BILL ANALYSIS                                                                                                                                                                                                    

                                                                     AB 521

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          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.


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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  

          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  

          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  

             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  

          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.


          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: