Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques, as specified.

The bill would require the Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the commission for allocation for specified grants for purposes of the bill, thereby making an appropriation. The bill would provide that its requirements would be implemented only if, and to the extent that, a total of at least $9,600,000 in private moneys is made available to the fund in a timely manner on or after January 1, 2019.

The bill would require the commission to submit a report to the Legislature, on or before December 31, 2020, and on or before December 31 of every year thereafter, until December 31, 2025, that includes, but is not necessarily limited to, specified information, in accordance with state and federal privacy law.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques, as specified.

The bill would require the Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the commission for allocation for specified grants for purposes of the bill, thereby making an appropriation. The bill would provide that its requirements would be implemented only if, and to the extent that, a total of at least $9,600,000 in private moneys are made available to the fund in a timely manner on or after January 1, 2019.

The bill would require the commission to submit a report to the Legislature, on or before December 31, 2020, and on or before December 31 of every year thereafter, until December 31, 2025, including, but not necessarily limited to, specified information, in accordance with state and federal privacy law.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques, as specified.

The bill would require the Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the commission for allocation for specified grants for purposes of the bill, thereby making an appropriation. The bill would provide that its requirements would be implemented only if, and to the extent that, a total of at least $9,600,000 in private moneys are made available to the fund in a timely manner on or after January 1, 2019.

The bill would require the commission to submit a report to the Legislature, on or before December 31, 2020, and then again on or before December 31, 2021, the number of public university student health centers that have begun to provide abortion by medication techniques. every year thereafter, until December 31, 2025, including, but not limited to, specified information, in accordance with state and federal privacy law.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques, as specified.

The bill would require the Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the commission for allocation for specified grants for purposes of the bill, thereby making an appropriation. The bill would provide that its requirements would be implemented only if, and to the extent that, a total of at least $9,600,000 in private moneys are made available to the fund in a timely manner on or after January 1, 2019.

The bill would require the commission to report to the Legislature, on or before December 31, 2020, and then again on or before December 31, 2021, the number of public university student health centers that have begun to provide abortion by medication techniques.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques only to the extent that private moneys are made available for funding, techniques, as specified.

The bill would require the Treasurer Commission on the Status of Women and Girls to administer the Medication Abortion Implementation College Student Health Center Sexual and Reproductive Health Preparation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the Treasurer commission for allocation for specified grants for purposes of the bill, thereby making an appropriation. The bill would require the Treasurer to establish the Medication Abortion Implementation Advisory Council, with a designated membership, to develop the objectives and priorities of the fund, as specified. The bill would provide that its requirements would be implemented only if, and to the extent that, a total of at least $9,600,000 in private moneys are made available to the fund in a timely manner on or after January 1, 2019.

The bill would require the Treasurer commission to report to the Legislature, on or before December 31, 2020, and then again on or before December 31, 2021, the number of public university student health centers that have begun to provide abortion by medication techniques.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would require, on and after January 1, 2022, each public university student health center, as defined, to offer abortion by medication techniques. techniques only to the extent that private moneys are made available for funding, as specified.

The bill would require the Treasurer to administer the Medication Abortion Implementation Fund, which the bill would establish, and would continuously appropriate the moneys in that fund to the Treasurer for allocation for purposes of the bill, thereby making an appropriation. The bill would require the Treasurer to establish the Medication Abortion Implementation Advisory Council, with a designated membership, to develop the objectives and priorities of the fund, as specified.

The bill would require the Treasurer to report to the Legislature, on or before December 31, 2020, and then again on or before December 31, 2021, the number of public university student health centers that have begun to provide abortion by medication techniques.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by medication techniques at on-campus student health centers at public postsecondary educational institutions in the state.

The bill would further require, on and after January 1, 2020, 2022, each campus of the California State University that operates an on-campus public university student health care center center, as defined, to either offer abortion by medication techniques and scientifically accurate abortion counseling services to its students or arrange for the provision of abortion by medication techniques at least 3 days per week at its on-campus health center through a contract or other arrangement with a qualified family planning provider, as specified. techniques.

Existing law establishes the University of California, under the administration of the Regents of the University of California, and the California State University, under the administration of the Trustees of the California State University, and the California Community Colleges, under the administration of the Board of Governors of the California Community Colleges, as the 3 as 2 of the segments of public postsecondary education in this state.

This bill would express findings and declarations of the Legislature relating to the availability of abortion by techniques at on-campus student health centers at public postsecondary educational institutions in the state.

Existing law imposes various functions and duties on the State Department of Public Health with respect to the administration and oversight of various health programs and facilities relating to the prevention of disease and the promotion of health. Existing law requires the department to develop a coordinated state strategy for addressing the health-related needs of women, as prescribed.

This bill would make technical, nonsubstantive changes to that provision.

 VETO  

Bill No: SB 320

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 6-2, 4/19/17

AYES: Hernandez, Atkins, Leyva, Mitchell, Monning, Roth

NOES: Nguyen, Nielsen

NO VOTE RECORDED: Newman

SENATE EDUCATION COMMITTEE: 4-2, 1/10/18

AYES: Allen, Galgiani, Leyva, Pan

NOES: Wilk, Vidak

NO VOTE RECORDED: Mendoza

SENATE APPROPRIATIONS COMMITTEE: 5-2, 1/18/18

AYES: Lara, Beall, Bradford, Hill, Wiener

NOES: Bates, Nielsen

SENATE FLOOR: 25-13, 1/29/18

AYES: Allen, Atkins, Beall, Bradford, De León, Dodd, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Wieckowski, Wiener

NOES: Anderson, Bates, Berryhill, Cannella, Fuller, Gaines, Moorlach, Morrell, Nguyen, Nielsen, Stone, Vidak, Wilk

NO VOTE RECORDED: Mendoza, Newman

SENATE FLOOR: 26-13, 8/30/18

AYES: Allen, Atkins, Beall, Bradford, De León, Delgado, Dodd, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Wieckowski, Wiener

NOES: Anderson, Bates, Cannella, Chang, Fuller, Gaines, Moorlach, Morrell, Nguyen, Nielsen, Stone, Vidak, Wilk

NO VOTE RECORDED: Berryhill

ASSEMBLY FLOOR: 52-25, 8/29/18 - See last page for vote

SUBJECT:

SOURCE: ACCESS Women’s Health Justice

ACT for Women and Girls

California Latinas for Reproductive Justice

Students United for Reproductive Justice at UC Berkeley

Women’s Policy Institute

DIGEST:

This bill (1) requires each public university student health center to offer abortion by medication techniques beginning January 1, 2022; (2) establishes the Reproductive Health Preparation Fund for the purposes of providing private moneys in the form of grants to on-campus student health centers at the University of California and California State University campuses for the implementation of abortion by medication techniques; and (3) requires the Commission on the Status of Women and Girls to administer the fund, as specified.

ANALYSIS: Existing law authorizes a licensed physician, or a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by aspiration techniques during the first trimester of pregnancy.

This bill:

Requires each public university student health center (SHC) to offer abortion by medication techniques on and after January 1, 2022.

Requires the Commission on the Status of Women and Girls (Commission) to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund (Fund), which is established by this bill for the purposes of providing private moneys in the form of grants to on-campus SHCs at public colleges and universities for medication abortion readiness. Permits the Commission to receive moneys from nonstate entities, including, but not necessarily limited to, private sector entities and local and federal government agencies, and deposit these moneys in the Fund. Continuously appropriates moneys in the Fund to the Commission for purposes of this bill.

Requires the Commission to utilize Fund moneys to:

Provide a grant of $200,000 to each public university student health center to pay for the cost, both direct and indirect, of medication abortion readiness. Permits expenses under these grants to include, but not be limited to: purchase of equipment used in the provision of medication abortion; facility and security upgrades; costs associated with enabling the campus health center to deliver telehealth services; costs associated with training staff in the provision of medication abortion; and, staff cost reimbursement and clinical revenue offset while staff are in trainings;

Provide a grant of $200,000 to both the University of California (UC) and the California State University (CSU), to pay for the cost, both direct and indirect, for each university system for: providing 24-hour, backup medical support by telephone to patients who have obtained a medication abortion at a UC or CSU SHC; one-time fees associated with establishing a corporate account to provide telehealth services; and, billing specialist consultation.

Pay itself for the costs, both direct and indirect, associated with administration of the Fund, including the costs of hiring staff, not to exceed $2.4 million.

Maintain a system of financial reporting on all aspects of the Fund.

Requires grantees, as a condition of receiving an award, to participate in an evaluation of its readiness for and provision of medication abortion.

Requires the Commission, working with UC and CSU SHCs, to assist and advise on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.

Requires the Commission, on or before December 31, 2020, and annually until December 31, 2025, to submit a report to the Legislature, including, but not limited to, the following information separately for the UC and CSU:

The number of SHCs that provide abortion by medication techniques;

The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;

The total amount of funds granted by the Commission to the university and the university’s SHCs that is expended on medication abortion readiness, and, separately, the total amount of any other funds expended on medication abortion readiness and the source of those funds, disaggregated by function and, to the extent possible, disaggregated by SHCs; and,

The total amount of funds expended on the provision of abortion by medication techniques and the source of those funds, disaggregated by function and, to the extent possible, disaggregated by student health center.

Requires the report, and any associated data collection, to be conducted in accordance with state and federal privacy law, as specified. Sunsets the report requirements on January 1, 2026.

Requires this bill to be implemented only if, and to the extent that, a total of at least $9.6 million in private funds is made available to the Fund in a timely manner on or after January 1, 2019.

Prohibits this bill from being interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.

Comments

1. Author’s statement. According to the author, many California public institutions of higher education already offer comprehensive reproductive health services for students at their on-campus SHCs. These services include pregnancy options counseling, contraceptives and other health related services. It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a UC or CSU already has a SHC, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care. This bill will help to improve the academic success of students and, if a pregnant student wishes, she will be able to receive this health care service with limited financial or logistical barriers. Early pregnancy termination is a constitutionally protected right and college aged women should not have to wait additional time or travel long distances when they may have already decided to end their pregnancy. The author firmly believes that women should have control over their bodies and when they choose to incorporate a family into their lives.
   
2. Health care at UC. There are 11 universities as part of the UC system, each with their own health center (open Monday through Friday, with a 24-hour after-hour counseling service call line available). These centers provide basic student health care with physicians and nurses on staff. According to UC, its SHCs receive little to no state funding. It spends an aggregate of $210 million in annual operating costs for all eleven SHCs, $164.5 million going towards student health and $45.4 million toward counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected, through the Health Service Referenda, to charge themselves an annual fee specifically designated to support health care delivery services and/or facilities on campus.
   
   UC requires students to have adequate health insurance, which is minimum essential coverage under the Affordable Care Act (ACA). The UC system offers its students the Student Health Insurance Plan (SHIP) through each campus, providing medical, pharmacy, dental, and vision benefits, as well as mental and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP, which vary by campus and type of student. Generally, the fees start at about $500 per quarter for a single undergrad and start at about $1100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including abortion by medication, the service is not offered at UC SHCs and students are referred to local family planning clinics for the procedure.
3. Health care at CSU. All 23 CSU campuses have a SHC, providing basic student health services that are available Monday through Friday. Basic health services include primary care consistent with skills and scope of staff, family planning services excluding surgical procedures, preventative services such as immunizations, health education, basic x-ray, and referral to off-campus health care providers. Not all campuses have their own pharmacy unit, sending students off campus to drug stores to pick up medications. Each health center is funded independently by campus through students fees. The fees vary across campuses, with an average cost of $269 per student per year going towards health care services and $20 per student per year going towards the health facilities. Health insurance is not mandatory for students at CSU and no plan is offered through the university.
4. For more background, see the Senate Floor Analysis dated August 30, 2018.

FISCAL EFFECT: Appropriation: Yes Fiscal Com.: Yes Local: No

According to the Assembly Appropriations Committee:

1. UC estimates one-time costs to each of its 11 SHCs in the mid-hundreds of thousands of dollars, totaling millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, telemedicine, and staffing. UC estimates that in addition to private funding, it may require additional one-time General Fund (GF) or student fees to cover start-up costs.
2. UC estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as in the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
3. CSU estimates one-time costs to each of its 23 SHCs in the low hundreds of thousands of dollars, totaling in the millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, and training. CSU indicates private funding likely would cover the start-up costs on most campuses, but certain variables, such as potential security upgrades, are unknown and could drive up costs at some SHCs.
4. CSU estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
5. To the extent this bill results in more students accessing medication abortions, and to the extent institutions bill Medi-Cal for this service, potential though likely low state costs to increase Medi-Cal reimbursements.

SUPPORT: (Verified 10/3/18)

ACCESS Women’s Health Justice (co-source)

ACT for Women and Girls (co-source)

California Latinas for Reproductive Justice (co-source)

Students United for Reproductive Justice at UC Berkeley (co-source)

Women’s Policy Institute (co-source)

Advocates for Youth

All Rise Alameda

American Academy of Pediatrics

American Association of University Women of California

American Civil Liberties Union

American Congress of Obstetricians and Gynecologists, District IX

American Nurses Association/California

Associated Students of the University of California, Berkeley

Business and Professional Women of Nevada County

California Commission on the Status of Women and Girls

California Immigrant Policy Center

California North state University College of Medicine

Californians United for a Responsible Budget

California State Council of the Service Employees International Union

California Voices for Progress

California Women’s Law Center

Center for Reproductive Rights

Center on Reproductive Rights and Justice at Berkeley Law

Citizens for Choice

City of Berkeley

Coalition of California Welfare Rights Organizations

Economic Development & Justice Giving Circle, Women’s Foundation of California

Equality California

Equal Rights Advocates

Essential Access Health

Fresno Barrios Unidos

Having Our Say Coalition

If/When/How: Lawyering for Reproductive Justice

Innovating Education in Reproductive Health

Korean Community Center of the East Bay

Korean Resource Center

Latino Coalition for a Healthy California

Los Angeles LGBT Center

Maternal and Child Health Access

Medical Students for Choice

Mixteco/Indígena Community Organizing Project

National Abortion Federation

NARAL Pro-Choice California

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center Youth Law

National Council of Jewish Women-California

National Health Law Program

National Network of Abortion Funds

National Partnership for Women & Families

Nevada County Citizens Educated Choices for Life Choice

Physicians for Reproductive Health

Physicians for Social Responsibility – San Francisco Bay Area Chapter

Peace over Violence

Planned Parenthood Action Fund of The Pacific Southwest

Planned Parenthood Affiliates of California

Planned Parenthood Affiliates Pasadena and San Gabriel Valley

Planned Parenthood Central Coast Action Fund

Planned Parenthood Mar Monte

Planned Parenthood Northern California Action Fund

Positive Women’s Network – USA

Program in Woman-Centered Contraception

Public Health Justice Collective

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

Run Women Run

Seifel Consulting

South Asian Network

Students at Stanford Medical School

Studio M Visual Design

Tara Health Foundation

The Community Action Fund of Planned Parenthood of Orange and San Bernardino

Time for Change

Training in Early Abortion for Comprehensive Healthcare

University of California Student Association

Voices for Progress Education Fund

Western Center on Law & Poverty

Women’s Leadership Project

Women’s Foundation of California

Youth Justice Coalition

OPPOSITION: (Verified 10/3/18)

California Catholic Conference

California Family Council

Californians for Life

California Nurses for Ethical Standards

California ProLife Council

California Right to Life Committee, Inc.

Capitol Resource Institute

Chico State Students for Life

Concerned Women for America

Crusaders for Life, Kolbe Academy and Trinity Prep

Department of Finance

Faith and Public Policy

Fresno State Students for Life

Right to Life of Central California

Right to Life of Kern County

Salt & Light Citizenship Ministry

Salt & Light Council

Students for Life at Berkeley

GOVERNOR'S VETO MESSAGE:

I am returning Senate Bill 320 without my signature.

This bill requires every student health center at University of California and California State University campuses to offer medication abortions beginning January 1, 2022.

Access to reproductive health services, including abortion, is a long-protected right in California. According to a study sponsored by supporters of this legislation, the average distance to abortion providers in campus communities varies from five to seven miles, not an unreasonable distance.

Because the services required by this bill are widely available off-campus, this bill is not necessary.

ASSEMBLY FLOOR: 52-25, 8/29/18

AYES: Aguiar-Curry, Arambula, Baker, Berman, Bloom, Bonta, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooper, Eggman, Frazier, Friedman, Gabriel, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Quirk, Reyes, Rivas, Rodriguez, Rubio, Santiago, Mark Stone, Thurmond, Ting, Weber, Wood, Rendon

NOES: Acosta, Travis Allen, Bigelow, Brough, Chávez, Chen, Choi, Cunningham, Dahle, Flora, Fong, Gallagher, Harper, Kiley, Lackey, Mathis, Mayes, Melendez, Obernolte, Patterson, Quirk-Silva, Salas, Steinorth, Voepel, Waldron

NO VOTE RECORDED: Cooley, Daly, Grayson

Prepared by:

10/11/18 15:03:09

**** END ****

 UNFINISHED BUSINESS  

Bill No: SB 320

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 6-2, 4/19/17

AYES: Hernandez, Atkins, Leyva, Mitchell, Monning, Roth

NOES: Nguyen, Nielsen

NO VOTE RECORDED: Newman

SENATE EDUCATION COMMITTEE: 4-2, 1/10/18

AYES: Allen, Galgiani, Leyva, Pan

NOES: Wilk, Vidak

NO VOTE RECORDED: Mendoza

SENATE APPROPRIATIONS COMMITTEE: 5-2, 1/18/18

AYES: Lara, Beall, Bradford, Hill, Wiener

NOES: Bates, Nielsen

SENATE FLOOR: 25-13, 1/29/18

AYES: Allen, Atkins, Beall, Bradford, De León, Dodd, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Skinner, Stern, Wieckowski, Wiener

NOES: Anderson, Bates, Berryhill, Cannella, Fuller, Gaines, Moorlach, Morrell, Nguyen, Nielsen, Stone, Vidak, Wilk

NO VOTE RECORDED: Mendoza, Newman

ASSEMBLY FLOOR: 52-25, 8/29/18 - See last page for vote

SUBJECT: Public university student health centers: medication abortion readiness: abortion by medication techniques: College Student Health Center Sexual and Reproductive Health Preparation Fund

SOURCE: ACCESS Women’s Health Justice

ACT for Women and Girls

California Latinas for Reproductive Justice

Students United for Reproductive Justice at UC Berkeley

Women’s Policy Institute

DIGEST:

This bill (1) requires each public university student health center to offer abortion by medication techniques beginning January 1, 2022; (2) establishes the Reproductive Health Preparation Fund for the purposes of providing private moneys in the form of grants to on-campus student health centers at the University of California and California State University campuses for the implementation of abortion by medication techniques; and (3) requires the Commission on the Status of Women and Girls to administer the fund, as specified.

Assembly Amendments (1) change the name of the newly created Medication Abortion Implementation Fund to the College Student Health Center Sexual and Reproductive Health Preparation Fund. Require the Commission on the Status of Women and Girls to administer the Fund, rather than the Treasurer; (2) delete the requirement that a Medication Abortion Implementation Advisory Council be created for purposes of implementing the activities required under this bill; (3) require that this bill be implemented only if, and to the extent that, a total of at least $9.6 million in private moneys are made available to the fund in a timely manner on or after January 1, 2019. Cap administrative funding for the purposes of implementing this bill at $2.4 million; (4) specify grant funding amounts and the activities permitted to be paid for by those grants. Delete private colleges or universities from eligibility for grants under this bill; (5) require an annual report to the Legislature, rather than just two reports, and expands the data required to be reported. Requires the report to comply with specified state and federal privacy law; and, (6) make technical, clarifying changes.

ANALYSIS: Existing law authorizes a licensed physician, or a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by aspiration techniques during the first trimester of pregnancy.

This bill:

Requires each public university student health center (SHC) to offer abortion by medication techniques on and after January 1, 2022.

Requires the Commission on the Status of Women and Girls (Commission) to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund (Fund), which is established by this bill for the purposes of providing private moneys in the form of grants to on-campus SHCs at public colleges and universities for medication abortion readiness. Permits the Commission to receive moneys from nonstate entities, including, but not necessarily limited to, private sector entities and local and federal government agencies, and deposit these moneys in the Fund. Continuously appropriates moneys in the Fund to the Commission for purposes of this bill.

Requires the Commission to utilize Fund moneys to:

Provide a grant of $200,000 to each public university student health center to pay for the cost, both direct and indirect, of medication abortion readiness. Permits expenses under these grants to include, but not be limited to: purchase of equipment used in the provision of medication abortion; facility and security upgrades; costs associated with enabling the campus health center to deliver telehealth services; costs associated with training staff in the provision of medication abortion; and, staff cost reimbursement and clinical revenue offset while staff are in trainings;

Provide a grant of $200,000 to both the University of California (UC) and the California State University (CSU), to pay for the cost, both direct and indirect, for each university system for: providing 24-hour, backup medical support by telephone to patients who have obtained a medication abortion at a UC or CSU SHC; one-time fees associated with establishing a corporate account to provide telehealth services; and, billing specialist consultation.

Pay itself for the costs, both direct and indirect, associated with administration of the Fund, including the costs of hiring staff, not to exceed $2.4 million.

Maintain a system of financial reporting on all aspects of the Fund.

Requires grantees, as a condition of receiving an award, to participate in an evaluation of its readiness for and provision of medication abortion.

Requires the Commission, working with UC and CSU SHCs, to assist and advise on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.

Requires the Commission, on or before December 31, 2020, and annually until December 31, 2025, to submit a report to the Legislature, including, but not limited to, the following information separately for the UC and CSU:

The number of SHCs that provide abortion by medication techniques;

The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;

The total amount of funds granted by the Commission to the university and the university’s SHCs that is expended on medication abortion readiness, and, separately, the total amount of any other funds expended on medication abortion readiness and the source of those funds, disaggregated by function and, to the extent possible, disaggregated by SHCs; and,

The total amount of funds expended on the provision of abortion by medication techniques and the source of those funds, disaggregated by function and, to the extent possible, disaggregated by student health center.

Requires the report, and any associated data collection, to be conducted in accordance with state and federal privacy law, as specified. Sunsets the report requirements on January 1, 2026.

Requires this bill to be implemented only if, and to the extent that, a total of at least $9.6 million in private funds is made available to the Fund in a timely manner on or after January 1, 2019.

Prohibits this bill from being interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.

Comments

1. Author’s statement. According to the author, many California public institutions of higher education already offer comprehensive reproductive health services for students at their on-campus SHCs. These services include pregnancy options counseling, contraceptives and other health related services. It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a UC or CSU already has a SHC, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care. This bill will help to improve the academic success of students and, if a pregnant student wishes, she will be able to receive this health care service with limited financial or logistical barriers. Early pregnancy termination is a constitutionally protected right and college aged women should not have to wait additional time or travel long distances when they may have already decided to end their pregnancy. The author firmly believes that women should have control over their bodies and when they choose to incorporate a family into their lives.
   
2. Medication abortion. According to the National Institute of Health (NIH), ending a pregnancy with medications is an option for women who are less than ten weeks pregnant and would like to have an abortion at home with a less invasive procedure. A health care professional confirms via ultrasound a pregnancy of ten weeks gestation or less, indicating that the woman may be eligible for medical abortion. The two-pill process leads to a result similar to a miscarriage. The first drug, Mifepristone, is taken at a health care provider’s office or clinic, stopping the release of the hormone progesterone, which breaks down the uterus lining, discontinuing the pregnancy. Between six to 72 hours later, as determine by their health care provider, the patient takes Misoprostol at home. This drug causes the uterus to contract and empty, leading to heavy bleeding and tissue discharge, comparable to a miscarriage. The bleeding can last up between four to six hours, with very rare cases lasting up to four weeks. Common side effects of the abortion medication include nausea, cramps, vomiting, fevers, chills, diarrhea, and headaches. While uncommon, more serious problems may occur, such as an incomplete abortion, where portions of the uterine lining are not discharged. In this case, a health care provider performs an in-clinic surgical abortion to complete the process, with follow-up visit in seven to 14 days.
3. Medication abortion effectiveness and risks. According to the NIH, medication abortions are effective for 98 out of 100 women who are less than eight weeks pregnant. For women who are eight to nine weeks pregnant, it is effective 96 out of 100 times. Between nine to ten weeks of pregnancy, the medication abortion works 93 out of 100 times. For those women for whom the medical abortion is not immediately effective, a surgical procedure to terminate the pregnancy or to stop heavy bleeding may be necessary. The drug is not recommended for use for pregnancies of 10 weeks or more. Serious infection can occur in about one in 1,000 women, and deaths due to infection occur in less than one per 100,000 women. Antibiotics are often prescribed in addition to the abortion medication to lower the risk of infections.
4. Health care at UC. There are 11 universities as part of the UC system, each with their own health center (open Monday through Friday, with a 24-hour after-hour counseling service call line available). These centers provide basic student health care with physicians and nurses on staff. According to UC, its SHCs receive little to no state funding. It spends an aggregate of $210 million in annual operating costs for all eleven SHCs, $164.5 million going towards student health and $45.4 million toward counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected, through the Health Service Referenda, to charge themselves an annual fee specifically designated to support health care delivery services and/or facilities on campus.
   
   UC requires students to have adequate health insurance, which is minimum essential coverage under the Affordable Care Act (ACA). The UC system offers its students the Student Health Insurance Plan (SHIP) through each campus, providing medical, pharmacy, dental, and vision benefits, as well as mental and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP, which vary by campus and type of student. Generally, the fees start at about $500 per quarter for a single undergrad and start at about $1100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including abortion by medication, the service is not offered at UC SHCs and students are referred to local family planning clinics for the procedure.
5. Health care at CSU. All 23 CSU campuses have a SHC, providing basic student health services that are available Monday through Friday. Basic health services include primary care consistent with skills and scope of staff, family planning services excluding surgical procedures, preventative services such as immunizations, health education, basic x-ray, and referral to off-campus health care providers. Not all campuses have their own pharmacy unit, sending students off campus to drug stores to pick up medications. Each health center is funded independently by campus through students fees. The fees vary across campuses, with an average cost of $269 per student per year going towards health care services and $20 per student per year going towards the health facilities. Health insurance is not mandatory for students at CSU and no plan is offered through the university.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Assembly Appropriations Committee:

1. UC estimates one-time costs to each of its 11 SHCs in the mid-hundreds of thousands of dollars, totaling millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, telemedicine, and staffing. UC estimates that in addition to private funding, it may require additional one-time General Fund (GF) or student fees to cover start-up costs.
2. UC estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as in the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
3. CSU estimates one-time costs to each of its 23 SHCs in the low hundreds of thousands of dollars, totaling in the millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, and training. CSU indicates private funding likely would cover the start-up costs on most campuses, but certain variables, such as potential security upgrades, are unknown and could drive up costs at some SHCs.
4. CSU estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
5. To the extent this bill results in more students accessing medication abortions, and to the extent institutions bill Medi-Cal for this service, potential though likely low state costs to increase Medi-Cal reimbursements.

SUPPORT: (Verified 8/29/18)

ACCESS Women’s Health Justice (co-source)

ACT for Women and Girls (co-source)

California Latinas for Reproductive Justice (co-source)

Students United for Reproductive Justice at UC Berkeley (co-source)

Women’s Policy Institute (co-source)

Advocates for Youth

All Rise Alameda

American Academy of Pediatrics

American Association of University Women of California

American Civil Liberties Union

American Congress of Obstetricians and Gynecologists, District IX

American Nurses Association/California

Associated Students of the University of California, Berkeley

Business and Professional Women of Nevada County

California Commission on the Status of Women and Girls

California Immigrant Policy Center

California North state University College of Medicine

Californians United for a Responsible Budget

California State Council of the Service Employees International Union

California Voices for Progress

California Women’s Law Center

Center for Reproductive Rights

Center on Reproductive Rights and Justice at Berkeley Law

Citizens for Choice

City of Berkeley

Coalition of California Welfare Rights Organizations

Economic Development & Justice Giving Circle, Women’s Foundation of California

Equality California

Equal Rights Advocates

Essential Access Health

Fresno Barrios Unidos

Having Our Say Coalition

If/When/How: Lawyering for Reproductive Justice

Innovating Education in Reproductive Health

Korean Community Center of the East Bay

Korean Resource Center

Latino Coalition for a Healthy California

Los Angeles LGBT Center

Maternal and Child Health Access

Medical Students for Choice

Mixteco/Indígena Community Organizing Project

National Abortion Federation

NARAL Pro-Choice California

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center Youth Law

National Council of Jewish Women-California

National Health Law Program

National Network of Abortion Funds

National Partnership for Women & Families

Nevada County Citizens Educated Choices for Life Choice

Physicians for Reproductive Health

Physicians for Social Responsibility – San Francisco Bay Area Chapter

Peace over Violence

Planned Parenthood Action Fund of The Pacific Southwest

Planned Parenthood Affiliates of California

Planned Parenthood Affiliates Pasadena and San Gabriel Valley

Planned Parenthood Central Coast Action Fund

Planned Parenthood Mar Monte

Planned Parenthood Northern California Action Fund

Positive Women’s Network – USA

Program in Woman-Centered Contraception

Public Health Justice Collective

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

Run Women Run

Seifel Consulting

South Asian Network

Students at Stanford Medical School

Studio M Visual Design

Tara Health Foundation

The Community Action Fund of Planned Parenthood of Orange and San Bernardino

Time for Change

Training in Early Abortion for Comprehensive Healthcare

University of California Student Association

Voices for Progress Education Fund

Western Center on Law & Poverty

Women’s Leadership Project

Women’s Foundation of California

Youth Justice Coalition

OPPOSITION: (Verified 8/29/18)

California Catholic Conference

California Family Council

Californians for Life

California Nurses for Ethical Standards

California ProLife Council

California Right to Life Committee, Inc.

