BILL ANALYSIS
AB 1640
Page 1
Date of Hearing: March 23, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1640 (Evans and Nava) - As Introduced: January 11, 2010
SUBJECT : Breast and cervical cancer screening.
SUMMARY : Reverses new administrative policy changes regarding
eligibility and enrollment requirements for breast cancer
screenings covered under "Every Woman Counts" (EWC), a state
program designed for low-income women who are uninsured or
underinsured. Specifically, this bill :
1)States legislative intent that screening services provided
under EWC meet the demand based on eligibility requirements in
place prior to January 1, 2010.
2)Requires the Department of Public Health (DPH) to provide
notification to the Joint Legislative Budget Committee at
least 90 days prior to changing eligibility requirements for
EWC services or reducing access to EWC screening services.
3)Appropriates an unspecified amount to DPH to fund the EWC
program.
EXISTING LAW :
1)Establishes in federal law the Breast and Cervical Cancer
Mortality Prevention Act of 1990 which creates the National
Breast and Cervical Cancer Early Detection Program (NBCCEDP)
and authorizes the Centers for Disease Control and Prevention
(CDC) to administer grants to states for screening services
for underserved eligible women, 40 years of age and older.
2)Establishes the California Breast Cancer Act of 1993 within
the California Department of Health Services (now DPH) which
mandates 50% of the revenues collected from a $0.02 tax on
tobacco products towards breast cancer control.
3)Requires DPH to provide for breast and cervical cancer
screening services under the NBCCEDP grant, at the level of
funding budgeted from state and other resources during the
fiscal year in which the Legislature has appropriated funds
for this purpose. These screenings are provided under the EWC
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program and are not deemed an entitlement.
4)Establishes in federal law the Breast and Cervical Cancer
Prevention and Treatment Act of 2000 which provides states the
option to provide medical assistance through Medicaid to
eligible women who are screened for and found to have breast
or cervical cancer, including precancerous condition, through
the NBCCEDP.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the authors, in December
of 2009, in response to an evolving budget crisis within the
EWC program, DPH announced two significant policy changes
effective January 1, 2010 that restrict access to the EWC
program: a) a permanent increase in the minimum age
eligibility for breast cancer screening services from age 40
to 50; and, b) a temporary six-month enrollment freeze for all
women seeking breast cancer screening services from January 1
through June 30, 2010. According to the authors, these two
changes will deny or delay services to approximately 100,000
women, putting an estimated 1,000 lives at risk by delaying
breast cancer diagnosis. The authors maintain that DPH made
these very significant changes to the program without seeking
the customary input from the Legislature or the breast cancer
advocacy community. The authors also maintain that since the
policy changes have taken effect, primary care providers,
hospitals, community clinics, breast cancer programs, family
resource centers, health centers, and various advocacy
organizations throughout the state have reported adverse
impacts including: a) the disqualification of nearly half of
all women who rely on the EWC to receive breast cancer
screenings; b) a decrease in the number of screenings and thus
the number of detected breast cancer cases; c) a
disproportionate impact on women from low-income communities
of color who depend primarily on receiving breast cancer
screenings through EWC; d) an increased risk of breast cancer
mortality for women both under and over age 50; and, e) a
shift in the financial burden onto local community clinics and
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county health facilities for breast cancer screening and
diagnosis.
2)BACKGROUND . According to a California Cancer Registry report,
"Female Breast Cancer in California, 2005," among women,
breast cancer is the most commonly diagnosed cancer and the
second most common cause of cancer death. Each year more than
25,000 California women develop breast cancer, and more than
4,000 California women die from the disease. According to the
California Breast Cancer Research Program (CBCRP), because of
early detection through widespread mammogram screening, a
California woman diagnosed with breast cancer today has a
better chance of surviving than in the past. Since 1973,
according to the CBCRP, the breast cancer death rate in
California has dropped 20%. However, California women are
more likely to get breast cancer today than in 1973.
While the death rate for breast cancer has dropped, the gains
have not been shared equally among all women. Minority and
low-income women are less likely than other women to be
diagnosed at an early stage, receive effective treatment, and
survive the disease. According to CBCRP, white women are most
likely to get the disease, followed closely by
African-American women, then Asian Pacific Islander women,
with the lowest rate among Hispanic women. African-American
women have the highest death rate, even though they are less
likely than white women to get the disease. Death rates for
Asian Pacific Islander and Hispanic women, although they were
lower to begin with, have not improved in recent years.
According to CBCRP, low-income women are less likely to
survive breast cancer, in part because their tumors are more
likely to be caught later, when treatment is less successful.
3)EVERY WOMAN COUNTS PROGRAM . The EWC program provides free
breast and cervical cancer screening services to low-income,
uninsured, and underinsured women. Administered by The Cancer
Detection Section at DPH, the EWC serves approximately 350,000
women per year of the approximately 1.2 million that are
eligible for breast cancer screening services through the
program in California. Prior to January 1, 2010 the
eligibility requirements for EWC were as follows: a) must have
been 40 years of age or older (25 years or older for cervical
cancer); b) lived in California; c) had no health insurance or
had a co-payment or a deductible that was not affordable; and,
d) had a family income below 200% of the federal poverty
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level. According to the CDC, of those women who received
mammography screening in California through the EWC program
from July 2003 to June 2008, 45.1% were between the ages of
40-49.
Under EWC, almost 1,000 health care providers and doctors
provide breast cancer screening services which include
clinical breast exams, screening mammograms, and diagnostic
work-ups. Breast cancer screening, under EWC, may also
include additional screening or diagnostic procedures if an
exam or mammogram is found to be abnormal. Cancer treatment
is not covered under this program. If a cancerous condition
is found, treatment services are available through the federal
Medicaid program, the Breast and Cervical Cancer Treatment
Program.
4)EVERY WOMAN COUNTS BUDGET . The EWC program receives no
General Fund support and is funded by the federal Breast and
Cervical Cancer Mortality Prevention Act of 1990 (Public Law
101-354), the California Breast Cancer Act of 1993 and
Proposition 99 tobacco tax funds. The program's 2009-10
budget is as follows:
-----------------------------------------------------------
| FUND | FY 2009-10 |
-----------------------------------------------------------
|----------------------------------------+-------------+---|
|Prop 99 (Local Assistance) | $22,081,000| |
|----------------------------------------+-------------+---|
|Breast Cancer Control Account (Local | $18,236,000| |
|Assistance) | | |
|----------------------------------------+-------------+---|
|Breast Cancer Control Account (State | $8,373,000| |
|Support) | | |
|----------------------------------------+-------------+---|
|State Funding Total | $48,690,000| |
|----------------------------------------+-------------+---|
|CDC Federal Grant | $6,324,811| |
|----------------------------------------+-------------+---|
|Total Funding | $55,014,811| |
----------------------------------------------------------
According to DPH, the EWC program is currently facing
unprecedented fiscal challenges as a result of increasing
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demand for breast cancer screening services and declining
state tobacco tax revenues, the primary source of funding for
the program. DPH further states that, even though the state
has redirected resources to provide short-term funding
increases for the program over the past few years, these
increases have not been enough to keep pace with the growing
demand for and cost of providing breast cancer screening
services to women in the EWC program.
According to DPH, the projected savings from the two policy
changes that are the subject of this bill is $16 million in
the current year and $25 million in the budget year. The
Governor also proposed in his January 2010 budget an
additional reduction to this program of $5.2 million in Breast
Cancer Control Account funds. Should the state not receive
the Administration's targeted federal funding threshold, the
Governor's budget proposes to eliminate the program
altogether.
The authors of this bill have requested the Office of
Statewide Audits and Evaluations, within the Department of
Finance, to complete a financial audit of the EWC program in
time for incorporation into the 2010-2011 budget. The audit
request poses two primary questions: a) How has the EWC
program ended up in such extreme budget crisis? and, b) Over
the past several years, has the program operated in an
efficient way, making the most of the funding it has received?
5)NATIONAL GUIDELINES . On November 16, 2009, the United States
Preventive Services Task Force (USPSTF), a group of experts
that makes recommendations on policies to prevent diseases,
issued revised guidelines for mammography recommending
biennial mammography screenings beginning at age 50 instead of
40. Leading cancer organizations, including the American
Cancer Society (ACS), the Mayo Clinic, the Susan G. Komen for
the Cure, and the National Breast Cancer Foundation, however,
are not changing their policies of recommending annual
mammography screenings for women when they turn 40 years old.
According to the chief medical officer of ACS, the
organization continues to recommend annual screening using
mammography and clinical breast examination for all women
beginning at age 40. He further states that ACS experts make
this recommendation having reviewed virtually all the same
data reviewed by the USPSTF, but also additional data that the
USPSTF did not consider. DPH maintains that their recent
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policy changes to the EWC program had nothing to do with the
USPSTF guideline changes.
6)SUPPORT . The Susan G. Komen for the Cure Affiliates (Komen
Affiliates) state that low-income, uninsured, and underinsured
women who rely on this vital safety net program have few, if
any, alternatives for potentially life-saving breast cancer
screening, diagnostic and treatment services. According to
the Komen Affiliates, without access to EWC, many of these
women will not get screened, leading to later diagnosis, more
advanced cancers, and lower chances of survival. The Komen
Affiliates further argue that this is a life or death issue.
The Western Center on Law and Poverty (WCLP) maintains that
delayed detection will result in increased costs to the state
and county healthcare programs that will pay more to treat
cancers that have reached their later stages. The ACS states
that the timing of DPH's policy changes left scant opportunity
to explore the situation and review alternatives. ACS
maintains requiring that the Legislature be notified of
eligibility changes in advance creates an opportunity for the
Legislature and the community to assess and explore the
situation.
7)RELATED AND PREVIOUS LEGISLATION .
a) SB 836 (Oropeza) requires DPH to provide breast cancer
screening services to individuals of any age who are
exhibiting symptoms, those that are 40 years of age or
older, and those that have been referred by a physician.
SB 836 is currently in the Senate Health Committee.
b) AB 56 (Portantino) of 2009, would have required health
insurers to provide coverage for mammography upon provider
referral by July 1, 2010, and would have required health
plans and health insurers to notify subscribers or
policyholders of recommended timelines for testing. AB 56
was vetoed by Governor Arnold Schwarzenegger stating in his
veto message that this mandate, like other mandates, will
only increase the overall cost of health care.
c) AB 359 (Nava), Chapter 435, Statutes of 2009, authorizes
EWC, until January 1, 2014, to the extent permitted by
federal law, to reimburse for digital mammography screening
at the Medi-Cal reimbursement rate for analog mammography,
and allows an EWC provider to provide digital mammography
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when analog mammography services are not available.
d) AB 2035 (Ma) of 2008 would have declared the intent of
the Legislature to enact in legislation an increase in
funding for mammograms for women participating to the
Breast and Cervical Cancer Early Detection Program. AB
2035 was held in Assembly Rules Committee.
e) AB 2234 (Portantino) of 2008 would have required health
plans and health insurers to provide coverage for screening
and tests to diagnose breast cancer in accordance with
national guidelines, professional standards, and
patient-specific risk. AB 2234 would have also required
health plans and insurers to send a written notice to
specified female enrollees to notify patients of
eligibility for testing. AB 2234 died on the Assembly
Appropriations Committee Suspense File
f) AB 2887 (Berg) of 2008 would have authorized coverage of
digital mammography screening for women covered under EWC,
a state program designed for low-income women who are
uninsured or underinsured. AB 2887 died on the Assembly
Suspense File.
g) SB 1348 (Cedillo) of 2008 would have required DPH to
provide breast cancer screening services to women who are
38 years of age and older and who meet other eligibility
standards for breast cancer screening services under
existing state and federal law. SB 1348 died on the Senate
Appropriations Committee Suspense File.
h) AB 478 (Friedman), Chapter 660, Statutes of 1993,
establishes a $0.02 tax on each pack of cigarettes sold,
with the revenue deposited in the Breast Cancer Fund and
divided equally between the Breast Cancer Research Account
and the Breast Cancer Control Account.
i) AB 2055 (Freidman), Chapter 661, Statutes of 1993,
establishes the Breast Cancer Control Account for purposes
of breast cancer research, detection services and
education; and modifies the allocation of tobacco tax funds
so that 50% of the funds are devoted to research and 50%
for early detection services for uninsured and underinsured
women.
REGISTERED SUPPORT / OPPOSITION :
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Support
American Cancer Society
Between Women, Inc.
Breast Cancer Network of Strength
California Breast Cancer Organizations
Disability Rights Legal Center
Susan G. Komen for the Cure Affiliates
The Elizabeth Center for Cancer Detection
Western Center on Law & Poverty
Young Survival Coalition
Opposition
None on file.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097