BILL ANALYSIS Ó
AB 572
Page 1
Date of Hearing: April 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Bonta, Chair
AB
572 (Beth Gaines) - As Amended April 8, 2015
SUBJECT: California Diabetes Program.
SUMMARY: Requires the California Department of Public Health
(DPH) to create a diabetes action plan for the state, and to
report the results of the plan to the legislature biennially.
Specifically, this bill:
1)Requires DPH to develop a detailed action plan for prevention
and treatment of diabetes in the state of California,
including at least:
a) Priorities and performance measures that are based upon
evidence-based strategies to prevent or control diabetes,
expected outcomes of the action steps proposed, and
establish benchmarks for prevention and control;
b) Analysis of the financial impact of all types of
diabetes on the state of California, as specified;
c) A summary of expenditures on programs and activities
aimed at preventing or controlling diabetes;
d) A summary of the amount and source for any funding
directed to the department for programs and activities
aimed controlling or preventing diabetes;
e) A description of the level of coordination existing
AB 572
Page 2
between state departments and entities on activities,
programmatic activities, and providing information to the
public regarding managing, treating, and preventing all
forms of diabetes and its complications;
f) The development of a detailed budget blueprint
identifying needs, costs, and resources required to
implement the plan, include a proposed budget for each
action step identified; and,
g) Policy recommendations for the prevention and treatment
of diabetes.
2)Specifies that in developing the plan, DPH may include
previously developed priorities or performance measures from
other relevant programs.
3)Requires DPH to report to the Legislature on an unspecified
date, and biennially thereafter, the status of the plan,
progress of plan objectives, and recommendations for future
improvements. Includes a sunset provision for the reporting
requirement, with an unspecified date.
4)Makes findings and declarations related to the fiscal impacts
of diabetes in California.
EXISTING LAW: Establishes DPH to protect and improve the health
of communities through education, promotion of healthy
lifestyles, and research for disease and injury prevention.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, diabetes has
reached epidemic levels in California. As of 2012, about one
AB 572
Page 3
in seven adult Californians have diabetes and many more will
be diagnosed in the near future, and is estimated to affect
one in three adults within the next 10 years. Some estimate
the yearly cost of diabetes in California to be over $24.5
billion. The author points out that California has no
statutory requirements in place for the prevention and
management of diabetes, and states that the State of
California has no action plan that specifically addresses the
fiscal impact of diabetes. Furthermore, the author asserts
that the state must create an action plan that provides policy
guidance and considers the escalating fiscal impact of
diabetes treatment and care.
2)BACKGROUND. Diabetes is a chronic medical condition marked by
high levels of blood glucose (a form of sugar) resulting from
defects in insulin production, insulin action, or both. Type
1 diabetes, previously known as juvenile diabetes, is an
autoimmune disease in which the body does not produce the
hormone insulin. There is no known way to prevent type 1
diabetes. Type 2 diabetes (previously called
non-insulin-dependent diabetes or adult-onset diabetes),
accounts for about 90% to 95% of all diagnosed cases of
diabetes. It usually begins as insulin resistance, a disorder
in which the cells do not use insulin properly. As the need
for insulin rises, the pancreas gradually loses its ability to
produce it. Gestational diabetes occurs in pregnant women who
have never had diabetes before but have higher than normal
blood glucose levels during pregnancy. Immediately after
pregnancy, 5% to 10% of women with gestational diabetes are
found to have diabetes, usually type 2. Women who have had
gestational diabetes have a 35% to 60% chance of developing
diabetes in the next 10-20 years. Prediabetes is a condition
in which individuals have blood glucose levels higher than
normal but not high enough to be classified as diabetes.
People with prediabetes have an increased risk of developing
type 2 diabetes, heart disease, and stroke. Without
intervention, about one out of four people with prediabetes
will develop diabetes within three to five years. Ethnic
minorities and those who are poor or disadvantaged have
especially high rates of diabetes. In 2010, one in seven
African American (14.3%), one in nine American Indian/Alaskan
Natives/Native Hawaiian/Other Pacific Islander (11.6 %), one
AB 572
Page 4
in 10 Latino (10.9%), one in 11 Asian American (7.7%), and one
in 14 white (7.0%) adults had diagnosed diabetes.
According to the California Diabetes Program (CDP), diabetes
costs in California exceed $24 billion each year. Total
health care and related costs for the treatment of diabetes in
California are about $24.5 billion. Direct medical costs
(e.g., hospitalizations, medical care, treatment, supplies)
account for about $18.7 billion, the other $5.8 billion
include indirect costs such as disability payments, time lost
from work, and premature death. The average annual treatment
cost per case for diagnosed diabetes in the U.S. was nearly
$10,000 in 2007.
There is no known cure for diabetes. Increased risk of heart
disease, stroke, and kidney damage (and the need for dialysis
as a result) are the most deadly effects. Uncontrolled high
blood sugars may also affect the eyes and cause blindness.
Diabetes frequently affects circulation, and a simple cut on
the foot can lead to an amputation due to infection.
Diabetics tend to experience longer hospitalizations and
mortality rates. California has an estimated 3.9 million
adults with diabetes (2010), and the numbers are rising
rapidly.
3)THE CALIFORNIA DIABETES PROGRAM. CDP was established in 1981
and represents a partnership between DPH and the University of
California, San Francisco. It primarily receives its funding
from the Centers for Disease Control and Prevention (CDC). A
few key objectives that CDP focuses on include:
a) Monitoring statewide diabetes health status and risk
factors;
b) Engaging in outreach to increase awareness about the
disease;
c) Guiding public policy to support at-risk and vulnerable
populations;
d) Offering leadership, guidance, and resources to
community health interventions;
e) Seeking to improve the health care delivery system; and,
f) Reducing diabetes-related health disparities.
AB 572
Page 5
CDP achieves these through partnering with different
individual, community, health care, policy, and environmental
entities. On July 1, 2013, a new CDC-funded program "State
Public Health Actions to Prevent and Control Diabetes, Heart
Disease, Obesity and Associated Risk Factors and Promote
School Health" began. Funding allocated to pre-diabetes and
diabetes decreased by $250,000. With this new grant, CDC
funding for California chronic disease prevention overall
decreased by $2.2 million. The new collaborative grant, known
as Prevention First, Advancing Synergy for Health, requires
coordination among programs that historically were
categorically funded and stand-alone programs. Prevention
First addresses individuals with pre-diabetes and diabetes.
4)THE CALIFORNIA WELLNESS PLAN. In February 2014, DPH Chronic
Disease Prevention Branch published the California Wellness
Plan (Plan), the result of a statewide process led by DPH to
develop a roadmap for DPH and partners to promote health and
eliminate preventable chronic disease in California. The plan
aligns with the Let's Get Healthy California Taskforce
priorities and includes 26 priorities and performance measures
developed in 2012 that are based upon evidence-based
strategies to prevent chronic disease and promote equity. The
Plan contains short, intermediate, and long-term objectives
with measurable effects on a variety of chronic diseases, of
which diabetes is a major focus. The plan contains 15
objectives specific to diabetes, including objectives to
increase utilization of diabetes prevention and
self-management programs, as well as broad objectives to
reduce the prevalence of obesity and diabetes among children
and adults. DPH's chronic disease programs plan to
collaborate with local and state partners, including the
Office of Health Equity, engaged in diabetes prevention to
implement the objectives. DPH intends to monitor the progress
of Plan objectives and publish regular reports on outcomes.
5)PROGRESS UPDATES AND PLAN REVISIONS. According to DPH, the
Chronic Disease Control Branch Chief ensures that, at a
minimum, the Plan is reviewed in conjunction with partners
every five years to assess the need for a new version. As
funding permits and partners agree, a process to create a new
version of the Plan will be developed and implemented,
AB 572
Page 6
overseen by the Director of Coordination. The process will
capture observations and recommendations based on lessons
learned from Plan implementation efforts and from which
updated priorities and evidence-based strategies can be
determined. The process will identify specific revisions,
assign them to responsible parties and establish targets dates
for completion. This review process will be consistent with
the CDC and Evaluation Program guidelines. Triggers for
reviewing the Plan sooner than the five year cycle include,
but are not limited to: a) major changes to DPH authority;
or, b) major changes in federal and/or state funding,
guidance, or requirements. Any future versions of the Plan
developed in conjunction with partners will also be available
to the public on the DPH Website."
DPH further states that a one-day statewide conference is
planned for 2017 for partners and programs to report on
progress or short term outcomes of goals of the plan. A
summary of conference reports will be posted online after the
conference.
6)DIABETES BURDEN REPORT. In September 2014 DPH published the
Burden of Diabetes in California, a report funded by a grant
from the CDC and Prevention. The brief report seeks to
describe the current burden of diabetes among adults in the
state, and to describe some of the current diabetes prevention
and control activities being implemented by DPH. The report
analyzed data from a variety of state sources, including the
California Health Interview Survey, the California Death
Statistical Master File, the Office of Statewide Health
Planning and Development Patient Discharge Data, and that
Department of Finance Population Data to assess the most
significant health risks associated with Diabetes. The report
also discusses a number of ongoing activities by DPH that
support the primary prevention of diabetes through the
promotion of health eating, increased physical activity,
tobacco cessation, and the prevention and control of
overweight and obesity. Secondary prevention activities focus
on evidence-based strategies to prevent or delay the onset of
complications among California's diagnosed with type 2
diabetes. DPH is establishing a statewide network of
evidence-based lifestyle change programs that are designed to
AB 572
Page 7
prevent the development of type 2 diabetes among people at
highest risk and prevent or delay the onset of complications
among people diagnosed with type 2 diabetes.
7)STATE AUDITORS REPORT. In January 2015, The California State
Auditor published report 2014-113, titled "Even With a Recent
Increase in Federal Funding, Its Efforts to Prevent Diabetes
Are Focused on a Limited Number of Counties." The report
highlighted the fact that DPH manages federal grants that fund
its diabetes prevention efforts. California does not provide
any state funding for diabetes prevention. DPH spending on
diabetes prevention has declined over time due to reductions
in its federal funding. In fiscal year 2013-14, its federal
funding for diabetes prevention decreased from more than $1
million in previous fiscal years to $817,000. Moreover, DPH's
maternal diabetes program also experienced significant
reductions in federal funding over the last three fiscal
years, declining from $1.2 million in fiscal year 2010-11 to
only $71,000 in fiscal year 2013-14. In fact, in fiscal year
2012-13-the most recent year for which nationwide data is
available-California had the lowest per capita funding for
diabetes prevention in the nation.
The Auditor's report also found that DPH spent its limited
federal funds in an appropriate manner and complied with
applicable grant requirements. For the 40 expenditures we
reviewed from fiscal years 2009-10 through 2013-14, DPH
expenditures were in accordance with federal requirements, and
the amounts spent were reasonable. Additionally, despite a
concern that was raised about the relationship between DPH
diabetes and tobacco control programs, DPH has not spent its
limited diabetes funds on tobacco cessation activities.
The recommendations of the report were that the state should
consider providing state funding to support efforts to address
diabetes, that DPH should develop a process for identifying
and applying for federal funding opportunities, including
routinely and proactively searching for grants, and DPH should
ensure that staff responsible for diabetes prevention
continues to develop appropriate knowledge and skills.
8)SUPPORT. The California Black Health Network supports this
AB 572
Page 8
bill due to the states lack of plan to mitigate the escalating
fiscal impact of diabetes. They point out that while there
has been extensive legislation enacted to promote awareness
and cost saving measures for conditions such as cardiovascular
disease and tobacco addiction, current law is woefully
inadequate in regards to diabetes. The Bayer Corporation
states this bill would help the state in managing the growing
numbers and costs associated with diabetes.
9)RELATED
LEGISLATION.
a) AB 270 (Nazarian) requires DPH to apply to the State
Department of Motor Vehicles to sponsor a diabetes
awareness, education, and research specialized license
plate program. Establishes the Diabetes Awareness Fund and
specifies that revenues from the fund will be used by DPH
to fund programs related to diabetes awareness and
prevention. AB 270 was unanimously approved by the
Assembly Transportation Committee on March 23, 2014 and is
pending in the Assembly Appropriations Committee.
b) SB 203 (Monning) requires a safety warning to be affixed
to sugar sweetened beverages that states "STATE OF
CALIFORIA SAFETY WARNING: Drinking beverages with added
sugar(s) contributes to obesity, diabetes, and tooth
decay". SB 203 is pending in the Senate Health Committee.
10) PREVIOUS LEGISLATION.
a) AB 1592 (Beth Gaines) of 2014 would have required DPH to
complete and submit to the Legislature a Diabetes Burden
Report by December 31, 2015 including, among other things,
actionable items for consideration by the Legislature that
will aid in attaining the goals set forth by DPH in the
California Wellness Plan for 2014. Would have required DPH
to include in the report guidelines that will reduce the
fiscal burden of diabetes to the state. This bill was
vetoed by the Governor, stating that DPH had already
submitted its Diabetes Burden Report to the CDC, as
required, and is unable to withdraw the report to include
additional information prescribed by the bill.
AB 572
Page 9
b) SB 1316 (Cannella) of 2014 would have required the
Department of Health Care Services, DPH, and the Board of
Administration of the Public Employees' Retirement System
to submit a report to the Legislature regarding their
diabetes-related programs, and states it is the intent of
the Legislature to coordinate a response that assesses the
quality of care and manages the costs paid for by
state-financed health programs relating to diabetes. SB
1316 was held in the Senate Rules Committee without action.
c) SB 64 (Solis), Chapter 540, Statutes of 1999, requires
every health care service plan and disability (health)
insurer to provide coverage for the management and
treatment of diabetes including equipment, supplies,
medications, outpatient self-management education, and
medical nutrition therapy, as medically necessary,
determined by the plan and insurers in conjunction with the
treating physician.
11)POLICY COMMENTS.
a) DPH has developed proposed actions to address diabetes
in California. The 2014 California Wellness Plan, which
focuses heavily on diabetes and closely linked illnesses,
outlines a number of obtainable, measurable goals for
reducing diabetes in this state, similar to those requested
in this bill. The 2014 Burden of Diabetes in California
report contains some of the demographic information
requested in this bill. DPH already has stated that it
will issue the first progress report on the Plan in January
2017.
b) The research goals of this bill are ambitious. As
drafted, this bill requires DPH to assess the entire fiscal
impact of diabetes on the state, as well as to project the
cost of treating the issue. The breadth and this request
is large and beyond what DPH typically undertakes, although
knowing more about the fiscal impacts of the disease on the
state could be valuable information for policy makers.
12)TECHNICAL AMENDMENTS.
AB 572
Page 10
a) The bill was drafted with an open date for DPH to report
the plan to the legislature and the sunset on report
provisions. The author would like the amend the previously
open dates to be:
(1) (c) The State Department of Public Health
shall submit a report to the Legislature on or before
January 1, 2018, and biennially thereafter,
(2) (d) This section shall remain in effect only
until January 1, 2024, and as of that date is
repealed, unless a later enacted statute deletes or
extends that date.
b) Section 104251 (a)(3) will be amended to read "A summary
of expenditures by the Department on programs and
activities aimed at preventing or controlling diabetes."
REGISTERED SUPPORT / OPPOSITION:
Support
American Diabetes Association
Bayer Corporation
Biocom
Boehringer-Ingelheim Pharmaceutical Company
California Academy of Family Physicians
California Black Health Network
Opposition
None on file.
Analysis Prepared
by: Dharia McGrew / HEALTH / (916) 319-2097
AB 572
Page 11