Capitol Resource Institute

Chico State Students for Life

Concerned Women for America

Crusaders for Life, Kolbe Academy and Trinity Prep

Department of Finance

Faith and Public Policy

Fresno State Students for Life

Right to Life of Central California

Right to Life of Kern County

Salt & Light Citizenship Ministry

Salt & Light Council

Students for Life at Berkeley

ASSEMBLY FLOOR: 52-25, 8/29/18

AYES: Aguiar-Curry, Arambula, Baker, Berman, Bloom, Bonta, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooper, Eggman, Frazier, Friedman, Gabriel, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Quirk, Reyes, Rivas, Rodriguez, Rubio, Santiago, Mark Stone, Thurmond, Ting, Weber, Wood, Rendon

NOES: Acosta, Travis Allen, Bigelow, Brough, Chávez, Chen, Choi, Cunningham, Dahle, Flora, Fong, Gallagher, Harper, Kiley, Lackey, Mathis, Mayes, Melendez, Obernolte, Patterson, Quirk-Silva, Salas, Steinorth, Voepel, Waldron

NO VOTE RECORDED: Cooley, Daly, Grayson

Prepared by:

8/30/18 10:22:06

**** END ****

SENATE THIRD READING

STR Bill Id:SB 320

Author:(Leyva)

As Amended Ver:August 24, 2018

Majority vote

SENATE VOTE: 25-13

SUMMARY: Requires public university student health centers (SHCs), as defined, by January 1, 2022, to offer medication abortion services. Specifically, this bill:

1. Defines the following, for the purposes of this bill:
   1. "Commission" as the Commission on the Status of Women and Girls;
   2. "Fund" as the College Student Health Center Sexual and Reproductive Health Preparation Fund;
   3. "Grantee" as any qualifying SHC at a public college or university;
   4. "Medication abortion readiness" includes, but is not limited to, assessment of each individual clinic to determine facility and training needs before beginning to provide abortion by medication techniques, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff. Excludes the provision of abortion by medication techniques from this definition; and,
   5. "Public university student health center" as a clinic providing primary health care services to students that is located on the campus of a university within the University of California (UC) or California State University (CSU) systems.
2. Requires the Commission to administer the Fund, which is continuously appropriated, for the purposes of providing private moneys in the form of grants to on-campus student health centers at public and private colleges and universities for medication abortion readiness. Authorizes the Commission to receive moneys from nonstate entities, including but not limited to private sector entities and local and federal government agencies.
3. Requires the Commission to utilize fund moneys to do all of the following:
   1. Provide a grant of $200,000 to each public university student health center to pay for the cost, both direct and indirect, of medication abortion readiness. Allows expenses under the grants to include, but not be limited to, all of the following:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the campus health center to deliver telehealth services;
      4. Costs associated with training staff in the provision of abortion by medication techniques; and,
      5. Staff cost reimbursement and clinical revenue offset while staff are in trainings.
   2. Provide a grant of $200,000 to both the UC and CSU to pay for the cost, both direct and indirect, of the following, for each university system:
      1. Providing 24-hour, backup medical support by telephone to patients who have obtained abortion by medication techniques at a public university student health center;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Paying itself for the costs, both direct and indirect, associated with administration of the fund, including the costs of hiring staff, not to exceed $2.4 million; and,
   4. Maintaining a system of financial reporting on all aspects of the Fund.
4. Requires each grantee to, as a condition of receiving a grant award from the Fund, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Specifies that implementation of this bill is contingent upon a total of at least $9.6 million in private funds being made available to the Fund in a timely manner on or after January 1, 2019, and that nothing in this bill is to be interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.
6. Requires the Commission, working with the SHCs, to assist and advise the public university SHCs on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing medication abortions.
7. Requires the Commission to report to the Legislature, on or before December 31, 2020, and on or before December 31 of each year thereafter until December 31, 2025, which includes, but is not necessarily limited to, all of the following information for each reporting period, separately for the University of California and the California State University:
   1. The number of student health centers that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at student health centers, disaggregated, to the extent possible, by student health center;
   3. The total amount of funds granted by the commission to the university and the university's student health centers that is expended on medication abortion readiness, and, separately, the total amount of any other funds expended on medication abortion readiness and the source of those funds, disaggregated by function and, to the extent possible, disaggregated by student health center; and,
   4. The total amount of funds expended on the provision of abortion by medication techniques and the source of those funds, disaggregated by function, and, to the extent possible, disaggregated by student health center.
8. Requires the report required pursuant to 7), above, to be conducted in accordance with state and federal privacy laws.
9. Makes various findings and declarations regarding current law recognizing abortion as a basic health service, the Legislatures intent that public university SHCs make medication abortions as accessible and cost-effective for students as possible, and that the National Academies of Sciences, Engineering, and Medicine have found that prescribing abortion by medication techniques is no different from prescribing other medications.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. One-time costs totaling millions of dollars systemwide. UC estimates that in addition to private funding, it may require additional one-time General Fund (GF) or student fees to cover start-up costs.
2. Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide, depending on various factors.
3. One-time costs totaling in the millions of dollars systemwide. CSU indicates private funding likely would cover the start-up costs on most campuses, but certain variables are unknown and could drive up costs at some SHCs.
4. Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide, depending on various factors.

5) Potential though likely low state costs to increase Medi-Cal reimbursements.

COMMENTS: According to the author, California public institutions of higher education strive to offer comprehensive reproductive health care for students in on-campus SHCs, however, currently none of the SHCs at California's public institutions of higher education provide medication abortion services, despite how clinically simple the service is to offer. The author states that medication abortion is safer and less complicated than much of the care already offered at college health centers, including diabetes management, mental health care, or diagnosis/treatment of sexually transmitted infections. It is important that college students have access to safe and reliable comprehensive reproductive health care on campus which should include early pregnancy termination. The author concludes that if a public institution of higher education already has a SHC, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care.

The United States (U.S.) Supreme Court recognized a woman's constitutional right to abortion in 1973 in Roe v. Wade, and subsequent decisions have reaffirmed that right. Despite this constitutional protection, access to abortion in the U.S. is becoming more limited. According to the Guttmacher Institute, the number of abortion-providing facilities declined 3% between 2011 and 2014 (from 1,720 to 1,671). Ninety percent of all U.S. counties lacked a clinic in 2014, and 39% of women of reproductive age lived in those counties. In 2014, 43% of California counties had no clinics that provided abortions, and 5% of California women lived in those counties. According to U.S. census data there are almost 4 million women of childbearing age (15 to 44 years of age) in California.

1. Abortion. According to the Guttmacher Institute, more than half of all U.S. abortion patients in 2014 were in their 20s: patients aged 20 to 24 obtained 34% of all abortions, and patients aged 25 to 29 obtained 27% of all abortions. White patients accounted for 39% of abortion procedures in 2014, African Americans for 28%, Hispanics for 25%, and patients of other races and ethnicities for 9%. Seventy-five percent of abortion patients in 2014 were poor or low-income and 17% traveled more than 50 miles to obtain an abortion. The three most common reasons for getting an abortion, cited by three-fourths of patients were: concern for or responsibility to other individuals; the inability to afford raising a child; and, the belief that having a baby would interfere with work, school, or the ability to care for dependents. Fifty-one percent of abortion patients in 2014 were using contraception in the month they became pregnant.
2. Medication abortion. The U.S. Food and Drug Administration approved the use of mifepristone for early nonsurgical, or medication, abortion in 2000. Medication abortion is the termination of a pregnancy until 10 weeks' gestation using a combination of two medications, mifepristone and misoprostol. The first medication starts the process and the second medication is used in the privacy of the person's home to start bleeding, which is similar to a heavy menstrual period. The same combination of medications is also used in the management of early miscarriage and gives people the option to pass failed pregnancies at home. Medication abortions accounted for 31% of all nonhospital abortions in 2014, and for 45% of abortions before nine weeks' gestation.
3. SHCs. No SHCs currently provide medication abortion. The UC system has SHCs at all 10 campuses as well as Hastings School of Law. All 11 have a physician on staff. UC Hastings SHC operates nine months a year and for three months physician services are not available. All UC SHCs have a 24 hour advice nurse line. The CSU system has SHCs on all 23 campuses; each campus has a least one physician on staff and at least one nurse practitioner and/or physician assistant. About half of CSU SHCs have after-hour nurse advice lines. CSU students are eligible for health services provided at any CSU campus. All SHCs refer off-campus for abortion care and most refer for ultrasound (one UC provides on-site ultrasound) and miscarriage management (three UCs provide on-site miscarriage management.)
4. Student Healthcare Coverage. UC requires students to have adequate health insurance, the minimum essential coverage under the federal Patient Protection and Affordable Care Act, which covers abortion services as part of maternity care. The UC Student Health Insurance Plan (SHIP) provides medical, pharmacy, dental and vision benefits, as well as mental health and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP. The 2017-18 student health premiums range from $2,517.29 to $4,773.29 for graduate students and from $1,757.75 to $3,324.00 for undergraduate students (depending on campus and other factors.)
5. CSU does not require students to be insured and no plan is offered through the university. CSU SHCs are funded entirely through student fees, which are mandatory for all enrolled students and vary across campuses, with an average cost of $269 per student per year.
6. UC San Francisco School of Medicine, Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The sponsors of this bill facilitated the completion of two surveys, conducted by ANSIRH. Surveys were completed by all 11 UC campuses and by 20 of the 23 CSU campuses. The results of the surveys were compiled into two reports: "Evaluating University of California and California State University Capacity to Provide Medication Abortion" and "Assessing Barriers to Medication Abortion Among California's Public University Students." The reports made the following findings and conclusions:
7. Student access to abortion. "Assessing Barriers to Medication Abortion Among California's Public University Students," states there are several barriers to students in obtaining an abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Two-thirds of UC students and one-third of the CSU student body do not have a car, and 62% of the UC and CSU student body are more than 30 minutes away from the closest abortion provider via public transportation. ANSIRH contends, for these students, the multiple visits for a medication abortion requires a minimum of two hours travel by public transportation. The brief also notes that only 15% of providers closest to university campuses are open on weekends, students may have to wait an average of a week for the next available appointment, and ultimately, the delay can make a student ineligible for medication abortion.
8. SHC capacity to provide medication abortion. "Evaluating University of California and California State University Capacity to Provide Medication Abortion," notes that in California any physician or advanced practice clinician trained to do so may provide medication abortion. The provider must be able to assess the pregnancy duration, diagnose ectopic pregnancy, and, provide surgical intervention if needed, either personally or by referral. Required facilities and equipment needed include a private room for pelvic exams (not required for all medication abortions) and counseling, ultrasound capability for pregnancy dating and to rule out ectopic pregnancy, on-site laboratory for urine pregnancy testing, hemoglobin, and Rh Status (or the ability to refer to a lab), and a 24-hour telephone hotline staffed by clinicians to answer questions and refer as needed to emergency care. The chart below provides an assessment of SHC capacity for implementing medication abortion services given current resources:

As the chart illustrates, while all of the SHCs have the minimum requirements for medication abortion provision: a private exam room, ability to do pregnancy testing and counseling, and clinicians who are licensed in the state of California, none of them are fully equipped to provide medication abortions. All SHCs would need training; even though a few sites have a clinician trained in abortion care, they are not currently providing care. Most CSU SHCs would also need an ultrasound machine and nurse hotline.

1. Concerns. Neither the UC or CSU system has taken a position on this bill; however, the ANSIRH surveys identified some of their concerns. SHCs are concerned with the need for follow-up care and back-up care for emergencies, and how medication abortion will continue to be funded once the grant money is expended. UC SHCs are also concerned about security issues that may arise if they begin providing abortions on campus, and CSUs are concerned that, given the infrequency of its use, staff may not be able to maintain the skill necessary to use an ultrasound machine to accurately determine whether the medication can be administered safely.
2. Estimated need for medication abortions among college students. According to the Centers for Disease Control and Prevention in 2014, 652,639 legal induced abortions were reported from 49 reporting areas. The abortion rate for 2014 was 12.1 abortions per 1,000 women aged 15 to 44 years. Women in their twenties accounted for the majority of abortions in 2014 and the majority took place early in gestation: 91.5% of abortions were performed at ≤13 weeks' gestation; a smaller number of abortions (7.2%) were performed at 14–20 weeks' gestation, and even fewer (1.3%) were performed at ≥21 weeks' gestation. In 2014, 22.6% of all abortions were early medical abortions. The percentage of abortions reported as early medical abortions increased 110% from 2005 to 2014, with a 1% increase from 2013 to 2014. ANSIRH estimates, based on age- and state-adjusted abortion rates (California's abortion rate is 34% higher than the national rate) and a range of rates for medication abortion as a preferred abortion type, that there would be between 322 to 519 medication abortions each month across the UC and CSU campuses if SHCs offered medication abortion.

California Latinas for Reproductive Justice (CLRJ) is a co-sponsor of this bill and states that while Latinas represent over a third of the state's female population, they represent 12% of all women (25 or older) to complete a Bachelor's degree or higher in California, they are twice as likely as white women to report having no usual source of care, and to report delaying or foregoing needed medical care. CLRJ notes that all students who may become pregnant attending California higher education institutions will benefit from this bill because it will help foster a supportive environment where students can concentrate on their studies; have truly comprehensive healthcare; and, avoid the added financial, logistical, and emotional burden of seeking necessary reproductive healthcare off campus. The American Civil Liberties Union (ACLU) supports this bill and states that no public universities in California currently provide medication abortion services on-campus, and notes that students seeking this basic health care must travel off-campus; a serious logistical and financial barrier for a first-generation student, low-income student, or those struggling with debt and rising tuition costs.

