BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 136
S
AUTHOR: Yee
B
AMENDED: As Introduced
HEARING DATE: April 27, 2011
1
CONSULTANT:
3
Orr
6
SUBJECT
Health care coverage: tobacco cessation
SUMMARY
Requires a health care services plan (health plan) contract
or health insurance policy to cover specified tobacco
cessation treatments. Requests the California Health
Benefits Review Program (CHBRP) of the University of
California (UC) to prepare an analysis of the cost savings
as a result of the provisions of this bill. Requires this
bill to become inoperative if the state determines that the
requirements of this bill will result in additional costs
to the state.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes the Patient Protection and Affordable Care Act
(PPACA) (Public Law 111-148) as amended by the Health Care
and Education Reconciliation Act (H.R. 4872). PPACA
requires health plans and issuers, subject to the minimum
interval established by the U.S. Secretary of Health and
Human Services (HHS), to provide coverage and not impose
cost-sharing requirements for selected preventive services
with respect to plan years beginning on and after September
23, 2010.
Continued---
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Establishes essential health benefits (EHBs) as a set of
health care service categories that must be covered by
plans, starting in 2014.
Under PPACA, requires each state, by January 1, 2014, to
establish an American Health Benefit Exchange (Exchange)
that makes qualified health plans available to qualified
individuals and qualified employers. If a state does not
establish an Exchange, the federal government administers
the Exchange. Federal law establishes requirements for the
Exchange, for health plans participating in the Exchange,
and defines who is eligible to receive coverage in the
Exchange.
Existing state law:
Provides for regulation of health plans by the Department
of Managed Health Care (DMHC) and health insurers by the
California Department of Insurance (CDI). Allows health
insurers (but not health plans) to subject treatment for
nicotine use to separate deductibles, co-pays, and overall
cost limitations. Pursuant to regulations, allows health
plans covering prescription drug benefits to require prior
authorization and to establish co-payments or deductibles
and, for smoking cessation, require counseling prior to
receiving a prescription for cessation pharmaceuticals.
Requires DMHC-regulated health plans to provide all
medically necessary basic health care services, as defined.
Permits DMHC to define the scope of the required services
and to exempt plans from this requirement for good cause.
Establishes the California Health Benefits Exchange
(Exchange) within the state government to implement PPACA
requirements.
This bill:
Requires a health plan contract or health insurance policy
issued, amended, renewed, or delivered on or after January
1, 2012 to cover a minimum of 2 courses of treatment in a
12-month period for all smoking cessation treatments rated
"A" or "B" by the United States Preventive Services Task
Force (USPSTF), which include counseling, over-the-counter
(OTC) medication and prescription pharmacotherapy approved
STAFF ANALYSIS OF SENATE BILL 136 (Yee) Page
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by the federal Food and Drug Administration (FDA). For the
purposes of this bill, defines "course of treatment" as
applied to counseling to include at least 4 counseling
sessions lasting at least 10 minutes, and as applied to
prescription or OTC medication to include the FDA-approved
duration of treatment for that medication.
Provides that coverage provided pursuant to this bill is
only available upon the order of an authorized provider but
that nothing in this bill precludes a health plan from
allowing enrollees to access tobacco cessation services on
a self-referral basis.
Provides that after the patient's first course of
treatment, enrollees are not required to enter counseling
in order to receive tobacco cessation medications, and that
health plan contracts and health insurance policies are
prohibited from imposing prior authorization or step
therapy requirements on tobacco cessation treatments.
Excludes Medicare supplement plan contracts and specialized
health plan contracts from the requirements in this bill.
Becomes inoperative on the date that the state determines
that, taking into account any state savings identified in
the CHBRP report, the requirements of this bill will result
in the state assuming additional costs pursuant to
specified requirements of the PPACA.
Requests that the UC, as part of CHBRP, prepare a report by
December 31, 2014, to determine any state savings as a
result of the requirements of this bill, and to make the
report available to the Legislature, DMHC and CDI.
Makes specified findings and declarations regarding the
costs of tobacco use in California and the benefits of
tobacco cessation services.
FISCAL IMPACT
According to the CHBRP analysis, among publicly funded
DMHC-regulated health plans, CHBRP estimates that premium
increases for Medi-Cal Managed Care Plans (MMCPs), MRMIB
plans, and CalPERS HMOs would range from averages of 0.00
percent to 0.05 percent. Specifically the CHBRP report
estimates:
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Premium expenditures by persons with group
insurance, CalPERS HMOs, Healthy Families Program, AIM
or MRMIP would increase by $3,601,000, representing a
change of 0.0237 percent;
CalPERS HMO employer expenditures would increase by
$1,592,000, representing a change of 0.0459 percent;
MRMIB plan expenditures would increase by $153,000,
representing a change of 0.0146 percent;
MMCP expenditures would not change; and
Total net health expenditures would increase by
$16.4 million, representing a change of 0.017 percent.
BACKGROUND AND DISCUSSION
The author claims that tobacco is the greatest cause of
disease and premature death in America today and it is
responsible for more than 435,000 deaths annually. The
costs of tobacco-related death and disease approach $96
billion annually in medical expenses and $97 billion in
lost productivity.
The author claims that in 2009, 47 percent of smokers
reported trying to quit in the last year. The author
believes that smoking cessation treatment is not
one-size-fits all and that everyone responds to treatment
differently, which is why patients try more than one
treatment option before finding the right one. Therefore,
the author believes patients should have the full range of
treatment options available to them to personally tailor
their treatment. The author claims that California has an
opportunity to ensure access to a comprehensive cessation
benefits package that includes at minimum
nicotine-replacement therapies, non-nicotine medications
and counseling. The author believes that a comprehensive
smoking cessation benefit package reduces the long-term
cost of smoking and thus financial liability for health
care plans.
Tobacco use and cessation
Tobacco use, cigarette smoking in particular, is the
leading preventable cause of death in the United States.
Tobacco use results in more than 400,000 deaths annually
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from cardiovascular disease, respiratory disease, and
cancer. Smoking during pregnancy results in the deaths of
about 1,000 infants annually and is associated with an
increased risk for premature birth and intrauterine growth
retardation. Environmental tobacco smoke contributes to
death in an estimated 38,000 people annually.
Despite significant efforts to reduce smoking in
California, nicotine use remains prevalent, particularly
among ethnic communities. While fifteen percent of all
Californians smoke, Native Americans smoke at twice this
rate and one in five African Americans smoke. Nicotine is
highly addictive and difficult to quit. According to the
HHS, 70 percent of smokers attempt to quit each year, but
only 7 percent remain smoke free for one year after
attempting to quit.
Cessation significantly reduces the risk of suffering from
smoking-related diseases, such as cancer (especially of the
lung), coronary heart disease, stroke, peripheral vascular
disease, and chronic obstructive pulmonary disease.
Tobacco dependence is a chronic condition that often
requires repeated interventions, but effective treatments
and helpful resources exist. Comprehensive tobacco
cessation services include telephone, group, or individual
counseling, and all prescription and OTC medication
approved by the FDA.
FDA-approved tobacco cessation products include OTC and
prescription nicotine replacement therapy administered by
gum, patch, nasal spray, inhaler and lozenge, and
prescription non-nicotine medications varenicline
(Chantix) and bupropion SR (Zyban), an antidepressant
medication used in smoking cessation. There are other
medications, including clonidine and nortriptyline, that
have been found to be effective for smoking cessation but
that have a greater risk of side effects than the
abovementioned medications and have not been approved by
the FDA for smoking cessation. Numerous studies show that
behavioral and pharmacological treatments and combinations
of the two significantly improve quit rates and increase
the likelihood of sustained abstinence from smoking.
Patient Protection and Affordable Care Act
On March 23, 2010, the federal government enacted PPACA,
which was further amended by the Health Care Education
STAFF ANALYSIS OF SENATE BILL 136 (Yee) Page
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Reconciliation Act (H.R. 4872). Under PPACA, effective
2011, Medicaid covers tobacco cessation counseling and
pharmacotherapy for pregnant women.
PPACA requires all new plans (as opposed to grandfathered
plans) to provide coverage of certain preventive services,
including tobacco use counseling and interventions with
zero cost-sharing effective September 23, 2010. Tobacco
use counseling and interventions services include tobacco
use counseling for pregnant women and tobacco use
counseling and interventions for non-pregnant adults. This
means that any new plan developed after September 23, 2010
must include tobacco cessation services for both pregnant
women and non-pregnant adults and cannot incorporate
cost-sharing for those services.
SB 136 does not make a distinction between grandfathered
plans and new plans and requires all DMHC- and
CDI-regulated plans in California to include tobacco
cessation, including grandfathered plans which are exempt
from this requirement under the federal law. SB 136 is
silent on cost-sharing, which means that plans classified
as grandfathered under federal law would be required to
offer cessation services, but could choose to incorporate
cost-sharing and still be in compliance with both state and
federal law.
Essential health benefits
EHBs are described in PPACA as a set of health care service
categories that must be covered by certain plans, starting
in 2014. PPACA defines EHBs to include at least the
following: ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health
and substance use disorder services, including behavioral
health treatment; prescription drugs; rehabilitative and
habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease
management; and pediatric services, including oral and
vision care.' Insurance policies must cover these benefits
in order to be certified and offered in exchanges, and all
Medicaid state plans must cover these services by 2014.
It is currently unknown if these EHBs will include certain
benefits and services mandated by SB 136. For example,
smoking cessation prescription drugs could be considered
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covered under the prescription drug EHB; counseling could
be considered under behavioral health treatment, and any
benefit or service included in SB 136 might be considered
covered under substance abuse disorder services.
In the near future, the Secretary of HHS will define what
constitutes EHBs. When making the determination, the
Secretary must ensure that the scope of EHBs is equal to
the scope of benefits provided under a typical employer
plan. However, using carrier surveys, CHBRP found
variations in cessation coverage in typical employer plans,
such as the type of counseling services provided and
inclusion of OTC smoking cessation items.
PPACA allows states to require health plans offered in the
exchange to include additional benefits not already
included in the EHB package, but requires that the state
make payments to defray the cost of those additionally
mandated benefits to persons receiving coverage through the
exchange.
California Health Benefits Review Program analysis of SB
136
Pursuant to AB 1996 (Thomson), Chapter 795, Statutes of
2002 and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
the UC is requested to assess legislation proposing a
mandated benefit or service, or the repeal of a mandated
benefit or service, through CHBRP. CHBRP prepares a
written analysis of the public health, medical, and
economic impacts of such measures. CHBRP analyzed SB 136
in several categories: efficacy of smoking cessation
treatments; effects of coverage for smoking cessation
treatments; impacts to benefit coverage, utilization, cost,
and public health; EHBs offered by qualified health plans
in the health insurance exchange; and preventive benefits
as required under PPACA.
Medical effectiveness of cessation treatments
According to CHBRP, the literature on the
effectiveness of tobacco cessation treatments,
including counseling and certain pharmacological
agents, is clear and convincing that it improves quit
rates and increases the likelihood of sustained
abstinence from smoking. CHBRP also claims there is
clear and convincing evidence that this bill would
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contribute to the reduction in premature death from
smoking-related conditions such as cancer, low birth
weight infants, and cardiovascular and respiratory
disease.
Impacts on utilization and effects of cessation
coverage
The increase of utilization of smoking cessation
treatment would occur amongst the estimated 1.93
million adult smokers with DMHC- or CDI-regulated
plans or policies, since they will be the population
who might seek cessation services. Of the population
affected by this mandate, CHBRP says 82.5 percent of
enrollees have mandate-compliant coverage for
cessation related counseling and 98.8 percent have
mandate-compliant coverage for prescription smoking
cessation treatment, but only 62 percent have
mandate-compliant coverage for OTC smoking cessation
treatment. CHBRP estimates that of the insured adult
smokers, SB 136 would increase utilization of
counseling services by 9.2 percent, OTC treatments by
19.8 percent, and prescription treatments by 0.6
percent. CHBRP estimates this bill would likely
produce a positive public health benefit by increasing
the number of successful quitters by 2,364 enrollees
annually.
CHBRP notes that the rates of abstinence from smoking
found in randomized clinical trials may be greater
than those that would be achieved under this bill
because some studies may have excluded some smokers
who would have had coverage for these treatments under
this bill, and smokers enrolling in these studies may
have been more motivated than an average smoker to
quit.
Impacts on cost and coverage
According to CHBRP, the average cost per course of
smoking cessation treatment is on average $200 for
counseling, $236 for OTC medications, and $240 for
prescriptions. CHBRP assumes that the available supply
of services would meet the slightly increased demand
and that costs for services would not increase. CHBRP
estimates per member per month premiums would vary
depending on the type of market, but overall increases
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will range between 0.0 percent up to 0.17 percent.
Total net health expenditures are projected to
increase by $16.4 million according to CHBRP
estimates.
CHBRP estimates that the percentage of enrollees with
mandate-compliant benefit coverage would increase from
62 percent who currently have any coverage for all
smoking cessation treatment types to 100 percent in
the CDI- and DMHC-regulated markets. However, the
increase is mostly among people who moved from no
coverage to partial coverage of counseling and/or OTC
smoking cessation treatments, since SB 136 does not
expressly prohibit cost-sharing. Therefore, the impact
of the marginal changes in utilization and premiums is
less than might be expected were the smoking cessation
benefits mandated without cost-sharing.
Potential impacts of federal health care reform
CHBRP states that it is uncertain whether federal
regulations and guidance would deem all the services
mandated under SB 136 as being included under the EHB
package. They recommend the state examine differences
in the scope of benefits in the final EHB package
compared to the scope of benefits in this bill, the
number of enrollees in qualified health plans sold in
the health exchange, and the methods used to define
and calculate the cost of additional benefits.
U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) is the
leading independent panel of private-sector experts in
prevention and primary care. The USPSTF conducts rigorous,
impartial assessments of the scientific evidence for the
effectiveness of a broad range of clinical preventive
services, and makes recommendations that certain services
be provided based on the risk and benefit of the service
and the level of evidence supporting the provision of the
service.
Services rated "A" and "B" by USPSTF mean that at least
fair scientific evidence suggests that the benefit of the
clinical service outweighs the potential risks and that
clinicians should discuss the service with eligible
patients. Tobacco use counseling and interventions are
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classified by USPSTF as preventive services that fall under
"A" and "B" benefits. The USPSTF recommends that clinicians
ask all adults about tobacco use and provide tobacco
cessation interventions for those who use tobacco products,
and recommends that clinicians ask all pregnant women about
tobacco use and provide augmented, pregnancy-tailored
counseling to those who smoke. In non-pregnant adults, the
USPSTF found convincing evidence that smoking cessation
interventions, including brief behavioral counseling
sessions (less than ten minutes) and pharmacotherapy
delivered in primary care settings, are effective in
increasing the proportion of smokers who successfully quit
and remain abstinent for one year. Although less effective
than longer interventions, even minimal interventions (less
than three minutes) have been found to increase quit rates.
Massachusetts tobacco cessation coverage
In July 2006, Massachusetts passed a comprehensive health
reform law that mandated tobacco cessation coverage for its
Medicaid population. The coverage, which included
behavioral counseling and all FDA approved medications has
been utilized by over 70,000 Medicaid users, or 37 percent
of all Medicaid smokers. A recent report, entitled
"Medicaid Coverage for Tobacco Dependence Treatments in
Massachusetts and Associated Decreases in Smoking
Prevalence," found that smoking rates decreased from 38
percent in the pre-benefit period to 28 percent in the
post-benefit period, representing a decline of 26 percent.
The authors of the report concluded that providing access
to tobacco cessation coverage, combined with broad
promotion, can significantly reduce smoking prevalence.
An additional study, "A Longitudinal Study of Medicaid
Coverage for Tobacco Dependence Treatments in Massachusetts
and Associated Decreases in Hospitalizations for
Cardiovascular Disease," found that the use of the tobacco
cessation pharmacotherapy benefit was associated with a 46
percent annual decrease in hospitalizations for acute
myocardial infarction and a 49 percent annual decrease in
hospitalizations for coronary atherosclerosis. The cost of
tobacco treatments and promotions was $5.1 million for
21,656 subscribers over 2 years, but the savings from
decreased hospitalizations for cardiovascular conditions
alone was $10.2 million, yielding a $2.00 return on
investment for every dollar spent in the first 2 years.
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Related bills
SB 330 (Padilla) would impose an additional tax on the
distribution of cigarettes
at the rate of $0.075 for each cigarette (approximately
$1.50 per pack) distributed which would be reset by the
State Board of Equalization each fiscal year to reflect any
increase in the California Consumer Price Index. Pending in
the Senate Health Committee.
SB 575 (DeSaulnier) would remove specified exemptions in
existing laws that allow tobacco smoking in certain indoor
workplaces and restrict indoor tobacco smoking in
owner-operated businesses. Pending in the Senate
Appropriations Committee.
AB 217 (Carter) would narrow an exemption in current law
authorizing smoking in "patient smoking areas" in long-term
health care facilities, to only allow patient smoking in
outdoor areas that meet specified conditions. Pending in
the Assembly Appropriations Committee.
