BILL ANALYSIS
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
354 (Arambula)
Hearing Date: 8/12/2010 Amended: 6/23/2009
Consultant: Katie Johnson Policy Vote: Health 9-0
_________________________________________________________________
____
BILL SUMMARY: AB 354 would delete certain age limits for
specified childhood immunizations required for admission to
schools.
_________________________________________________________________
____
Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12 2012-13 Fund
Medi-Cal vaccination likely $0 $300 - $875 $300 -
$875 General/*
administrative fee Federal
School reimbursement likely $0 up to $400up to
$400 General**
for vaccine confirmation
Potential increased ADA likely $0 $50 - $550$50 -
$550 General**
*Costs would be shared 50 percent General Fund and 50 percent
federal funds.
**Counts toward Proposition 98 guarantee
*** Since potential costs to this bill would occur only if CDPH
made a decision to promulgate regulations to update its
immunization requirements, the fiscal years in which potential
costs and savings would occur are unknown and would depend on
when CDPH regulations went into effect.
_________________________________________________________________
____
STAFF COMMENTS: SUSPENSE FILE. AS PROPOSED TO BE AMENDED.
Existing law prohibits a school from admitting any person as a
pupil unless he or she has been fully immunized, as specified.
Some of the diseases need not be documented based on the age of
the child.
This bill would delete those specified age restrictions in
statute. The changes would be as follows. Currently, school
districts need not document:
1) Haemophilus influenzae type b for children over 4 years
and 6 months of age,
2) Mumps for children over seven years of age,
3) Pertussis (whooping cough) for children over seven years
of age, and,
4) Hepatitis B for all children above the kindergarten
level.
The California Department of Public Health (CDPH) uses both
statute and regulation to define "fully immunized." Although
this bill would eliminate age restrictions in statute, they
would continue to exist in regulation. The deletions of the age
restrictions in this bill would permit CDPH to modify the
existing immunization requirements via regulations for those
diseases that were age restricted. Without this bill, CDPH would
not be able to administratively promulgate regulations to update
the requirements in regulation. With
Page 2
AB 354 (Arambula)
the passage of this bill, CDPH could make an administrative
decision to update its regulations to align them with the
Centers for Disease Control and Prevention (CDC) recommendations
for childhood vaccinations.
The existing immunization requirements in regulation generally
follow the vaccine schedule recommended by the CDC. Of the
diseases with age restrictions listed above, pertussis is the
only disease for which the CDC recommends a vaccine that CDPH is
currently restricted by statute from adding to its regulations.
The CDC recommends that a child aged 11 or 12 years receive a
pertussis booster shot, also known as Tdap, a vaccine for
tetanus, diphtheria, and acellular pertussis. Additionally, CDPH
regulations currently recommend, but do not require, that
children entering 7th grade receive a Td shot, a vaccine against
tetanus and diphtheria. The CDC now recommends Tdap in lieu of
Td.
According to a June 23, 2010, CDPH press release that urges the
population to get vaccinated for pertussis, pertussis infections
affect the population in cycles that peak every two to five
years. The last peak in California was in 2005 with 3,182 cases
reported and seven deaths. As of June 15 of this year, 910 cases
have been reported and five infants have died. The CDPH website
advises Californians that children need 5 doses of DTaP vaccine
by kindergarten (ages 4-6) and one dose of Tdap booster by age
11 or 12. It also recommends Tdap for teens and adults up to age
65.
Since this bill is not specific to pertussis, it would also give
CDPH flexibility to be able to update its regulations in the
future to conform with any updated CDC recommendations with
regard to those diseases specified in statute.
This bill would also update the names of the entities whose
guidelines CDPH is required to consider when deeming vaccines
for additional diseases appropriate for requirement and would
add the American Academy of Family Physicians to that list.
Medi-Cal Potential Costs and Savings
If CDPH made an administrative decision to update its
regulations to require all 7th graders to have received a
pertussis booster shot prior to entering school, there would be
costs to the Medi-Cal program, which pays a $9 administrative
fee to physicians who administer vaccines to Medi-Cal
beneficiaries. All other costs related to vaccines for Medi-Cal
beneficiaries under age 19 are paid for by the federally-funded
Vaccines for Children program.
Based on 2006 Medi-Cal counts, 188,379 children were 11 years
old. Also, according to January 2009 Medi-Cal population data,
an average of approximately 140,000 were in each age year for
children aged 11 - 18. According to a 2008 National Immunization
Survey of 13 - 17 year old immunization rates, approximately
43.7 percent of California adolescents had received the Tdap
vaccine and 71.3 percent had received either the Td or Tdap
vaccine. To achieve a benefit to the population where there are
enough people vaccinated against pertussis to where their
immunization would protect those people
Page 3
AB 354 (Arambula)
who were not immunized, referred to as "herd immunity",
approximately 90 - 95 percent of the population must be
vaccinated against pertussis.
Assuming 1) there were 140,000 - 190,000 7th grade Medi-Cal
beneficiaries in any given year, 2) that 43.7 percent of them
would have been vaccinated with Tdap without this bill, and 3) a
goal to immunize 95 percent of the population, costs to
vaccinate 51.3 percent of Medi-Cal 7th graders would be
approximately $645,000 - $875,000 in total funds, or $325,000 -
$440,000 in General Funds and $325,000 - $440,000 in federal
funds.