The California Catholic Conference, Inc., opposes this bill and states that the bill blatantly discriminates against students and health care providers who do not support abortion and hold a pro-life point of view, and that by turning college campuses into a one-stop shop that offers abortions on-demand without connection to appropriate medical care, this bill discriminates against women by limiting the information and assistance that they need and deserve. The Capitol Resource Institute (CRI) is opposed to this bill and states that mandating that abortion by medication be available at all public universities will cut down the effort, and therefore the thought, behind making a decision to get an abortion. CRI concludes a student might make a hasty decision which she later regrets simply because of the availability of an abortion.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004780

SENATE THIRD READING

STR Bill Id:

Author:(Leyva)

As Amended Ver:

Majority vote

SENATE VOTE: 25-13

SUMMARY: Requires public university student health centers (SHCs), as defined, by January 1, 2022, to offer medication abortion services. Specifically, this bill:

1. Defines the following, for the purposes of this bill:
   1. "Commission" as the Commission on the Status of Women and Girls;
   2. "Fund" as the College Student Health Center Sexual and Reproductive Health Preparation Fund;
   3. "Grantee" as any qualifying SHC at a public college or university;
   4. "Medication abortion readiness" includes, but is not limited to, assessment of each individual clinic to determine facility and training needs before beginning to provide abortion by medication techniques, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff. Excludes the provision of abortion by medication techniques from this definition; and,
   5. "Public university student health center" as a clinic providing primary health care services to students that is located on the campus of a university within the University of California (UC) or California State University (CSU) systems.
2. Requires the Commission to administer the Fund, which is continuously appropriated, for the purposes of providing private moneys in the form of grants to on-campus student health centers at public and private colleges and universities for medication abortion readiness. Authorizes the Commission to receive moneys from nonstate entities, including but not limited to private sector entities and local and federal government agencies.
3. Requires the Commission to utilize fund moneys to do all of the following:
   1. Provide a grant of $200,000 to each public university student health center to pay for the cost, both direct and indirect, of medication abortion readiness. Allows expenses under the grants to include, but not be limited to, all of the following:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the campus health center to deliver telehealth services;
      4. Costs associated with training staff in the provision of abortion by medication techniques; and,
      5. Staff cost reimbursement and clinical revenue offset while staff are in trainings.
   2. Provide a grant of $200,000 to both the UC and CSU to pay for the cost, both direct and indirect, of the following, for each university system:
      1. Providing 24-hour, backup medical support by telephone to patients who have obtained abortion by medication techniques at a public university student health center;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Paying itself for the costs, both direct and indirect, associated with administration of the fund, including the costs of hiring staff, not to exceed $2.4 million; and,
   4. Maintaining a system of financial reporting on all aspects of the Fund.
4. Requires each grantee to, as a condition of receiving a grant award from the Fund, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Specifies that implementation of this bill is contingent upon a total of at least $9.6 million in private funds being made available to the Fund in a timely manner on or after January 1, 2019, and that nothing in this bill is to be interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.
6. Requires the Commission, working with the SHCs, to assist and advise the public university SHCs on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing medication abortions.
7. Requires the Commission to report to the Legislature, on or before December 31, 2020, and every year thereafter until January 1, 2026, which includes, but is not limited to, all of the following:
   1. The number of public university student health centers that have begun providing abortion by medication techniques;
   2. The total cost and source of the funds for implementing and providing abortion by medication techniques performed at each student health center; and,
   3. The number of abortions by medication technique performed at each student health center.
8. Requires the report required pursuant to 7), above, to be conducted in accordance with state and federal privacy laws.
9. Makes various findings and declarations regarding current law recognizing abortion as a basic health service, the Legislatures intent that public university SHCs make medication abortions as accessible and cost-effective for students as possible, and that the National Academies of Sciences, Engineering, and Medicine have found that prescribing abortion by medication techniques is no different from prescribing other medications.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. One-time costs totaling millions of dollars systemwide. UC estimates that in addition to private funding, it may require additional one-time General Fund (GF) or student fees to cover start-up costs.
2. Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide, depending on various factors.
3. One-time costs totaling in the millions of dollars systemwide. CSU indicates private funding likely would cover the start-up costs on most campuses, but certain variables are unknown and could drive up costs at some SHCs.
4. Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide, depending on various factors.

5) Potential though likely low state costs to increase Medi-Cal reimbursements.

COMMENTS: According to the author, California public institutions of higher education strive to offer comprehensive reproductive health care for students in on-campus SHCs, however, currently none of the SHCs at California's public institutions of higher education provide medication abortion services, despite how clinically simple the service is to offer. The author states that medication abortion is safer and less complicated than much of the care already offered at college health centers, including diabetes management, mental health care, or diagnosis/treatment of sexually transmitted infections. It is important that college students have access to safe and reliable comprehensive reproductive health care on campus which should include early pregnancy termination. The author concludes that if a public institution of higher education already has a SHC, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care.

The United States (U.S.) Supreme Court recognized a woman's constitutional right to abortion in 1973 in Roe v. Wade, and subsequent decisions have reaffirmed that right. Despite this constitutional protection, access to abortion in the U.S. is becoming more limited. According to the Guttmacher Institute, the number of abortion-providing facilities declined 3% between 2011 and 2014 (from 1,720 to 1,671). Ninety percent of all U.S. counties lacked a clinic in 2014, and 39% of women of reproductive age lived in those counties. In 2014, 43% of California counties had no clinics that provided abortions, and 5% of California women lived in those counties. According to U.S. census data there are almost 4 million women of childbearing age (15 to 44 years of age) in California.

1. Abortion. According to the Guttmacher Institute, more than half of all U.S. abortion patients in 2014 were in their 20s: patients aged 20 to 24 obtained 34% of all abortions, and patients aged 25 to 29 obtained 27% of all abortions. White patients accounted for 39% of abortion procedures in 2014, African Americans for 28%, Hispanics for 25%, and patients of other races and ethnicities for 9%. Seventy-five percent of abortion patients in 2014 were poor or low-income and 17% traveled more than 50 miles to obtain an abortion. The three most common reasons for getting an abortion, cited by three-fourths of patients were: concern for or responsibility to other individuals; the inability to afford raising a child; and, the belief that having a baby would interfere with work, school, or the ability to care for dependents. Fifty-one percent of abortion patients in 2014 were using contraception in the month they became pregnant.
2. Medication abortion. The U.S. Food and Drug Administration approved the use of mifepristone for early nonsurgical, or medication, abortion in 2000. Medication abortion is the termination of a pregnancy until 10 weeks' gestation using a combination of two medications, mifepristone and misoprostol. The first medication starts the process and the second medication is used in the privacy of the person's home to start bleeding, which is similar to a heavy menstrual period. The same combination of medications is also used in the management of early miscarriage and gives people the option to pass failed pregnancies at home. Medication abortions accounted for 31% of all nonhospital abortions in 2014, and for 45% of abortions before nine weeks' gestation.
3. SHCs. No SHCs currently provide medication abortion. The UC system has SHCs at all 10 campuses as well as Hastings School of Law. All 11 have a physician on staff. UC Hastings SHC operates nine months a year and for three months physician services are not available. All UC SHCs have a 24 hour advice nurse line. The CSU system has SHCs on all 23 campuses; each campus has a least one physician on staff and at least one nurse practitioner and/or physician assistant. About half of CSU SHCs have after-hour nurse advice lines. CSU students are eligible for health services provided at any CSU campus. All SHCs refer off-campus for abortion care and most refer for ultrasound (one UC provides on-site ultrasound) and miscarriage management (three UCs provide on-site miscarriage management.)
4. Student Healthcare Coverage. UC requires students to have adequate health insurance, the minimum essential coverage under the federal Patient Protection and Affordable Care Act, which covers abortion services as part of maternity care. The UC Student Health Insurance Plan (SHIP) provides medical, pharmacy, dental and vision benefits, as well as mental health and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP. The 2017-18 student health premiums range from $2,517.29 to $4,773.29 for graduate students and from $1,757.75 to $3,324.00 for undergraduate students (depending on campus and other factors.)
5. CSU does not require students to be insured and no plan is offered through the university. CSU SHCs are funded entirely through student fees, which are mandatory for all enrolled students and vary across campuses, with an average cost of $269 per student per year.
6. UC San Francisco School of Medicine, Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The sponsors of this bill facilitated the completion of two surveys, conducted by ANSIRH. Surveys were completed by all 11 UC campuses and by 20 of the 23 CSU campuses. The results of the surveys were compiled into two reports: "Evaluating University of California and California State University Capacity to Provide Medication Abortion" and "Assessing Barriers to Medication Abortion Among California's Public University Students." The reports made the following findings and conclusions:
7. Student access to abortion. "Assessing Barriers to Medication Abortion Among California's Public University Students," states there are several barriers to students in obtaining an abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Two-thirds of UC students and one-third of the CSU student body do not have a car, and 62% of the UC and CSU student body are more than 30 minutes away from the closest abortion provider via public transportation. ANSIRH contends, for these students, the multiple visits for a medication abortion requires a minimum of two hours travel by public transportation. The brief also notes that only 15% of providers closest to university campuses are open on weekends, students may have to wait an average of a week for the next available appointment, and ultimately, the delay can make a student ineligible for medication abortion.
8. SHC capacity to provide medication abortion. "Evaluating University of California and California State University Capacity to Provide Medication Abortion," notes that in California any physician or advanced practice clinician trained to do so may provide medication abortion. The provider must be able to assess the pregnancy duration, diagnose ectopic pregnancy, and, provide surgical intervention if needed, either personally or by referral. Required facilities and equipment needed include a private room for pelvic exams (not required for all medication abortions) and counseling, ultrasound capability for pregnancy dating and to rule out ectopic pregnancy, on-site laboratory for urine pregnancy testing, hemoglobin, and Rh Status (or the ability to refer to a lab), and a 24-hour telephone hotline staffed by clinicians to answer questions and refer as needed to emergency care. The chart below provides an assessment of SHC capacity for implementing medication abortion services given current resources:

As the chart illustrates, while all of the SHCs have the minimum requirements for medication abortion provision: a private exam room, ability to do pregnancy testing and counseling, and clinicians who are licensed in the state of California, none of them are fully equipped to provide medication abortions. All SHCs would need training; even though a few sites have a clinician trained in abortion care, they are not currently providing care. Most CSU SHCs would also need an ultrasound machine and nurse hotline.

1. Concerns. Neither the UC or CSU system has taken a position on this bill; however, the ANSIRH surveys identified some of their concerns. SHCs are concerned with the need for follow-up care and back-up care for emergencies, and how medication abortion will continue to be funded once the grant money is expended. UC SHCs are also concerned about security issues that may arise if they begin providing abortions on campus, and CSUs are concerned that, given the infrequency of its use, staff may not be able to maintain the skill necessary to use an ultrasound machine to accurately determine whether the medication can be administered safely.
2. Estimated need for medication abortions among college students. According to the Centers for Disease Control and Prevention in 2014, 652,639 legal induced abortions were reported from 49 reporting areas. The abortion rate for 2014 was 12.1 abortions per 1,000 women aged 15 to 44 years. Women in their twenties accounted for the majority of abortions in 2014 and the majority took place early in gestation: 91.5% of abortions were performed at ≤13 weeks' gestation; a smaller number of abortions (7.2%) were performed at 14–20 weeks' gestation, and even fewer (1.3%) were performed at ≥21 weeks' gestation. In 2014, 22.6% of all abortions were early medical abortions. The percentage of abortions reported as early medical abortions increased 110% from 2005 to 2014, with a 1% increase from 2013 to 2014. ANSIRH estimates, based on age- and state-adjusted abortion rates (California's abortion rate is 34% higher than the national rate) and a range of rates for medication abortion as a preferred abortion type, that there would be between 322 to 519 medication abortions each month across the UC and CSU campuses if SHCs offered medication abortion.

California Latinas for Reproductive Justice (CLRJ) is a co-sponsor of this bill and states that while Latinas represent over a third of the state's female population, they represent 12% of all women (25 or older) to complete a Bachelor's degree or higher in California, they are twice as likely as white women to report having no usual source of care, and to report delaying or foregoing needed medical care. CLRJ notes that all students who may become pregnant attending California higher education institutions will benefit from this bill because it will help foster a supportive environment where students can concentrate on their studies; have truly comprehensive healthcare; and, avoid the added financial, logistical, and emotional burden of seeking necessary reproductive healthcare off campus. The American Civil Liberties Union (ACLU) supports this bill and states that no public universities in California currently provide medication abortion services on-campus, and notes that students seeking this basic health care must travel off-campus; a serious logistical and financial barrier for a first-generation student, low-income student, or those struggling with debt and rising tuition costs.

The California Catholic Conference, Inc., opposes this bill and states that the bill blatantly discriminates against students and health care providers who do not support abortion and hold a pro-life point of view, and that by turning college campuses into a one-stop shop that offers abortions on-demand without connection to appropriate medical care, this bill discriminates against women by limiting the information and assistance that they need and deserve. The Capitol Resource Institute (CRI) is opposed to this bill and states that mandating that abortion by medication be available at all public universities will cut down the effort, and therefore the thought, behind making a decision to get an abortion. CRI concludes a student might make a hasty decision which she later regrets simply because of the availability of an abortion.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004186

Date of Hearing: August 8, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 320

Author:(Leyva) – As Amended Ver:June 14, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires, contingent upon a total of at least $9.6 million in private funds being made available on or after January 1, 2019, all on-campus student health centers (SHCs) at every campus of the University of California (UC) and California State University (CSU) to offer abortion by medication services by January 1, 2022. Specifically, it requires the Commission on the Status of Women and Girls to (a) administer private moneys in the form of $200,000 grants to each SHC for medication abortion readiness, (b) provide a grant of $200,000 in private funds to each the UC and CSU to support readiness through 24-hour support for complications, telehealth services, and billing consultation, and (c) pay itself for administration and other duties related to the program, not to exceed $2.4 million in private funds. The bill also requires each SHC, as a condition of receiving private funds, to participate in an evaluation of its readiness and its provision of medication abortion, and the commission to submit two reports on the status of the bill’s implementation. It also specifies that nothing in the bill requires a SHC to use General Fund or student fees for medication abortion readiness before January 1, 2022.

FISCAL EFFECT:

1. UC estimates one-time costs to each of its 11 SHCs in the mid-hundreds of thousands of dollars, totaling millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, telemedicine, and staffing. UC estimates that in addition to private funding, it may require additional one-time General Fund (GF) or student fees to cover start-up costs.
2. UC estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as in the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
3. CSU estimates one-time costs to each of its 23 SHCs in the low hundreds of thousands of dollars, totaling in the millions of dollars systemwide. These costs are associated with estimates for equipment, facilities, and training. CSU indicates private funding likely would cover the start-up costs on most campuses, but certain variables, such as potential security upgrades, are unknown and could drive up costs at some SHCs.
4. CSU estimates ongoing GF or student fee cost pressures at each of its SHCs, potentially as high as the low hundreds of thousands of dollars each year, totaling costs potentially as high as millions of dollars systemwide, depending on various factors, such as training, administrative costs, equipment replacement, and other unknown costs.
5. To the extent this bill results in more students accessing medication abortions, and to the extent institutions bill Medi-Cal for this service, potential though likely low state costs to increase Medi-Cal reimbursements.

COMMENTS:

1. Purpose. According to the author:

It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a public institution of higher education already has a student health center, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care.

Proponents of the measure indicate there currently are barriers to students receiving medication abortions that this bill would mitigate. Specifically, 22 campuses are more than 30 minutes away from the closest abortion provider via public transportation and 15% of providers closest to campus are open on weekends. On average, students wait one week for the next available appointment, and cumulative delays can make a student ineligible because medication abortion must be performed within the first 10 weeks of pregnancy

1. Medication Abortion. Medication abortion is the use of medications to terminate a pregnancy. Patients are eligible for medication abortion up to 10 weeks gestation. Medication abortion usually involves two visits to a qualified provider. At the first visit, pregnancy dating is confirmed by ultrasound, a standard medical evaluation is completed to ensure full eligibility, and the first medication, mifepristone, is provided to the patient in-office by the medical provider. The provider then gives instructions regarding symptom monitoring and when to seek medical attention in the event of a complication (1% to 7% percent of patients will require a surgical abortion to complete the abortion). The patient is then sent home with a second medication, misoprostol, which completes the abortion. An in-office follow-up is recommended. According to the American College of Obstetricians and Gynecologists, the safety and efficacy of mifepristone and misoprostol have been thoroughly evaluated by scientific research.

To date, national surveys indicate two college campuses in the U.S. provide medication abortions at their student health centers: The University of Illinois at Chicago and The College of New Jersey.

1. Student Health Centers. The UC has 10 campuses and 11 SHCs, which provide a wide variety of medical, mental health, and wellness services to students, though services vary by campus. According to UC, its student health care centers receive little-to-no state funding. The health centers are funded through a combination of funding including student service fees, referendum-based fees, income, and endowments. UC also has a student referendum process to levy additional fees, though the results of the referendum are advisory. For example, UC Berkeley students have passed referenda to expand mental health services which led to a student fee increase and expanded services at that campus.

The CSU has 23 campuses and 23 SHCs, which provide a wide variety of medical, mental health, and wellness services to students, though services vary by campus. Each campus health center is funded entirely through student fees, with an average cost of $269 per student per year. Similar to UC, CSU has a student referendum process to levy additional fees, though the results are advisory.

Although nothing legally bars SHCs from offering medication abortion, which they could fund with their general fund, increases in student fees, or other means, none offer the service. Instead, SHCs indicate they refer their students to other providers for these services, such as community clinics.

1. Student Health Insurance. All UC students are registered in their campus’s Student Health Insurance Plan, but may opt out if they are covered under a private health plan. The Student Health Insurance Plan costs about $2,500 annually. While students enrolled in SHIP have abortion coverage, including abortion by medication, the service is not offered at UC campus health centers and students are referred to local family planning clinics for the procedure.

The CSU does not require students to have health insurance and does not offer a student health plan. However, every enrolled student is assessed a student health fee of about $270 annually, which provides them with access to services at their SHC. For abortion procedures, including medication abortion, SHCs indicate they refer their students to other providers, such as community clinics.

1. Sponsor’s Cost Estimates. Estimates provided by the bill’s sponsors, which include the Women’s Foundation of California and California Latinas for Reproductive Justice, indicate the $200,000 to each campus, totaling $6.8 million for all SHCs in both systems, and $200,000 to each segment, totaling $400,000, would adequately cover the start-up costs of providing medication abortions at SHCs. In addition, sponsors indicate this funding would help with setting up infrastructure that could help mitigate the ongoing costs associated with offering the service after 2022. For example, a portion of the $200,000 in startup costs to each campus and the $200,000 in private funding to each segment could support the costs of establishing Medi-Cal billing for medication abortion at SHCs. Medi-Cal reimburses about $550 for a medication abortion, and the proponents indicate this reimbursement could cover the marginal costs of offering the procedure at SHCs in the long term.

The UC and CSU both have examined whether Medi-Cal billing would be a cost-effective means to providing services to students on an ongoing basis. Both UC and CSU indicate the administrative costs for billing Medi-Cal likely would be more than the funding they would reimbursed. They also indicate that although a portion of the $200,000 in startup costs to each campus and the $200,000 to each segment could offset costs of establishing billing, they are concerned the ongoing administrative costs still would result in cost pressures to campuses.

1. Additional Private Funding. In addition to the $9.6 million in private funds outlined in the bill for SHCs, the segments, and the commission, the sponsors indicate private funders have committed to provide an additional $9.9 million to further the bill’s goals. This funding, however, is not required to be provided by the bill. Specifically, sponsors indicate private funders are to contribute $750,000 to provide additional billing assistance to SHCs and $1.5 million for medical technical assistance, training, and telehealth accounts.

In addition, sponsors indicate private funders have committed to provide $5 million ($1 million for each of five years) for an evaluation of the program as well as $2 million to support one-time start-up costs for the California Community Colleges and private universities to providing medication abortions on campus, if they choose to do so.

1. Segment Concerns. Neither UC nor CSU is in opposition to the bill, however, each has shared concerns regarding the bill’s potential costs to their SHCs, including administrative costs, liability due to complications, and campus security. While private funding may cover or help cover many of these costs, the segments have concerns with the uncertainty surrounding expenditures necessary for compliance and the pressure the mandate could place on their general fund or to increase student health fees.

Analysis Prepared by: Natasha Collins / APPR. / (916) 319-2081

Date of Hearing: June 26, 2018

ASSEMBLY COMMITTEE ON HIGHER EDUCATION

Jose Medina, Chair

SBPCA Bill Id:SB 320

Author:(Leyva) – As Amended Ver:June 14, 2018

SENATE VOTE: 25-13

SUBJECT: Public university student health centers: medication abortion readiness: abortion by medication techniques: College Student Health Center Sexual and Reproductive Health Preparation Fund.

SUMMARY: Requires, by January 1, 2020, all student health centers (SHCs) at every campus of the University of California (UC) and California State University (CSU), to offer abortion by medication services. Specifically, this bill:

1. Defines the following, for the purposes of this bill:
   1. "Commission" as the Commission on the Status of Women and Girls;
   2. "Fund" as the College Student Health Center Sexual and Reproductive Health Preparation Fund;
   3. "Grantee" as any qualifying SHC at a public college or university;
   4. "Medication abortion readiness" includes, but is not limited to, assessment of each individual clinic to determine facility and training needs before beginning to provide abortion by medication techniques, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff. Excludes the provision of abortion by medication techniques from this definition; and,
   5. "Public university student health center" as a clinic providing primary health care services to students that is located on the campus of a university within the UC or CSU systems.
2. Requires the Commission to administer the Fund, which is continuously appropriated, for the purposes of providing private moneys in the form of grants to on-campus student health centers at public colleges and universities for medication abortion readiness.
3. Authorizes the Commission to receive moneys from nonstate entities, including but not limited to private sector entities and local and federal government agencies.
4. Requires the Commission to utilize fund moneys to do all of the following:
   1. Provide a grant of $200,000 to each UC and CSU SHC to pay for the cost, both direct and indirect, of medication abortion readiness. Allows expenses under the grants to include, but not be limited to, all of the following:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the campus health center to deliver telehealth services;
      4. Costs associated with training staff in the provision of abortion by medication techniques; and,
      5. Staff cost reimbursement and clinical revenue offset while staff are in trainings.
   2. Provide a grant of $200,000 to both the UC and CSU to pay for the cost, both direct and indirect, of the following, for each university system:
      1. Providing 24-hour, backup medical support by telephone to patients who have obtained abortion by medication techniques at a UC and CSU SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Paying itself for the costs, both direct and indirect, associated with administration of the fund, including the costs of hiring staff, not to exceed $2,400,000; and,
   4. Maintaining a system of financial reporting on all aspects of the Fund.
5. Requires each grantee to, as a condition of receiving a grant award from the Fund, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
6. Specifies that implementation of this bill is contingent upon a total of at least $9.6 million in private funds being made available to the Fund in a timely manner on or after January 1, 2019, and that nothing in this bill is to be interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.
7. Requires the Commission, working with the SHCs, to assist and advise the UC and CSU SHCs on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing medication abortions.
8. Requires the Commission to report to the Legislature, on or before December 31, 2020, and again, on or before December 31, 2021, the number of public university SHCs that have begun providing medication abortions.
9. Makes various findings and declarations regarding current law recognizing abortion as a basic health service, the Legislature's intent that public university SHCs make medication abortions as accessible and cost-effective for students as possible, and that the National Academies of Sciences, Engineering, and Medicine have found that prescribing abortion by medication techniques is no different from prescribing other medications.

EXISTING LAW:

1. Establishes the UC, a public trust to be administered by the Regents of the UC and grants the Regents full powers of organization and government, subject only to such legislative control as may be necessary to insure security of its funds, compliance with the terms of its endowments, statutory requirements around competitive bidding and contracts, sales of property and the purchase of materials, goods and services (Article IX, Section (9)(a) of the California Constitution).
2. Establishes the CSU and confers upon the CSU Trustees the powers, duties, and functions with respect to the management, administration, and control of the CSU system Board of Trustees (Education Code Sections 66606 and 89030, et seq.).
3. Authorizes a licensed physician, or a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by aspiration techniques during the first trimester of pregnancy (Business and Professions Code Sections 2253 and 2725.4).
   
4. Provides for the regulation of health plans by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). Existing law exempts from the Knox-Keene Act a plan directly operated by a bona fide public or private institution of higher learning which directly provides health care services only to its students, faculty, staff, administration, and their respective dependents (Health and Safety Code (HSC) Sections 1340, et seq., 1343, and 1345).
   
5. Establishes as essential health benefits the Kaiser Small Group HMO plan along with the following ten federally mandated benefits under the Patient Protection and Affordable Care Act as well as other existing state mandated benefits including basic health care services:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care (HSC Section 1367.005 and Insurance Code Section 10112.27).

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. Likely one-time costs in the millions for capacity building at on-campus student health centers in the UC and CSU Systems (private funds). The universities have not provided estimates of the total costs to enable their student health centers to provide abortion by medication services. Based on surveys of student health centers and information provided by the sponsors of this bill, student health centers will need to purchase equipment, make facility upgrades, and provide training for staff. An estimate of those costs performed by the sponsors of the bill indicates that upfront costs would be about $12 million.
2. Unknown ongoing costs for student health centers to continue to provide medication by abortion services (private funds). In addition to the upfront costs that would be incurred to build initial capacity, there are likely to be ongoing costs, such as replacement of equipment over time and training for new staff.

COMMENTS: Double referral. This bill was heard by the Assembly Health Committee; and passed out with a vote of 10 - 4 on June 12, 2018.

Purpose of this bill. According to the author, "Many California public institutions of higher education already offer reproductive health services; these services include pregnancy options counseling, contraceptives, and other health related services".

The author contends that, "Medication abortion is a safe procedure and is clinically simpler than much of the care already offered at college health centers, such as diabetes management, mental health care, and diagnosis/treatment of sexually transmitted infections".

This bill mandates that all UC and CSU campus SHCs provide abortion by medication services.

Student health insurance options at the UC and CSU. Systemwide, the UC requires its students to have health insurance as a condition of attendance. The UC offers a health plan for students called the UC Student Health Insurance Plan (SHIP) which is funded solely by student fees and provides comprehensive health care coverage. The 2017-18 student health premiums range from $2,517.29 to $4,773.29 for graduate students and from $1,757.75 to $3,324.00 for undergraduate students (depending on campus and other factors). To note, UC students who have preexisting health care coverage can opt out of receiving SHIP.

Systemwide, CSU students are not required to have health insurance. To note, the CSU does not offer a student health plan. However, every enrolled student is assessed a student health fee. The student health fee varies campus by campus, but systemwide, the average student health fee is $269 per student per year.

Student health centers at the UC and CSU. All SHCs at every campus of the UC and CSU are supported by student fees.

Every UC campus has a SHC that provides some level of primary care, including some sexual and reproductive health services. No SHC offers abortion services. Students seeking such services are referred to providers in the community. Student health centers are traditionally open Monday through Friday, with a telephone hotline available to assist with referrals for care after hours.

Every CSU campus has a SHC that provides some health care services, although the scope of service varies by campus. No student health center offers abortion services. Students seeking such services are referred to providers in the community. Student health centers are traditionally open Monday through Friday.

Report from sponsors. Committee Staff understands that, at the request of the Senate Health Committee, the sponsors of this bill facilitated the completion of two surveys, conducted by the University of California San Francisco, School of Medicine, Advancing New Standards in Reproductive Health. Surveys were completed by all 11 UC campuses and by 20 of the 23 CSU campuses. The results of the surveys were compiled into two reports: Evaluating University of California and California State University Capacity to Provide Medication Abortion and Assessing Barriers to medication Abortion among California’s Public University Students.

The reports, found here: http://justcarecalifornia.org/wp-content/files/sb320barriers12-20-17.pdf

http://justcarecalifornia.org/wp-content/files/sb320evaluating-access1-3-18a.pdf, made the following findings and conclusions:

1. Capacity. The UC is better equipped to implement this bill due to their requirement for students to have adequate health insurance, which covers abortion.
   
   The CSU offers less specialized care and does not require students to have health insurance.
   
   Visiting clinicians and telemedicine could be models to provide medication abortion at sites that have limited internal capacity.
   
   With adequate funding for training and ultrasound machines, services could be integrated into the health care provided at all of the on-campus health centers. Additional funding would be needed to support implementation of this bill.
2. Primary area of need is ultrasound and training. Six campuses (both UC and CSU) have ultrasound machines, and 6 have at least one staff member trained in pregnancy dating.
3. Transportation and distance to local clinics. Twenty-two campuses (both UC and CSU) are more than 30 minutes away from the closest abortion provider via public transportation. For these students, the multiple visits for a medication abortion require a minimum of two hours travel by public transportation.

Fifteen campuses are further than 5 miles from the nearest provider. The median time by public transit to the closest provider is 34 minutes one-way. The maximum was 55 minutes for UCs (Davis), and 1 hour 32 minutes for CSUs (Stanislaus). Travel time for 5 campuses is one hour each way.

1. Time to appointment. Only 15 percent of providers closest to campuses are open on weekends. Students have to wait an average of one week for the next available appointment; cumulative delay can make a student ineligible for medication abortion (must be within the first 10 weeks of pregnancy).
2. Costs. Paying for an abortion may be a significant financial stressor as students may go to a provider that does not accept their student or other private health insurance, may not want to use their health insurance so they can keep the abortion private, may not have health insurance that covers abortion, or may not have insurance coverage at all.
   
