SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO:
AUTHOR:
AMENDED:
HEARING DATE:
CONSULTANT:
AB 210
Solorio
June 29, 2011
July 6, 2011
A
B
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Tadeo
SUBJECT
Emergency medical services
SUMMARY
Repeals and recasts provisions in the Emergency Medical Services (EMS) System and
the Pre-hospital Emergency Medical Care Personnel Act (EMS Act) pertaining to prehospital ambulance services agreements. Requires the continued authorization of a city
or fire district that has continuously contracted for or provided pre-hospital EMS since
June 1, 1980, to contract for or provide, with operational control, the same category of
pre-hospital (EMS) that it has continuously provided during that time, within the
geographical service area that it continuously served during that time, if the city or fire
district makes a formal written request to the local EMS (LEMSA) agency prior to
January 1, 2014, under specified conditions.
CHANGES TO EXISTING LAW
Existing law:
Establishes the EMS Act for the purpose of providing the state with a statewide EMS
system.
Establishes the EMS Authority (Authority), within the Health and Human Services
Agency, responsible for the coordination and integration of all state activities concerning
EMS including establishing the minimum standards for the policies and procedures
necessary for medical control of the EMS system.
Establishes a 16-member EMS Commission within the Health and Human Services
Agency, and defines duties and criteria for its members. Ten commissioners are
appointed by the Governor, three by the Senate, and three by the Speaker of the
Assembly.
Continued---
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Page 2
Authorizes counties to develop an EMS program and designate a LEMSA responsible for
planning and implementing an EMS system.
Requires the Authority to authorize LEMSAs, review and approve LEMSA plans for
implementation of EMS and trauma care systems, and provide for a LEMSA to appeal a
negative determination to the EMS Commission.
Allows a LEMSA to create an exclusive operating area (EOA) in the development of a
local plan if a competitive process is utilized to select the provider.
Defines an EOA to mean an EMS area or subarea defined by the EMS plan for which a
LEMSA restricts operations to one or more emergency ambulance services or providers
of advanced life support (ALS) or limited advanced life support (LALS).
Does not require a competitive process if the LEMSA develops or implements a local
plan that continues the use of existing providers that have continuously provided services
without interruption since January 1, 1981.
Requires a LEMSA which elects to develop an EOA to submit a plan to the Authority for
approval. Requires this plan to include provisions for a competitive process held at
periodic intervals.
Provides that nothing in the provisions pertaining to the creation of an EOA supersedes
the provisions pertaining to the grandfathering of administration of pre-hospital EMS by
cities and fire districts as of June 1, 1980.
Allows an emergency medical care committee to be established in each county. Requires
every emergency medical care committee to report its observations and recommendations
at least annually to the Authority.
This bill:
Repeals and recasts provisions in the EMS Act pertaining to pre-hospital ambulance
services agreements. Requires a city or fire district that has continuously contracted for
or provided pre-hospital EMS since June 1, 1980, to have continuing authorization to
contract for or provide, with operational control, the same category of pre-hospital EMS
within the same geographical area, if the city or fire district makes a formal written
request for recognition to the LEMSA prior to January 1, 2014, and the following
conditions are met:
 The city or fire district has not previously entered into a pre-hospital EMS
administration agreement; and
 The city or fire district enters into a written agreement with the LEMSA in a form
specified by the LEMSA that addresses only medical control, coordination of
EMS resources, recognition of the category of pre-hospital EMS, and designation
of the geographical service area.
Prohibits a city or fire district from performing or contracting for a category of prehospital EMS if it fails to enter into an agreement with the LEMSA by January 1, 2014,
or has failed to commence an appeal, unless formally authorized to do so by the LEMSA,
as specified.
STAFF ANALYSIS OF ASSEMBLY BILL 210 (Solorio)
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Requires that appeals proceed in the following order: first to the local emergency medical
care committee or its equivalent; then to the governing body of the LEMSA; and then to
judicial review. Requires the standard of appeal to be de novo, meaning the appeal
would have to be considered anew, as if it had not been heard before and as if no decision
had previously been rendered.
Prohibits a city or fire district that has not continuously performed, or contracted for a
category of pre-hospital EMS since January 1, 1980, to provide those services in that
category unless formally authorized to do so by the LEMSA, as specified.
Requires a LEMSA to include all pre-hospital EMS providers who comply with these
provisions in its local EMS plan.
Specifies the pre-hospital EMS categories as first responder, dispatch, 911 ambulance
transport service, and inter-facility ambulance service, and provides definitions for each.
Requires that a pre-hospital provider is not precluded from increasing the level of service
it provides within a category it has continuously provided since June 1, 1980.
Provides that the bill is not to be construed as permitting a pre-hospital EMS provider to
add a new category of service that it has not provided continuously since June 1, 1980.
Revises the definition of exclusive operating area, to exclude providers of ALS or LALS
Allows a LEMSA to create EOAs for emergency ambulance services, inter-facility
transport, or both if a competitive process is utilized. Allows a LEMSA to determine the
periodic intervals at which a competitive process for an EOA is held.
Removes the provisions that provide that nothing in the provisions pertaining to the
creation of an EOA supersedes the provisions pertaining to the administration of prehospital EMS by cities and fire districts as of June 1, 1980.
Requires the emergency medical care committee to be representative of the EMS system
participants.
Requires that nothing in this act shall be construed to affect, limit, or otherwise invalidate
any decision by a court that interprets and applies the EMS Act (Division 2.2
commencing with Section 1797) of the Health and Safety Code, as that division read on
December 31, 2011.
FISCAL IMPACT
The Assembly Floor analysis of AB 210 states negligible direct state impact according to
the Assembly Appropriations Committee.
STAFF ANALYSIS OF ASSEMBLY BILL 210 (Solorio)
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BACKGROUND AND DISCUSSION
The author states that in the last three decades since the enactment of the EMS Act and
particularly the enactment of the provisions relating to pre-hospital EMS agreements that
allow for exclusive operating areas, the practice of pre-hospital medicine has witnessed
significant changes and growth, thereby making it increasingly more important to have a
coordinated EMS system that provides the best possible emergency medical care. The
author further states that it has become common for EMS transportation providers to
function without entering into a written agreement with their respective LEMSA. The
author argues that this has created confusion in determining which EMS providers are
required to maintain services in certain areas.
California’s EMS system
The EMS system in California began its development with the passage of the WedworthTownsend Pilot Paramedic Act SB 772 (Wedworth), Chapter 1188, Statutes of 1974).
Paramedic programs began forming throughout the state without regard to EMS system
planning. The first paramedic program was formed in 1970 in the county of Los
Angeles. California was seen as a leader in EMS, with the utilization of paramedics in
the EMS system. Although most EMS systems that developed nationwide have been
structured with state involvement and/or standardization, the EMS system in California
evolved at the local level.
Prior to 1981, California did not have a central state agency responsible for ensuring the
development and coordination of EMS services and programs statewide. Because of
the manner in which EMS evolved in California, system management and operation
developed independently from county to county throughout the state. Each county
established its own EMS system (including protocols, scope of practice, training
standards, etc.) and tailored it to meet the specific needs of its geography, economy,
and client population. Though fragmented, these individual systems worked well as
long as EMS calls were confined within the local jurisdiction. However, when the
services of one county were required across county lines (e.g., for multi-casualty
incidents, patient transport, or mutual aid), the absence of common operating procedures
and methodologies often resulted in inconsistency of care. Questions regarding scope of
practice and specific protocols, created indecision and confusion among responders at the
scene.
The EMS Act created the Authority, effective January 1, 1981, and now provides the
foundation for EMS in the state. As the lead agency and centralized resource to oversee
emergency and disaster medical services, the Authority is charged with providing
leadership in developing and implementing local EMS systems throughout California,
and setting standards for the training and scope of practice of various levels of EMS
personnel. This includes assessing each EMS area to determine the need for additional
services, coordination and effectiveness of EMS. The Authority reviews EMS plans
submitted by LEMSAs to determine whether the plans effectively meet the needs of the
persons in the geographical areas served and are consistent with local coordinating
activities as well as with the guidelines and regulations established by the Authority.
LEMSAs occupy the second tier of governance under the EMS Act. California has 32
local EMS systems that provide EMS for California's 58 counties. (Seven regional EMS
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systems comprised of 33 counties and 25 single-county agencies provide the services.)
Regional systems are usually comprised of small, rural, less-populated counties, and
single-county systems generally exist in the larger and more urban counties. LEMSAs
are required to develop a formal plan for the system in accordance with the Authority's
guidelines and to submit the plan to the Authority annually. The EMS Act also provides
that medical direction and management of an EMS system is under the medical control of
the medical director of the LEMSA.
