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: 8/26/15 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. Senate Floor Amendments of 8/26/15 incorporate provisions from AB 1130 (Gray) in order to avoid chaptering-out problems. ANALYSIS: Existing federal law: 1)Establishes the Indian Health Service (IHS), which is charged AB 941 Page 2 with providing federal health services to American Indians and Alaska Natives who are members of 566 federally recognized tribes across the United States. 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 AB 941 Page 3 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 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 AB 941 Page 4 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 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 AB 941 Page 5 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 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: (Verified8/27/15) California Rural Indian Health Board (source) Big Valley Band of Pomo Indians Blue Lake Rancheria California Pan-Ethnic Health Network California Primary Care Association Chapa-De Indian Health Program Cloverdale Rancheria Feather River Tribal Health Greenville Rancheria Indian Health Council Karuk Tribe Kashia Band of Pomo Indians Lake County Tribal Health Consortium Latino Coalition for a Healthy California Manchester-Point Arena Band of Pomo Indians Northern Valley Indian Health Pit River Health Service Redding Rancheria Tribal Health Center Resighini Rancheria Riverside-San Bernardino County Indian Health System Santa Ynez Tribal Health Clinic AB 941 Page 6 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 Warner Mountain Indian Health Clinic Yurok Tribe OPPOSITION: (Verified8/27/15) 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 15 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 AB 941 Page 7 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 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 / 8/28/15 8:48:28 **** END ****