   The average out-of-pocket cost of medication abortion at the providers closest to campuses was $604. On-campus health centers could offer medication abortion at a lower cost because on-campus health centers would not need to charge to cover facility overhead.
3. Estimated demand. Based on national statistics on the demand for abortions by women aged 18-24, is it estimated that on average, there will be demand for 10-17 medication abortions per month per UC campus, and 9-15 medication abortions per month per CSU campus.
4. Concerns of each segment. On-campus health centers are most concerned with the need for follow-up care and back up care for emergencies. The UCs are concerned about security and low perceived demand. The CSUs are concerned about provider training and the need to prioritize basic services given limited fee-based funding.

Comments in support. The California Commission on the Status of Women and Girls, in their support letter, dated, June 19, 2018, state, "The Commission on the Status of Women and Girls believes this bill will allow students to focus on their future, without the added financial and logistical barriers of seeking reproductive care off campus". Planned Parenthood, in their support letter, dated June 1, 2018, state, "Delaying abortion due to appointment availability may make a student ineligible for medication abortion, may increase the cost of the procedure, and may increase the risk of side effects or complications. Eliminating barriers to access comprehensive reproductive health care, including medication by abortion, is vital to protecting the academic success of our students and ensuring they can make the best decisions about their health, their bodies, and their future".

Comments in opposition. Fresno State Students for Life in their opposition letter, dated, June 12, 2018, state, "Fresno State Students for Life has dedicated the last few months to educating our campus and community about the bill and have collected over 1,500 signatures to petition the California Assembly to vote 'no' on SB-320. These petitions were signed by both pro-life and pro-choice individuals, in an effort to keep our campus free of a procedure that will harm our students. Concerned Women for America, in their opposition letter, dated June 20, 2018, state, "While it appears the bill suggests that campus clinics will be equipped with ultrasound machines to detect correct gestation and location of the pregnancy, it does not explicitly make this a requirement. We are concerned that providing early medication abortions, even assuming the condition of ultrasound imaging, could be detrimental to young women's health".

Committee comments. As currently drafted, this bill is silent as to what can be considered a key policy question - Should the Legislature mandate a specific health service to be provided at each UC and CSU SHC when the state does not provide any form of finance assistance to these centers?

To note, all SHCs are supported entirely by student health fees and in some cases (mostly at the UC), by grants and philanthropic donations. There is no known case of the Legislature mandating any sort of required health service to SHCs.

The Committee may wish to decide if it wants to pass out a bill that could set a precedent – of the Legislature beginning to mandate what health services should be offered and/or provided at SHCs.

Additionally, there are other policy concerns associated with this bill:

1. Proven need for abortion by medication services? It is presently unclear if there is a demand or need at each campus of the UC and CSU for students to receive abortion by medication services at their SHCs. To note, Committee Staff understands that currently, only two institutions of higher education in the nation provide abortion by medication services.

The Committee may wish to ask the author to create a voluntary pilot program for each campus of the UC and CSU to participate in before mandating each campus of the UC and CSU SHCs shall provide abortion by medication services.

1. Security and privacy. What happens to students going to their SHC for other treatment needs– are they threatened? And what about those students going to their SHC seeking abortion by medication services - will their privacy be exposed?

Moving forward, should this measure pass out of this Committee, the author may wish to ensure there is more funding in place in order to provide additional security measures to protect all students entering their SHCs for medical services. Additionally, the author may wish to ensure the SHCs are able to be remodeled in order to provide additional privacy (i.e. tinted windows, sound proof exam rooms, etc.).

1. Liability. If a student who receives abortion by medication services should experience adverse reactions and suffer bodily or emotional harm or worse, death – who is liable? Does this bill create a situation whereby moneys that could be used for other vital student support needs are redirected by the CSU or UC in order to pay for personal injury law cases, etc. by students and/or their families?

Additionally, what happens if the ultrasound was not performed correctly at a SHC and a student receives the medication, but should not have?

1. Student health fees and billing. As mentioned above, SHCs are funded mainly through student health fees; they do not receive state funding. If students truly want to receive abortions by medication services, the Committee may wish to consider if the better policy option would be to have students on every campus vote to increase their student health fees in order to have abortion by medication services provided.

To note, Committee Staff understands that in most cases, students who have sought additional specific health services at their SHCs did so by a campus wide vote of the students; in some cases the vote was to increase the student health fee in order to offset the costs of the requested health service at the SHCs.

Committee Staff has heard some say that the SHCs can just bill the students' insurance companies, but to note, neither the CSU nor UC are equipped to start billing students' insurance companies (they would have to create and staff a billing office at each campus).

1. Commission on the Status of Women and Girls. This bill authorizes the Commission to:
   1. Administer the fund (as created by this bill) that will grant moneys to every campus to receive necessary equipment before providing pills to students; and,
   2. Write a report on the success of the program.

To note, the bill authorizes the Commission to work with the SHCs in order to assist and advise on potential pathways for SHCs to access public and private payers to provide funding for ongoing costs of providing abortion by medication services. The Commission is required to report to the Legislature, on or by December 31, 2020, and then on or by December 31, 2021, the number of UC and CSU SHCs that have begun providing abortion by medication services.

However, the bill is silent as to how the Commission will have access to necessary data, etc. to write this report and the required report does not call for additional metrics (i.e. number of students, demographics (to the extent possible by age, gender, and ethnicity) of students per month who received abortion by medication services, etc.).

Should this measure pass out of this Committee, the author may wish to amend this portion of the bill to instead authorize the systemwide offices of the UC and CSU to issue the reports to the Legislature with more specificity and/or authorize the systemwide offices to share their data with the Legislative Analyst's Office (LAO) and require the LAO to issue the reports.

REGISTERED SUPPORT / OPPOSITION:

Support

American Academy of Pediatrics, California

American Association of University Women

American Civil Liberties Union of California

American College of Obstetricians & Gynecologists - District IX

Associated Students, University of California, Berkeley

Business and Professional Women of Nevada County

California Academy of Family Physicians
California Commission on the Status of Women and Girls

Center on Reproductive Rights and Justice at Berkeley Law

Citizens for Choice

Having Our Say Coalition

National Abortion Federation

Planned Parenthood Affiliates of California

Students United for Reproductive Justice at Berkeley

University of California Student Association

Western Center on Law and Poverty

Opposition

California Catholic Conference, Inc.

Californians for Life

Concerned Women for America

Fresno State Students for Life
Right to Life of Central California
Right to Life of Kern County

Analysis Prepared by: Jeanice Warden / HIGHER ED. / (916) 319-3960

Date of Hearing: June 12, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 320

Author:(Leyva) – As Amended Ver:June 4, 2018

SENATE VOTE: 25-13

SUBJECT: Public health: public postsecondary education: public university student health centers: medication abortion readiness: abortion by medication techniques: College Student Health Center Sexual and Reproductive Health Preparation Fund.

SUMMARY: Requires public university student health centers (SHCs), as defined, by January 1, 2022, to offer medication abortion services. Specifically, this bill:

1. Defines the following, for the purposes of this bill:
   1. "Commission" as the Commission on the Status of Women and Girls;
   2. "Fund" as the College Student Health Center Sexual and Reproductive Health Preparation Fund;
   3. "Grantee" as any qualifying SHC at a public or private college or university;
   4. "Medication abortion readiness" includes, but is not limited to, assessment of each individual clinic to determine facility and training needs before beginning to provide abortion by medication techniques, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff. Excludes the provision of abortion by medication techniques from this definition; and,
   5. "Public university student health center" as a clinic providing primary health care services to students that is located on the campus of a university within the University of California (UC) or California State University (CSU) systems.
2. Requires the Commission to administer the Fund, which is continuously appropriated, for the purposes of providing private moneys in the form of grants to on-campus student health centers at public and private colleges and universities for medication abortion readiness. Authorizes the Commission to receive moneys from nonstate entities, including but not limited to private sector entities and local and federal government agencies.
3. Requires the Commission to utilize fund moneys to do all of the following:
   1. Provide a grant of $200,000 to each public university student health center to pay for the cost, both direct and indirect, of medication abortion readiness. Allows expenses under the grants to include, but not be limited to, all of the following:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the campus health center to deliver telehealth services;
      4. Costs associated with training staff in the provision of abortion by medication techniques; and,
      5. Staff cost reimbursement and clinical revenue offset while staff are in trainings.
   2. Provide a grant of two hundred thousand dollars ($200,000) to both the UC and CSU to pay for the cost, both direct and indirect, of the following, for each university system:
      1. Providing 24-hour, backup medical support by telephone to patients who have obtained abortion by medication techniques at a public university student health center until January 1, 2022;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Paying itself for the costs, both direct and indirect, associated with administration of the fund, including the costs of hiring staff; and,
   4. Maintaining a system of financial reporting on all aspects of the Fund.
4. Requires each grantee to, as a condition of receiving a grant award from the Fund, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Specifies that implementation of this bill is contingent upon a total of at least nine million six hundred thousand dollars ($9.6 million) in private funds being made available to the Fund in a timely manner on or after January 1, 2019, and that nothing in this bill is to be interpreted as requiring a public university to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2022.
6. Requires the Commission, working with the SHCs, to assist and advise the public university SHCs on potential pathways for their SHCs to access public and private payers to provide funding for ongoing costs of providing medication abortions.
7. Requires the Commission to report to the Legislature, on or before December 31, 2020, and again, on or before December 31, 2021, the number of public university SHCs that have begun providing medication abortions.
8. Makes various findings and declarations regarding current law recognizing abortion as a basic health service, the Legislatures intent that public university SHCs make medication abortions as accessible and cost-effective for students as possible, and that the National Academies of Sciences, Engineering, and Medicine have found that prescribing abortion by medication techniques is no different from prescribing other medications.

EXISTING LAW:

1. Grants a specific right of privacy under the California Constitution and provides that the right to have an abortion may not be infringed upon without a compelling state interest.
2. Licenses and regulates clinics, including primary care clinics and specialty clinics such as surgical clinics, by the Department of Public Health (DPH). Provides for exemptions from licensing requirements for certain types of clinics, including federally operated clinics, local government primary care clinics, clinics affiliated with an institution of higher learning, clinics conducted as outpatient departments of hospitals, and community or free clinics.
3. Permits a nurse practitioner, certified nurse-midwife or physician assistant, who completes specified training and complies with specified standardized procedures or protocols, to perform an abortion by medication and aspiration techniques during the first trimester of pregnancy.
4. Requires all residency programs in obstetrics and gynecology to comply with the program requirements of the Accreditation Council for Graduate Medical Education which, among other provisions, require training in the performance of abortion services.
5. Provides for the regulation of health plans by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). Exempts from the Knox-Keene Act a plan directly operated by a bona fide public or private institution of higher learning which directly provides health care services only to its students, faculty, staff, administration, and their respective dependents.
6. Establishes as essential health benefits the Kaiser Small Group HMO plan along with the following 10 federally mandated benefits under the Patient Protection and Affordable Care Act (ACA) as well as other existing state mandated benefits including basic health care services:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care.
7. Defines telehealth as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. States that "telehealth" includes "telemedicine," as specified.

FISCAL EFFECT: According to the Senate Appropriations Committee, likely one-time costs in the millions for capacity building at on-campus SHCs in the UC and CSU systems (private funds). The universities have not provided estimates of the total costs to enable their SHCs to provide abortion by medication services. Based on surveys of SHCs and information provided by the sponsors of this bill, SHCs will need to purchase equipment, make facility upgrades, and provide training for staff. An estimate of those costs performed by the sponsors of the bill indicates that upfront costs would be about $12 million. Unknown ongoing costs for SHCs to continue to provide medication by abortion services (private funds). In addition to the upfront costs that would be incurred to build initial capacity, there are likely to be ongoing costs, such as replacement of equipment over time and training for new staff.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California public institutions of higher education strive to offer comprehensive reproductive health care for students in on-campus SHCs, however, currently none of the SHCs at California’s public institutions of higher education provide medication abortion services, despite how clinically simple the service is to offer. The author states that medication abortion is safer and less complicated than much of the care already offered at college health centers, including diabetes management, mental health care, or diagnosis/treatment of sexually transmitted infections. It is important that college students have access to safe and reliable comprehensive reproductive health care on campus which should include early pregnancy termination. The author concludes that if a public institution of higher education already has a SHC, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care.
2. BACKGROUND. The U.S. Supreme Court recognized a woman's constitutional right to abortion in 1973 in Roe v. Wade, and subsequent decisions have reaffirmed that right. The Court has held that a state cannot ban abortion before viability (the point at which a fetus can survive outside the uterus), and that any restriction on abortion after viability must contain exceptions to protect the life and health of the woman. Any pre-viability abortion restriction cannot create an "undue burden" by placing a substantial obstacle in the path of a woman seeking an abortion.
   
   Despite this constitutional protection, access to abortion in the U.S. is becoming more limited. According to the Guttmacher Institute, the number of abortion-providing facilities declined 3% between 2011 and 2014 (from 1,720 to 1,671). Ninety percent of all U.S. counties lacked a clinic in 2014, and 39% of women of reproductive age lived in those counties. There were 512 abortion-providing facilities in California in 2014 and 152 of those were clinics. These numbers represent no change since 2011 in overall providers, and a 5% decline in clinics from 2011, when there were 512 abortion providers overall, of which 160 were clinics. In 2014, 43% of California counties had no clinics that provided abortions, and 5% of California women lived in those counties. According to U.S. census data there are almost 4 million women of childbearing age (15 to 44 years of age) in California.
   
   1. Abortion. According to the Guttmacher Institute, more than half of all U.S. abortion patients in 2014 were in their 20s: patients aged 20 to 24 obtained 34% of all abortions, and patients aged 25 to 29 obtained 27% of all abortions. White patients accounted for 39% of abortion procedures in 2014, African Americans for 28%, Hispanics for 25%, and patients of other races and ethnicities for 9%. Seventy-five percent of abortion patients in 2014 were poor or low-income and 17% traveled more than 50 miles to obtain an abortion. The three most common reasons for getting an abortion, cited by three-fourths of patients were: concern for or responsibility to other individuals; the inability to afford raising a child; and, the belief that having a baby would interfere with work, school, or the ability to care for dependents. Fifty-one percent of abortion patients in 2014 were using contraception in the month they became pregnant.
      
      The abortion rate in 2014 was 14.6 abortions per 1,000 women aged 15 to 44, down 14% from 16.9 per 1,000 in 2011. This is the lowest rate ever observed in the U.S.
   2. Medication abortion. The U.S. Food and Drug Administration approved the use of mifepristone for early nonsurgical, or medication, abortion in 2000. Medication abortion is the termination of a pregnancy until 10 weeks’ gestation using a combination of two medications, mifepristone and misoprostol. The first medication starts the process and the second medication is used in the privacy of the person’s home to start bleeding, which is similar to a heavy menstrual period. The same combination of medications is also used in the management of early miscarriage and gives people the option to pass failed pregnancies at home. Medication abortions accounted for 31% of all nonhospital abortions in 2014, and for 45% of abortions before nine weeks' gestation.
      
      A first trimester abortion is one of the safest medical procedures and carries minimal risk. According to a 2015 Obstetrics and Gynecology article: Incidence of emergency department visits and complications after abortion, major complications requiring hospital care, surgery, or transfusion occur at a rate of less than 0.5%.
   3. SHCs. No SHCs currently provide medication abortion. The UC system has SHCs at all 10 campuses as well as Hastings School of Law. All 11 have a physician on staff. UC Hastings SHC operates nine months a year and for three months physician services are not available. All UC SHCs have a 24 hour advice nurse line. The CSU system has SHCs on all 23 campuses, each campus has a least one physician on staff and at least one nurse practitioner and/or physician assistant. About half of CSU SHCs have after-hour nurse advice lines. CSU students are eligible for health services provided at any CSU campus.
      
      All SHCs provide primary care services, including basic and sexual and reproduction health care and contraception, as well as emergency contraception on site or by prescription from the pharmacy. All SHCs refer off-campus for abortion care and most refer for ultrasound (one UC provides on-site ultrasound) and miscarriage management (three UCs provide on-site miscarriage management.)
   4. Student Healthcare Coverage. UC requires students to have adequate health insurance, the minimum essential coverage under the ACA, which covers abortion services as part of maternity care. The UC Student Health Insurance Plan (SHIP) provides medical, pharmacy, dental and vision benefits, as well as mental health and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP. The 2017-18 student health premiums range from $2,517.29 to $4,773.29 for graduate students and from $1,757.75 to $3,324.00 for undergraduate students (depending on campus and other factors.)
      
      CSU does not require students to be insured and no plan is offered through the university. CSU SHCs are funded entirely through student fees, which are mandatory for all enrolled students and vary across campuses, with an average cost of $269 per student per year.
   5. UC San Francisco School of Medicine, Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The sponsors of this bill facilitated the completion of two surveys, conducted by ANSIRH. Surveys were completed by all 11 UC campuses and by 20 of the 23 CSU campuses. The results of the surveys were compiled into two reports: “Evaluating University of California and California State University Capacity to Provide Medication Abortion” and “Assessing Barriers to Medication Abortion Among California’s Public University Students.” The reports made the following findings and conclusions:
      1. Student access to abortion. “Assessing Barriers to Medication Abortion Among California's Public University Students,” states there are several barriers to students in obtaining an abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Two-thirds of UC students and one-third of the CSU student body do not have a car, and 62% of the UC and CSU student body are more than 30 minutes away from the closest abortion provider via public transportation. ANSIRH contends, for these students, the multiple visits for a medication abortion requires a minimum of two hours travel by public transportation. The brief also notes that only 15% of providers closest to university campuses are open on weekends, students may have to wait an average of a week for the next available appointment, and ultimately, the delay can make a student ineligible for medication abortion.
         
      2. SHC capacity to provide medication abortion. “Evaluating University of California and California State University Capacity to Provide Medication Abortion,” notes that in California any physician or advanced practice clinician trained to do so may provide medication abortion. The provider must be able to assess the pregnancy duration, diagnose ectopic pregnancy, and, provide surgical intervention if needed, either personally or by referral. Required facilities and equipment needed include a private room for pelvic exams (not required for all medication abortions) and counseling, ultrasound capability for pregnancy dating and to rule out ectopic pregnancy, on-site laboratory for urine pregnancy testing, hemoglobin, and Rh Status (or the ability to refer to a lab), and a 24-hour telephone hotline staffed by clinicians to answer questions and refer as needed to emergency care. The chart below provides an assessment of SHC capacity for implementing medication abortion services given current resources:
         

As the chart illustrates, while all of the SHCs have the minimum requirements for medication abortion provision: a private exam room, ability to do pregnancy testing and counseling, and clinicians who are licensed in the state of California, none of them are fully equipped to provide medication abortions. All SHCs would need training; even though a few sites have a clinician trained in abortion care, they are not currently providing care. Most CSU SHCs would also need an ultrasound machine and nurse hotline.

• 1. Concerns. Neither the UC or CSU system has taken a position on this bill; however, the ANSIRH surveys identified some of their concerns. SHCs are concerned with the need for follow-up care and back-up care for emergencies, and how medication abortion will continue to be funded once the grant money is expended. UC SHCs are also concerned about security issues that may arise if they begin providing abortions on campus, and CSUs are concerned that, given the infrequency of its use, staff may not be able to maintain the skill necessary to use an ultrasound machine to accurately determine whether the medication can be administered safely.
  2. Estimated need for medication abortions among college students. According to the Centers for Disease Control and Prevention in 2014, 652,639 legal induced abortions were reported from 49 reporting areas. The abortion rate for 2014 was 12.1 abortions per 1,000 women aged 15 to 44 years. Women in their twenties accounted for the majority of abortions in 2014 and the majority took place early in gestation: 91.5% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (7.2%) were performed at 14–20 weeks’ gestation, and even fewer (1.3%) were performed at ≥21 weeks’ gestation. In 2014, 22.6% of all abortions were early medical abortions. The percentage of abortions reported as early medical abortions increased 110% from 2005 to 2014, with a 1% increase from 2013 to 2014. ANSIRH estimates, based on age- and state-adjusted abortion rates (California's abortion rate is 34% higher than the national rate) and a range of rates for medication abortion as a preferred abortion type, that there would be between 322 to 519 medication abortions each month across the UC and CSU campuses if SHCs offered medication abortion.

1. SUPPORT. California Latinas for Reproductive Justice (CLRJ) is a co-sponsor of this bill and states that while Latinas represent over a third of the state's female population, they represent 12% of all women (25 or older) to complete a Bachelor's degree or higher in California, they are twice as likely as white women to report having no usual source of care, and to report delaying or foregoing needed medical care. CLRJ notes that all students who may become pregnant attending California higher education institutions will benefit from this bill because it will help foster a supportive environment where students can concentrate on their studies; have truly comprehensive healthcare; and, avoid the added financial, logistical, and emotional burden of seeking necessary reproductive healthcare off campus. The ACLU supports this bill and states that no public universities in California currently provide medication abortion services on-campus, and notes that students seeking this basic health care must travel off-campus; a serious logistical and financial barrier for a first-generation student, low-income student, or those struggling with debt and rising tuition costs.
   
   OPPOSITION. The California Catholic Conference, Inc., opposes this bill and states that the bill blatantly discriminates against students and health care providers who do not support abortion and hold a pro-life point of view, and that by turning college campuses into a one-stop shop that offers abortions on-demand without connection to appropriate medical care, this bill discriminates against women by limiting the information and assistance that they need and deserve. The Capitol Resource Institute (CRI) is opposed to this bill and states that mandating that abortion by medication be available at all public universities will cut down the effort, and therefore the thought, behind making a decision to get an abortion. CRI concludes a student might make a hasty decision which she later regrets simply because of the availability of an abortion. The California Family Council (CFC) opposes this bill and states that, while their organization believes an unborn human being has the same rights to life as that of the mother, even those who are pro-choice oppose this bill due to its dangerous lowering of health and safety standards. CFC contends that chemical abortion medication has a notorious reputation for being very painful and traumatic, and the drugs are known for not just causing physical pain to the mother, but psychological anguish that could last a lifetime.
2. PREVIOUS LEGISLATION. AB 154 (Atkins), Chapter 662, Statutes of 2013, permits a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by medication and aspiration techniques during the first trimester of pregnancy.
3. DOUBLE REFERRAL. This bill is double referred; upon passage in this Committee, this bill will be referred to the Assembly Committee on Higher Education.
4. POLICY COMMENT. Given the SHCs concerns, particularly around providing follow-up and emergency care, the author may wish to continue to work with the stakeholders to further refine the implementation timeline of this bill, and provide more specificity on the type of support SHCs, particularly those at the CSUs, will be given as they move toward implementation of the provisions of this bill.
5. SUGGESTED TECHNICAL AMENDMENTS.
   1. As currently drafted the definition of a grantee includes private universities; however the requirements of this bill only apply to public universities. The author may wish to amend the bill to strike references to private universities.
   2. As currently drafted the bill authorizes the Commission to pay itself for the costs, direct and indirect, associated with administration of the Fund. The author may wish to clarify how much of the funds can be spent on administration.
   3. As currently drafted the bill allows for grant funds to be spent providing 24-hour, backup medical support by telephone to patients who have obtained abortion by medication techniques at a public university student health center until January 1, 2022. It is unclear whether any SHCs will begin providing medication abortions prior to that date. The author may wish to amend the bill to clarify that grant funds for 24-hour medical support may also be used after January 1, 2022.

REGISTERED SUPPORT / OPPOSITION:

Support

ACCESS Women’s Health Justice (co-sponsor)

ACT for Women and Girls (co-sponsor)

California Latinas for Reproductive Justice (co-sponsor)

Students United for Reproductive Justice at UC Berkeley (co-sponsor)

Women's Foundation of California/Women’s Policy Institute (co-sponsor)

Advocates for Youth

All Rise Alameda

American Academy of Pediatrics, California

American Association of University Women of California

American Civil Liberties Union

American College of Obstetricians and Gynecologists, District IX

American Congress of Obstetricians and Gynecologists, District IX

American Nurses Association/California

Associated Students of the University of California

Associated Students of the University of California, Berkeley

California Academy of Family Physicians

California Commission on the Status of Women and Girls

California Immigrant Policy Center

California State Council of the Service Employees International Union

California Voices for Progress

California Women’s Law Center

Californians United for a Responsible Budget

Center for Reproductive Rights

Center on Reproductive Rights and Justice at Berkeley Law

Citizens for Choice

City of Berkeley

Coalition of California Welfare Rights Organizations

Community Action Fund of Planned Parenthood of Orange and San Bernardino Counties

Economic Development & Justice Giving Circle, Women’s Foundation of California

Equal Rights Advocates

Equality California

Essential Access Health

Fresno Barrios Unidos

Having Our Say Coalition

If/When/How: Lawyering for Reproductive Justice

Innovating Education in Reproductive Health

Korean Community Center of the East Bay

Korean Resource Center

Latino Coalition for a Healthy California

Los Angeles LGBT Center

Maternal and Child Health Access

Medical Students for Choice

Mixteco/Indígena Community Organizing Project

NARAL Pro-Choice California

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center Youth Law

National Council of Jewish Women-California

National Health Law Program

National Institute for Reproductive Health

National Network of Abortion Funds

National Partnership for Women & Families

Nevada County Citizens for Choice

Physicians for Reproductive Health

Physicians for Social Responsibility – San Francisco Bay Area Chapter

Planned Parenthood Action Fund of The Pacific Southwest

Planned Parenthood Advocates Pasadena and San Gabriel Velley

Planned Parenthood Affiliates of California

Planned Parenthood Central Coast Action Fund

Planned Parenthood Mar Monte

Planned Parenthood Northern California Action Fund

Positive Women’s Network – USA

Public Health Justice Collective

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

Run Women Run

San Francisco Bay Area Physicians for Social Responsibility

South Asian Network

Students at Stanford Medical School

Studio M Visual Design

Training in Early Abortion for Comprehensive Healthcare

University of California Student Association

Voices for Progress Education Fund

Western Center on Law & Poverty

Women’s Foundation of California

Women’s Leadership Project

Youth Justice Coalition

Opposition

Archdiocese of Los Angeles

California Catholic Conference, Inc.

California Family Council

California Nurses for Ethical Standards

California ProLife Council

California Right to Life Committee, Inc.

Californians for Life

Capitol Resource Institute

Chico State Students for Life

Concerned Women for America

Crusade for Life

Crusaders for Life

Eagle Forum of California

Faith and Public Policy

Fresno State Students for Life

International Life Services

Right to Life of Central California

Right to Life of Kern County

Salt & Light Citizenship Ministry

Salt & Light Council

Students for Life at Berkeley

Numerous individuals

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 320

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 6-2, 4/19/17

AYES: Hernandez, Atkins, Leyva, Mitchell, Monning, Roth

NOES: Nguyen, Nielsen

NO VOTE RECORDED: Newman

SENATE EDUCATION COMMITTEE: 4-2, 1/10/18

AYES: Allen, Galgiani, Leyva, Pan

NOES: Wilk, Vidak

NO VOTE RECORDED: Mendoza

SENATE APPROPRIATIONS COMMITTEE: 5-2, 1/18/18

AYES: Lara, Beall, Bradford, Hill, Wiener

NOES: Bates, Nielsen

SUBJECT:

SOURCE: ACCESS Women’s Health Justice

ACT for Women and Girls

California Latinas for Reproductive Justice

Women’s Policy Institute

DIGEST:

This bill requires each public university student health center to offer abortion by medication techniques beginning January 1, 2022. Establishes the Medication Abortion Implementation Fund (fund) for the purposes of providing private moneys in the form of grants to on-campus student health centers at public and private colleges and universities for the implementation of abortion by medication techniques. Requires the California State Treasurer to administer the fund, as specified.

ANALYSIS: Existing law authorizes a licensed physician, or a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by aspiration techniques during the first trimester of pregnancy.

