BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 836
S
AUTHOR: Oropeza
B
AMENDED: As introduced
HEARING DATE: March 24, 2010
8
CONSULTANT:
3
Tadeo/
6
SUBJECT
Breast cancer screening: expanded coverage
SUMMARY
Requires the Department of Public Health (DPH) to provide
breast cancer screening and diagnostic services to any
individual 40 years of age or older, and to provide
services to any individual who is symptomatic, upon a
doctor's recommendation, if other state eligibility
criteria are met.
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.
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
Continued---
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 2
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.
This bill:
This bill requires DPH to provide breast cancer screening
and diagnostic services to any individual 40 years of age
or older, and to provide services to any individual who is
symptomatic, upon a doctor's recommendation, if other state
eligibility criteria are met.
This bill would also appropriate an unspecified level of
funding from the General Fund for funding these services
through the EWC program.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
The EWC program is administered through DPH to provide
breast and cervical cancer screening services to low-income
California women. Effective January 1, 2010, DPH made two
policy changes to the EWC program: a permanent increase in
the minimum age eligibility for breast cancer screening
services from age 40 to age 50, and a temporary six- month
enrollment freeze for all women seeking breast cancer
services from January 1, 2010 through June 30, 2010.
According to the author, this change in policy will result
in the loss of access to breast cancer screening and
diagnostic services and timely treatment for thousands of
low-income women and women of color. The author states
that this program is a crucial part of the health care
safety net as it provides preventative services to women
who could not otherwise afford them. The author states
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 3
that these changes will shift the financial burden of
screening and diagnosis onto local community clinics and
county facilities already struggling to serve existing
clients, and will likely lead to an increase in breast
cancer deaths.
The author adds that a drop in the number of women seeking
mammograms also compromises training for medical residents
who are reading significantly fewer mammograms, and that
radiologists, who were in high demand, are also conducting
less mammograms, creating a job security issue.
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.
Every Woman Counts
The EWC program is administered through DPH to provide
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.
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 4
Under the program, breast cancer screening 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 available 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 aged 25 and over who meet
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,
CDC federal funds, which provided $6.3 million for
breast and cervical cancer screening combined in FY
2009-10.
Federal funding 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 screening and diagnostic
services, with 75 to 100 percent of clients served to be 50
years of age or older.
The Every Woman Counts program does not receive General
Fund support.
The EWC program 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
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 5
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 these two policies
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.
The Office of Statewide Audits and Evaluations (OSAE),
within the Department of Finance, has begun an audit of the
EWC program which is expected to be completed in the
spring, in time to inform the Governor's May budget
revision.
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
screening mammography 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
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 Breast Cancer Fund, a non-profit organization dedicated
to examining breast cancer and exposure to chemical and
radiation links, states that there is evidence that medical
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 6
X-rays (including mammography, fluoroscopy and CT scans)
are an important and controllable cause of breast cancer.
Although X-rays have been a valuable diagnostic tool for
more than a century, the radiation dose has not always been
carefully controlled and sometimes has been higher than
needed to obtain high quality images. Fortunately, the dose
given per X-ray has been drastically reduced over the past
several decades and the regulatory oversight of equipment
and personnel has increased. In mammography, efforts to
reduce the radiation dose to lower levels has been achieved
without compromising image quality. Digital mammography can
yield doses that are one-third those of conventional
mammography. According to the Centers for Disease Control,
mammography is the best available method to detect breast
cancer in its earliest, most treatable form.
The USPSTF recommendations also state that the decision to
start regular, biennial screening mammography 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 alarms, 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
an amendment to health reform legislation that requires
insurers to offer free mammograms and other preventive
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 7
services to women. This amendment and legislation has not
been finalized by Congress.
Insurance coverage for breast cancer screening
California state law 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) a baseline
mammogram for women age 35 to 39, b) a mammogram for women
age 40 to 49 every two years, or more frequently based on
the woman's physician's recommendation; and c) a mammogram
every year for women age 50 and over.
Related bills
AB 1640 (Evans and Nava) requires DPH to provide at least a
90-day notice to the Joint Legislative Budget Committee
regarding intended changes to the Every Woman Counts
program. This bill would also express the intent of the
Legislature that the screening services for the program
meet the demand based on the eligibility requirements in
place as of December 31, 2009. This bill is scheduled to
be heard in Assembly Health Committee on March 23, 2010.
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 currently
located in the Senate Health Committee.
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 to states for screening services for eligible
women.
Prior state legislation
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 8
SB 1348 (Cedillo, 2008) would have required DPH to extend
eligibility for breast cancer screening under the EWC
program for women under 40 determined to be at high risk
for the disease. This bill died 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, 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 died in
Assembly Appropriations Committee.
AB 2234 (Portantino, 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 died 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,
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 this bill contend that the loss of access to
the services available through the EWC program to
low-income, uninsured and underinsured women will result in
higher mortality rates due to later diagnosis and more
advanced cancers. Proponents also argue that although
breast cancer is less common among women under the age of
40, when it is diagnosed in this age group, the cancer may
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 9
be more aggressive and less responsive to treatment.
The Elizabeth Center for Cancer Detection (Center) states
that it will vote at the end of March to close its doors
due to the changes in the EWC program. The Center contends
that it cannot survive without the financial support of
the EWC program.
The California Radiological Society states that
approximately 17 percent of breast cancer deaths occur in
women aged 40-49 and that there is a statistically
significant reduction of 15 percent in breast cancer deaths
through the use if mammography screening in this age group.
COMMENTS
1. Inherent problems exist in the funding structure of
the EWC program.
The EWC relies on tobacco tax monies for funding which
will continue to diminish as the rate of tobacco products
sold in California continues to drop. Reliance on this
funding source is an ongoing problem.
2. Conflicting guidelines.
The USPSTF guidelines which DPH has relied on in
making the recent changes in eligibility for routine
breast cancer screening services under the EWC program
have generated controversy and are not accepted by a
number of organizations. SB 986 would return eligibility
criteria for routine screening to where it was before the
issuance of the USPSTF guidelines and make eligibility
consistent with the guidelines set forth by the American
Cancer Society.
3. Technical amendment.
Page 2, lines 18 - 24:
(2) Insofar as consistent with federal law and
without jeopardizing federal funding
for the program, the department shall provide
breast cancer screening and
diagnostic services to individuals of any age
who are symptomatic, with a
physician recommendation, and to individuals
STAFF ANALYSIS OF SENATE BILL SB 836 (Oropeza)Page 10
who are 40 years of age or older,
provided that the individual otherwise meets
the state eligibility requirement
described in this section.
POSITIONS
Support: American Cancer Society
Borrego Community Health Foundation
California Affiliates of Susan G. Komen for the
Cure
California Nurses Association
California Radiological Society
City of West Hollywood
Clinicas De Salud Del Pueblo, Inc.
Community Health Partnership
Disability Right Legal Center
Elizabeth Center for Cancer Detection
Family Health Care Centers of Greater Los Angeles,
Inc.
Grossmont Healthcare District
Integrated Healthcare Medical Group, Inc.
L.A. Community Care Medical Associates
Mariposa County Board of Supervisors
Mariposa County Public Health Department
Michelle's Place, Breast Cancer Resource Center
Riverside County Board of Supervisors
Saban Free Clinic
Santa Cruz County Board of Supervisors
Tarzana Treatment Centers
USC Norris Comprehensive Cancer Center
Vista Community Clinic
Watts Healthcare Corporation
Western Center on Law and Poverty
YWCA Harbor Area and South Bay ENCORE Program
Oppose: None received.