BILL ANALYSIS                                                                                                                                                                                                    



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          Date of Hearing:  September 4, 2015


                            ASSEMBLY COMMITTEE ON FINANCE


                                Shirley Weber, Chair


          ABX2 15  
          (Eggman) - As Amended September 3, 2015


          SUBJECT:  End of life.


          SUMMARY:  Enacts the End of Life Option Act allowing an adult  
          diagnosed with a terminal disease, and with the capacity to make  
          medical decisions, to receive a prescription for an aid-in-dying  
          drug to end his or her life in a humane and dignified manner.    
          Specifically, this bill (among many additional provisions):  


          1)Defines a qualified individual as an adult who has the  
            capacity to make medical decisions, is a resident of  
            California, and has satisfied all of the requirements of these  
            provisions in order to obtain a prescription for a drug to end  
            his or her life.


          2)Requires an individual requesting an aid-in-dying drug to have  
            done so voluntarily.


          3)Allows a request for a prescription for an aid-in-dying drug  
            to be made only by the individual diagnosed with the terminal  
            disease, not by others on behalf of the individual, including  
            prohibiting requests through a power of attorney, an advance  
            health care directive, a conservator, health care agent,  








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            surrogate, or any other legally recognized health care  
            decision maker.


          4)Specifies that a person will not be qualified to obtain an  
            aid-in-dying drug solely because of age or disability.


          5)Requires an individual requesting a prescription for an  
            aid-in-dying drug to submit two oral requests, a minimum of 15  
            days apart, and a written request, and for the attending  
            physician to personally receive all three requests.  Requires  
            written requests to be signed and dated by the individual in  
            the presence of two witnesses who must attest to the best of  
            their knowledge and belief that the individual is personally  
            known to them or has provided proof of identity, is of sound  
            mind, and not under duress, fraud, or undue influence.


          6)Prohibits the attending physician, consulting physician, or  
            the mental health specialist of the requesting individual from  
            being a witness on the written request.


          7)Allows only one of the witnesses to be related to the  
            individual by blood, marriage, registered domestic  
            partnership, or adoption or be entitled to a portion of the  
            individual's estate upon death, and only one of the witnesses  
            to own, operate, or be employed at a health care facility  
            where the individual is receiving medical treatment or  
            resides.


          8)Specifies that at any time an individual may withdraw or  
            rescind his or her request for an aid-in-dying drug, or decide  
            not to ingest an aid-in-dying drug, without regard to their  
            mental state.










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          9)Prohibits an attending physician from writing a prescription  
            for an aid-in-dying drug without first personally offering the  
            individual an opportunity to withdraw or rescind the request. 


                                          


          EXISTING LAW:  Requires a health care provider, who makes a  
          diagnosis that a patient has a terminal illness, to notify the  
          patient of his or her right to comprehensive information, as  
          specified, and counseling regarding legal end-of-life options.  
          Requires a health care provider who does not wish to provide the  
          specified information to refer or transfer a patient to another  
          health care provider who will provide this information.


          FISCAL EFFECT:  


          Department of Health Care Services


          Potential minor costs and savings in Medi-Cal based on the  
          Medi-Cal program choosing to cover this end-of-life option  
          (General Fund (GF)).





          Department of Public Health


          The Department of Public Health (DPH) would incur one-time GF  
          costs of $90,000 for information technology services, and  
          ongoing GF costs in the range of $250,000. 

          DPH anticipates that a secure drive with password protection  








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          would be needed to store the confidential data collected  
          pursuant to this bill, and would require an SQL database to  
          perform data collection and storage.  DPH states that a database  
          could be developed with one-time development costs of  
          approximately $88,000, and ongoing yearly maintenance by  
          Information Technology Services Division (ITSD) of approximately  
          $10,000 per year, as shown in the chart below.
            
           


            ---------------------------------------------------------------- 
           |Database Development Task                |Hours    |Cost        |
           |-----------------------------------------+---------+------------|
           |Application Development                  |         |            |
           |-----------------------------------------+---------+------------|
           |            Requirements Specifications |267      |$16,000     |
           |-----------------------------------------+---------+------------|
           |            Design/Test Plan            |133      |$8,000      |
           |-----------------------------------------+---------+------------|
           |            System Development / Code & |800      |$48,000     |
           |       Test                              |         |            |
           |-----------------------------------------+---------+------------|
           |            Acceptance Testing/User     |133      |$8,000      |
           |       Training                          |         |            |
           |-----------------------------------------+---------+------------|
           |            Initial Internet/SQL DBA    |133      |$8,000      |
           |       setup                             |         |            |
           |-----------------------------------------+---------+------------|
           |                                         |         |            |
           |-----------------------------------------+---------+------------|
           |Total One-Time Cost                      |1466     |$88,000     |
           |-----------------------------------------+---------+------------|
           |Ongoing yearly maintenance ($845 x 12)   |14/mo    |$10,140     |
            ---------------------------------------------------------------- 



          Additionally, once the database is established, DPH estimates  








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          that two full-time positions would be required to perform  
          confidential program and reporting duties outlined in this bill,  
          with duties including:  
                 Collect data, enter reports received, collect forms,  
               track program utilization and associated deaths;
                 Follow-up with providers that submit incomplete reports;
                 Perform data analysis, cross-check decedent deaths with  
               list of prescribed participants, and draft annual reports;
                 Prepare the annual report mandated by the bill;
                 Maintain program information on the public website, and  
               respond to inquiries regarding program policy; and
                 Update website as needed, and make reporting forms  
               available for download online.


































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           Summary of Total Cost to DPH
           
          


           ------------------------------------------------------------ 
          |     Total Budget Year Cost     |Total Cost Budget Year + 1 |
          |--------------------------------+---------------------------|
          |            $323,087            |$245,227                   |
          |                                |                           |
          |                                |                           |
          |                                |                           |
           ------------------------------------------------------------ 



          Department of Managed Health Care
          Due to the sensitive and controversial nature of aid-in-dying  
          medication, the Department of Managed Health Care (DMHC)  
          anticipates a high level of public interest, which will result  
          in Public Records Act (PRA) or Information Practices Act (IPA)  
          requests during the first three years.  The Office of Legal  
          Services (OLS) anticipates PRA/IPA requests regarding which  
          health plans that cover aid-in-dying medications and under what  
          terms the medications are covered, as well as information on  
          relevant policy decisions, enforcement policies, and consumer  
          grievances. OLS estimates that these tasks will have no cost in  
          the current fiscal year, $276,000 (Managed Care Fund (MCF)) and  
          2.0 positions in the 2015-16 fiscal year, and $244,000 MCF and  
          2.0 positions each in the 2016-17 and 2017-18 fiscal years.  OLS  
          does not anticipate ongoing costs after the 2017-18 fiscal year.

          The Help Center, Office of Administrative Services, Office of  
          Technology and Innovation, Office of Enforcement, Office of Plan  
          Licensing, Division of Plan Surveys, and Office of Financial  








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          Review anticipate absorbable workload that will have no  
          significant fiscal impact on those programs.

          Medical Board of California
          Minor costs to the Medical Board to update several of the forms  
          required by this bill as deemed necessary (Contingent Fund of  
          the Medical Board of California).

          Board of Pharmacy
          Minor costs to the Board of Pharmacy.  The Board would not need  
          to amend or adopt any regulations. The Board estimates that any  
          additional enforcement actions due to this bill would result in  
          minor costs (Pharmacy Fund).



          COMMENTS:  


          PURPOSE OF THIS BILL.  According to the author, this bill would  
          allow an adult in California with a terminal disease who has the  
          capacity to make medical decisions, and who has been given a  
          prognosis of less than six months to live, to make end of life  
          decisions.  The author states by giving these patients the legal  
          right to ask for and receive an aid-in-dying prescription from  
          his/her physician, this bill would provide one more option to  
          the number of options one has when faced with the end of their  
          life.  The author notes this bill includes strong provisions to  
          safeguard patients from coercion and to allow voluntary  
          participation by physicians, pharmacists, and health care  
          facilities, and that this medical practice is already recognized  
          in five other states.  The author contends there is substantial  
          evidence from those states that prove this law can be used  
          safely and effectively.  













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          BACKGROUND.  Five states have authorized what is referred to as  
          Death with Dignity, Aid-in-Dying or Assisted Suicide.  Oregon  
          and Washington enacted their legislation through voter  
          initiatives that took effect in 1997 and 2009, respectively.   
          Vermont enacted legislation in 2013.  In Montana and New Mexico,  
          the courts have effectively authorized doctors to engage in the  
          practice.  Belgium, the Netherlands, Luxembourg, and Switzerland  
          all allow for physician aid-in-dying, and next year Canada will  
          implement the practice as well.




          COST AND COVERAGE.  This bill does not mandate coverage of  
          the aid-in-dying medication.  Individual insurers will  
          determine whether or not to participate.  However, federal  
          funding cannot be used for services rendered under the End  
          of Life Options Act.  The Oregon Medicaid program, which is  
          paid for in part with federal funds, ensures that these  
          costs are covered only with state funds.  According to  
          Compassion & Choices (C&C), the current approximate cost of  
          the medication in Oregon is $1,500 per prescription.




          California's Medi-Cal program could choose to cover these  
          drugs for this purpose, using state-only funds. Staff notes  
          if Medi-Cal were to choose not to cover this but other  
          health insurers did, it could create unequal access to this  
          end-of-life option based on economic status.


          SUPPORT.  C&C supports this bill, stating it will improve the  
          quality of end-of-life care for terminally ill Californians and  
          their families, while protecting physicians who care for them.   
          C&C writes they want people to be free to choose how they live -  
          and when the time comes, how they die.  They contend that all  








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          Californians should have the option, in consultation with their  
          families and doctors, to make the end-of-life decisions that are  
          right for them in the final stages of a terminal illness.  



