BILL ANALYSIS Ó
AB 521
Page 1
GOVERNOR'S VETO
AB
521 (Nazarian)
As Enrolled September 16, 2015
2/3 vote
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|ASSEMBLY: | | (June 4, |SENATE: |27-11 | (September 10, |
| |51-21 |2015) | | |2015) |
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|ASSEMBLY: | |(September 11, | | | |
| |53-20 |2015) | | | |
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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
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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
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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.
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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
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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
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follow-up care.
Analysis Prepared by:
Patty Rodgers / HEALTH / (916) 319-2097 FN:
0002488