MINUTES OF THE meeting
of the
ASSEMBLY Committee on Commerce and Labor
Seventy-Second Session
April 25, 2003
The Committee on Commerce and Laborwas called to order at 11:50 a.m., on Friday, April 25, 2003. Chairman David Goldwater presided in Room 4100 of the Legislative Building, Carson City, Nevada, and, via simultaneous videoconference, in Room 4401 of the Grant Sawyer State Office Building, Las Vegas, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
Note: These minutes are compiled in the modified verbatim style. Bracketed material indicates language used to clarify and further describe testimony. Actions of the Committee are presented in the traditional legislative style.
COMMITTEE MEMBERS PRESENT:
Mr. David Goldwater, Chairman
Ms. Barbara Buckley, Vice Chairwoman
Mr. Morse Arberry Jr.
Mr. Bob Beers
Mr. David Brown
Mrs. Dawn Gibbons
Ms. Chris Giunchigliani
Mr. Josh Griffin
Mr. Lynn Hettrick
Mr. Ron Knecht
Ms. Sheila Leslie
Mr. John Oceguera
Mr. David Parks
Mr. Richard Perkins
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
Senator Bernice Mathews, Senatorial District No. 1
STAFF MEMBERS PRESENT:
Vance Hughey, Committee Policy Analyst
Diane Thornton, Senior Research Analyst
Wil Keane, Committee Counsel
Patricia Blackburn, Committee Secretary
OTHERS PRESENT:
Jack Kim, Legislative Advocate, Nevada Association of Health Plans
Buffy Gail Martin, Legislative Advocate, American Cancer Society
Randy Richardson, Volunteer, American Cancer Society
Maureen Brower, Legislative Advocate, American Cancer Society
Gil Robison, Volunteer, American Cancer Society
We will call the Commerce and Labor Committee meeting to order. It is 11:50 a.m. All members are here and a quorum is present. On the agenda today is Senate Bill 183, presented to us by Senator Mathews. Senator Mathews, welcome to Assembly Commerce and Labor. We are so happy you are here.
Senate Bill 183 (1st Reprint): Requires certain policies of health insurance and health care plans to provide for colorectal cancer screening under certain circumstances. (BDR 57-726)
Senator Bernice Mathews, Washoe Senatorial District No. 1:
[Introduced herself] This is a simple bill that a number of people have already asked us some questions about and I am sure they will ask on the record. We are here to solicit your support of S.B. 183. It is a colorectal cancer bill brought to me by Buffy Gail Martin from the American Cancer Society. She is very faithful in getting her bills through; she works these bills like a trouper.
S.B. 183 requires various policies of health insurance and health care plans to include coverage for screening examinations and tests for colorectal cancer. An insurer would be required to provide such coverage for a person who is 50 years of age or older, or a person who is less than 50 years of age but is at high risk. What we are asking, in this bill, is that the insurance carriers cover colorectal exams and the treatments thereof. Buffy Martin will explain the details of the bills.
Chairman Goldwater:
I think there is one issue we need to clear up before we get the support for this bill. Jack [Kim], why don't you come up? Wil [Keane], will you outline our Legislative Counsel Bureau's concerns with what we perceive as mandated coverage, which is a little different from most of our usual mandated coverage bills?
Wil Keane, Committee Counsel:
[Introduced himself] There are a few things that we normally do when providing for mandated coverage and this bill provides for a type of mandated coverage. A policy is not required up front to provide the coverage for colorectal cancer treatment. But, if they provide that coverage for colorectal cancer treatment, then they are required to provide coverage for the screening.
This would be a version of mandated coverage. We have provisions existing in NRS [Nevada Revised Statutes], such as the coverage related to mastectomies. According to that existing provision, NRS 689B.0375, if coverage is provided for mastectomies, then there also must be coverage provided for reconstructive surgery after the fact. In other words, we are not requiring the coverage for the mastectomies, but if they do cover it, then they also must provide coverage for the reconstructive surgery. I see this bill as providing for mandated coverage in a similar fashion. We don't require them, up front, to cover colorectal cancer treatment, but if they do, then they must provide coverage for the screening. If that is what we intend to do [with this bill], then we would need to say, for example, on page 1, Section 1, line 4, after the word "provide," we need to say "provide coverage for colorectal cancer," so it is clear that we are actually providing coverage for it and not just making it available if the patient wants to pay.
Another provision that was taken out of the bill as it was originally drafted was Section 1, subsection 5. This would provide that policies of health insurance, which are delivered, issued for delivery or renewed on or after the effective date of this bill, must include the coverage required by this Section. We put those provisions in so that if, for some reason, a policy does not have that provision in it, then it is assumed to be included. By specifically taking that provision out, we are not sure what the legal effect would be. Finally, all of the inclusive references were taken out, so that it is no longer clumped with the other mandated coverage provisions. Once again, for enforcement purposes, we don't know what that would end up meaning.
Jack Kim, Legislative Advocate, Nevada Association of Health Plans:
When this bill was originally presented in the Senate Committee, there was discussion about all those provisions. All the health plans looked at the bill; we already cover all those requirements. Our concern, at that time, was a policy statement from our Association. We have always opposed mandated benefits. We didn't have a problem with colorectal cancer screening; we think it is a good idea. We think everyone should be doing it and this should be used as a national guideline. Those national guidelines are for those persons 50 and over, and people under high risk. The [American] Cancer Society guidelines and other guidelines are very similar. When we came to realize that the health plans all covered colorectal cancer, we tried to figure out who doesn't cover it. That is the reason you see the last section, Section 5. A problem came to light when one municipality didn't cover colorectal cancer. We had talked to the sponsor and said, because we are already covering it now, our concern is that if the clinical mandates or guidelines ever change, we will be stuck with what is in our current statute. We would want to use the most scientific guidelines. That is the reason we have drafted it the way it is. You are right. It is not a mandate on the health plans, because we already all cover it, we did not think we needed additional language to state we should cover something that we already covered. If you are going to cover it, including the counties and cities, they need to follow some standardized clinical guidelines that have scientific backing behind them. With the comments that have been made by Mr. Keane, adding coverage on line 4, I thought we had covered that point already, but if you need to do some technical changes to that, I don't think that is a problem. We would not oppose that.
The issue on whether we need the other statement about including it in your EOCs (evidence of coverage) effective October 1, we don't think that is needed, at least under these statutes, because it is already covered by all the health plans.
Wil Keane:
Absolutely, the reason we have included those provisions is not that we don't believe that everybody, right now, covers it, if that is what you said. But, somebody in the future might want to issue a policy that did not cover it; that is why we would want those provisions. Unless what you are saying is that if a policy were issued in the future that did not cover it, then you don't want it to have to be covered.
Jack Kim:
I think we are looking at two different issues. The way this bill is drafted, it says, if you cover it, this is the way you need to cover it. What we are saying is that it mandates that we cover it. Those are two different issues. In our discussions with Senator Mathews and the (American) Cancer Society, we didn't want a mandate. We have always opposed mandates. I know we have come and testified against mandates and we have tried to work with this Committee and the Committee in the Senate to address those types of issues. That is why we did not think that part was necessary, since we already do cover it. We talked to other health insurers and everyone seems to cover it. The only ones we found that did not cover it were some of the self-insured entities that you have control over and, maybe, some self-insured that you don't have control over. That is why it was fashioned that way it was.
Chairman Goldwater:
Jack, I think, for my edification – and you know we have sympathy for the mandates – they are tough bills to pass, we understand the issues you have outlined very well over the years, but one thing I have never understood, is, if you already cover them, why would the mandates be so bad? I have not heard a really good answer on that one.
Jack Kim:
This bill is a bad example to use. There are other mandates that have been proposed that some of us cover and some don't. As a policy position from our Association, we have always opposed mandates because they impact the small employers and the rates. The bill, as currently written, shouldn't impact our rates at all. It should have no impact, since we already provide this coverage. It is a policy decision. There are certain mandates that everyone feels are great, other people don't like them. A few years ago, there was a mandate on in vitro fertilization. Some of the proponents of the bill loved the mandates, but then there was an entire group of people that didn't want to pay for that. That would be a choice of the employer. We are trying to work with Senator Mathews in drafting a piece of legislation that we could support, that we did not have problems with. That is what we have at this point.