          Numerous other organizations support this bill because they  
          value autonomy in making fundamental life decisions.  These  
          organizations also applaud the many patient protections in the  
          bill, including provisions which make it a felony to coerce  
          someone to request an aid-in-dying prescription.
          OPPOSITION.  There is a broad coalition of opposition to this  
          bill, including, Disability Rights Education & Defense Fund  
          (DREDF), Silicon Valley Independent Living Center, and The ARC  
          California, who all state physician-assisted suicide is bad for  
          Californians, particularly those with low incomes who may lack  
          adequate access to health care, including mental health  
          services.  These organizations contend this bill will have a  
          devastating impact on the treatment of terminally ill and  
          disabled patients, stating that if assisted suicide is made  
          legal it quickly becomes just another treatment option, always  
          being the cheapest, and therefore, eventually the treatment of  
          choice.


          The Association of Northern California Oncologists states they  
          oppose this bill for several specific reasons-first, they note  
          it is contrary to a physician's oath and primary responsibility  
          to do no harm.  Secondly, legalizing physician-assisted suicide  
          undermines the valuable and overwhelmingly successful work of  
          their hospice and pain and palliative care colleagues.  Finally,  
          they state the legislation is based on a common misunderstanding  
          that it is easy to determine when a patient is terminal, noting  
          that despite a physician's prognosis, many patients outlive  
          terminal diagnoses.












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          Opponents to this bill also make the following arguments:


                 This option could be used as a form of elder abuse by an  
               heir or abusive caregiver who stands to gain economically  
               or otherwise by the hastened death of the patient,  
               particularly in the absence of a required witness to the  
               death.


                 Coercion and inappropriate approval of this option could  
               occur, and has in Oregon (according to the opposition), by  
               way of: "doctor shopping," ignoring histories of  
               depression, psychiatric disabilities, dementia or other  
               developmental disabilities, and economic pressures of the  
               patient, relatives or caregivers.


                 Legalizing suicide, even for a narrow set of  
               circumstances, can have a contagious effect, sending the  
               message to the general public that suicide is justified and  
               appropriate in certain situations, thereby leading to  
               increasing rates of suicide in the general population.  
               Opponents cite evidence of a substantial increase in the  
               suicide rate in Oregon in the general population since  
               passage of the assisted suicide law in that state.


                 Opponents state that the data from Oregon is woefully  
               inadequate and do not prove the safety of this law in that  
               state. Specifically, the Disability Rights Education and  
               Defense Fund states that available data is quite minimal  
               and there is no oversight, investigation of abuse,  
               enforcement, penalties for non-compliance, nor monitoring.












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          REGISTERED SUPPORT / OPPOSITION:




          Support


          AIDS Healthcare Foundation


          The American Nurses Association 


          California Church IMPACT


          California Psychological Association


          Cardinal Point at Mariner Square Residents' Association


          The City of Cathedral City


          The City of Santa Barbara 


          The City of Santa Cruz


          The Community Church of California City


          Compassion & Choices CA










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          County of Santa Cruz Board of Supervisors 


          Death with Dignity National Center


          Democratic Women of Monterey County 


          Democratic Women of Santa Barbra 


          Equality California


          Five Counties Council Labor Council


          Full Circle Living and Dying Collective, Western Nevada County,  
          CA


          GLMA Health Professionals Advancing LGBT Equality


          Gray Panthers


          The Humboldt and Del Notre Counties Central Labor Commission


          The Libertarian Party of Orange County  


          Los Angeles LGBT Center


          The Mar Vista Community Council









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          The National Association of Social Workers, California Chapter  
          (NASW-CA)


          The National Center for Lesbian Rights


          The National Council of Jewish Women 


          People of Faith for Justice


          Potrero Hill Democratic Club


          Progressive Christians Uniting


          San Benito County Democratic Central Committee


          San Francisco AIDS Foundation 


          San Mateo County Democracy for America 


          The San Mateo County Democratic Party


          Santa Barbara County  Board of Supervisors  


          Sacramento Central Labor Council AFL-CIO


          Seal Beach Leisure World Democratic Club








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          The Sierra County Democratic Central Committee


          Shasta County Citizens for Democracy


          The South Orange County Democratic Club


          The Tehachapi Mountain Democratic Club


          The Unitarian Universalist Church of the Desert


          The Unitarian Universalist Church of the Verdugo Hills


          Ventura County Board of Supervisors 


          Visalia Democratic Club


          West Hollywood United Church of Christ




          Opposition


          Alliance of Catholic Health Care


          American Disabled For Attendant Programs









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          Association of Northern California Oncologists


          Autistic Self Advocacy Network


          California Disability Alliance


          California Foundation for Independent Living Centers


          Disability Rights California


          Disability Rights Education & Defense Fund


          Not Dead Yet


          Silicon Valley Independent Living Center


          United African American Ministerial Action Council


          Several Physicians and Other Individuals




          Analysis Prepared by:Andrea Margolis / FINANCE /916-319-2099













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