BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 2424
---------------------------------------------------------------
|AUTHOR: |Gomez |
|---------------+-----------------------------------------------|
|VERSION: |June 20, 2016 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |June 29, 2016 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Reyes Diaz |
---------------------------------------------------------------
SUBJECT : Community-based Health Improvement and Innovation Fund
SUMMARY : Creates the Community-based Health Improvement and Innovation
Fund for allocation to the Department of Public Health to reduce
health inequity and disparities in the rates and outcomes of
priority chronic health conditions, as defined, and to evaluate
the effectiveness of community-based prevention strategies, as
specified.
Existing law:
1)Establishes the Department of Public Health (DPH) to protect
and improve the health of communities through education,
promotion of healthy lifestyles, and research for disease and
injury prevention. Establishes the California Diabetes Program
(CDP) within DPH.
2)Provides DPH with the authority to perform activities that
protect, preserve, and advance public health, including
studies and dissemination of information.
This bill:
1)Creates in the State Treasury the Community-based Health
Improvement and Innovation Fund (CHII Fund) consisting of any
revenues deposited, including, but not limited to, fine or
penalty revenue, any revenue from appropriation credited to
the CHII Fund, and any funds from public or private gifts,
grants, or donations.
2)Required moneys from the CHII Fund to be available, as
specified, for purposes that include, but are not limited to:
a) Reducing health inequity and disparities in
the rates and outcomes of "priority chronic health
AB 2424 (Gomez) Page 2 of ?
conditions," as defined, and injuries. Defines
"priority chronic health conditions" as asthma, type
II diabetes, cardiovascular and cerebrovascular
disease, cancer, dental disease, obesity, and other
chronic conditions and injuries, as specified;
b) Preventing the onset of priority chronic
health conditions using community-based strategies, as
specified;
c) Strengthening local, regional, and state-level
collaborations between public health jurisdictions and
health care providers, and across government agencies
and community partners, as specified;
d) Supporting collaboration between public health
entities and non-health organizations and agencies in
fields to include housing, transportation, land use
planning, and food access; and,
e) Evaluating the effectiveness and
cost-effectiveness of innovative community-based
prevention strategies for priority chronic health
conditions, as specified.
3)Requires CHII Fund moneys to be used to address social,
environmental, and behavioral determinants of chronic disease
and injury, as specified, including, but not limited to
promotion of health diets, improved access to healthy foods,
and health food environments; promotion of physical activity
and of a safe, physical activity-promoting environment;
prevention of unintentional and intentional injury; and
building partnerships to address social determinants of
chronic disease. Requires policy, systems, and environmental
change approaches to be emphasized when expending CHII Fund
moneys, and allows moneys to support implementation of
community-based programs. Prohibits CHII Fund moneys from
being used for clinical services and from reverting to the
State General Fund.
4)Requires DPH to be allocated an amount not greater than 20% of
the annual appropriation from the CHII Fund for activities
that include, but are not limited to:
a) Mandatory activities that include: statewide
media and communications campaigns; evaluation of all
program activities supported through the CHII Fund,
including regular monitoring, data collection and
reporting requirements, and ensuring moneys supplement
AB 2424 (Gomez) Page 3 of ?
and do not supplant existing funds or efforts; and
other activities, including overall program
implementation and oversight, the definition of
criteria for evidence-based and innovative approaches
to improving health and health equity, the definition
of priority chronic health conditions and health
equity priority populations, and development of tools
that can be used by the state and grantees to monitor
progress, as specified; and,
b) Discretionary activities to support
community-based prevention that include: research,
development, and dissemination of best practices;
development of infrastructure, as specified;
coordination of local efforts and statewide
initiatives; and grants or contracts to nonprofit
organizations at the state level, as specified.