If this becomes an issue down the line, and this body wants to have the discussion on whether this should be mandated coverage, you can have that discussion. We are trying to come up with something that addresses the realities in the marketplace, since everyone covers it already and we all use these different guidelines, and we thought this would be sufficient. It also acknowledges the fact that the health plans are doing something that is appropriate, the only entity that wasn't were some of the counties and cities that you have control over.
Chairman Goldwater:
Okay, you are like me, you don't mind doing something, but if you tell me I have to do it, I hate doing it.
Wil Keane:
I am concerned that we are talking about two different things. I wasn't suggesting any change to the first few lines that said this only applies "if you already provide" coverage for colorectal cancer treatment. I wasn't speaking about that. The concern I had is that if, in the future, you had a policy that provided coverage for the treatment of colorectal cancer but [the heath insurer] decided they were not going to provide coverage for screening, that would be okay under this bill because we have taken out the provisions where we have the enforcement mechanisms that require policies to provide that coverage, if you see what I am saying. In other words, you have set up a bill that would be asking for the individual patients to have to go to court because we have taken out the usual enforcement mechanisms.
Jack Kim:
I understand.
Wil Keane:
If I could just follow-up with one example, just to make sure we are on the same page. NRS 695C.330 is the provision that allows the Commissioner to suspend or revoke certificates of authority of health maintenance organizations that don't provide the coverage that is required. Since that section was specifically taken out, that would appear to indicate a legislative intent that a health maintenance organization in the future could go ahead and offer policies where they provide coverage for colorectal cancer treatment, then decide they are not going to provide any coverage for screening, and the Commissioner can't do anything about it. The individual patient may have to go to court to enforce this right because of the provisions that were taken out. I know that is a technical point, but it could make a difference.
Jack Kim:
That was never the intent. The intent was to make sure that the screening was covered. If we need some technical changes in order to do that, I don't think any of us would have a problem with that. Of course, we would like to see the language, just to make sure.
Chairman Goldwater:
Jack, let me check the intent with the bill's sponsor, Senator Mathews. Tell us what you want to do and we will see if we can't do that.
Senator Mathews:
The intent was for the insurer to provide for the exam and for the follow-up treatment. That is the whole intent of the bill. When we took out the other part to make it palatable for the people who didn't like mandates, the intent was still that if you cover it, you pay for it.
Chairman Goldwater:
Wil, can we do that in such a fashion that it is not a mandate, or do we have to mandate it?
Wil Keane:
If it is all right with the Chair, I would like to talk with the parties afterwards and see if we can come up with something.
Chairman Goldwater:
Can we do that?
Jack Kim:
I think it is a technical change; we wouldn't have any problems working with the Committee on that.
Senator Mathews:
Sure.
Chairman Goldwater:
Okay, we will adhere to your intent, Ms. Mathews, and if things go in a different direction, we will request that you communicate with the Chair and we will make sure that they go in your direction.
Chairman Goldwater:
So we will conduct this hearing with the assumption that we will have an unmandated mandate.
Buffy Gail Martin, Legislative Advocate, American Cancer Society:
[Introduced herself] I want to thank you for affording us the opportunity to bring forward this very important bill, and I would also like to thank Senator Mathews and Assemblywoman Gibbons for sponsoring this proposed legislation. We have prepared packets (Exhibit C) for your review that include statistics on colorectal cancer and insurance companies that provide colorectal cancer screening, as well as a copy of a letter from the Mayor of Sparks, Tony Armstrong, asking you to support S.B. 183. This bill has been through a metamorphosis from its original version, although the intent of the bill remains the same.
[Ms. Martin continued] During the March 13, 2003, Senate Commerce and Labor hearing, Senator Mathews, Assemblywoman Gibbons, and the American Cancer Society accepted a friendly amendment, and that amendment is now this bill. Two colon cancer survivors join me today. You will also hear testimony that Ms. Maureen Brower will be presenting from a young woman who lost her mother to colon cancer. They will be presenting their testimony to this Committee, and I thank you for allowing them the opportunity to share their experience and how it relates to S.B. 183.
