BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 1763|
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THIRD READING
Bill No: AB 1763
Author: Gipson (D)
Amended: 6/27/16 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 7-1, 6/22/16
AYES: Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
NOES: Nielsen
NO VOTE RECORDED: Nguyen
SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/11/16
AYES: Lara, Beall, Hill, McGuire, Mendoza
NOES: Bates, Nielsen
ASSEMBLY FLOOR: 67-5, 6/2/16 - See last page for vote
SUBJECT: Health care coverage: colorectal cancer: screening
and testing
SOURCE: American Cancer Society Cancer Action Network
California Colorectal Cancer Coalition
DIGEST: This bill requires health plan and health insurance
coverage without cost sharing for specified colorectal cancer
screening examinations and laboratory tests for individuals at
average risk, and requires coverage for additional colorectal
cancer screening examinations without cost-sharing for
individuals at high risk, as specified. Prohibits the
imposition of cost sharing on colonoscopies, including the
removal of polyps, for an enrollee who is between 50 and 75
years of age and has received a positive test, as specified.
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ANALYSIS:
Existing federal law:
1)Requires, pursuant to the Affordable Care Act (ACA), coverage
of 10 essential health benefits and places limits on cost
sharing.
2)Requires, pursuant to Section 2713 of the Public Health
Services Act, as added by the ACA, the preventive services
without cost sharing (such as copayment, coinsurance, or
deductible), as soon as 12 months after a recommendation
appears in any of the following sources:
a) A and B rated recommendations of the United States
Preventive Services Task Force (USPSTF);
b) Immunizations recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control
and Prevention;
c) For infants, children, and adolescents,
evidence-informed preventive care and screenings provided
for in the comprehensive guidelines supported by the Health
Resources and Services Administration (HRSA); and,
d) For women, preventive care and screenings provided for
in comprehensive guidelines supported by HRSA.
3)States, pursuant to federal regulation, that nothing in 2)
above requires a plan or insurer that has a network of
providers to provide benefits for the items or services
described in 2) above that are delivered by an out-of-network
provider; or precludes a plan or insurer that has a network of
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providers from imposing cost-sharing requirements for the
items or services described in 2) above that are delivered by
an out-of-network provider.
Existing state law:
1)Requires health plans to be regulated by the Department of
Managed Health Care (DMHC) and health insurers to be regulated
by the California Department of Insurance (CDI).
2)Mandates coverage for all generally accepted cancer screening
tests, subject to all terms and conditions that apply, and
screening for breast cancer, cervical cancer, mammography, and
prostate cancer. Requires coverage for breast cancer diagnosis
and treatment. Establishes requirements for mastectomies and
lymph node dissections. Limits copayments on orally
administered anticancer medications, as specified, until
January 1, 2019. Mandates coverage for routine patient care
costs related to clinical trials for an enrollee or insured
diagnosed with cancer, as specified.
This bill:
1)Requires every health plan contract and health insurance
policy, except a specialized health plan contract or health
insurance policy, that is issued, amended, or renewed on or
after January 1, 2018, to provide coverage without any cost
sharing for all colorectal cancer screening examinations and
laboratory tests assigned either a grade of A or a grade of B
by the USPSTF for individuals at average risk. Requires if an
enrollee is at high risk for colorectal cancer, the plan or
insurer to include additional colorectal cancer screening
examinations as listed by the USPSTF as recommended screening
strategy and at least at the frequency established pursuant to
regulations issued by the federal Centers for Medicare and
Medicaid Services for the Medicare program.
2)Prohibits, for an enrollee who is between 50 and 75 years of
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age, a health plan contract or insurance policy from imposing
cost sharing on colonoscopies, including the removal of
polyps, when either of the following applies:
a) The colonoscopy is a screening procedure not occasioned
by a recent positive test or procedure; or,
b) The colonoscopy has been scheduled because of a positive
result on a test or procedure, other than a colonoscopy,
assigned either a grade of A or a grade of B by the USPSTF.
3)States that nothing in this bill requires a plan or insurer
that has a network of providers to provide benefits for items
or services described in this bill that are delivered by an
out-of-network provider or precludes a plan or insurer that
has a network of providers from imposing cost-sharing
requirements for the items or services described in this
section that are delivered by an out-of-network provider.
Comments
1)Author's statement. According to the author, stool blood
tests are an important colorectal cancer screening option.
Availability is better than for colonoscopy, the cost is
lower, and they offer the opportunity to increase the overall
screening rate which would reduce incidence and mortality.
Some individuals, including those from low income communities
and communities of color may not have initial access to
screening colonoscopy. Some prefer a stool blood test because
the procedure is simpler, there is lower risk of complications
and it is less invasive. Screening with stool blood tests has
been shown to decrease incidence and mortality in randomized
controlled trials, and years of life saved are essentially the
same as with colonoscopy screening. However, the benefits of
stool blood tests as a strategy to reach more Californians,
especially in communities with lower access to colonoscopy
services are not realized when there is a cost to patients. A
co-pay or cost-sharing can be a barrier, preventing some
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individuals with positive stool blood tests from getting a
follow up colonoscopy to complete the colorectal cancer
screening process, defeating the purpose of screening. A
policy that removes the cost to patients will make stool blood
tests a more viable screening option and will reduce costs to
payers.