AB 1030 (Achadjian) would subject a person who fails to pay
a tax liability in violation of the Cigarette and Tobacco
Products Tax Law to suspension of any distributor's license
and seizure of any assets related to tobacco distribution.
Pending in the Assembly Revenue and Taxation Committee.
Prior legislation
SB 220 (Yee) of 2010 is substantially similar to this bill.
SB 220 was vetoed with the following message: "This bill
represents a costly health mandate that goes beyond current
federal law and removes the ability to manage the
ever-increasing costs of prescription drugs. Instead, I am
signing Assembly Bill 2345 to ensure that the new federal
health reform legislation for preventive services is fairly
and consistently enforced by the Department of Managed
Health Care and Department of Insurance?. Because Senate
Bill 220 goes beyond federal requirements, it will expose
California to potentially significant unreimbursed mandate
costs in 2014 when the remaining provisions of federal
reform take effect."
AB 2345 (De la Torre), Chapter 657, Statutes of 2010,
requires health plan contracts and health insurance
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policies issued, amended, renewed, or delivered on or after
September 23, 2010, to comply with the provisions of PPACA
regarding coverage of, and cost-sharing for, preventive
services and any rules or regulations issued pursuant to
those provisions to the extent required under federal law.
SB 576 (Ortiz) of 2005 would have required health plans and
health insurers to provide coverage for two courses of
tobacco cessation treatments per year, including counseling
and prescription and OTC medications, and would have
prohibited plans and insurers from applying deductibles but
allowed specified co-payments for those benefits. SB 576
was vetoed by Governor Schwarzenegger, who stated that the
bill would impose costs on employers, plans, and
individuals with only a small increase in utilization of
cessation benefits.
Arguments in support
The American Heart Association, the American Lung
Association, and Breathe California all are co-sponsors of
this measure and agree that health plans should be
obligated to fully cover smoking cessation for their
members. They claim that, each year, tobacco costs
billions in health care costs and lost productivity, but
cessation treatments can return $1.40 for every $1
invested. Supporters state that, of the approximately 4
million adult smokers, nearly 75 percent say they would
like to quit, and that a person's chance of successfully
quitting smoking more than doubles when an evidence-based
tobacco cessation service or treatment is used, such as
those proposed by this bill.
The American Academy of Pediatrics believes this bill
acknowledges that tobacco use is a major public health
concern and moves to ease the financial burden of quitting.
They believe there is no safe way to use tobacco, nor is
there a safe level of exposure to second-hand smoke, citing
the U.S. Environmental Protection agency classification of
second-hand smoke as a Class A known human carcinogen. The
California Medical Association (CMA) believes it is
critical to support patients in their efforts to quit
smoking and preserve access to medications that physicians
deem necessary to assist in that process. CMA claims this
bill will help reduce health care costs both in the short-
and long-term.
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The California State Firefighters Association argues that
not only is smoking detrimental to health, but that
cigarettes are also the number one cause of fatal fires in
California which unnecessarily claim human life (including
many firefighters), inflict significant property damage and
have a catastrophic impact on natural forests. They claim
that according to the California Department of Forestry,
fires caused by smoking damage more than 34,000 acres of
land annually in California and cost taxpayers more than
one billion dollars in 2008 alone.
Arguments in opposition
The California Association of Health Plans (CAHP) opposes
this bill because they believe it is an expensive new
mandate that would eliminate a plan's ability to require
coverage authorization for drugs that are not on a health
plan formulary. CAHP believe "it is the wrong time for the
legislature to consider enacting new benefit mandates, and
points out that the cost of any additional benefits
required by state law that exceed the federal EHB package
must be borne by the states." CAHP also questions
provisions in the bill that render the bill inoperative
under specified circumstances, claiming that authorizing
and then repealing coverage of services in this manner will
disrupt the continuity of care for health plan enrollees.
The Association of California Life and Health Insurance
Companies (ACLHIC) generally opposes all benefit mandates
because they believe mandates increase the already high
cost of care for everyone, and mandates eliminate the
flexibility an employer would otherwise have to choose the
benefits that best address the needs of his or her
employees. ACLHIC believes that requiring all plans to
include specific benefits is counterproductive to their
members' efforts to make health insurance more affordable
and available to Californians. The California Chamber of
Commerce believes that benefit mandates make insurance less
affordable, and they believe this bill will further
exacerbate the problem of rising health care costs and thus
contribute to the increasing number of uninsured
Californians.
