BILL ANALYSIS
SB 961
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Date of Hearing: August 4, 2010
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
SB 961 (Wright) - As Amended: June 10, 2010
Policy Committee: Health Vote:13-6
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill:
1)Requires health plans and insurers (carriers) who provide
coverage for cancer chemotherapy treatment to provide coverage
for prescribed orally administered chemotherapy.
2)Requires carriers to provide the lowest choice of patient
cost-sharing arrangements for oral chemotherapy. Health
coverage administered by CalPERS is excluded from the
requirements of this bill.
FISCAL EFFECT
1)According to the California Health Benefits Review Program
(CHBRP), this bill, as most recently amended, is similar to
the author's SB 161 (2009), which was vetoed. Therefore fiscal
comments are drawn from CHBRP's prior analysis of SB 161.
2)No fiscal impacts to CalPERS, Medi-Cal, or the Healthy
Families Program. CalPERS is specifically exempted from the
mandate established by this bill and Medi-Cal and the Healthy
Families Program already provide oral chemotherapy treatment
under current law.
3)Increased premium costs in the employer-based and individual
insurance markets of $18 million, largely offset by a
reduction in out-of-pocket costs paid under current law by
individuals for oral chemotherapy treatments that are not a
covered benefit or with less favorable cost sharing
requirements.
4)According to CHRBP, 100% of Californians with health insurance
have some coverage for inpatient anticancer medications and
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some outpatient coverage for intravenous (IV) and injected
cancer medications. In addition, 98% of Californians with
health insurance have coverage for some outpatient oral
chemotherapy. Therefore, the main group of patients, almost
500,000 statewide, who would reap the greatest benefit from
this legislation are those either with no coverage for
medications generally, or no coverage for oral chemotherapy,
specifically.
COMMENTS
1)Rationale . This bill is sponsored by Carrie's Touch, a
Sacramento non-profit addressing issues of concern to African
American breast cancer survivors. Three of the most commonly
prescribed oral chemotherapy medications are used to treat
breast cancer. According to the author the recent emergence of
effective orally administered chemotherapy medications
increases treatment options for patients. This means patients
are able to take chemotherapy in the form of capsules or
tablets at home, rather than requiring injections or IV
administration of treatment that may be painful,
time-consuming, inconvenient, or may increase the risk of
infection. This bill attempts to reduce and eliminate barriers
patients may face in acquiring coverage for oral chemotherapy
by requiring health insurance to provide coverage in a
favorable cost sharing arrangement relative to other
medications.
2)Background . There are three main ways to treat cancer:
surgery, radiotherapy, and chemotherapy. Chemotherapy is often
utilized for patients with more advanced cancers. The type of
chemotherapy used depends on the type of cancer, the state of
the disease and various patient-specific considerations. Aside
from oral chemotherapy, anticancer medications are
administered either intravenously through a vein or injected
into a muscle. Although a few medications are available in
more than one format, most cancer drugs are only administered
by one route.
3)Industry Cost Concerns . Opponents of this bill indicate
legislatively mandated health benefits increase costs and
limit insurer, employer, and individual choices with respect
to a variety of health benefits. Opponents indicate health
mandates can hinder compliance with evidence-based medical
standards that reflect new medical technology or other
advances. Specific concerns about this mandate include "the
unprecedented step of micromanaging a health plan's benefits
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for brand name drugs" and the limitation this bill places on
health plan flexibility to design other affordable benefits
when lower-cost medications become available.
4)Related Legislation . There are more than two dozen current law
health mandates, established over the last two decades, to
provide coverage for specified services such as cancer
screenings and treatment. There are another handful of
mandates to offer coverage for a number of other health
services. Several current law mandates address both cancer
treatment and prescription drug coverage.
5)Similar legislation, SB 161 (Wright) was vetoed last year.
The governor stated, "This bill limits a plan's ability to
control both the appropriateness of the care and the cost by
requiring them to immediately cover every medication as soon
as it receives federal approval regardless of the provisions
of the health plan's formulary placing them at a severe
disadvantage when negotiating prices with drug manufacturers."
6)Other Health Mandates in the Current Session . There are nine
health mandates under legislative consideration this year,
including SB 961. Other proposed health mandates include:
a) AB 1600 (Beall): mental health parity; pending in the
Senate.
b) AB 1825 (De La Torre): maternity services; pending in
the Senate Appropriations.
c) AB 1826 (Huffman): pain prescriptions; pending in the
Senate Appropriations.
d) AB 1904 (Villines): out-of-state carriers; failed
passage in Assembly Health.
e) AB 2587 (Berryhill): benefit mandates; never heard in
Assembly Health.
f) SB 220 (Yee): tobacco cessation services; before this
committee today.
g) SB 890 (Alquist): basic health treatment services;
before this committee today.
h) SB 1104 (Cedillo): diabetes-related treatment; held in
Senate Appropriations.
Analysis Prepared by : Mary Ader / APPR. / (916) 319-2081