BILL ANALYSIS Senate Appropriations Committee Fiscal Summary Senator Christine Kehoe, Chair 354 (Arambula) Hearing Date: 8/12/2010 Amended: 6/23/2009 Consultant: Katie Johnson Policy Vote: Health 9-0 _________________________________________________________________ ____ BILL SUMMARY: AB 354 would delete certain age limits for specified childhood immunizations required for admission to schools. _________________________________________________________________ ____ Fiscal Impact (in thousands) Major Provisions 2010-11 2011-12 2012-13 Fund Medi-Cal vaccination likely $0 $300 - $875 $300 - $875 General/* administrative fee Federal School reimbursement likely $0 up to $400up to $400 General** for vaccine confirmation Potential increased ADA likely $0 $50 - $550$50 - $550 General** *Costs would be shared 50 percent General Fund and 50 percent federal funds. **Counts toward Proposition 98 guarantee *** Since potential costs to this bill would occur only if CDPH made a decision to promulgate regulations to update its immunization requirements, the fiscal years in which potential costs and savings would occur are unknown and would depend on when CDPH regulations went into effect. _________________________________________________________________ ____ STAFF COMMENTS: SUSPENSE FILE. AS PROPOSED TO BE AMENDED. Existing law prohibits a school from admitting any person as a pupil unless he or she has been fully immunized, as specified. Some of the diseases need not be documented based on the age of the child. This bill would delete those specified age restrictions in statute. The changes would be as follows. Currently, school districts need not document: 1) Haemophilus influenzae type b for children over 4 years and 6 months of age, 2) Mumps for children over seven years of age, 3) Pertussis (whooping cough) for children over seven years of age, and, 4) Hepatitis B for all children above the kindergarten level. The California Department of Public Health (CDPH) uses both statute and regulation to define "fully immunized." Although this bill would eliminate age restrictions in statute, they would continue to exist in regulation. The deletions of the age restrictions in this bill would permit CDPH to modify the existing immunization requirements via regulations for those diseases that were age restricted. Without this bill, CDPH would not be able to administratively promulgate regulations to update the requirements in regulation. With Page 2 AB 354 (Arambula) the passage of this bill, CDPH could make an administrative decision to update its regulations to align them with the Centers for Disease Control and Prevention (CDC) recommendations for childhood vaccinations. The existing immunization requirements in regulation generally follow the vaccine schedule recommended by the CDC. Of the diseases with age restrictions listed above, pertussis is the only disease for which the CDC recommends a vaccine that CDPH is currently restricted by statute from adding to its regulations. The CDC recommends that a child aged 11 or 12 years receive a pertussis booster shot, also known as Tdap, a vaccine for tetanus, diphtheria, and acellular pertussis. Additionally, CDPH regulations currently recommend, but do not require, that children entering 7th grade receive a Td shot, a vaccine against tetanus and diphtheria. The CDC now recommends Tdap in lieu of Td. According to a June 23, 2010, CDPH press release that urges the population to get vaccinated for pertussis, pertussis infections affect the population in cycles that peak every two to five years. The last peak in California was in 2005 with 3,182 cases reported and seven deaths. As of June 15 of this year, 910 cases have been reported and five infants have died. The CDPH website advises Californians that children need 5 doses of DTaP vaccine by kindergarten (ages 4-6) and one dose of Tdap booster by age 11 or 12. It also recommends Tdap for teens and adults up to age 65. Since this bill is not specific to pertussis, it would also give CDPH flexibility to be able to update its regulations in the future to conform with any updated CDC recommendations with regard to those diseases specified in statute. This bill would also update the names of the entities whose guidelines CDPH is required to consider when deeming vaccines for additional diseases appropriate for requirement and would add the American Academy of Family Physicians to that list. Medi-Cal Potential Costs and Savings If CDPH made an administrative decision to update its regulations to require all 7th graders to have received a pertussis booster shot prior to entering school, there would be costs to the Medi-Cal program, which pays a $9 administrative fee to physicians who administer vaccines to Medi-Cal beneficiaries. All other costs related to vaccines for Medi-Cal beneficiaries under age 19 are paid for by the federally-funded Vaccines for Children program. Based on 2006 Medi-Cal counts, 188,379 children were 11 years old. Also, according to January 2009 Medi-Cal population data, an average of approximately 140,000 were in each age year for children aged 11 - 18. According to a 2008 National Immunization Survey of 13 - 17 year old immunization rates, approximately 43.7 percent of California adolescents had received the Tdap vaccine and 71.3 percent had received either the Td or Tdap vaccine. To achieve a benefit to the population where there are enough people vaccinated against pertussis to where their immunization would protect those people Page 3 AB 354 (Arambula) who were not immunized, referred to as "herd immunity", approximately 90 - 95 percent of the population must be vaccinated against pertussis. Assuming 1) there were 140,000 - 190,000 7th grade Medi-Cal beneficiaries in any given year, 2) that 43.7 percent of them would have been vaccinated with Tdap without this bill, and 3) a goal to immunize 95 percent of the population, costs to vaccinate 51.3 percent of Medi-Cal 7th graders would be approximately $645,000 - $875,000 in total funds, or $325,000 - $440,000 in General Funds and $325,000 - $440,000 in federal funds. As mentioned above, 71.3 percent of California adolescents had received either Td or Tdap in 2008. The CDC now recommends Tdap in lieu of Td. For those children who would receive the recommended Td vaccination prior to 7th grade, costs would be neutral, essentially an exchange of a shot for a shot. Assuming 1) there were 140,000 - 190,000 7th grade Medi-Cal beneficiaries in any given year, 2) that 71.3 percent of them would have been vaccinated either with Td or Tdap without this bill, 3) that those who would have received Td would now receive Tdap upon the passage of this bill, and 4) a goal to immunize 95 percent of the population, costs to vaccinate 23.7 percent of Medi-Cal 7th graders would be approximately $300,000 - $405,000 in total funds, or $150,000 - $200,000 in General Funds and $150,000 - $200,000 in federal funds. In addition to the predictions above, it is also possible that a Medi-Cal beneficiary may have received a Tdap booster shot, but does not appear in Medi-Cal claims data. For example, county health departments and clinics often offer free vaccines to the public. If Medi-Cal beneficiaries received the vaccine through a means other than a Medi-Cal physician, costs to the program could be less than estimated above. If CDPH chose to require Tdap upon admission to 7th grade and promulgated the regulation to require the whole cohort of adolescents aged 11-18 in Medi-Cal to receive a catch-up Tdap shot in order to attend school in the fall of the fiscal year in which CDPH adopted the regulation, there could be a significant one-time cost to Medi-Cal in an amount up to 6 times that predicted for a single cohort of 7th graders. However, the potential of savings would increase since inoculating all adolescent Medi-Cal beneficiaries could significantly decrease the risk that Medi-Cal would need to treat pertussis in the future for this population. There could be unknown, potentially significant future Medi-Cal savings to the extent that this immunization requirement led to decreased incidences of disease, diagnosis, treatment, hospitalization, and death of Medi-Cal beneficiaries. School Potential Costs In 2000, the Commission on State Mandates approved reimbursement for schools that were required to check that 7th graders had received their Hepatitis B vaccination. Reimbursement was approved at approximately $4.42 per dose for 2008-2009. Costs could be similar for requiring that schools check for pertussis vaccination prior to 7th grade entrance. However, the Hepatitis B vaccination is given in 3 doses; Tdap is only Page 4 AB 354 (Arambula) one. Therefore, staff estimates that it is reasonable to assume that schools could be reimbursed at about $1.47 per dose. In a February 2010 report by the Legislative Analyst's Office on reforming state reimbursement of K-14 school mandates that discussed the funding, modification, and elimination of the mandates, it was recommended that the state fund school immunization mandates, including the 7th grade check for Hepatitis B. According to the California Department of Education's website, there were about 480,000 7th graders in California in 2008-2009. If CDPH were to require schools to check and document for an additional vaccine upon entrance to 7th grade, such as the pertussis booster, at $1.47 - $4.42 per dose, it could cost approximately $706,000 - $2.1 million annually. Additionally, if CDPH were to require schools to not only annually check 7th graders for pertussis immunization, but were to also require them to check and document pertussis immunization for all of California's estimated 2.5 million children in 8th - 12th grades to ensure as many children were immunized as possible, it could cost approximately $3.7 million - $11.1 million one-time. Ongoing, annual costs would only be the 7th grade cost. The Commission on State Mandates could determine that this would be a reimbursable mandate. Additionally, to the extent that this bill would prevent children from missing days of school due to illness, the state could incur costs of approximately $33 per student per day. The incidence of pertussis varies from year to year and from state to state. The following estimate is based of a range of 10 to 130 in 100,000 students. If 10 in 100,000 students were to no longer miss an average of 5.5 days, as reported by Massachusetts, of school annually for pertussis, the state could need to pay school districts an additional $50,000 in average daily attendance (ADA) annually. If 130 in 100,000 students were to no longer miss an average of 5.5 days of school annually for pertussis, the state could need to pay school districts an additional $550,000 in average daily attendance (ADA) annually. The proposed author's amendments would, commencing July 1, 2011, delete the requirement that schools check that all 7th graders have been immunized against Hepatitis B. They would also require that schools check that all 7th graders have been immunized against pertussis. In FY 2007-2008, 517 of 1084 school districts submitted claims for the Hepatitis B immunization verification at a cost of $1.7 million. Staff estimates that the pertussis 7th grade verification could be $706,000 - $2.1 million annually. Exchanging one mandate for another could significantly reduce the costs of the school mandate portion of this bill. Additionally, there could be potential savings to the state to the extent that an increase in the number of Californians fully vaccinated against pertussis would prevent cases of pertussis for which Medi-Cal pays claims. In 2009, 658 fee-for-service Medi-Cal beneficiaries received treatment for pertussis at a cost of $1.7 million total funds. 89 percent of those cases were diagnosed in individuals aged 0-20 years of age and they accounted for the majority of the claims costs. In 2010, as of 7/27/2010, 2,174 cases of pertussis have been reported in the state. This number is 6 times that during the same period in 2009. If one were to assume that Medi-Cal claims for fee-for-service beneficiaries in 2010 would be 6 times that in 2009, total costs would be $10.2 million.