SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO:
AUTHOR:
AMENDED:
HEARING DATE:
CONSULTANT:
SB 136
Yee
As Introduced
April 27, 2011
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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 111148) 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.
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.
Continued---
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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-thecounter (OTC) medication and prescription pharmacotherapy approved 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 FDAapproved 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.
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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 nicotinereplacement 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 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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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 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
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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
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.
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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 contribute to the reduction in premature death from
smoking-related conditions such as cancer, low birth weight infants, and
cardiovascular and respiratory disease.
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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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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.
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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 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.
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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.
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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 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.
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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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 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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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 shortand long-term.
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
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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
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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 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
STAFF ANALYSIS OF SENATE BILL 136 (Yee)
American Russian Medical Association
Association of Northern California Oncologists
BayBio
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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