At the American Cancer Society we have a saying in regards to colorectal cancer screening: "It's time to think about the unthinkable." This is a topic that makes most people uncomfortable, but I say to you, it is time to think about the unthinkable. Colorectal cancer is the second leading cause of cancer-related deaths. Colorectal cancer will take the lives of more than 56,600 American men and women this year alone. Through screening, we can prevent over half of all deaths from this horrible disease. S.B. 183 would allow us to reduce suffering and save lives with relatively little or no costs to health plans, while saving taxpayer dollars and avoiding further strain on our Medicaid system. More importantly, though, this bill could save lives. To date, there are four colorectal cancer-screening tests that are currently recommended:
Their effectiveness is not all equal. The fecal occult blood test is the least expensive but, unfortunately, only detects about half of all cancers. Colonoscopy is the most complete and accurate and it is considered the gold standard for colorectal screening tests, not only because it is highly effective, but because the colonoscopy has the added benefit of removing pre-cancerous polyps during screening, thereby preventing cancer altogether. Additionally, all positive results from the other exams need to be followed-up by a colonoscopy. S.B. 183 would assure coverage for the full range of colorectal cancer screening options.
The benefit of providing access to the full range of screening tools far outweighs the costs. For example, a polyp can be removed during screening for about $1,100, but if the patient is not diagnosed until colorectal cancer symptoms are exhibited, the chance of survival drops to 8 percent and treatment can cost up to $60,000.
[Ms. Martin continued.] The American Cancer Society commissioned a study from the Lewin Group to analyze insurance company coverage and costs associated with the full range of colorectal cancer screening. The results showed that every participating plan covers the basic tests, the fecal occult blood test and the flexible sigmoidoscopy, but fewer than 5 percent also cover a colonoscopy. Furthermore, for the plans that do cover colonoscopy, the co-pay amounts do not differ between the plans that do not offer colonoscopy. Thus, the most comprehensive benefits for colorectal cancer screening do not appear to have a significant impact on member out-of-pocket expenses. The Lewin study also revealed that if a health plan were offering fecal occult blood tests only, adding a colonoscopy coverage would cost an additional eight cents more. If plans offer both the fecal occult blood test and the flexible sigmoidoscopy, adding a colonoscopy can actually save plans eleven cents.
Just as a side note, I am an employee of the American Cancer Society. However, my medical insurance company operating in the state of Nevada does not cover colonoscopies.
The American Cancer Society asks you to pass S.B. 183. Providing for the full range of colorectal cancer screening saves lives. When this disease is diagnosed early, more than 90 percent of patients survive for five years or more. However, once the disease has metastasized, a grim 92 percent of patients die within five years. We cannot afford to continue to neglect the possibility of providing the full range of colorectal cancer screening tools. S.B. 183 will save money, but more importantly, it will save lives. We urge you to vote to support this vital legislation. Thank you.
Chairman Goldwater:
Thank you, Buffy. Another thorough presentation from you. We appreciate hearing it. Are there questions from the Committee? I don't see any. Gentlemen?
Randy Richardson, Volunteer, American Cancer Society:
[Read from prepared testimony (Exhibit D)] I live in Sparks. I am an American Cancer Society volunteer Ambassador for the state of Nevada and a cancer survivor. In March of 1999, after waiting ten years between colonoscopies due to lack of insurance coverage, I had a colonoscopy performed by Dr. Clark Harrison. I can remember the horror that I felt when he told me that I had cancer, and due to its advanced stage my entire colon had to be removed. I was sent to a surgeon, Dr. Harold Kennedy, to have my colon removed and a J-pouch built out of my small intestine. I was to have an ileostomy for eight weeks while the J-pouch healed inside of me, then the procedure was to remove the ileostomy and connect my small intestine to my internal J-pouch.
[Mr. Richardson continued.] I awoke from surgery to hear the worst possible news. I had gallbladder cancer that had spread to my liver, colon, and lymph nodes. I had stage 4 gallbladder cancer, 100 percent terminal. I was given only six months to live. All I could think about was my children. I was a single dad with an eight-year-old son and a two-year-old daughter. During surgery, I had my gallbladder, a large section of my liver, several lymph nodes and all but six inches of my colon removed. They did not perform the J-pouch surgery due to my prognosis. I went through a very aggressive chemotherapy and radiation treatment. I wore a chemo pump and a pick line feeding me chemo 24 hours a day, 7 days weeks, for 8 weeks, with daily radiation treatments.
I decided that no matter what the books said, I was going to try to live as long as I could in hope that a cure for cancer would be found while I fought to stay alive. When my chemo pump turned on I would envision the chemicals killing the cancer; during radiation I would envision the game Pac-Man eating up my cancer. During treatment I took my chemo pump in one hand, took my daughter in my right arm and waded out into the lake with her, not knowing if I would have another summer with my children. I can remember my dad telling me "a parent isn't supposed to bury his children, you will beat this." I was very lucky to have the best doctors, treatment, and family support. I even had my mom trying to burn down churches she was lighting so many candles.
In September of 1999, approximately six months after my first diagnosis, I received the most incredible call. I was making dinner for my kids and it was my oncologist, Dr. Craig Conrath. He said, "I have great news, your last test results came back. We can't find any sign of cancer." I hung up the phone, knelt to the floor, crying, thanking God. My son, who knew about his dad's cancer ran to me, worried, asking "What's the matter, dad?" I hugged him and said, "Your dad is cancer-free, so you save those front row seats for me.” My son wants to be a pro baseball player. Then, barely able to speak, I turned to my daughter and said, "Your daddy is going to walk you down that aisle." In September of 2001, I had the remainder of my colon removed and my J-pouch surgery performed. One of the nurses in surgery came skipping down the hallway with tears in her eyes to let my family know that the doctor couldn't find any sign of cancer and I would be out of surgery soon.
It is now four years and one month, since my first diagnosis and I happily can say, "I'm still cancer-free."
So why am I here before you in support of the colorectal cancer screening bill? Cancer tried to take the life of my friends' friend, my brother and sister's sibling, my parents' child, and my children's father. I'm lucky to be here; others aren't and won't be so lucky. As a cancer survivor, I know how important early detection is. In the state of Nevada, one out of every three Nevadans will be diagnosed with cancer, and approximately half of them will die. You can change those numbers by passing the colorectal cancer-screening bill. You can save lives, possibly even your own. Thank you very much.
Chairman Goldwater:
Thank you, Mr. Richardson, for your brave story. Good luck to you.
Maureen Brower, Legislative Advocate, American Cancer Society:
A young lady named Jessica Clayton could not be here today because she had to work, but she has a very compelling story. You will find it in your packet (Exhibit C) but I would like to offer it for the record. Basically, her mother died of colorectal cancer. She was not able to have a colonoscopy because her insurance, at that time, did not cover it. Now, this young lady has a young child that will never see the grandmother and she will never have her mother back. Her last statement here is, "On behalf of Nevada families, I ask you to please vote to support this life-saving bill."
Chairman Goldwater:
Thank you very much, Ms. Brower. We will look forward to reading the letter.
Gil Robison, volunteer, American Cancer Society:
[Read from prepared testimony (Exhibit E).] April 5, 1993, the day I will always think of as Black Monday, is the day I was diagnosed with colon cancer. As I was lying on the table my doctor asked me how old I was. When I told him I was 39, he just shook his head. At that point, I knew there was something wrong. When I asked him what was going on, he told me I had a tumor. I asked him what that meant and he told me it looked like cancer. Not believing that I could have cancer, it really hadn't hit me yet. When I asked him if he was sure, he nodded and said he was 98 percent sure. At that moment it was like getting a death sentence. The whole world closed in around me and all I could think of was my daughter and the possibility of her growing up without a daddy. I don't think I heard another word that my doctor said after that. He wanted to schedule me for surgery the very next day, as the cancer had progressed to stage three. I told him I needed some time to get my things in order. As I walked out of the hospital, I was unaware of anyone around me; it was like I had tunnel vision. I phoned my wife to tell her the news and when she answered the phone, I just choked up and couldn't talk. On the drive home, so much was going through my head, I could barely think. The thought of leaving my daughter and the financial burden I would put on my family, as I had no insurance, was almost too much to bear. I almost felt guilty.
