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California Bill Aims to Give Medi-Cal Patients With Complex Cancers Access to Cutting-Edge Care


NEW YORK – The California Senate Health Committee voted last week to advance a bill addressing disparities in access to cancer care for patients covered by California's Medicaid healthcare program, Medi-Cal.

The California Cancer Care Equity Act (SB987), sponsored by state Senator Anthony Portantino (D-25th district), would ensure that people covered by Medi-Cal have access to a National Cancer Institute-designated comprehensive cancer center (NCI-CCC) where they can receive cutting-edge therapies, including molecularly informed precision medicines that are often unavailable within community care settings.

The new legislation builds on the Cancer Patients Bill of Rights resolution sponsored by state Senator Susan Rubio (D-22nd district) and passed in the California legislature in August 2021. That law states that cancer patients have the right to fully understand their diagnosis and be informed about treatment options in culturally appropriate language. It also asserts the right of patients with complex cancers to see doctors at an NCI-CCC and have access to "relevant clinical trials, research, and innovative therapies including evidence-supported precision medicine."

The California legislature also passed a bill in 2021 restricting health insurers, including Medi-Cal, from using prior authorization to limit advanced cancer patients' timely access to biomarker testing.

In 2020, researchers from the University of California Irvine Medical Center reported that around 47 percent of California cancer patients received care concordant with the National Comprehensive Cancer Network's guidelines. Medi-Cal beneficiaries with breast, prostate, colon, rectal, gastric, and liver cancers were less likely to receive NCCN-adherent care, however. And those who weren't treated in line with NCCN guidelines had increased mortality.

Medi-Cal is the largest state Medicaid program in the US, serving about one third of California's population, or roughly 13 million people. California was the first state to test out managed care in Medicaid, starting in the 1970s, and has expanded its use of managed care since then with an emphasis on controlling costs.

Moreover, its provisions for cancer patients have not kept up with treatment advances, especially for people with complex cancers like multiple myeloma or advanced-stage non-small cell lung cancer, according to Joseph Alvarnas, a hematologist at City of Hope in Duarte, California. "I keep a textbook of oncology on my desk that dates back to 2012. And much of what's in that book is entirely wrong about how you treat different cancers," said Alvarnas, who is also chief political adviser at Access Hope, an organization that connects patients and doctors with expertise from NCI-designated cancer centers. "It's become increasingly true across many cancer types as a result of advances in genomic testing and this avenue of delivery called precision medicine," said Alvarnas. 

The crux of the problem is that Medi-Cal is a capitated health plan, in which the state contracts with health plans to deliver benefits to enrollees in exchange for a flat monthly payment. That system distributes risk to medical groups, and those medical groups contract with oncology providers. Not including an NCI-CCC for in-network patients reduces costs for the medical group, but it also limits patients' access to cutting-edge care including genomic testing, molecularly targeted therapies, and biomarker-informed clinical trials.

Under the current model, Medi-Cal patients who want to see a doctor at an NCI-CCC would have to get permission to go out of network, which can involve multiple appeals. "The challenge here is that patients' success shouldn't be predicated upon how many 30-day appeals processes they can get through in order to get to the right care at the right time, because cancer isn't going to wait," said Alvarnas.

SB987 would rejigger that risk model and place the financial responsibility on the plans rather than on the medical groups. It would require a Medi-Cal managed care plan to include in its contracted provider network at least one NCI-CCC, and ensure that any Medi-Cal beneficiary receiving a complex cancer diagnosis is referred to one within 15 business days. The bill's provisions would allow patients with a range of complex hematologic and solid cancers, such as pancreatic cancer, advanced lung, prostate, and breast cancers, and relapsed or refractory colon cancer, to see doctors at an NCI-CCC. The list of eligible cancer types would be updated periodically to keep up with advances.

The bill would also require Medi-Cal to reimburse an NCI-CCC for services provided to beneficiaries and for that center to accept a payment amount set by the California State Department of Health Care Services. 

Autumn Ogden-Smith, the California state legislation director for the American Cancer Society Cancer Action Network (ACSCAN), said that the new bill, if passed, would open the door for people to have access to cutting-edge cancer therapies that otherwise would be out of reach. But some Medi-Cal beneficiaries may still not have access due to geography.

Six of California's NCI-CCCs are in Southern California, and two are in Northern California. "If you're in Southern California, you're within a reasonable distance of a cancer center. But the further up the state you go, the harder it is to actually get there," said Ogden-Smith. "That is one of the areas that we're having to work out because we need to make sure everyone has access that is inclusive of being able to physically get there."

Alvarnas noted that expert cancer care based on the newest research isn't the only benefit of receiving care at an NCI-CCC. These institutions are also likely to offer "social work, supportive care medicine, and care navigation as part of their suite of services," said Alvarnas. As an example, he said at City of Hope, which is an NCI-CCC, the supportive medicine care department coordinates with families to review patient care resources and needs and identifies opportunities for funding or resources for travel.

These same geographic and financial barriers also make clinical trial participation more difficult for the Medicaid population. And because Medicaid beneficiaries tend to be a more diverse group, limited research access to historically marginalized groups then raises questions about the generalizability of clinical trials data.

"As we engage patients in clinical trials, we can improve health literacy among the underserved among those indviduals who haven't had that opportunity," Alvarnas said. "And as you improve health literacy in a patient, and the family's understanding of what they should expect, it allows them to be much more powerful self advocates for the remainder of their care."

Examples of precision medicine clinical trials currently recruiting at NCI-CCCs in California include a Phase I/II trial of Cyclacel Pharmaceuticals' PLK1 inhibitor CYC140 in patients with solid tumors bearing KRAS mutations at City of Hope; a Phase II trial of Amgen's KRAS inhibitor AMG510 in non-squamous, non-small cell lung cancer with the KRAS G12C mutation at Stanford Medicine (part of the NCI Lung-MAP master protocol trial); and a Phase Ib trial of Senhwa Biosciences' RNA polymerase I inhibitor, CX-5461, in solid tumors in patients with mutations in BRCA1,BRCA2 and/or PALB2 at the University of California, Los Angeles.

The bill is supported broadly by a coalition led by co-sponsors ACSCAN and City of Hope. Other supporting organizations include the bone marrow donor program Be the Match, the Leukemia and Lymphoma Society, and the Western Center on Law and Poverty.

The California Association of Health Plans opposed the bill, however, based on disagreements over proposed implementation plans for SB987 and the bill's definition of complex cancer. CAHP said amendments to the bill's language in committee resolved most of those concerns but did not specify which, if any, of their points remain unaddressed.

The amended language clarifies that the health plan must make a "good faith effort to contract with an NCI-designated CCC." The definition of "complex cancer" has also been expanded to include more cancer types, according to Ogden-Smith, who maintained that these changes did not dilute or weaken the bill's overarching aim to improve cancer care equity.