The EMS Act includes a provision that "grandfathers" the administration of pre-hospital
EMS by cities and fire districts as of June 1, 1980, and requires those rights to be retained
until there is a written agreement regarding the provision of these services between the
LEMSA and the city or fire district (referred to as Section 201 rights or administrative
control). A city or fire district must provide pre-hospital EMS during the transitional
period of time before an agreement is reached to integrate into the local EMS system. In
1984, the EMS Act was amended for the purpose of authorizing LEMSAs to grant EOAs
to private EMS providers such as ambulance companies (referred to as Section 224).
Litigation and court rulings regarding conflict in the EMS system
Section 201 and Section 224 have been the source of friction between the fire districtbased providers and LEMSAs, at times resulting in litigation. The issues related to EMS
system coordination and the interpretation of Health and Safety Code Sections 1797.201
and 1797.224 have been addressed by the California Supreme Court in its opinions
contained in the cases of County of San Bernardino v. City of San Bernardino, 15 Cal. 4th
909 (1997) (the San Bernardino decision) and Valley Medical Transport v. Apple Valley
Fire Protection District, 17 Cal. 4th 747 (1998) (the Apple Valley decision). More
recently, additional EMS system guidance was also set forth in the Appellate Court
decision in County of Butte v. California Emergency Medical Services Authority, 3rd
Appellate District Docket # C060407 (2010) (the Butte County decision).
The California Supreme Court first ruled on the respective roles of counties, the
LEMSAs, cities and fire districts in the 1997 San Bernardino decision. That case arose
from a dispute between the city of San Bernardino and the LEMSA over who controlled
the dispatch of pre-hospital emergency paramedics and ambulance services. The court
ruled that the city had Section 201 rights to continue to administer its own pre-hospital
EMS, but not to provide ambulance services that it was not providing prior to the June 1,
1980 grandfather date. The Court also ruled that even the City’s administrative control
was limited by the LEMSA’s medical control authority which included the power to issue
protocols regarding dispatch and patient management. In order to resolve this dispute,
the court conducted an extensive review of the legislative history as well as a detailed
analysis of the meaning of nearly every phrase. The San Bernardino decision noted that
“…1797.201 is ‘transitional’ in the sense that there is a manifest legislative expectation
that cities and counties will eventually come to an agreement with regard to the provision
of emergency medical services…”. The decision also states that “Nothing in this
reference to 1797.201 suggests that cities and fire district are to be allowed to expand
their services, or to create their own exclusive operating areas.” 15 Cal. 4th 922.
The specific Section 201 eligibility criteria are identified in the San Bernardino and
Apple Valley decisions. In order to be an eligible Section 201 agency, the agency must
meet all of the following:
STAFF ANALYSIS OF ASSEMBLY BILL 210 (Solorio)
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Be a city or fire district that existed on June 1, 1980.
Be the same entity that existed on the date of the Section 201 eligibility
evaluation.
Provided service on June 1, 1980, at one of these types: ALS, LALS, or
emergency ambulance services.
Operated continuously in the same type of service.
Has not yet entered into a written agreement that intended or contemplated
“integration and coordination” into the local EMS system, including, but not
limited to ALS, LALS or emergency ambulance services.
In the case of County of Butte v. California Emergency Medical Services Authority, the
appellate court was asked to decide whether the Authority has the statutory power to
disapprove a LEMSA’s designation of an EOA through the grandfathering provisions of
section 1797.224. Butte County argued that under section 1797.224, when the LEMSA
continues the use of existing providers operating within the LEMSA area in the manner
and scope in which the services have been provided without interruption since January 1,
1981, there is no competitive process to submit to the Authority for its approval and,
therefore, the LEMSA determination with respect to grandfathering in the existing
providers is not subject to the Authority’s review and approval. The court disagreed,
stating “we cannot read section 1797.224 in isolation; instead, we are required to read the
statute with reference to the entire statutory scheme so that the EMS Act as a whole may
be harmonized and retain effectiveness.” Butte County, p. 31.
The court concluded that “… the Authority has the statutory authority to review a local
EMS agency’s creation of an EOA as part of the transportation portion of the local EMS
plan, regardless of whether the EOA was created through a competitive process or
grandfathering and then to reject the local EMS plan if it is not “concordant and
consistent with applicable guidelines or regulations, or both the guidelines and
regulations, established by the Authority.” Butte County, p. 32.
EMS task force
To help resolve the longstanding disputes regarding these issues, the Authority hosted a
stakeholder workshop in May 2010. The EMS Commission also established a
subcommittee to evaluate these issues. In December 2010, the subcommittee submitted a
report and recommendations which were intended to serve as a road map for further
action for the Authority and the EMS community at large. In response, the Authority
convened a task force consisting of EMS constituents with knowledge of these issues.