[Mr. Robison continued.] The symptoms had been there for almost two years. Nobody in my family had ever had cancer so the thought of cancer had never entered my mind. Since then, my mom, my aunt, my uncle and three of my dogs have died of cancer, not to mention some very close friends. Some say it is good to be a trendsetter. If I had been a bit more educated on the symptoms of cancer, I might have been able to catch it sooner. Dr. Yamamoto had wanted me to have a colonoscopy for some time, but the cost was prohibitive and I didn't have it done until it was too late. Even now, I try to put it off as long as possible, as my insurance will not cover it. Yes, I have finally been able to get health insurance that is reasonably affordable.
During surgery, they removed approximately 6 inches of my colon. They also removed 13 lymph nodes, 9 of which were cancerous. The prognosis wasn't very good. My oncologist had given me a 30 percent chance of surviving for 5 years. Not very optimistic. Well, it has been 10 years and I am still here; maybe it is a good thing to be a trendsetter. After that I was scheduled for radiation, 5 days a week for 5 weeks and then I would undergo chemotherapy for 12 months.
Not having insurance, all of my doctors gave me some pretty fair discounts. Even with discounts my medical bills topped $150,000. I just finished paying them off.
The fear of the cancer coming back is something that will never go away; however, I am here and I am living proof that there are survivors. One of the greatest things I can do is to give back what was given to me and be there to support others who have gone, or are going through, what I have gone through. The importance of having support like I had from my daughter when I was going through all of this and the support I get from my wife, family, and friends, now, not to mention the cancer support group I help facilitate, is some of the best medicine money can't buy.
So, as a colon cancer survivor and volunteer for the American Cancer Society, I ask that you vote to support S.B. 183. Early detection can and will save lives. What a great gift. Thank you.
Chairman Goldwater:
Thank you for your brave story, Mr. Robison, we appreciate it. In fact, I am doing a memorial for my best friend's father who died of colorectal cancer.
Assemblyman Hettrick:
I would like to say that one of my very best friends died of colorectal cancer. Going in and getting the test is everything. It needs to be covered. This is a good bill. I had the fortunate experience of having my doctor insist that I have a colonoscopy, and when they did the colonoscopy they found polyps, which were removed. That is a good sign. Unfortunately, my friend never did that.
Chairman Goldwater:
Mr. Keane, you have evidently reviewed this with Mr. Kim.
Wil Keane:
I was speaking with Mr. Kim and I think we are in complete agreement. On page 1, line 4, after "provide," we would add the word "coverage" and we would add it in a similar location for all of the new provisions. We would also add from the original bill, Section 1, subsection 5 with a provision that read, "a policy of health insurance subject to the provisions of this Chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this Section and any provision of the policy that conflicts with the provisions of this Section is void." That would be added in to all the new provisions. We would add in the clumping references from the original bill, Sections 2, 6, and 7.
Jack Kim:
Yes, I think if you will draft an amendment we would just like to take another quick look at it, because I think we are all on the same page on this.
Chairman Goldwater:
Okay, Wil, if that is the case. Do we have any further testimony on this bill?
Senator Mathews:
I don't think so. I appreciate the work between these two.
Chairman Goldwater:
It sounds like what we want to accomplish. I'll close the hearing on S.B. 183. I think we need a motion to get going on the amendment.
ASSEMBLYMAN HETTRICK MOVED TO AMEND AND DO PASS S.B. 183.
ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.
THE MOTION CARRIED. (Mr. Arberry, Mr. Parks, Ms. Buckley, Ms. Giunchigliani, and Ms. Leslie were absent for the vote.)
Chairman Goldwater:
Congratulations, Senator. Ms. Martin, well done. Gentlemen, again, congratulations on your heroic stories. Jack, thanks for your good work. We'll make sure we get this all fixed up.
This Committee has 50 bills referred from the Senate. I don't have to work out the calendar for you, so we are going to do our best to hear only the bills that have a chance of passing. This may lead to some longer Committee hearings. Also, we are trying to dedicate one full day to S.B. 400, which is the telecommunication regulation bill. I think we all need a little background before we can consider the prime policies of that bill.
[The meeting was adjourned at 12:24 p.m.]
RESPECTFULLY SUBMITTED:
Patricia Blackburn
Committee Secretary
APPROVED BY:
Assemblyman David Goldwater, Chairman
DATE: