BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    SCR 134             
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          |AUTHOR:        |Pan                                            |
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          |VERSION:       |April 25, 2016                                 |
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          |HEARING DATE:  |June 8, 2016   |               |               |
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          |CONSULTANT:    |Reyes Diaz                                     |
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           SUBJECT  :  Diabetes: the "Screen at 23" campaign

        SUMMARY  :1) Urges the Department of Public Health (DPH) to endorse and  
          support the "Screen at 23" campaign's efforts to increase  
          awareness of diabetes among Asian-American communities,  
          including the use of appropriate screening measures for  
          Asian-American patients and to eliminate disparities. Urges DPH  
          to encourage all public and private health providers and  
          facilities to also participate in these efforts.
          
          Existing law:
          1) Establishes 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 measure:
          1) Finds that approximately 2.5 million Californians, or 9% of  
             the population, are diagnosed with diabetes (the fifth  
             leading cause of death among Asian Americans); 46% are  
             estimated to have prediabetes; and residents of Asian  
             American heritage comprise 14% of the state's population, who  
             are 30% more likely to have diabetes than White Americans and  
             are at greater risk of developing prediabetes, diabetes, and  
             associated risks at a lower body mass index (BMI) than  
             Whites, Hispanics, Blacks, and Native Americans.

          2) Finds that Asian Americans face health care disparity in type  
             2 diabetes detection and diagnosis, as the current guidelines  







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             for screening Asian Americans at a BMI of 25kg/m2 not only  
             miss 36% of diabetes diagnoses but also underestimate the  
             prevalence of prediabetes among Asian Americans.

          3) Finds that two out of three people with type 2 diabetes die  
             from heart attack or stroke, and adults with diabetes are at  
             risk for developing end-stage renal disease and kidney  
             failure, blindness, and lower limb loss.

          4) Finds that the per capita health care cost of diabetes in the  
             state is $14,800 per year, and the annual cost is $37.1  
             billion, including $27.6 billion in medical costs and $9.5  
             billion in indirect costs and productivity loss.

          5) Finds that 38% of all hospitalized Asian Americans in the  
             state have diabetes, which leads to more expensive hospital  
             care regardless of the reason for hospitalization, and that  
             early detection and treatment can mitigate diabetes-related  
             complications, risks, and costs.

          6) Finds that screening Asian American patients at a BMI of 23  
             instead of 25 would unmask more than 67,000 diabetes cases  
             and many thousands more prediabetes cases in the state,  
             thereby initiating treatment or early interventions to reduce  
             negative comorbidities like heart disease, kidney disease,  
             and limb amputations.

          7) States that the National Institutes of Health recently found  
             that more than half of Asian Americans with diabetes are  
             undiagnosed, and community-based participatory research and  
             studies on Asian-American subpopulations have shown that  
             Asian Americans develop diabetes at a lower BMI; states that  
             the World Health Organization recommends screening Asian  
             patients at a lower BMI than non-Hispanic Whites, and the  
             2015 official guidelines of the American Diabetes Association  
             recommend Asian Americans be tested for type 2 diabetes at a  
             BMI of 23.

          8) Finds that the Asian American, Native Hawaiian, and Pacific  
             Islanders Diabetes Coalition has coordinated the "Asian BMI"  
             efforts of more than 15 national and regional organizations,  
             culminating in the launch of the "Screen at 23" campaign;  
             states that California has the opportunity to become one of  
             the first states to formally recognize and recommend  
             screening adult Asian Americans for type 2 diabetes at a BMI  








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             of 23, enabling thousands of individuals to get the early  
             care and treatment needed to live healthier and happier  
             lives.

          9) Urges DPH to endorse and support the "Screen at 23"  
             campaign's efforts to increase awareness of diabetes among  
             Asian-American communities, including the use of appropriate  
             screening measures for Asian-American patients and to  
             eliminate disparities; urges DPH to encourage all public and  
             private health providers and facilities to also participate  
             in these efforts.

          10)Requests the Secretary of the Senate to transmit copies of  
             this measure to the author, the Governor, and the Director of  
             DPH for appropriate distribution.

           FISCAL  
          EFFECT  : This measure has not been analyzed by a fiscal  
          committee. 
           
          COMMENTS  :
          1)Author's statement. According to the author, approximately 2.5  
            million Californians, or 9% of the population, are diagnosed  
            with diabetes. However, Asian Americans are often not screened  
            for diabetes but are 30% more likely to develop diabetes than  
            White Americans.  Additionally, diabetes is the fifth leading  
            cause of death among Asian Americans. Since Asian Americans  
            can develop diabetes at a lower body mass index, the current  
            guidelines for diabetes screening miss 36% of Asian American  
            diabetes diagnoses, or approximately 116,000 individuals in  
            California. SCR 134 raises much needed awareness to screen all  
            Asian American adults for diabetes at a body mass index of 23  
            kg/m2 or greater versus the standard 25 kg/m2. 
            
          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 Center for Disease Control and  
            Prevention (CDC), more than one-third of U.S. adults are  








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            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  
            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. 

          4)The California Wellness 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  








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            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, that are engaged in  
            diabetes prevention to implement the objectives. DPH intends  
            to monitor the progress of Plan objectives and publish regular  
            reports on outcomes.

          5)State Auditor report. In January 2015, the 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 (FY) 2013-14, federal  
            funding for diabetes prevention decreased from more than $1  
            million in previous FYs to $817,000. DPH's maternal diabetes  
            program also experienced significant reductions in federal  
            funding over the last three FYs, declining from $1.2 million  
            in FY 2010-11 to $71,000 in FY 2013-14. In FY 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 report also found that DPH spent its limited  
            federal funds in an appropriate manner and complied with  
            applicable grant requirements. For the 40 expenditures  
            reviewed from FYs 2009-10 through 2013-14, DPH expenditures  
            were in accordance with federal requirements, and the amounts  
            spent were found reasonable. Additionally, despite a concern  
            that was raised about the relationship between DPH diabetes  
            and tobacco control programs, the report found DPH has not  
            spent its limited diabetes funds on tobacco cessation  
            activities. The Auditor recommended that the state 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.

          6)Related legislation. AB 2782 (Bloom), would have imposed a  
            health promotion fee of $0.02 per fluid ounce on bottled sugar  
            sweetened beverages (SSBs) and concentrates, and established  








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            the Healthy California Fund from which moneys would be  
            allocated to various state departments for purposes of  
            reducing the incidence and impact of diabetes, obesity, and  
            dental disease in California. AB 2782 failed without being  
            heard in the Assembly Health Committee. 

            AB 2424 (Gomez), would, among other things, create the  
            Community-based Health Improvement and Innovation Fund in the  
            State Treasury from which moneys would be available, upon  
            appropriation by the Legislature, for certain purposes,  
            including, but not limited to, reducing health inequity and  
            disparities in the rates and outcomes of priority chronic  
            health conditions, including diabetes. AB 2424 is pending on  
            the Senate Floor.

          7)Prior legislation. SB 203 (Monning, of 2015), would have  
            required a safety warning to be affixed to SSBs that states  
            "STATE OF CALIFORIA SAFETY WARNING: Drinking beverages with  
            added sugar(s) contributes to obesity, diabetes, and tooth  
            decay." SB 203 failed in the Senate Health Committee. 

            AB 1357 (Bloom, of 2015), was substantially similar to AB  
            2782. AB 1357 failed passage in the Assembly Health Committee.

            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, that includes 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 Department of Motor Vehicles to sponsor a diabetes  
            awareness, education, and research specialized license plate  
            program; established the Diabetes Awareness Fund; and  
            specified that revenues from the fund would 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  








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            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, 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; and 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.  
            
          8)Support. The cosponsors and other supporters of this bill cite  
            information from the National Institutes of Health and the CDC  
            that states over half of all Asian Americans with diabetes are  
            undiagnosed. Supporters argue that this measure will help  
            doctors be aware of the appropriate screening guidelines for  
            Asian Americans; help Asian Americans be more aware of their  
            risk for developing diabetes; lead to earlier treatment and  
            intervention to manage and care for diabetes; and allow those  
            with prediabetes the opportunity to reverse their diabetes and  
            avoid it completely.
          
           SUPPORT AND OPPOSITION  :
          Support:  Asian American, Native Hawaiian, and Pacific Islander  
                    Diabetes Coalition (cosponsor)
                    American Federation of State, County and Municipal  
                    Employees (AFSCME), AFL-CIO
                    National Council of Asian Pacific Islander Physicians  
                    (cosponsor)
                    American Diabetes Association
          
          Oppose:   None received

                                      -- END --
          
          
          










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