The task force has been meeting on a bi-weekly basis since late January 2011, and is
developing a draft set of regulations and possible statutory changes to address the same
issues this bill is seeking to address. According to the December 2010 subcommittee
report, the regulatory package and recommended statutory framework were to be
considered at the June 2011 Commission meeting, but consideration of them has been
delayed to September 2011. The language in AB 210 reflects stakeholder input; however
not all of the stakeholders are in agreement with the language in the bill in its current
version.
Prior legislation
AB 3153 (Bronzan), Chapter 1349, Statutes of 1984, provides that a LEMSA which
elects to create an EOA must develop and submit its competitive process for selecting
STAFF ANALYSIS OF ASSEMBLY BILL 210 (Solorio)
Page 7
providers to EMSA for approval as part of the local plan. Provides that nothing in the
provisions pertaining to the creation of an EOA supersedes the provisions pertaining to
the administration of pre-hospital EMS by cities and fire districts as of June 1, 1980.
SB 125 (Garamendi), Chapter 1260, Statutes of 1980, establishes the EMS Act for the
purpose of providing the state with a statewide EMS system.
Arguments in support
The California Professional Firefighters (CPF), a co-sponsor of AB 210, states that
agencies with Section 201 rights have frequently functioned without entering into written
agreements with their respective LEMSAs to coordinate, participate in the local EMS
plan, and abide by standard field protocols. CPF adds that while this approach may work
in some jurisdictions, in others it has not and this is what has led to expensive litigation
over the proper provision of pre-hospital EMS. CPF contends that it is appropriate to
statutorily clarify the need for a written agreement, as well as to clarify exactly what
should be contained in that agreement to recognize a city or fire district’s continuing
authorization to provide pre-hospital EMS in its jurisdiction, manage its own EMS
resources and be subject to LEMSA medical control. Understanding that pre-hospital
patient care treatment protocols and policies regarding emergency medical services vary
by county, and, in order to promote an efficient delivery of the highest level of patient
care and transport, CPF states that each county should establish and maintain an
Emergency Medical Care Committee (EMCC) representative of local EMS system
participants so that collaboration among stakeholders is streamlined and coordinated.
Statement of concern
The EMS Administrator’s Association of California (EMSACC), a co-sponsor of AB
210, states that it does not believe the current language in AB 210 represents a consensus
view by all stakeholders, despite the coalition’s best efforts. EMSACC adds that it has
issues with the language and is concerned that the American Medical Responders and the
California Ambulance Association are in opposition. EMSACC contends that this
important work has not been completed and recommends that AB 210 be made a twoyear bill.
Arguments in opposition
The California Ambulance Association (CAA) states that the Authority is hosting a task
force which is developing regulations on the very issues AB 210 addresses, and it is
critical that this work be allowed to continue and be completed before additional
statutory changes to the EMS act are made. CAA contends that the best approach is to
defer statutory changes and allow the regulatory process to continue.
The county of Tulare states that AB 210 changes EMS systems in every county even
though there have been problems in only a few jurisdictions. The county of Tulare
contends that AB 210 attempts to overturn longstanding legal precedent which currently
provides clarity and consistency to the EMS planning process in counties. The county of
Tulare adds that this bill unnecessarily removes Section 201 and re-creates it in another
form, inviting more legal challenges to counties.
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PRIOR ACTIONS
Assembly Health:
Assembly Appropriations:
Assembly Floor:
14 – 5
12 – 5
53 – 20
COMMENTS
1. Suggested technical amendments:
On page 5, line 36, amend as follows:
(EMS) since June 1, 1980, shall continue to have continuing authorization to
On page 5, line 38, amend as follows:
of prehospital EMS that is it has continuously provided during that
On page 6, line 35, amend as follows:
or contracted for, a specific category of prehospital EMS since June 1,
On page 7, line 5, amend as follows:
shall only include only one or more of the following:
POSITIONS
Support:
California Professional Firefighters (co-sponsor)
American Federation of State, County and Municipal Employees
California Senior Legislature
Santa Ana Firemen’s Benevolent Association
Concern:
Emergency Medical Services Administrator’s Association of California
(co-sponsor)
Oppose:
American Medical Response
California Ambulance Association
San Joaquin County Board of Supervisors
Tulare County Board of Supervisors
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