BILL ANALYSIS                                                                                                                                                                                                    

                                                                     AB 521

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          Date of Hearing:  May 6, 2015


                                 Jimmy Gomez, Chair

          521 (Nazarian) - As Amended April 23, 2015

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          Urgency:  No  State Mandated Local Program:  NoReimbursable:  No


          This bill applies existing human immunodeficiency virus (HIV)  
          testing requirements for primary care clinics to hospital  
          emergency departments (EDs), requiring most patients seeking  
          emergency care in an ED to be offered an HIV test any time blood  


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          is drawn.

          FISCAL EFFECT: 

          The California Department of Public Health reports nearly 20,000  
          individuals in California are infected with HIV and don't know  
          it. It is unknown how many HIV-positive individuals would be  
          identified through these new testing requirements. Assuming this  
          ED testing mandate identifies1,500 individuals eligible for  
          treatment through state programs, including Medi-Cal and ADAP,  
          and that 65% of those are linked to care, state costs as  

          1)Potential Medi-Cal costs (in fee-for service Medi-Cal) or cost  
            pressure (in managed care) of $4.5 million (GF/federal) for  
            increased testing.

          2)$6.5 million annually (GF/federal) to Medi-Cal for increased  
            HIV/AIDS treatment costs.

          3)$2.5 million annually (potential GF/federal) to the AIDS Drug  
            Assistance Program (ADAP) and the Office of AIDS Health  
            Insurance Premium Program (OA/HIPP) for increased HIV/AIDS  
            treatment costs, on a net basis.  Actual expenditures would be  
            higher, but approximately 70% of ADAP expenditures return to  
            the state in the form of rebate revenues.  This estimate is  
            net of rebate revenue funds.  As the availability of  
            additional federal funds made available to the state through  
            the state's current Medi-Cal Section 1115 waiver, and because  
            the amount of federal funds for these purposes are capped, it  
            is likely that at least a portion of any additional increased  
            ADAP costs would be borne by the GF. 


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          4)Costs are potentially offset by unknown long-term state cost  
            avoidance by identifying HIV infection and beginning treatment  
            earlier before significant medical complications arise, and by  
            potentially preventing additional transmission.  Currently,  
            about 5,000 people are newly diagnosed with HIV in California  
            every year.  


          1)Purpose. According to the author, California has led the way  
            in identifying people living with HIV and linking them with  
            care and treatment.  For example, AB 446 (Mitchell), Chapter  
            589, Statues of 2013, requires public health clinics to offer  
            an HIV test.  The author states EDs continue to play a  
            critical role in delivering primary care services to many  
            individuals, and this bill will bridge the gap in lack of HIV  
            testing by requiring EDs to uniformly provide HIV testing.

          2)Background. HIV destroys cells that are crucial to the normal  
            function of the human immune system. Although a person  
            infected with HIV may not show symptoms until several years  
            later, the virus is active in the body and, if untreated, the  
            HIV disease will progress to AIDS. An AIDS diagnosis is made  
            when the count of CD4+, or T cells, falls below a certain  
            level or when the person has a history of infections commonly  
            associated with AIDS.  HIV/AIDS can be treated with a complex  
            regimen of antiretroviral medications. Although fewer people  
            are dying from AIDS, the total number of HIV cases in  
            California is still increasing every year because of new  
            diagnoses, and because the mortality rate from AIDS has  
            declined dramatically. 

          3)HIV Testing. Identifying those with HIV and linking them to  
            treatment can allow them to live a normal life span, and also  
            prevent the spread of the virus by suppressing their viral  


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            load.  However, many HIV-positive people have not achieved  
            viral suppression because many people do not know their  
            status, and because some who do are not in care. Despite  
            recommendations for universal testing, identifying those who  
            are HIV-positive and do not know it has proven challenging.   
            The challenges and opportunities of providing HIV testing in  
            emergency departments have been well-documented in the public  
            health literature.  On one hand, testing is fairly efficient  
            with high prevalence rates. Models for such testing appear to  
            be public health department-driven, such as local  
            collaborations with EDs where public health departments  
            provide either direct funding or staffing to provide testing  
            services within EDs, or provide technical assistance,  
            training, free test kits, or other related services.  

          4)Opposition. The California Hospital Association, California  
            Medical Association, and emergency department doctors oppose  
            this bill as an unfunded mandate on EDs and doctors, whose  
            primary mission is to stabilize patients with emergent  
            conditions, to conduct a widespread and ongoing public health  
            diagnostic screening campaign. 

          5)Related Legislation. AB 383 (Gipson), pending in this  
            committee, requires primary care clinics to screen for  
            Hepatitis C.  

          6)Previous Legislation. 

             a)   AB 446 required primary care clinics to offer an HIV  
               test when taking a blood draw.

             b)   AB 1894 (Krekorian), Chapter 631, Statutes of 2008,  
               requires health care service plans and disability insurers  
               selling health insurance to offer testing for HIV  
               antibodies and AIDS, regardless of whether the testing is  


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               related to a primary diagnosis.

          Analysis Prepared by:Lisa Murawski / APPR. / (916)