As mentioned above, 71.3 percent of California adolescents had
received either Td or Tdap in 2008. The CDC now recommends Tdap
in lieu of Td. For those children who would receive the
recommended Td vaccination prior to 7th grade, costs would be
neutral, essentially an exchange of a shot for a shot. Assuming
1) there were 140,000 - 190,000 7th grade Medi-Cal beneficiaries
in any given year, 2) that 71.3 percent of them would have been
vaccinated either with Td or Tdap without this bill, 3) that
those who would have received Td would now receive Tdap upon the
passage of this bill, and 4) a goal to immunize 95 percent of
the population, costs to vaccinate 23.7 percent of Medi-Cal 7th
graders would be approximately $300,000 - $405,000 in total
funds, or $150,000 - $200,000 in General Funds and $150,000 -
$200,000 in federal funds.
In addition to the predictions above, it is also possible that a
Medi-Cal beneficiary may have received a Tdap booster shot, but
does not appear in Medi-Cal claims data. For example, county
health departments and clinics often offer free vaccines to the
public. If Medi-Cal beneficiaries received the vaccine through a
means other than a Medi-Cal physician, costs to the program
could be less than estimated above.
If CDPH chose to require Tdap upon admission to 7th grade and
promulgated the regulation to require the whole cohort of
adolescents aged 11-18 in Medi-Cal to receive a catch-up Tdap
shot in order to attend school in the fall of the fiscal year in
which CDPH adopted the regulation, there could be a significant
one-time cost to Medi-Cal in an amount up to 6 times that
predicted for a single cohort of 7th graders. However, the
potential of savings would increase since inoculating all
adolescent Medi-Cal beneficiaries could significantly decrease
the risk that Medi-Cal would need to treat pertussis in the
future for this population.
There could be unknown, potentially significant future Medi-Cal
savings to the extent that this immunization requirement led to
decreased incidences of disease, diagnosis, treatment,
hospitalization, and death of Medi-Cal beneficiaries.
School Potential Costs
In 2000, the Commission on State Mandates approved reimbursement
for schools that were required to check that 7th graders had
received their Hepatitis B vaccination. Reimbursement was
approved at approximately $4.42 per dose for 2008-2009. Costs
could be similar for requiring that schools check for pertussis
vaccination prior to 7th grade entrance. However, the Hepatitis
B vaccination is given in 3 doses; Tdap is only
Page 4
AB 354 (Arambula)
one. Therefore, staff estimates that it is reasonable to assume
that schools could be reimbursed at about $1.47 per dose. In a
February 2010 report by the Legislative Analyst's Office on
reforming state reimbursement of K-14 school mandates that
discussed the funding, modification, and elimination of the
mandates, it was recommended that the state fund school
immunization mandates, including the 7th grade check for
Hepatitis B.
According to the California Department of Education's website,
there were about 480,000 7th graders in California in 2008-2009.
If CDPH were to require schools to check and document for an
additional vaccine upon entrance to 7th grade, such as the
pertussis booster, at $1.47 - $4.42 per dose, it could cost
approximately $706,000 - $2.1 million annually. Additionally, if
CDPH were to require schools to not only annually check 7th
graders for pertussis immunization, but were to also require
them to check and document pertussis immunization for all of
California's estimated 2.5 million children in 8th - 12th grades
to ensure as many children were immunized as possible, it could
cost approximately $3.7 million - $11.1 million one-time.
Ongoing, annual costs would only be the 7th grade cost. The
Commission on State Mandates could determine that this would be
a reimbursable mandate.
Additionally, to the extent that this bill would prevent
children from missing days of school due to illness, the state
could incur costs of approximately $33 per student per day. The
incidence of pertussis varies from year to year and from state
to state. The following estimate is based of a range of 10 to
130 in 100,000 students. If 10 in 100,000 students were to no
longer miss an average of 5.5 days, as reported by
Massachusetts,
of school annually for pertussis, the state could need to pay
school districts an additional $50,000 in average daily
attendance (ADA) annually. If 130 in 100,000 students were to no
longer miss an average of 5.5 days of school annually for
pertussis, the state could need to pay school districts an
additional $550,000 in average daily attendance (ADA) annually.
The proposed author's amendments would, commencing July 1, 2011,
delete the requirement that schools check that all 7th graders
have been immunized against Hepatitis B. They would also require
that schools check that all 7th graders have been immunized
against pertussis. In FY 2007-2008, 517 of 1084 school districts
submitted claims for the Hepatitis B immunization verification
at a cost of $1.7 million. Staff estimates that the pertussis
7th grade verification could be $706,000 - $2.1 million
annually. Exchanging one mandate for another could significantly
reduce the costs of the school mandate portion of this bill.
Additionally, there could be potential savings to the state to
the extent that an increase in the number of Californians fully
vaccinated against pertussis would prevent cases of pertussis
for which Medi-Cal pays claims. In 2009, 658 fee-for-service
Medi-Cal beneficiaries received treatment for pertussis at a
cost of $1.7 million total funds. 89 percent of those cases were
diagnosed in individuals aged 0-20 years of age and they
accounted for the majority of the claims costs. In 2010, as of
7/27/2010, 2,174 cases of pertussis have been reported in the
state. This number is 6 times that during the same period in
2009. If one were to assume that Medi-Cal claims for
fee-for-service beneficiaries in 2010 would be 6 times that in
2009, total costs would be $10.2 million.