2)ACA Preventive services mandate. The ACA requires coverage
for and elimination of cost-sharing on certain recommended
preventive health services, for policies renewing on or after
September 23, 2010, based on guidelines from the USPSTF.
There are 15 covered preventive services for adults which
include one-time screening for abdominal aortic aneurysm,
screening and counseling for alcohol misuse, aspirin, blood
pressure screening, cholesterol screening, depression
screening, screening for Type 2 Diabetes, diet counseling, HIV
screening, immunizations, obesity screening and counseling,
prevention counseling for sexually transmitted infection,
screening and cessation interventions for tobacco use, and
colorectal cancer screening for adults over 50.
3)Colorectal cancer screening. According to the National Cancer
Institute, colorectal cancer is a disease in which malignant
(cancer) cells form in the tissues of the colon or the rectum.
Colorectal cancer is the second leading cause of death from
cancer in the United States. For the vast majority of adults,
the most important risk factor for colorectal cancer is older
age. Most cases of colorectal cancer occur among adults older
than 50 years; the median age at diagnosis is 68 years. A
positive family history (excluding known inherited familial
syndromes) is thought to be linked to about 20% of cases of
colorectal cancer. About 3% to 10% of the population has a
first-degree relative with colorectal cancer. Male sex and
black race are also associated with higher colorectal cancer
incidence and mortality. Black adults have the highest
incidence and mortality rates compared with other
racial/ethnic subgroups. The final USPSTF recommendation for
colorectal cancer screening recommends screening with one of
several approved methodologies for colorectal cancer starting
at age 50 years and continuing until age 75 years. The
decision to screen for colorectal cancer in adults aged 76 to
85 years should be an individual one, taking into account the
patient's overall health and prior screening history. The
screening modalities and intervals are fecal occult blood test
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(FOBT), which has received an A or B recommendation from the
USPSTF and Fecal immunochemical test, which is recommended in
the 2016 draft updated guidelines. Both tests are suggested
annually to detect cancer. A flexible sigmoidoscopy is
recommended every five years to detect polyps and cancer and
has received an A or B recommendation from the USPSTF. A
colonoscopy is recommended every 10 years to detect polyps and
cancer and has received an A or B recommendation. It is also
recommended that a colonoscopy should be performed if test
results are positive.
4)California Health Benefits Review Program (CHBRP) analysis.
AB 1996 (Thomson, Chapter 795, Statutes of 2002) requested the
University of California assess legislation proposing a
mandated benefit or service and prepare a written analysis
with relevant data on the medical, economic, and public health
impacts of proposed health plan and health insurance benefit
mandate legislation. CHBRP was created in response to AB 1996,
and reviewed an earlier version of this bill and issued an
updated letter based on the April 27, 2016 version of this
bill. Key findings include that there is a preponderance of
evidence that USPSTF-recommended colorectal cancer screening
modalities are medically effective for the detection and
prevention of colorectal cancer screenings among average and
high-risk individuals. For average-risk individuals, evidence
exists suggesting a small but positive impact of insurance
coverage for colorectal cancer screening and utilization
(Cokkinides, 2011), and that low socioeconomic status
individuals may benefit from the elimination of barriers to
screening utilization (Fedewa, 2015a). CHBRP projects no
measurable public health impact on the diagnosis or prevention
of colorectal cancer at the population level due to the small
number of enrollees who would avail themselves of the
additional screening.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Senate Appropriations Committee:
1)No fiscal impact on the Medi-Cal program is anticipated, as
program beneficiaries are not subject to cost sharing.
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2)Increased costs of $1.3 million per year to the California
Public Employees' Retirement System (CalPERS), due to
increased utilization of screening tests (various funds).
According to an analysis of a prior version of this bill by
CHBRP, prohibiting cost sharing for specified screening will
modestly increase utilization of screening examinations.
Overall, CHBRP projects that about 2,500 additional
individuals per year will receive colorectal screening exams
due to the elimination of cost sharing. The proportional
impact of that increased utilization on the CalPERS system is
$1.3 million. According to CHBRP, subsequent amendments to the
bill since that analysis was prepared will not substantially
change the projected costs.
3)No state cost to subsidize health care coverage through
Covered California is anticipated. Under federal law, any new
mandated health benefit that exceeds the benefits in the
state's essential health benefits benchmark plan would be a
state responsibility. In other words, to the extent that the
state imposes a new benefit mandate that exceeds the essential
health benefits benchmark, the state would be responsible for
paying for the cost to subsidize that benefit for those
individuals who receive subsidized coverage through Covered
California. Because this bill does not mandate a new benefit,
but only change the terms of an existing benefit, the bill is
not expected to result in the state being responsible for
subsidizing coverage.
4)One-time costs of about $90,000 over the first two years and
ongoing costs of $25,000 per year for reviews of insurance
plan compliance by CDI (Insurance Fund).
5)Ongoing costs of less than $50,000 per year for review of
health plan compliance by DMHC (Managed Care Fund).
SUPPORT: (Verified8/11/16)
American Cancer Society Cancer Action Network (co-source)
California Colorectal Cancer Coalition (co-source)
American College of Gastroenterology
American College of Surgeons
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American Gastroenterology Association
American Society for Gastrointestinal Endoscopy
Association of Northern California Oncologists
Bayer
California Academy of Physician Assistants
California Academy of Preventive Medicine
California Black Health Network
California Chapters of the American College of Physicians
California Immigrant Policy Center
California Life Sciences Association
California Primary Care Association
Fresno Center for New Americans
Fresno Interdenominational Refugee Ministries
Health Officers Association of California
Medical Oncology Association of Southern California
Southeast Asia Resource Action Center
The Cambodian Family Community Center
Several individuals
OPPOSITION: (Verified8/16/16)
America's Health Insurance Plans
Blue Shield of California
California Association of Health Plans
California Chamber of Commerce
Department of Managed Health Care
ARGUMENTS IN SUPPORT: The American Cancer Society Action
Network writes that colorectal cancer is the second leading
cause of cancer deaths in the United States but is the most
preventable with screening and early detection. Timely and
appropriate screening can decrease colorectal cancer incidence
and mortality by 30% to 60%. High-sensitivity FOBT tests are
effective, non-invasive, easily accessible and safe screening
tests that are more cost efficient than colonoscopies. However,
a positive test result requires that a follow-up colonoscopy be
provided. Multiple studies have shown that individuals are less
likely to seek additional health services, including preventive
screenings, when they are required to pay out-of-pocket.
Additionally, research has shown that limiting colorectal cancer
screening choices to only colonoscopy can result in a lower
colorectal cancer screening completion rate compared to
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providing a choice between colonoscopy and a stool-based test,
particularly among racial and ethnic minorities. The California
Colorectal Cancer Coalition writes that many health insurers
apply cost-sharing to colonoscopies that follow a positive stool
blood test because they consider it a diagnostic procedure
rather than a screening test. Patient cost can be more than
$300 when a polyp or abnormal growth is removed during the
screening colonoscopy. This charge is generally received
unexpectedly after having a screening and can act as a
disincentive for future screening for colon cancer. Finding an
adenomatous polyp during a screening colonoscopy can be found in
at least 50% of good quality colonoscopy exams. This bill
eliminates this unexpected cost, and removes the financial
disincentives, which prevent people from getting their colon
cancer screening.
ARGUMENTS IN OPPOSITION:America's Health Insurance Plans (AHIP)
write that this bill creates a new mandate for health plans and
insurers to cover costly services for diagnostic purposes
without cost-sharing, which threatens the efforts of all health
care stakeholders to provide consumers with meaningful health
care choices and affordable coverage options. This bill will
increase annual expenditures by $5.63 million for enrollees with
DMHC-regulated plans and CDI-regulated policies. The state
should be looking for ways to bring down health care costs for
consumers, not drive them up. Extending the elimination of
cost-sharing to diagnostic care in this instance creates a
slippery slope to eliminating cost-sharing for other similar
types of diagnostic care. As currently amended, this bill fails
to follow the federal standard by not recognizing the value of
in-network benefits - and results in increased costs in premiums
if cost-sharing on out-of-network benefits was not permitted. A
recent study conducted by AHIP found that in California the
average billed charge for colonoscopies and biopsies was 252.7%
of the Medicare rate. Requiring plans to cover such services
and pay full billed charges would allow those providers to set
charges at any level that they wish. According to DMHC, this
bill imposes a zero cost sharing requirement on colorectal
cancer services above and beyond the zero cost-sharing mandate
for preventive services under the Affordable Care Act. This type
of disease specific statute creates disparities and inequities
for individuals that suffer from other diseases.
ASSEMBLY FLOOR: 67-5, 6/2/16
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AYES: Achadjian, Alejo, Arambula, Atkins, Baker, Bloom,
Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chau, Chávez,
Chiu, Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman,
Frazier, Cristina Garcia, Eduardo Garcia, Gatto, Gipson,
Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger
Hernández, Holden, Irwin, Jones, Jones-Sawyer, Lackey, Levine,
Linder, Lopez, Low, Maienschein, Mathis, McCarty, Medina,
Mullin, Nazarian, O'Donnell, Olsen, Quirk, Ridley-Thomas,
Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond,
Ting, Wagner, Weber, Wilk, Williams, Wood, Rendon
NOES: Travis Allen, Brough, Melendez, Obernolte, Patterson
NO VOTE RECORDED: Bigelow, Chang, Dahle, Beth Gaines,
Gallagher, Kim, Mayes, Waldron
Prepared by:Teri Boughton / HEALTH / (916) 651-4111
8/16/16 13:00:08
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