are provided in "contract health
service delivery areas," which are federally designated areas
that are located in counties that contain, or are adjacent to,
tribal land. Separate from these tribal health programs in
contract areas, IHS funds eight "urban health programs" that
operate under a separate provision of federal law, intended to
offer services to Indians located in urban areas. This bill
does not affect urban tribal health programs, as this bill is
AB 941
Page 5
limited to clinics in contract areas (typically more rural).
While the primary purpose of tribal health programs is to
provide federally required health care to tribal members,
these programs can, if they choose, treat non-tribal members.
This is true regardless of whether the clinic is located on or
off tribal land. These clinics, again regardless of where they
are located, are permitted to seek reimbursement from Medicare
and Medi-Cal, though they have to be certified by the Centers
for Medicare and Medicaid Services (CMS) in order to bill
these programs. CRIHB reports that almost all tribal clinics
in California are CMS-certified.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
SUPPORT: (Verified8/18/15)
California Rural Indian Health Board (source)
Big Valley Band of Pomo Indians
California Pan-Ethnic Health Network
California Primary Care Association
Chapa-De Indian Health Program
Cloverdale Rancheria
Feather River Tribal Health
Greenville Rancheria
Karuk Tribe
Lake County Tribal Health Consortium
Latino Coalition for a Healthy California
Manchester-Point Arena Band of Pomo Indians
Pit River Health Service
Redding Rancheria Tribal Health Center
Riverside-San Bernardino County Indian Health System
Santa Ynez Tribal Health Clinic
Sherwood Valley Band of Pomo Indians
Smith River Rancheria
Sonoma County Indian Health Project
Southern Indian Health Council
Toiyabe Indian Health Project
Tule River Indian Health Center
Twenty-Nine Palms Band of Mission Indians
United Indian Health Services
AB 941
Page 6
Warner Mountain Indian Health Clinic
Yurok Tribe
OPPOSITION: (Verified8/18/15)
American Nurses Association/California
ARGUMENTS IN SUPPORT: This bill is sponsored by CRIHB, and
supported by numerous tribal health programs. CRIHB states that
this bill creates a much-needed single standard for clinic
licensure for federal Tribal Health Program sites. According to
CRIHB, regardless of where a tribal health program is located,
it is required to adhere to all federal IHS operating
requirements in order to maintain its status as a federal
contractor. CRIHB states that tribal health programs are
committed to maintaining high standards of corporate conduct and
are audited annually. CRIHB points out that there are currently
more than fifteen state licensing exemptions for various types
of health clinics in California. According to CRIHB, if a tribal
health program is located on Indian land or has a working
partnership with an institution of higher learning, it is exempt
from state licensure, but if it is not located on Indian land or
does not have an affiliation with an institution of higher
learning, it must be licensed as a primary care clinic. CRIHB
states that the multiple tribal health licensing standards
create undue administrative challenges, confusion, and burden
for tribal health programs in their mission of providing
federally contracted health services. The Riverside-San
Bernardino County Indian Health System, in its support letter,
described delays in getting its two clinics licensed, and having
to undergo an unnecessary comprehensive audit that resulted in a
great deal of cost to its organization. The California Primary
Care Association states in support that this bill is a simple
yet effective way for tribal health organizations to meet the
unique healthcare needs of the communities they serve in a
culturally competent, accessible manner.
ARGUMENTS IN OPPOSITION: This bill is opposed by the
American Nurses Association/California (ANAC). ANAC states that
it opposes this bill because it will exclude tribal health
AB 941
Page 7
clinics from California licensing and safety provisions outside
of federally designated tribal lands, and that without
licensing, clinics would not have to comply with state building
or state professional standards which assure minimal protections
for employees working in clinics that may or may not be tribal
members.
ASSEMBLY FLOOR: 77-0, 5/11/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina
Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez,
Gordon, Gray, Grove, Hadley, Roger Hernández, Holden, Irwin,
Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Low,
Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin,
Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,
Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,
Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,
Wilk, Williams, Wood
NO VOTE RECORDED: Harper, Lopez, Atkins
Prepared by:Vince Marchand / HEALTH /
8/20/15 13:57:05
**** END ****