COMMENTS
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1. Differences between PPACA and SB 136. PPACA requires
that any new plans (as opposed to grandfathered plans)
developed after September 23, 2010 must include tobacco
cessation services for both pregnant women and non-pregnant
adults, and prohibits cost-sharing for these services. SB
136 does not make a distinction between grandfathered plans
and new plans. Should SB 136 become law, grandfathered
plans that are currently exempt from federal requirements
to provide tobacco cessation will be required to provide
tobacco cessation services under California law.
This bill also prohibits plans and insurers from requiring
stepped-care or prior authorization, and from requiring
enrollees to enter counseling prior to receiving cessation
medications after the patient's first course of treatment.
It is possible that, if tobacco cessation is included in
the EHB package, the federal requirements for offering such
services will differ from these requirements in SB 136.
Future changes in federal law and guidance concerning EHBs,
or changes made by the USPSTF, could potentially result in
federal requirements that are either narrower or more
expansive than those contained in SB 136. CHBRP also notes
that while Medi-Cal Managed Care Plans (MMCPs) generally
provide mandate-compliant smoking cessation treatment, that
some individual MMCPs may need to be amended to comply with
specific provisions of this bill, including restrictions on
prior authorization.
2. Cost-sharing. Unlike federal law, which prohibits
cost-sharing for preventive services (including tobacco
counseling and interventions), SB 136 is silent on
cost-sharing. Should SB 136 become law, plans classified
as grandfathered under federal law but that would be
required to offer specified cessation services under
California law, could potentially choose to incorporate
cost-sharing provisions for enrollees and insured
individuals and still be in compliance with both state and
federal law.
3. Tobacco cessation services. CHBRP's analysis assumes
that the demand for tobacco cessation services would
increase only slightly, that the available supply of
services would meet the demand, and that costs for services
would not increase. Many health plans and insurers offer
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some cessation coverage now, but they have the option to
choose which products and services will be offered to
enrollees and insured individuals. By requiring all
FDA-approved cessation medications to be covered by plans
and insurers, SB 136 could lead to a change in demand for
cessation products and services, especially those not
already offered by insurers or plans, which could cause
changes in prices. SB 136 could also limit a plan or
insurer's ability to negotiate rates for cessation products
with pharmaceutical companies, which could also cause
changes in prices.
4. Condition for SB136 becoming inoperative is vague. SB
136 provides that the provisions of the bill will become
inoperative if the state determines that there are
additional costs. However, the bill does not specify which
state entity will make that determination (i.e. the
Governor, the Legislature and the Governor, CDI and/or
DMHC). The author may wish to clarify the intended state
entity.
5. Technical amendment. The USPSTF recommendations
describe tobacco use counseling and interventions for
non-pregnant adults and tobacco use counseling for pregnant
women as preventive services. To be more consistent with
the USPSTF, the author may wish to change "smoking
cessation treatments" to "tobacco cessation preventive
services," on page 2, line 30 and page 4, line 8.
POSITIONS
Support: American Heart Association (co-sponsor)
American Lung Association in California
(co-sponsor)
Breathe California (co-sponsor)
American Academy of Pediatrics, California
District
American Bone Health
American Cancer Society
American Civil Liberties Union
American GI Forum of California
American Russian Medical Association
Association of Northern California Oncologists
BayBio
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California Academy of Family Physicians
California Academy of Physician Assistants
California Center for Public Health Advocacy
California Chapter of American College of
Cardiology
California Dental Association
California Medical Association
California Psychiatric Association
California Psychological Association
California State Firefighters' Association
Coalition of Lavender-Americans on Smoking &
Health
First 5 LA
Foundation for Osteoporosis Research and
Education
Los Angeles County Board of Supervisors
Los Angeles County Medical Association
Los Angeles Society of Allergy, Asthma & Clinical
Immunology
Orange County Medical Association
Pharmacists Planning Service, Inc.
San Francisco Asthma Task Force
San Francisco Fire Fighters Local 798
San Francisco Tobacco Free Coalition
State Building and Construction Trades Council,
AFL-CIO
Four individuals
Oppose: America's Health Insurance Plans
Association of California Life and Health
Insurance Companies
California Association of Health Plans
California Chamber of Commerce
Health Net
Molina Healthcare of California
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