BILL ANALYSIS
------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 1640|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
------------------------------------------------------------
THIRD READING
Bill No: AB 1640
Author: Evans (D), et al
Amended: 8/18/10 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 8-0, 6/30/10
AYES: Alquist, Strickland, Aanestad, Cedillo, Leno,
Negrete McLeod, Pavley, Romero
NO VOTE RECORDED: Cox
SENATE APPROPRIATIONS COMMITTEE : 11-0, 8/12/10
AYES: Kehoe, Ashburn, Alquist, Corbett, Emmerson, Leno,
Price, Walters, Wolk, Wyland, Yee
ASSEMBLY FLOOR : 61-13, 6/2/10 - See last page for vote
SUBJECT : Breast and cervical cancer screening
SOURCE : American Congress of Obstetricians and
Gynecologists,
District IX
Susan G. Komen for the Cure, California
Collaborative
DIGEST : This bill requires that women aged 40 years and
older would be eligible for the Every Woman Counts (EWC)
breast and cervical cancer screening program, requires the
Department of Public Health (DPH) to notify providers and
the Legislature of program changes 90 days prior to their
implementation, and requires that DPH must submit its
CONTINUED
AB 1640
Page
2
annual EWC report on or before February 1 of each year and
that the report must include specified information.
ANALYSIS : 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.
Existing state law:
1. 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.
2. Requires the Department of Public Health (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.
3. 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.
4. 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.
A mammogram every year for women age 50 and over.
This bill makes findings and declarations related to the
EWC program and breast cancer statistics and restates that
CONTINUED
AB 1640
Page
3
funding for the EWC would come from the Breast Cancer Fund,
specifies that DPH's annual report to the Legislature on
EWC would be due on or before February 1 of each year and
requires that specified additional information be included
in the report, and requires the report to describe the
activities and effectiveness of the program and shall
include, but not be limited to, the following types of
information regarding those served by the program:
The number.
The ethnic, geographic, and age breakdown.
The stages of presentation.
The diagnostic and treatment status.
The coverage cost per individual served.
Information provided to the CDC on the number of
individuals served based on the federal funds provided.
Background
Every Woman Counts (EWC)
The EWC program, 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
CONTINUED
AB 1640
Page
4
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
similar eligibility criteria.
EWC 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
fiscal year (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 the University of California
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.
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.
CONTINUED
AB 1640
Page
5
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
the program.
A proposed budget conference compromise, currently under
consideration:
1. Provides 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.
2. Adopts 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 will 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:
1. DPH could do more to maximize the funding available to
pay for breast and cervical cancer screening services.
2. 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.
CONTINUED
AB 1640
Page
6
3. 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.
4. 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. 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:
1. 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.
2. 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
CONTINUED
AB 1640
Page
7
to effectively advocate for appropriate funding and hampers
the Legislature's and the public's ability to exercise
effective oversight.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12
2012-13 Fund
EWC additional cost $25,000 $29,750
$35,400 General
pressure to cover
women aged 40-50
SUPPORT : (Verified 8/18/10)
American Congress of Obstetricians and Gynecologists,
District IX (co-source)
Susan G. Komen for the Cure, California Collaborative
(co-source)
American Cancer Society
American Federation of State, County and Municipal
Employees
Association of California State Supervisors
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
CONTINUED
AB 1640
Page
8
Susan G. Komen for the Cure, California Affiliates
The Elizabeth Center for Cancer Detection, Board of
Directors
Western Center on Law and Poverty
Young Survival Coalition
OPPOSITION : (Verified 8/18/10)
Department of Finance
ARGUMENTS IN SUPPORT : Proponents of this bill 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 this bill 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.
ASSEMBLY FLOOR :
AYES: Ammiano, Arambula, Bass, Beall, Bill Berryhill,
Blakeslee, Block, Blumenfield, Bradford, Brownley,
Buchanan, Caballero, Charles Calderon, Carter, Chesbro,
Conway, Coto, Davis, De La Torre, De Leon, Emmerson, Eng,
Evans, Feuer, Fletcher, Fong, Fuentes, Furutani, Gaines,
Galgiani, Garrick, Gilmore, Hall, Hayashi, Hernandez,
CONTINUED
AB 1640
Page
9
Hill, Huber, Huffman, Jeffries, Jones, Bonnie Lowenthal,
Ma, Mendoza, Monning, Nava, Nestande, V. Manuel Perez,
Portantino, Ruskin, Salas, Saldana, Skinner, Solorio,
Swanson, Torlakson, Torres, Torrico, Tran, Villines,
Yamada, John A. Perez
NOES: Adams, Anderson, DeVore, Fuller, Hagman, Harkey,
Logue, Miller, Niello, Nielsen, Norby, Silva, Smyth
NO VOTE RECORDED: Tom Berryhill, Cook, Knight, Lieu, Audra
Strickland, Vacancy
CTW:mw 8/18/10 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED