BILL ANALYSIS                                                                                                                                                                                                    Ó






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          |SENATE RULES COMMITTEE            |                        AB 941|
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                                   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  








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            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  







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               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  







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            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  







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            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







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          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  







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          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


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