BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 1640
A
AUTHOR: Evans, Nava
B
AMENDED: June 21, 2010
HEARING DATE: June 30, 2010
1
CONSULTANT:
6
Tadeo/
4
0
SUBJECT
Breast and cervical cancer screening
SUMMARY
Establishes additional requirements, including age
requirements, in order for a client to receive services
under the Every Woman Counts (EWC) program. Requires the
Department of Public Health (DPH), 90 days prior to making
policy changes to the EWC program, to send written notice
outlining the proposed changes to contractors providing
services, and to notify the Legislature if these changes
would restrict access or reduce services offered.
Replicates provisions in the Revenue and Taxation Code,
relating to the Breast Cancer Fund, in the Health and
Safety Code.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes 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 breast cancer screening and diagnostic
services for eligible women, 40 years of age and older.
Continued---
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Existing state law:
Under the Every Woman Counts (EWC) program, requires that a
provider or entity that participates in the NBCCEDP may
provide screening services to an individual only if the
individual's family income has been determined not to
exceed 200 percent of the federal poverty level.
Requires DPH to provide breast cancer and cervical cancer
screening services under the federal grant at the level of
funding budgeted from state and other resources. These
screening services are deemed not to be an entitlement.
Establishes a two-cent 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.
Requires every individual or group policy of disability
insurance or self-insured employee welfare benefit plan, to
provide coverage to a patient, upon referral, for breast
cancer screening or diagnostic purposes. This includes, at
the least:
A baseline mammogram for women age 35 to 39;
A mammogram for women age 40 to 49 every two years,
or more frequently based on the woman's physician's
recommendation; and,
A mammogram every year for women age 50 and over.
This bill:
Requires a person who receives breast or cervical cancer
screening through the EWC program, in addition to current
requirements established in existing law, to meet the
following:
Be 40 years of age or older to receive breast
cancer screening services;
Be 25 years of age or older to receive cervical
cancer screening services;
Be uninsured or underinsured, as defined in
existing law; and,
Be a resident of California.
Requires DPH, 90 days prior to making policy changes
relating to the EWC program to
send a written notice outlining the proposed changes to
contractors providing services pursuant to the program; and
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to notify the Legislature, in writing, if those changes
would restrict access or reduce the services offered.
Establishes a deadline, on or before February 1 of each
year, for DPH to submit an annual report regarding the EWC
program required by existing law, to the Legislature and
any other appropriate entity.
Requires the cost per individual served, and information
provided to the CDC on the number of individuals served
based on the federal funds provided, to be included in the
annual report.
Replicates provisions in the Revenue and Taxation Code,
relating to the Breast Cancer Fund, in the Health and
Safety Code.
States findings and declarations regarding the EWC program.
FISCAL IMPACT
According to the Assembly Appropriations Committee analysis
of AB 1640, this bill would result in an annual unknown
appropriation in the range of $55 million (90 percent
special fund and 10 percent federal fund), to provide
breast cancer screening services to approximately 240,000
women in California. According to the analysis, this
projection is reflective of the range of actual spending
and screening caseloads over the past eight years.
BACKGROUND AND DISCUSSION
In December 2009, DPH announced two significant policy
changes, effective January 1, 2010, to the EWC program: (1)
The age eligibility for breast cancer screening was changed
from 40 to 50 years of age; and, (2) All new enrollments
for breast cancer screening services were suspended until
July 1, 2010.
According to the author, primary care providers, hospitals,
community clinics, breast cancer programs, family resource
centers, health centers, and various health advocacy
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organizations throughout the state reported a lack of
sufficient notice to implement these changes for the
preparation, planning, and mitigation of these changes.
The author adds that these policy changes immediately
disqualify nearly half of all women who rely on the EWC
program for breast cancer screening; decrease the number of
screenings and thus the number of detected breast cancer
cases; disproportionately affect women from low-income
communities of color; place lower-income, uninsured and
underinsured women, both under and over the age of 50, at
increased risk for breast cancer mortality; and shift the
financial burden of screening and diagnosis to local
community clinics and county health facilities, already
struggling to serve their current clients.
Every Woman Counts
The EWC program, which is administered by DPH provides
breast and cervical cancer screening services to low-income
California women. To be eligible for services a woman
must:
Have no health insurance.
Have a co-payment or deductible she cannot afford.
Have a family income below 200 percent of the
federal poverty level.
Have had a previous breast cancer screening and/or
cervical cancer screening through the program.
Not receive these services through Medi-Cal or
another government insurance program.
Be 50 years of age or older.
Breast cancer screening under the program includes clinical
breast exams, screening mammograms, and diagnostic work
ups. It may also include additional screening or
diagnostic procedures, if an exam or mammogram is found to
be abnormal. Cancer treatment is not covered by this
program. If a cancerous condition is found, treatment
services are provided through a federal Medicaid program
(the Breast and Cervical Cancer Treatment Program). The
state's breast cancer treatment program under Medi-Cal has
a state-only component for women who do not qualify for
federal financial participation; treatment for women in the
state-only program is limited to 18 months.
The EWC program also provides cervical cancer screening and
diagnostic services to women age 25 and over who meet
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similar eligibility criteria.
Every Woman Counts program funding
Funding for the EWC program is provided by a combination of
three federal and state funding sources:
Proposition 99 funds, which provided $22.1 million
in FY 2009-10,
Breast Cancer Control Account funds, a two-cent
tobacco tax revenue, of which 50 percent is
appropriated to the program and 50 percent to UC for
California-specific breast cancer research. These
funds provided $18.2 million in local assistance and
$8.4 million in state support in FY 2009-10; and,
CDC federal funds, which provided $6.3 million for
breast and cervical cancer screening combined in FY
2009-10.
Federal grants through the CDC must be matched by $1 of
nonfederal resources for each $3 of federal funds. The CDC
also requires 60 percent of the federal funds to be spent
on providing direct breast cancer screening and diagnostic
services, and requires 75 to 100 percent of clients served
to be 50 years of age or older.
The EWC program does not receive General Fund (GF) support
and is facing a funding shortage as a result of increasing
caseload and decreasing tobacco tax revenue. In order to
address this shortfall, DPH made two policy changes to the
program in December, 2009: (1) A permanent increase in the
minimum age eligibility for breast cancer screening
services from age 40 to age 50; and, (2) A temporary
six-month enrollment freeze for all women seeking breast
cancer services from January 1, 2010 through June 30, 2010.
DPH estimates that 350,000 women will seek services through
EWC during the 2009-10 budget year, and estimate these two
policy changes will result in approximately 100,000 fewer
women being served by the program. The projected savings
from these actions is $16 million in the current year and
$25 million in the budget year.
The Governor has also proposed to shift Proposition 99
funds supporting the program to Medi-Cal in the FY 2010-11
budget, which would result in the loss of $22.1 million for
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the program.
A proposed budget conference compromise, currently under
consideration, would:
Provide a funding increase of $20.1 million (GF) to
the EWC to provide access to breast cancer screening
for women 40 years of age and over. The $20.1 million
figure is based upon the most recent data available
and was reviewed by the Legislative Analyst's Office
(LAO) and the Department of Finance.
Adopt LAO recommendation to implement a two-tier
case management approach and only reimburse providers
$50 for follow-up case management when a breast cancer
screen is abnormal. Currently, a $50 case management
payment is given to all providers. This
recommendation would save $13.7 million (GF).
Bureau of State Audits
As requested by the Joint Legislative Audit Committee, the
Bureau of State Audits recently completed an audit of the
EWC program. The June 10, 2010 audit report concludes
that:
DPH could do more to maximize the funding available
to pay for breast and cervical cancer screening
services;
Although total tobacco tax revenues supporting the
EWC program are declining, and costs to administer the
program are rising, the program provides services at
the level of funding appropriated by the Legislature.
When it requested $13.8 million in additional
funding from the Legislature in June 2009, DPH claimed
that redirecting funds from other areas of the EWC
program-such as efforts aimed at providing health
education to women and technical assistance to medical
providers-to pay for additional screening services
would not be possible, given federal requirements, and
would jeopardize federal funding. However, a review
of federal requirements and discussions with the CDC
indicate that DPH has the flexibility to redirect
funding to screening activities without risking the
loss of federal funds.
DPH's ability to identify and redirect funds toward
paying for clinical aspects of the EWC program is
hampered by the fact that it does not know how much
its contractors are spending on specific activities.
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As a result, in an environment of scarce fiscal
resources, DPH lacks a basis to know whether paying
for certain contract activities is a better use of
funds than paying for additional mammograms or other
screening procedures.
The audit report also states that DPH should do more to
improve the public transparency and accountability with
which it administers the EWC program. For example:
State law requires DPH to develop regulations to
implement the EWC program in a manner that considers
the public's input. However, nearly 16 years after
the program began, such regulations still have not
been developed. According to the audit report, DPH
has cited staff and funding limitations as the cause
for the delay.
State law also requires DPH to report on the
activities and effectiveness of the EWC program and to
submit an annual report to the Legislature. Although
DPH has provided information on an ad hoc basis,
including during the state's budgetary process, it has
provided only one formal report to the Legislature-in
August 1996.
The audit report concludes that this lack of information on
the effectiveness of the EWC program limits DPH's ability
to effectively advocate for appropriate funding and hampers
the Legislature's and the public's ability to exercise
effective oversight.
Office of State Audits and Evaluations (OSAE)
DPH requested that the Department of Finance, Office of
State Audits and Evaluations, review DPH's fiscal processes
involved in the receipt of funding for the EWC program and
related expenditures. Additionally, DPH requested
recommendations be provided to streamline and improve
revenue and expenditure processes. The review confirmed
that DPH does not have adequate processes in place to
monitor or project current and/or future obligations of
resources, and the most far-reaching and mission critical
weaknesses are program governance, decreasing revenues, and
increasing program expenditures.
The report recommends that DPH and the Department of Health
Care Services (DHCS) work together to implement a system of
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assigning each beneficiary a unique identifier and/or
implement controls to prevent duplicate beneficiaries from
being input into the system. Doing so would prevent or
mitigate opportunities for duplicate billings of fees by
Primary Care Providers. Additionally, it is recommended
both DPH and DHCS as well as internal units within DPH
improve governance processes to ensure effective
communication, coordination, and management of the EWC
program.
Breast cancer and screening
According to the American Cancer Society, breast cancer is
the most commonly diagnosed cancer among women in the
United States, after skin cancer, and the second most
common cause of cancer death, after lung cancer. The
American Cancer Society estimates for breast cancer in the
United States for 2009 include 92,370 new cases of invasive
breast cancer diagnosis, 62,280 new cases of carcinoma in
situ (the earliest form of breast cancer), and 40,170
deaths from breast cancer.
The American Cancer Society reports that death rates from
breast cancer have been declining since 1990, with larger
decreases occurring in women younger than 50. These
decreases are believed to be the result of earlier
detection through screening and increased awareness, as
well as improved treatment. Women of color are less likely
to be diagnosed with breast cancer and are more likely to
die from the disease.
National breast cancer screening guidelines and safety
Several organizations have adopted evidence-based national
recommendations for breast cancer. The U.S. Preventive
Services Task Force (USPSTF) issued new screening
guidelines in November 2009 that recommend against routine
mammography screening in women 40 to 49 years of age and
instead recommend screening every other year for women 50
to 74 years of age. The USPSTF states that, "while there
is evidence that screening with film mammography reduces
breast cancer mortality, there is a greater absolute
reduction for women aged 50 to 74 years than for younger
women." The USPSTF reports that harm due to screening
includes false-positive results, additional medical visits
and imaging, biopsies in women without cancer, and
unnecessary treatment and radiation exposure. These
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recommendations apply to women who are not at increased
risk for breast cancer by virtue of a known underlying
genetic mutation or history of chest radiation.
The USPSTF recommendations also state that the decision to
start regular, biennial mammography screening in women
before age 50 should be an individual one and take patient
context into account, including the patient's values
regarding specific benefits and harms. The American
Academy of Family Physicians and the American College of
Physicians guidelines are similar to the USPSTF guidelines.
The American Cancer Society continues to recommend annual
screening using mammography and clinical breast examination
for all women beginning at age 40, and that women with a
higher risk of breast cancer consult a doctor about the
best approach for them, which could mean starting
mammograms when they are younger, having extra screening
tests, or having more frequent exams. The American Medical
Association and the College of Obstetrics and Gynecology
follow similar guidelines.
Both the USPSTF and the American Cancer Society find that
mammography has limitations - some women who are screened
will have false positive results, some cancers will be
missed, and some women will undergo unnecessary treatment,
and agree that the overall effectiveness of mammography
increases with increasing age.
Due to the number of women diagnosed with breast cancer
prior to 50 years of age, concerns about the USPSTF
recommendation prompted the United States Senate to approve
legislation that requires insurers to offer free mammograms
and other preventive services to women. This amendment and
legislation has not been finalized by Congress.
Related bills
SB 836 (Oropeza) would appropriate an unspecified amount of
GF monies to DPH for the screening of individuals of any
age who exhibit breast cancer symptoms, as determined by a
physician, and to individuals who are 40 years of age or
older, provided the individual otherwise meets state
eligibility requirements. This bill is on the suspense file
in the Senate Appropriations Committee.
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AB 113 (Portantino) requires health care service plan
contracts and health insurance policies that are issued,
amended, delivered, or renewed on or after July 1, 2011 to
provide coverage for mammography for screening or
diagnostic purposes upon referral of certain health care
professionals, regardless of age. This bill is in the
Senate Appropriations Committee.
Prior legislation
Prior federal legislation
The National Breast and Cervical Cancer Mortality Reduction
Act of 1990 establishes the National Breast and Cervical
Cancer Early Detection Program and authorizes the CDC to
create grants for states for screening services for
eligible women.
Prior state legislation
SB 1348 (Cedillo) of 2008 would have required DPH to
extend eligibility for breast cancer screening under the
EWC program for women under age 40 determined to be at high
risk for the disease. This bill was held in Senate
Appropriations Committee.
AB 359 (Nava), Chapter 435, Statutes of 2009, permits a
provider for the EWC program to employ and be reimbursed
for digital mammography commencing January 1, 2010.
AB 2887 (Berg) of 2008 would have provided that the
definition of "treatment services" for purposes of the
Breast and Cervical Cancer Treatment Program also includes
digital and analog mammography, where mammography services
are otherwise covered under the program. This bill was
held in Assembly Appropriations Committee.
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. This bill was held in the Assembly
Appropriations Committee.
AB 2055 (B. Friedman), Chapter 661, Statutes of 1993, the
Breast Cancer Act of 1993, establishes the Breast Cancer
Control Account for purposes of breast cancer research,
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detection services and education, and modifies the
allocation of tobacco tax funds so that 50 percent of the
funds are devoted to research and 50 percent for early
detection services for uninsured and underinsured women.
AB 478 (B. Friedman), Chapter 660, Statutes of 1993,
establishes a two-cent 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.
Arguments in support
Proponents of AB 1640 state that low-income, uninsured and
underinsured women who rely on the safety net services
provided by the EWC program have few, if any alternatives
for potentially life-saving breast cancer screening,
diagnostic, and treatment services. Proponents add that,
without access to the EWC program, many of these women will
not get screened, leading to later diagnosis, more advanced
cancers, and higher rates of mortality. Proponents contend
that this bill addresses what is literally a life and death
health issue.
Arguments in opposition
The Department of Finance analysis of AB 1640 states that
the 2010-11 Governor's Budget includes a contingency
proposal that redirects Proposition 99 revenue to the
Medi-Cal program if a certain level of funding is not
awarded to California. The analysis adds that, if this
money is redirected, as proposed, the cost to implement
this bill would put additional pressure on the GF. The
analysis also states that the recent policy changes were
the result of a decline in available resources, and were
meant to sustain a full year of services. The analysis
further states that current funding sources are expected to
continually decline throughout the next fiscal year, likely
resulting in another enrollment freeze.
PRIOR ACTIONS
Assembly Health: 15- 0
Assembly Appropriations: 12- 5
Assembly Floor: 61-13
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POSITIONS
Support: American Congress of Obstetricians and
Gynecologists, District IX (co-
sponsor)
Susan G. Komen for the Cure, California
Collaborative (co-sponsor)
American Cancer Society
Association of California State Supervisors
American Federation of State, County and Municipal
Employees
Bay Area Women's Health Advocacy Council
Bay Bio
Between Women
Breast Cancer Network of Strength
California Breast Cancer Organizations
California Health Care Collaborative
California Primary Care Association
California State Employees Association
California State University Employees Union
Community Health Councils
CSEA Retirees, Inc.
Disability Rights Legal Center
Having Our Say Coalition
Latina Breast Cancer Agency
Monterey County Board of Supervisors
Susan G. Komen for the Cure, California Affiliates
The Elizabeth Center for Cancer Detection, Board of
Directors
Western Center on Law & Poverty
Young Survival Coalition
Oppose: Department of Finance
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