5)Requires DPH to award at least 80% of moneys from the CHII
Fund to eligible applicants to be used consistent with
requirements in 2) above, and distributed and awarded
according to criteria that includes, but is not limited to:
a) At least 47% of funds awarded to local health
jurisdictions, as specified, that submit an
application for a three-year funding cycle that
includes, but is not limited to: a detailed assessment
of community health needs, as specified; a health
improvement and evaluation plan; the level of local
funds; documentation of the existence and activities
of a community health partnership, as specified; and
how funds will be used in a manner consistent with
provisions in this bill; and,
b) At least 33% of funds allocated for
competitive grants, including, but not limited to:
grants awarded to local or regional-level entities or
statewide nonprofit organizations; the identification
by participating health care plans or hospitals of
monetary, in-kind, or both, contributions to projects;
investments by local or regional projects that serve
communities, as specified; funds used for statewide
nonprofit organizations to support activities; funds
used for competitive grant programs administered by
DPH to support health food incentives for low-income
Californians and community food projects, as
specified; and coordinated efforts of grant awardees
AB 2424 (Gomez) Page 4 of ?
with DPH and any local health jurisdiction, as
specified.
6)Creates the CHII Fund Advisory Committee (Committee) that is
required to advise DPH on policy development, integration, and
evaluation of community-based chronic disease and injury
prevention activities, as specified. Requires the Committee to
include, at a minimum, experts on priority chronic health
conditions, effective nonclinical prevention strategies, and
policy strategies for prevention. Requires the Committee to be
composed of 13 members appointed for a term of two years,
renewable at the option of the appointing authority as
follows:
a) One member representing voluntary health
organizations, as specified, appointed by the Speaker
of the Assembly;
b) One member representing health care employees
appointed by the Senate Rules Committee;
c) One member representing a statewide nonprofit
health organization, as specified, appointed by the
Governor;
d) One member representing a community-based
organization, as specified, appointed by the Governor;
e) One representative of a university, as
specified, appointed by the Governor;
f) Two representatives of a population group with
priority health conditions appointed by the Governor;
g) One representative of the Health and Human
Services Agency appointed by the Governor;
h) One representative of the Department of Food
and Agriculture appointed by the Governor;
i) One representative of the Health in All
Policies Task Force appointed by the Strategic Growth
Council;
j) One member representing the interests of the
general public appointed by the Governor;
aa) One representative of the California
Conference of Local Health Officers; and,
bb) One representative from the California Health
Benefit Exchange appointed by the executive board of
the exchange.
7)Requires the Committee to meet as deemed necessary but not
less than four times per year. Requires the Committee members
AB 2424 (Gomez) Page 5 of ?
to serve without compensation, except as specified, and to be
advisory to DPH, the Department of Food and Agriculture (DFA),
and the Health and Human Services Agency (HHSA) for purposes
that include, but are not limited to:
a) Evaluation of research on community-based
policies, practices, and programs, as specified;
b) Facilitation of programs directed at reducing
and eliminating preventable chronic disease and
injury, as specified;
c) Making recommendations to DPH, DFA, and HHSA,
as specified;
d) Reporting to the Legislature on or before
January 1 of each year on the number and amount of
activities funded by the CHII Fund, as specified; and,
e) Ensuring that the most current research
findings are applied in designing CHII Fund
activities, as specified.
8)Requires the Committee, based on results of programs funded by
the CHII Fund and other proven methodologies, to produce a
comprehensive set of recommendations and proposed strategies
for advancing chronic disease and injury prevention throughout
the state that include specific goals for reduction of the
burden of preventable chronic conditions and injuries by 2030.
Requires the recommendations to include implementation
strategies for each priority chronic health condition
throughout the state and identification of areas where
innovative solutions are especially needed. Requires the
Committee to submit the recommendations and proposed
strategies to the Legislature triennially.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1)DPH would incur one-time costs for staffing, information
technology, and contracts, likely in the low millions of
dollars. Ongoing costs would depend on the total allocation
and the number of grants and contracts to be managed.
2)This bill does not specify a funding source or amount, but it
is safe to assume a program of the scale envisioned would cost
in the tens of millions of dollars General Fund (GF) per
three-year cycle, in absence of another fund source. Based on
the minimum $250,000 allocated to each local health
AB 2424 (Gomez) Page 6 of ?
jurisdiction, which would make up 50% of the funding, as well
as the ambitious nature and comprehensiveness of the program,
staff estimates cost pressure of $30.5 million GF at a
minimum. Assuming a program of this size, $2.8 million would
be allocated to communications and media, $1.5 million to
evaluation, up to $1.8 million for DPH administration and
oversight, $15.3 to local health jurisdictions to implement
community-based health improvement activities, and $9.1
million for competitive grants.
3)A related stakeholder proposal request for a $380 million GF
appropriation for a CHII Fund was discussed in the Assembly
Budget Subcommittee 1 on April 11, 2016. This represents
nearly a $10 per capita investment, which would support one
cycle of a three-year grant program.
4)Research indicates funding evidence-based, community-based
chronic disease prevention activities can have a high return
on investment in terms of health care cost savings. A return
on investment (ROI) analysis is beyond the scope of this
estimate, but as this bill focuses on the most costly and
preventable conditions, including obesity, heart disease, and
diabetes, and assuming the activities were evidence-based and
well-implemented, it is reasonable they could lead to
improvements in population health and a corresponding
reduction in health care cost growth statewide, and for the
state as a large payer. In addition, the bill's focus on
health equity priority populations is likely to have a
significant overlap with the Medi-Cal population, increasing
the chances of a positive ROI for the state. Finally, the
bill's emphasis on funding systems and policy changes means
health-promoting changes adopted pursuant to this program may
have a lasting impact. For example, the tobacco control
program led to changes in public acceptance of tobacco use,
which in turn resulted in policies that are unlikely to be
reversed, such as tobacco-free workplaces.
PRIOR
VOTES :
-----------------------------------------------------------------
|Assembly Floor: |57 - 22 |
|------------------------------------+----------------------------|
|Assembly Appropriations Committee: |14 - 6 |
|------------------------------------+----------------------------|
AB 2424 (Gomez) Page 7 of ?
|Assembly Health Committee: |14 - 2 |
| | |
-----------------------------------------------------------------
COMMENTS :
1)Author's statement. According to the author, this bill would
create the CHII Fund to ensure that all Californians are able
to achieve optimal, equitable health regardless of their
socioeconomic status, race, ethnicity, or place of residence.
Specifically, money allocated from the CHII Fund would support
sustainable funding toward public health and prevention
programs and efforts within disadvantaged communities. The
sources of funding for public health and prevention programs
are perpetually threatened. These funds are currently
declining from past levels of prior funding, and are often
subject to significant federal restrictions. Strategic
investment in upstream and primary prevention would protect,
not deplete, our crucial health programs. Investment in
prevention has a strong evidence base of positive returns on
investment by reducing health care costs on a long-term basis.
Soaring health care costs for government, business, and labor
takes money out of wages and hurts competitiveness. Eighty
percent of our health spending is on chronic disease, most of
which is preventable. Other innovations may improve care, but
innovation increases costs. Preventing obesity and chronic
disease is the only way to save money in the long-term.
2)Diabetes in California. DPH issued a study, The Burden of
Chronic Disease and Injury, in 2013 that highlights some of
the leading causes of death, such as heart disease, cancer,
stroke, and respiratory disease, all of which have a strong
connection to obesity. Diabetes is another serious chronic
disease stemming from obesity that adversely affects quality
of life and results in serious medical costs. The last decade
has witnessed a 32% rise in diabetes prevalence, affecting
some 3.9 million people and costing upwards of $24 billion per
year. According to the Centers for Disease Control and
Prevention (CDC), more than one-third of U.S. adults are
obese, and approximately 12.5 million children and adolescents
ages two to 19 years are obese. Research indicates a tripling
in the youth obesity rate over the past three decades. While
this increase has stabilized between the years 2005 and 2010,
in 2010, 38% of public school children were overweight and
obese. Overweight youth face increased risks for many serious
detrimental health conditions that do not commonly occur
AB 2424 (Gomez) Page 8 of ?
during childhood, including high cholesterol and type-2
diabetes. Additionally, more than 80% of obese adolescents
remain obese as adults.
3)CDP. The 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 CDC. A
few key objectives that the 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.
The CDP achieves these through partnering with different
individual, community, health care, policy, and environmental
entities.
1)The California Wellness Plan (Plan). In February 2014, DPH's
Chronic Disease Prevention Branch published the 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 also 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 (OHE), that are engaged
in diabetes prevention to implement the objectives. DPH
intends to monitor the progress of Plan objectives and publish
AB 2424 (Gomez) Page 9 of ?
regular reports on outcomes.
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. 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 DPH's Web site. 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.
2)Health equity. According to the CDC, health equity is achieved
when every person has the opportunity to "attain his or her
full health potential" and no one is "disadvantaged from
achieving this potential because of social position or other
socially determined circumstances." Health inequities are
reflected in differences in length of life; quality of life;
rates of disease, disability, and death; severity of disease;
and, access to treatment. Established in 2012, DPH's OHE aims
to reduce health and mental health disparities in vulnerable
communities. OHE's work is directed through their advisory
committee and stakeholder meeting process. The OHE is required
to consult with community-based organizations and local
governmental agencies to ensure that community perspectives
and input are included in policies, strategic plans,
recommendations, and implementation activities. According to
the U.S. Department of Health and Human Services' report,
"Healthy People 2020: An Opportunity to Address the Societal
Determinants of Health in the United States," Americans do not
all have equal opportunities to make healthy choices. A
person's health and chances of becoming sick and dying early
are greatly influenced by powerful social factors including
education, income, nutrition, housing, and neighborhoods. The
"Healthy People 2020" report indicates that if we, as a state,
develop strategies and programs to help more Californians
become physically active and adopt good nutrition practices,
and create social and physical environments that promote good
health for all, California could substantially improve health
AB 2424 (Gomez) Page 10 of ?
and reduce health care costs.
3)Related legislation. AB 2696 (Beth Gaines), would require DPH
to submit a report to the Legislature, as specified with
certain criteria, regarding the prevention and management of
diabetes and its complications. Requires DPH to post annually
specified information on its Internet Web site. AB 2696 is
pending in the Senate Appropriations Committee.
4)Prior legislation. AB 572 (Beth Gaines of 2015), would have
required DPH to update the California Wellness Plan 2014 to
include specified items, including priorities and performance
measures that are based upon evidence-based strategies to
prevent and control diabetes, and to submit a report to the
Legislature by January 1, 2018, to include the progress of
those specified plan items. AB 572 was held under submission
in the Senate Appropriations Committee.
AB 270 (Nazarian of 2015), would have required DPH to apply to
the State Department of Motor Vehicles to sponsor a diabetes
awareness, education, and research specialized license plate
program. Would have established the Diabetes Awareness Fund,
with revenues to be used by DPH to fund programs related to
diabetes awareness and prevention. AB 270 was held under
submission in the Senate Appropriations Committee.
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 respective diabetes-related
programs. SB 1316 was never referred out of Senate Rules
Committee.
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
would 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 would reduce the fiscal
burden of diabetes to the state. AB 1592 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 2424 (Gomez) Page 11 of ?
5)Support. Supporters of this bill argue that chronic disease
accounts for eight out of every 10 deaths in the state and
affects the quality of life for approximately 14 million
Californians, and disproportionately affects communities of
color. Supporters state that, in 2010, 42% of all health care
expenditures in the state was spent on treating common chronic
health conditions: arthritis, asthma, cardiovascular disease,
diabetes, cancer, and depression, most of which can be
prevented. Supporters argue that this bill will empower
entities to enact primary prevention programs to help improve
policies and behaviors, which can be bigger determinants of
health.
6)Opposition. DPH states that, while it is committed to
achieving health equity and supports efforts to reduce and
prevent the chronic disease burden among all Californians,
this bill requires the administration of a program without
identifying a funding source or providing funding for the
program. DPH states that without funding it would not be able
to award any grants.
7)Amendments. The author requests the following amendments in
bold, italics, and underline :
On page 11, line 27:
(v) How funds will be used in a manner consistent with
principles of effectiveness, cost efficiency, relevance to
community needs, maximal impact to improve community health,
and and sustainability of impact over time. time, and
projections of return on investment to the state. over time.
SUPPORT AND OPPOSITION :
Support: American Cancer Society Cancer Action Network
American Heart Association/American Stroke Association
Boehringer Ingelheim Pharmaceuticals, Inc.
California Immigrant Policy Center
California Naturopathic Doctors Association
California Pan-Ethnic Health Network
Community Clinic Association of Los Angeles County
Health Access California
Health Officers Association of California
Public Health Institute
SEIU California
AB 2424 (Gomez) Page 12 of ?
Sonoma County Board of Supervisors
Oppose: Department of Public Health
-- END --