BILL ANALYSIS Ó
AB 1795
Page 1
Date of Hearing: April 6, 2016
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
AB
1795 (Atkins) - As Amended March 28, 2016
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill makes several changes to the state's breast and
cervical cancer screening and treatment programs. Specifically,
this bill:
1)Requires DHCS to provide breast cancer screening and
diagnostic services (through the Every Woman Counts program)
to any individual that meet existing eligibility requirements
and are either a) symptomatic, as defined; or b) 40 years of
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age or older.
2)Deletes existing limits on the period of coverage for
treatment of breast cancer (18 months) and cervical cancer (24
months) and instead requires coverage for both cancers to
remain for the duration of treatment, as long as the
individual continues to meet all other eligibility
requirements for the Breast and Cervical Cancer Treatment
Program (BCCTP).
3)Allows an individual to be eligible for cancer treatment if
diagnosed with a reoccurrence of breast cancer or cervical
cancer for either new cancer sites or the same cancer site, as
long as the individual continues to meet all other eligibility
requirements.
FISCAL EFFECT:
1)The Department of Health Care Services has not provided a
fiscal estimate for this bill. These provisions of the bill
will result in costs for cancer treatment funded by state-only
dollars:
a) Allowing an individual to remain on the program
longer by deleting the 18- and 24-month limits on the
period of coverage will result in additional months of
eligibility.
b) Specifying an individual is eligible for cancer
treatment for additional cancers at the same cancer site.
This will allow beneficiaries to be eligible for
additional treatment services where they would otherwise
be denied.
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c) Allowing screening for symptomatic women under 40
would allow more women to gain eligibility for breast
cancer treatment through the BCCTP.
Staff has estimated this bill could result in costs in the low
millions GF in the FFS program for cancer treatment by
allowing additional months and courses of treatment for women
who would otherwise not be eligible. For example, if an
additional 1,000 months of treatment are provided at an
average cost of $1,270 per month, costs would be $1.3 million.
Precise costs are difficult to predict based on limited
available data and unknown enrollment take-up.
2)Unclear, potential minor fiscal impact to Every Woman Counts
program (EWC) associated with the provision requiring
screening for symptomatic women under 40. If specifying in
statute that screening symptomatic women under 40 expands the
number of women seeking care, staff estimates additional cost
pressure is approximately $100,000 (likely Proposition 99 or
Breast Cancer Control funds).
The potential minor cost pressure to EWC is unclear because
the Department has provided contradictory information about
whether the current program covers services to women under 40.
Eligibility criteria are not enumerated in statute. EWC
services are not an entitlement, and provision of services is
limited in statute to the level of resources provided. Even
so, the state budget has tended to provided enough resources
to meet demand, suggesting expanding eligibility to women
under 40 in statute would increase state costs even though
it's not technically an entitlement-assuming the state does
not currently provide services to this age group.
COMMENTS:
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1)Background: State screening and treatment programs. The state
operates both screening and treatment programs for breast and
cervical cancer, for those who are low-income and do not have
access to affordable coverage. The demand for such
disease-specific state health programs has decreased due to
the wider availability of affordable, comprehensive health
care coverage, but these small programs still play an
important role in reducing cancer mortality.
Screening: Most low-income women who do not qualify for
Medi-Cal or have high out- of-pocket costs can receive free
screening through public health programs designed to reduce
cancer mortality. Specifically, individuals can receive
cervical cancer screening through the Family Planning,
Access, Care and Treatment (FamilyPACT) program, and breast
cancer screening through EWC. This bill changes
eligibility criteria for EWC. EWC relies on several
different funding streams, including, in 2015-16, federal
grant funding ($4.5 million), Proposition 99 ($25 million),
and Breast Cancer Control Account funds ($8 million). The
General Fund also has historically contributed to fund EWC
services, although given reduced demand for services due to
lower rates of uninsured women, the Governor's January 2016
budget projects little to no GF cost in 2015-16 and
2016-17.
Treatment: The Breast and Cervical Cancer Treatment
Program (BCCTP) operates as two separate programs that run
side-by-side: a state-federal Medi-Cal eligibility program
and state-only cancer treatment program.
o State-Federal: The state receives enhanced
federal matching for BCCTP at the CHIP matching rate
of 65% for individuals eligible under federal
guidelines. Such individuals receive full-scope
Medi-Cal coverage, and this comprises the majority of
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BCCTP beneficiaries. Eligibility runs for the
duration of treatment and there is no restriction on
treating a recurrence of the same cancer site.
o State-Only: Individuals not eligible for the
federal program-for example, low-income women who have
insurance but have high out-of-pocket costs-can
receive cancer treatment services only through the
state-only program funded exclusively by state GF
dollars. In contrast to the federal program,
eligibility is limited to 18 or 24 months for breast
and cervical cancer, respectively, and a recurrence of
cancer at the same site is ineligible for treatment.
This bill addresses these limitations specific to the
state-only program.
1)Guidelines for Routine Breast Cancer Screening. This bill
would specify in statute screening must be available for all
women over 40 who meet other eligibility criteria. This
age-related eligibility standard has not previously been
codified. Although it used to be the norm, routine screening
starting at age 40 is now somewhat controversial. There are
many organizations that produce recommendations and guidelines
for mammography screening, including various physicians
groups, cancer non-profits, and the U.S. Preventative Services
Task Force (USPSTF), which is an independent, volunteer panel
of national experts in prevention and evidence-based medicine.
These groups have disagreed in recent years about the age at
which women should begin routine screening, as well as the
frequency of screening (every year, or every other year). The
USPSTF recommends routine screening every two years starting
at age 50, while other groups recommend routine screening
earlier and with greater frequency. Coverage-what plans or
programs will pay for- is often based on clinical guidelines.
Currently, EWC allows women age 40 and over to enroll in the
program and reimburses for annual mammograms. According to
the USPSTF, these mammograms can do more harm than good for
women of average risk under age 50.
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2)Staff Comments. Eligibility guidelines for EWC mustn't
necessarily equate to clinical guidelines- they only specify
what EWC will pay. And DHCS currently uses 40 years of age as
an eligibility benchmark. However, affirmatively codifying
eligibility for age 40 and above for a state breast cancer
screening program does suggest the state believes age 40 is
the clinically appropriate age to begin screening, in spite of
considerable disagreement about the net benefit of such
screening for most women before age 50. Given such
disagreement, it is worth considering whether codifying age 40
is appropriate, or if there is a different way to ensure
limited state dollars are used for effective services that
truly benefit women, particularly since statute does not
always change as clinical guidelines evolve. For example, the
author may wish to consider requiring a periodic reexamination
of an age-based standard based on the latest medical evidence,
or directing the department to ensure EWC providers are
recommending mammograms for women under 50 consistent with
specified guidelines. This would guard against the state
paying in perpetuity for services that may be of uncertain
value.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081