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California cancer care: Making it fairer

in summary

Low-income patients who need specialized cancer treatment often have difficulty accessing it. Proponents say a new law is a small step toward improving services for these patients.

Cancer is the second leading cause of death in California, behind only heart disease. This year alone, the state is expected to record 189,000 new cancer cases and nearly 61,000 deaths.

But while patients often need specialists, treatment, and the opportunity to participate in clinical trials, this access is not equitable across the state. It usually depends on where they live and sometimes their health insurance.

Low-income cancer patients – and especially those in rural areas – tend to fare worse. Studies have shown that patients with Medi-Cal, the health insurance program for low-income residents, are less likely to receive recommended care and have lower cancer survival rates than those with private insurance.

That discrepancy is at the heart of a recent California bill signed into law by Gov. Gavin Newsom that proponents say will make it at least a little easier for Medi-Cal patients to access cancer subspecialties, treatments and clinical trials.

The new law, which goes into effect in January, requires Medi-Cal insurance plans to “use good faith efforts” to contract with National Cancer Institute-approved cancer centers — which often have access to the latest treatments — or others qualifying cancer centers.

Written by Democratic Sen. Anthony Portantino of Glendale, it was originally drafted to mandate that Medi-Cal plans add at least one of these cancer centers to their provider networks, but negotiations resulted in a stripped-down version that only required the health plans to try one cancer center to add.

“I think incremental changes can save lives, and that’s what we’re trying to do here.”

condition sen. Anthony Portantino, Democrat from Glendale

The law also requires Medi-Cal plans to inform patients with complex cancers of their right to request a referral to one of these centers, even if it’s outside of their plan’s network. However, whether a patient can be treated at one of these centers depends on whether the plan and the off-grid provider can reach a payment agreement. That referral notification, supporters say, is critical: Patients can’t ask for something they don’t know is an option.

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Proponents say this law, even if limited, will be an important step in helping low-income cancer patients access specialized care.

“I think incremental changes can save lives, and that’s what we’re trying to do here,” Portantino said.

Learn about the lawmakers featured in this story

State Senate, District 25 (Glendale)

As he voted in 2019-2020

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District 25 demographics


Latino 28%

White 49%

Asian fifteen%

Black 4%

multi race 3%

voter registration

to the 45%

GOP 25%

No party 25%

Miscellaneous 6%

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At least Sen. Anthony Portantino scored 2 million dollars of the party sector since he was elected to the legislature. That represents 21% all of his campaign contributions.

Too often, patients from underserved communities arrive at these specialized cancer centers very late after their diagnosis, said Dr. Joseph Alvarnas, hematologist-oncologist and vice president of government affairs at City of Hope, one of eight California cancer centers with a National Cancer Institute designation and a sponsor of the law.

“The conversation starts with ‘If only I could have gotten here sooner,’ or ‘My family and I fought tooth and nail to get here,'” he said.

Alvarnas said City of Hope has seen more Medi-Cal patients in the past, but that changed when the state largely transitioned its Medi-Cal program from a fee-for-service model (where patients choose any provider who accepted Medi-Cal and which state-paid providers for each service rendered) to Managed Care (considered a more cost-effective model where the state pays health plans a fixed amount per insured person).

“One of the things that makes the model work in managed care is that it includes tighter clinic networks and a more limited choice of hospitals,” Alvarnas said. “If you have high blood pressure or you have a condition that can be treated by many types of doctors, that’s an OK model.

“But when it comes to cancer care, your network of clinicians may not have an expert in leukemia or relapsed myeloma.”

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Hospitals sometimes have to send some of their sickest patients to cancer centers like City of Hope — as in the case of Patrick Nandy of Whittier. In 2008, during his senior year at college, he was diagnosed with acute lymphoblastic leukemia, a cancer of the blood and bone marrow that can progress very quickly. Nandy said that when oncologists at St. Jude Medical Center could no longer treat him, he was transferred to the City of Hope, where he participated in a clinical trial of chemotherapy and a cord blood stem cell transplant.

“I’m thinking about how lucky I am,” Nandy said. “Doctors said two more weeks and I probably would have been gone.”

These are the types of therapies that should be available to all patients with complex or aggressive cancers, but that’s not always the case, Alvarnas said.

A 2015 analysis by the University of California, Davis found poorer outcomes for cancer patients with Medi-Cal compared to people with other types of insurance. Some of the findings: 39% of breast cancer patients who received Medi-Cal were diagnosed at an early stage, compared to 61% of those privately insured.

The study also found that Medi-Cal patients diagnosed with early-stage lung cancer had a 48% five-year survival rate, which was lower than the 65% five-year survival rate for patients with private insurance. Medi-Cal patients are also less likely to receive the necessary therapies or treatments for multiple cancers.

The law will apply to people with rare or complex cancers, including advanced brain cancer, lung cancer, colon cancer, leukemia and lymphoma, among others, Alvarnas said. Coveted treatment and research centers include City of Hope, the University of California Comprehensive Cancer Centers, the Stanford Cancer Institute, as well as a number of Kaiser Permanente locations and the Cancer Institute of Cedars Sinai.

Although the passed law had no registered opposition, it was watered down during negotiations between providers, health insurance companies and the California Department of Health and Human Services, which oversees the Medi-Cal program.

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Health insurance plans initially opposed Portantino’s bill because the requirement to contract with centers comes with new administrative hurdles that could disrupt or delay patient care.

Linda Nguy, an attorney with the Western Center on Law and Poverty, said her organization withdrew its support after the law was narrowed. “Actually asking for plans (to get deals with cancer centers) — that would have put some meat on the table,” Nguy said. “Our understanding is that there are already plans to contract with as many suppliers as possible, but it boils down to a refund issue.”

Medi-Cal, which covers about a third of Californians, pays providers a lower rate than other types of insurance. While lower reimbursement rates make the program more cost-effective, low payments can discourage providers from participating in Medi-Cal.

“There’s a gap between coverage and real access because the state is also focused on making sure healthcare costs are controlled to some extent.”

dr Joseph Alvarnas, hematologist-oncologist and vice president of government affairs at City of Hope

The debate about equity in cancer care highlights the complexities of achieving real access, even in a state that has extended coverage to more people. California aims to become the first state in the country to offer Medi-Cal coverage to all income-eligible individuals regardless of immigration status. Last week, Gov. Gavin Newsom’s office announced that 286,000 undocumented people ages 50 and older began receiving comprehensive coverage in May. In 2024, California will open the Medi-Cal program to approximately 700,000 more people ages 26 to 49.

“The state has worked very hard over the past decade to improve healthcare,” Alvarnas said. “The problem, however, is that there is a gap between coverage and real access because the state is also careful to ensure that healthcare costs are controlled to some extent.”

While the bill falls short of proponents’ original goals, work to make cancer care more accessible continues, said Autumn Ogden-Smith, director of state legislation for the American Cancer Society’s Cancer Action Network, another sponsor of the bill. For example, making it easier for a patient to get to one of these cancer centers if they don’t live nearby is a priority, she said.

“If you pull up a map, you see these centers cover specific areas: San Diego, Los Angeles, San Francisco, Davis-Sacramento,” Ogden-Smith said. “We need to focus on how to get people in Northern California and central state to cancer centers.

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