BILL ANALYSIS
SB 161
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Date of Hearing: August 19, 2009
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Kevin De Leon, Chair
SB 161 (Wright) - As Amended: August 17, 2009
Policy Committee: HealthVote:13-6
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill requires health plans and insurers who provide
coverage for cancer chemotherapy treatment to provide coverage
for prescribed orally administered chemotherapy. In order to
comply with the requirements of this bill, health plans and
insurers are prohibited from imposing cost sharing for oral
chemotherapy medications to any greater extent than other
medications. Health coverage administered by CalPERS is excluded
from the requirements of this bill.
FISCAL EFFECT
1)According to the California Health Benefits Review Program
(CHBRP), no fiscal impact to Medi-Cal or the Healthy Families
Program. Amendments adopted since the initial CHBRP analysis
remove CalPERS coverage and costs identified in an earlier
version of this bill.
2)Increased premium costs in the employer-based and individual
insurance markets of $18 million, largely offset by a
reduction in out-of-pocket costs paid under current law by
individuals for oral chemotherapy treatments that are not a
covered benefit or with less favorable cost sharing
requirements.
3)According to CHRBP, 100% of Californians with health insurance
have some coverage for inpatient anticancer medications and
some outpatient coverage for intravenous (IV) and injected
cancer medications. In addition, 98% of Californians with
health insurance have coverage for some outpatient oral
chemotherapy. Therefore, the main group of patients, almost
500,000 statewide, who reap the greatest benefit from this
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legislation are those either with no coverage for medications
generally or no coverage for oral chemotherapy, specifically.
COMMENTS
1)Rationale . This bill is co-sponsored by the American Cancer
Society and Carrie's Touch, a Sacramento non-profit addressing
issues of concern to African American breast cancer survivors.
Three of the most commonly prescribed oral chemotherapy
medications are used to treat breast cancer. Recent amendments
address a concern discussed in the Assembly Health Committee
with regard to the cost sharing language and unintended
consequences that may emerge. According to the author and
sponsors, the recent emergence of a number of effective orally
administered chemotherapy medications increases treatment
options for patients. This means patients are able to take
chemotherapy in the form of capsules or tablets at home,
rather than requiring injections or IV administration of
treatment that may be painful, time-consuming, inconvenient,
or may increase the risk of infection. This bill attempts to
reduce and eliminate barriers patients may face in acquiring
coverage for oral chemotherapy by requiring health insurance
to provide coverage in a favorable cost sharing arrangement
relative to other medications.
2)Recent Amendments clarify "A health care service plan contract
shall not provide for an increase in enrollee cost sharing for
cancer patients to any greater extent than the contract
provides for an increase in enrollee cost sharing for other
covered medications."
3)Background . There are three main ways to treat cancer:
surgery, radiotherapy, and chemotherapy. Chemotherapy is often
utilized for patients with more advanced cancers. The type of
chemotherapy used depends on the type of cancer, the state of
the disease and various patient-specific considerations. Aside
from oral chemotherapy, anticancer medications are
administered either intravenously through a vein or injected
into a muscle. Although a few medications are available in
more than one format, most cancer drugs are only administered
by one route.
4)Industry Cost Concerns . Opponents of this bill indicate
legislatively mandated health benefits increase costs and
limit insurer, employer, and individual choices with respect
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to a variety of health benefits. Opponents indicate health
mandates can hinder compliance with evidence-based medical
standards that reflect new medical technology or other
advances in knowledge. When considered together, mandates may
also hinder the ability of insurers and employers to offer a
wide range of affordable products to consumers with a variety
of health care needs. Specific concerns about this mandate
include increased administrative costs and the bill's
disregard for health plan processes for placing drugs on their
respective formularies.
5)Related Legislation . There are more than two dozen current law
health mandates, established over the last two decades, to
provide coverage for specified services such as cancer
screenings and treatment. There are another handful of
mandates to offer coverage for a number of other health
services. Several current law mandates address both cancer
treatment and prescription drug coverage.
6)Other Health Mandates in the Current Session . There are nine
health mandates under legislative consideration this year,
including SB 161. Other proposed health mandates include:
a) SB 630 (Steinberg): cleft palate coverage- also being
heard in this committee today
b) AB 56 (Portantino): mammography notification- pending in
the Senate
c) AB 98 (De La Torre): maternity coverage- pending in the
Senate
d) AB 163 (Emmerson): amino acid-based elemental formulas-
held on the Suspense File of this Committee
e) AB 214 (Chesbro): durable medical equipment coverage-
held on the Suspense File of this Committee
f) AB 244 (Beall): mental health parity- pending in the
Senate
g) AB 259 (Skinner): access to nurse midwives- pending in
the Assembly Health Committee
h) AB 513 (De Leon): lactation consultant coverage- pending
in the Senate
Two other bills address specification of current law mandates
with respect to minimum coverage or loosening of current law
mandates. These two bills are:
a) AB 786 (Jones): standardization of individual market
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products- pending in the Senate
b) SB 92 (Aanestad): out-of-state carrier coverage- failed
passage in the Senate Health Committee.
Analysis Prepared by : Mary Ader / APPR. / (916) 319-2081