BILL ANALYSIS Ó AB 521 Page 1 GOVERNOR'S VETO AB 521 (Nazarian) As Enrolled September 16, 2015 2/3 vote -------------------------------------------------------------------- |ASSEMBLY: | | (June 4, |SENATE: |27-11 | (September 10, | | |51-21 |2015) | | |2015) | | | | | | | | | | | | | | | -------------------------------------------------------------------- -------------------------------------------------------------------- |ASSEMBLY: | |(September 11, | | | | | |53-20 |2015) | | | | | | | | | | | | | | | | | | -------------------------------------------------------------------- Original Committee Reference: HEALTH SUMMARY: Requires a patient who has been admitted as an inpatient to a hospital through the emergency department (ED) and has blood drawn after being admitted to the hospital, and who has consented, to be offered an human immunodeficiency virus (HIV) test. AB 521 Page 2 The Senate amendments: 1)Specify the provisions of this bill only apply if the patient is admitted to the hospital through the ED. 2)Clarify that the HIV test can be offered at any time during admission. 3)Prohibit the ED from being held responsible for offering an HIV test. 4)Specify the provisions of this bill do not prohibit a patient's health plan from applying any patient share of cost or other limitation that is allowed by law and included in the patient's health plan. EXISTING LAW: Requires each patient who has blood drawn in a primary care clinic, and who has consented to an HIV test, to be offered an HIV test. Requires the test to conform with the United States Preventative Services (USPS) Task Force recommendation. Exempts from the requirement of testing, if the patient was tested, or offered testing and declined, within the last 12 months. Requires subsequent testing to be consistent with the most recent guidelines of the USPS Task Force. FISCAL EFFECT: According to the Senate Appropriations Committee: 1)By requiring hospitals to offer additional HIV testing to patients, this bill will increase the number of tests provided and the number of previously undiagnosed individuals who will AB 521 Page 3 be diagnosed with HIV, typically leading to treatment. The number of additional tests provided and the number of previously undiagnosed cases of HIV discovered through those tests is subject to uncertainty. Based on information developed by the Office of Statewide Planning and Development, there are about 11.6 million ED patient encounters per year, of which about 160,000 lead to an inpatient admission at a hospital. If 50% of those admissions lead to an HIV test and the population accepting the test has roughly the same rate of undiagnosed HIV as the overall state population, there would be about 60 newly diagnosed cases of HIV identified under the bill per year. This would result in the following state costs: a) About $300,000 per year for additional HIV testing (including follow up testing for positive test results) by the Medi-Cal program (General Fund (GF) and federal funds). b) About $300,000 per year to provide medical care Medi-Cal enrollees newly diagnosed with HIV (GF and federal funds). c) About $200,000 per year to provide medical care to new Aids Drug Assistance Program enrollees (federal funds and drug rebate funds). 2)Unknown long-term cost savings to Medi-Cal due to earlier medical intervention for HIV-positive Medi-Cal enrollees. To the extent that HIV-positive Medi-Cal enrollees are diagnosed earlier and begin treatment earlier, it is likely that the long-term health status of those individuals will improve and some of the health effects of HIV will be delayed or avoided. There are indications that untreated HIV causes long-term health impacts such as elevated risk of diabetes and heart disease, even before the effects of compromised immune system function associated with HIV infection become evident. AB 521 Page 4 Earlier diagnosis and treatment for HIV-positive individuals may to reduce long-term Medi-Cal expenditures for those individuals. However, to some unknown extent the improvement in health status and reduction in health care needs will be offset by longer lifespans, potentially offsetting cost savings. 3)Unknown cost savings due to reduced HIV infections in the state, including amongst Medi-Cal beneficiaries. There are academic findings that diagnosis of HIV significantly reduces the likelihood that an HIV positive individual will infect others. This is due both to a reduction in risky behavior by those aware of their HIV positive status and reductions in viral loads in the blood due to antiretroviral treatments. To the extent that this bill results in new diagnoses of HIV and that newly diagnosed individuals are able to access appropriate medical care, this bill is likely to prevent future HIV infections. COMMENTS: 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. Until the Patient Protection and Affordable Care Act has been fully implemented, EDs will continue to play a critical role in delivering primary care services to many new enrollees and the uninsured. Given that there are more than 5,000 new HIV infections in California every year, this bill will bridge the gap in lack of HIV testing by requiring EDs to uniformly provide HIV testing. According to the sponsor, the acquired immune deficiency syndrome (AIDS) Healthcare Foundation (AHF), this bill simply requires the offer of an HIV test in an ED if blood is already being drawn for another purpose. AHF writes that they recognize that EDs are constantly under pressure to meet the immediate AB 521 Page 5 needs of their patients. AHF concludes, this bill seeks to balance the public health demands of controlling this epidemic with the operational needs of an ED. AHF points at the Emergency Room as the last remaining major source for the identification of new people with HIV. In opposition, the California Chapter of the American College of Emergency Physicians (Cal/ACEP) argues that while this bill may appear to be an easy and efficient way to increase HIV diagnosis and treatment, it is unfortunately extremely problematic. Although fewer than 5% of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of acute care visits by the uninsured. Diagnosing and treating HIV is an important public health endeavor, but EDs are not the proper venue for a diagnostic public health campaign. According to Cal/ACEP, this bill would place additional stress on California's overcrowded and burdened EDs, while diverting precious time away from patients with critical conditions toward public health screening. GOVERNOR'S VETO MESSAGE: This bill would mandate hospitals to offer an HIV test to consenting patients who have blood drawn after being admitted through the emergency department. This bill is not the best approach to identifying those who are undiagnosed with HIV. The demographics of patients targeted by this bill do not match the demographics of the population at risk for exposure to HIV infection. In addition, hospitals are not appropriately staffed nor are they the place to provide counseling, routine preventive screenings, or follow-up care for sensitive HIV testing. Limited resources would be better spent supporting outreach and education activities by existing providers which have the staff and training for HIV testing and AB 521 Page 6 follow-up care. Analysis Prepared by: Patty Rodgers / HEALTH / (916) 319-2097 FN: 0002488