This bill:

1. Requires each public university student health center to offer abortion by medication techniques beginning January 1, 2022.
2. Establishes the Medication Abortion Implementation Fund for the purposes of providing private moneys in the form of grants to on-campus student health centers at public and private colleges and universities for the implementation of abortion by medication techniques. Requires the California State Treasurer to administer the fund. Permits the Treasurer to receive moneys from nonstate entities, including, but not necessarily limited to, private sector entities and local and federal government agencies, and deposit these moneys in the fund. Continuously appropriates the moneys in the fund to the Treasurer for allocation for purposes of this bill.
3. Requires the Treasurer to establish an implementation schedule over the three-year time period that will take into account student health centers that are prepared to begin providing abortion by medication techniques in the first, second, or third year based on criteria to be established, which may include whether the clinic has already trained providers and ultrasound machines.
4. Requires the Treasurer to use the moneys in the fund to:
   1. Provide grants to public university student health centers to pay for the cost, both direct and indirect, of implementing abortion by medication techniques;
      1. Permits the Treasurer to additionally provide grants to student health centers at other public and private postsecondary educational institutions to pay for direct costs associated with implementing abortion by medication techniques.
      2. Requires the Treasurer to prioritize grants to public university student health centers over grants to student health centers at other public and private postsecondary educational institutions.
   2. Hire appropriate individuals or contract with an external organization or organizations to provide consultation to each public university student health center to establish plans and budgets for implementation of abortion by medication techniques;
   3. Hire appropriate individuals or contract with external organizations to create and provide appropriate trainings for staff of each public university student health center;
   4. Hire an evaluator with experience in evaluating abortion services, to determine provider, staff, and patient satisfaction and experience with the implementation of abortion by medication techniques at each grantee, as well as report on usage and outcomes;
   5. Provide overall coordination of the fund;
   6. Pay itself direct costs and overhead; and,
   7. Maintain a system of financial reporting and accountability.
5. Permits the Treasurer to directly expend fund moneys for certain aspects of implementation, such as equipment purchases for grantees, if the Treasurer determines that such expenditure of funds would be financially prudent and timely.
6. Requires each grantee to, as condition of receiving a grant award from the fund, participate in an evaluation of their implementation of abortion by medication techniques.
7. Requires this bill to be implemented only to the extent that private moneys are made available to the fund in an amount sufficient to fund all of the costs for public university student health centers to implement this chapter by January 1, 2022, and thereafter. The Treasurer shall consult with the State Department of Public Health and the governing bodies of the public universities in making the determination whether funds are sufficient.
8. Prohibits anything in this bill from being interpreted as requiring public universities to support implementation of abortion by medication techniques with General Fund appropriations or student fees.
9. Requires the Treasurer to establish the Medication Abortion Implementation Advisory Council. Requires the advisory council to develop the objectives and priorities of the fund, actively participate in the overall management of the Fund, and make final recommendations on which student health centers should be funded based on the technical merits of their proposals
10. Requires the advisory council to determine the qualifications and scope of work in a request for proposals to select an organization that will provide one-on-one support to each public university student health center for the purposes of creating individual student health center implementation plans, proposals, and budgets.
11. Requires the Treasurer to work in close collaboration with the advisory council and seek its consent before taking an action different from the action recommended by the advisory council.
12. Requires the advisory council to consist of at least nine and no more than 11 members representing a range of expertise and experience, appointed by the Treasurer. Permits individuals and organizations to submit nominations to the Treasurer, and requires the Treasurer to solicit nominations from relevant organizations and individuals. Requires the composition of the advisory council to be:
    1. Two members from California nonprofit organizations providing supportive services to individuals seeking abortions;
    2. Three members who are scientists or clinicians who study or provide abortion by medication techniques;
    3. Two members who are currently students at a public university, who have utilized student health services in the past 12 months, and who seek to expand access to abortion by medication techniques on campus; and,
    4. Two members drawn from the ranks of staff or providers, or both, at a public university student health center.
13. States that if the Treasurer appoints more than nine members, it is the intent of the Legislature that the proportional representation remains substantially the same as set forth in a) through c) above.
14. Requires advisory council members to serve without compensation, but permits them to receive reimbursement for travel and other necessary expenses actually incurred in the performance of their official duties.
15. Requires advisory council members to serve at the pleasure of the Treasurer, and requires any vacancies to be filled by the Treasurer, in consultation with the remaining advisory council members, keeping the proportional representation as set forth in a) through c) above.
16. Requires the Treasurer, working with the public university student health centers, to assist and advise on potential pathways for their student health centers to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
17. Requires the Treasurer to report to the Legislature, on or before December 31, 2020, and then again on or before December 31, 2021, the number of public university student health centers that have begun providing abortion by medication techniques. Sunsets the reporting requirements on January 1, 2026.

Comments

1. Author’s statement. According to the author, many California public institutions of higher education already offer comprehensive reproductive health services for student at their on-campus student health centers. These services include pregnancy options counseling, contraceptives and other health related services. It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a UC, CSU or CCC already has a student health center, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care. SB 320 will help to improve the academic success of students and, if a pregnant student wishes, she will be able to receive this health care service with limited financial or logistical barriers. Early pregnancy termination is a constitutionally protected right and college aged women should not have to wait additional time or travel long distances when they may have already decided to end their pregnancy. The author firmly believes that women should have control over their bodies and when they choose to incorporate a family into their lives.
   
2. Medication abortion. According to the National Institute of Health (NIH), ending a pregnancy with medications is an option for women who are less than ten weeks pregnant and would like to have an abortion at home with a less invasive procedure. A health care professional confirms via ultrasound a pregnancy of ten weeks gestation or less, indicating that the woman may be eligible for medical abortion. The two-pill process leads to a result similar to a miscarriage. The first drug, Mifepristone, is taken at a health care provider’s office or clinic, stopping the release of the hormone progesterone, which breaks down the uterus lining, discontinuing the pregnancy. Between six to 72 hours later, as determine by their health care provider, the patient takes Misoprostol at home. This drug causes the uterus to contract and empty, leading to heavy bleeding and tissue discharge, comparable to a miscarriage. The bleeding can last up between four to six hours, with very rare cases lasting up to four weeks. Common side effects of the abortion medication include nausea, cramps, vomiting, fevers, chills, diarrhea, and headaches. While uncommon, more serious problems may occur, such as an incomplete abortion, where portions of the uterine lining are not discharged. In this case, a health care provider performs an in-clinic surgical abortion to complete the process, with a seven to 14 day follow-up visit.
3. Medication abortion effectiveness and risks. According to the NIH, medication abortions are effective for 98 out of 100 women who are less than eight weeks pregnant. For women who are eight to nine weeks pregnant, it is effective 96 out of 100 times. Between nine to ten weeks of pregnancy, the medication abortion works 93 out of 100 times. For those women for whom the medical abortion is not immediately effective, a surgical procedure to terminate the pregnancy or to stop heavy bleeding may be necessary. The drug is not recommended for use for pregnancies of 10 weeks or more. Serious infection can occur in about 1 in 1,000 women, and deaths due to infection occur in less than 1 per 100,000 women. Antibiotics are often prescribed in addition to the abortion medication to lower the risk of infections.
4. Health care at UC. There are 11 universities as part of the UC system, each with their own health center (open Monday through Friday, with a 24-hour after-hour counseling service call line available). These centers provide basic student health care with physicians and nurses on staff. According to UC, its student health care centers receive little to no state funding. It spends an aggregate of $210 million in annual operating costs for all eleven health centers, $164.5 million going towards student health and $45.4 million toward counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected, through the Health Service Referenda, to charge themselves an annual fee specifically designated to support health care delivery services and/or facilities on campus.
   
   UC requires students to have adequate health insurance, which is minimum essential coverage under the Affordable Care Act (ACA). The UC system offers its students the Student Health Insurance Plan (SHIP) through each campus, providing medical, pharmacy, dental, and vision benefits, as well as mental and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP, which vary by campus and type of student. Generally, the fees start at about $500 per quarter for a single undergrad and start at about $1100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including abortion by medication, the service is not offered at UC campus health centers and students are referred to local family planning clinics for the procedure.
5. Health care at CSU. All 23 CSU campuses have a health center, providing basic student health services that are available Monday through Friday. Basic health services include primary care consistent with skills and scope of staff, family planning services excluding surgical procedures, preventative services such as immunizations, health education, basic x-ray, and referral to off-campus health care providers. Not all campuses have their own pharmacy unit, sending students off campus to drug stores to pick up medications. Each health center is funded independently by campus through students fees. The fees vary across campuses, with an average cost of $269 per student per year going towards health care services and $20 per student per year going towards the health facilities. Health insurance is not mandatory for students at CSU and no plan is offered through the university.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Committee on Appropriations:

• Likely one-time costs in the millions for capacity building at on-campus student health centers in the University of California and California State University Systems (private funds). The universities have not provided estimates of the total costs to enable their student health centers to provide abortion by medication services. Based on surveys of student health centers and information provided by the sponsors of this bill, student health centers will need to purchase equipment, make facility upgrades, and provide training for staff. An estimate of those costs performed by the sponsors of the bill indicates that upfront costs would be about $12 million.
• Unknown ongoing costs for student health centers to continue to provide medication by abortion services (private funds). In addition to the upfront costs that would be incurred to build initial capacity, there are likely to be ongoing costs, such as replacement of equipment over time and training for new staff.

SUPPORT: (Verified 1/24/18)

ACCESS Women’s Health Justice (co-source)

ACT for Women and Girls (co-source)

California Latinas for Reproductive Justice (co-source)

Women’s Policy Institute (co-source)

Advocates for Youth

All Rise Alameda

American Academy of Pediatrics

American Association of University Women of California

American Civil Liberties Union

American Congress of Obstetricians and Gynecologists, District IX

American Nurses Association/California

Associated Students of the University of California

California Immigrant Policy Center

Californians United for a Responsible Budget

California State Council of the Service Employees International Union

California Voices for Progress

California Women’s Law Center

Center for Reproductive Rights

Citizens for Choice

City of Berkeley

Coalition of California Welfare Rights Organizations

Economic Development & Justice Giving Circle, Women’s Foundation of California

Equality California

Equal Rights Advocates

Essential Access Health

Fresno Barrios Unidos

Having Our Say Coalition

If/When/How: Lawyering for Reproductive Justice

Innovating Education in Reproductive Health

Korean Community Center of the East Bay

Korean Resource Center

Latino Coalition for a Healthy California

Los Angeles LGBT Center

Maternal and Child Health Access

Medical Students for Choice

Mixteco/Indígena Community Organizing Project

NARAL Pro-Choice California

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center Youth Law

National Council of Jewish Women-California

National Health Law Program

National Network of Abortion Funds

National Partnership for Women & Families

Physicians for Reproductive Health

Physicians for Social Responsibility – San Francisco Bay Area Chapter

Planned Parenthood Action Fund of The Pacific Southwest

Planned Parenthood Affiliates of California

Planned Parenthood Affiliates Pasadena and San Gabriel Valley

Planned Parenthood Central Coast Action Fund

Planned Parenthood Mar Monte

Planned Parenthood Northern California Action Fund

Positive Women’s Network – USA

Public Health Justice Collective

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

Run Women Run

South Asian Network

Students at Stanford Medical School

Studio M Visual Design

Tara Health Foundation

The Community Action Fund of Planned Parenthood of Orange and San Bernardino

Training in Early Abortion for Comprehensive Healthcare

Voices for Progress Education Fund

Western Center on Law & Poverty

Women’s Leadership Project

Women’s Foundation of California

Youth Justice Coalition

OPPOSITION: (Verified 1/24/18)

California Catholic Conference

California Family Council

Californians for Life

California Nurses for Ethical Standards

California ProLife Council

California Right to Life Committee, Inc.

Capitol Resource Institute

Chico State Students for Life

Concerned Women for America

Crusaders for Life, Kolbe Academy and Trinity Prep

Faith and Public Policy

Fresno State Students for Life

Right to Life of Central California

Right to Life of Kern County

Salt & Light Citizenship Ministry

Salt & Light Council

Students for Life at Berkeley

Prepared by: 1/24/18 15:33:29

*** END****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 320 (Leyva) - Public health: public postsecondary education: on-campus student health centers: abortion by medication techniques

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 320 would require student health centers on University of California or California State University campuses to provide abortion by medication, contingent upon funding being available for that purpose.

Fiscal Impact:

• Likely one-time costs in the millions for capacity building at on-campus student health centers in the University of California and California State University Systems (private funds). The universities have not provided estimates of the total costs to enable their student health centers to provide abortion by medication services. Based on surveys of student health centers and information provided by the sponsors of this bill, student health centers will need to purchase equipment, make facility upgrades, and provide training for staff. An estimate of those costs performed by the sponsors of the bill indicates that upfront costs would be about $12 million.
• Unknown ongoing costs for student health centers to continue to provide medication by abortion services (private funds). In addition to the upfront costs that would be incurred to build initial capacity, there are likely to be ongoing costs, such as replacement of equipment over time and training for new staff.

Background:

Health care coverage and services for students in the University of California and California State University System varies.

In the University of California system, students are required to have health insurance as a condition of attendance. The University offers a health plan for students, paid for with student fees, that provides comprehensive health care coverage. Students who have preexisting health care coverage can opt out of joining the student plan. Every University of California campus has a student health center that provides some level of primary care, including some sexual and reproductive health services. No student health center offers abortion services. Students seeking such services are referred to providers in the community. Student health centers are open Monday through Friday, with hotline available to assist with referrals for care after hours.

In the California State University system, students are not required to have health insurance and the University does not offer a student health plan. Each campus has a student health center that provides some health care services, although the scope of service vary by campus. No student health center offers abortion services. Students seeking such services are referred to providers in the community. Student health centers are open Monday through Friday.

Proposed Law:

SB 320 would require student health centers on University of California or California State University campuses to provide abortion by medication, contingent upon funding being available for that purpose.

Specific provisions of the bill would:

• After January 1, 2022, require each University of California and California State University student health center to offer abortion by medication;
• Require the Treasurer to implement a new special fund to make grants to campus student health centers to implement the requirements of the bill;
• Continuously appropriate monies in the new special fund for the purposes of the bill;
• Require the Treasurer to make grants to public university student health centers to pay for the costs of providing abortion by medication;
• Authorize the Treasurer to make grants to student health centers at other public and private universities;
• Make implementation of the bill’s requirements contingent on sufficient private funds being made available to the Treasurer to implement by the bill by January 1, 2022;
• Specify that the bill does not require the expenditure of General Fund monies or student fees;
• Require the establishment of an advisory council;
• Require the Treasurer to report to the Legislature on the program.

Staff Comments:

The bill provides that the requirement to provide abortion by medication services on the University of California and the California State University System is contingent on the availability of sufficient funding, including funding extending beyond 2022. The intent of this language is to ensure that all costs to the universities are paid for without using General Fund monies or student fees. Typically, state grant programs provide funding over a specified time period, rather than an ongoing subsidy to pay for ongoing program costs. Under this bill, if the private funders of the program or the Treasurer stopped providing funding for the ongoing program costs to the university health centers, the universities would no longer be required to comply with the requirements of the bill.

Under the bill, there would be both upfront costs (such as training for staff and equipment purchases) and ongoing costs (replacement of equipment, training for new staff, and the costs of medications). Because the bill states that it does not require the use of student fees to support the bill, it is not clear how the costs for the medications will be paid for on an ongoing basis.

-- END --

SENATE COMMITTEE ON EDUCATION

Senator Benjamin Allen, Chair

2017 - 2018 Regular

Bill No: SB 320 Hearing Date: January 10, 2018

Subject: Public health: public postsecondary education: on-campus student health centers: abortion by medication techniques

SUMMARY

This bill requires each public university student health center to offer abortion by medication techniques by January 1, 2022.

BACKGROUND

Existing law:

1. Authorizes a licensed physician, or a nurse practitioner, certified nurse-midwife, or physician assistant, who complete specified training and complies with specified standardized procedures or protocols, to perform an abortion by aspiration techniques during the first trimester of pregnancy. (Business and Professions Code § 2253 and § 2725.4)
   
2. Provides for the regulation of health plans by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). Existing law exempts from the Knox-Keene Act a plan directly operated by a bona fide public or private institution of higher learning which directly provides health care services only to its students, faculty, staff, administration, and their respective dependents. (Health and Safety Code § 1340 et seq, § 1343, and
   § 1345)
   
3. Establishes as essential health benefits the Kaiser Small Group HMO plan along with the following ten federally mandated benefits under the Patient Protection and Affordable Care Act as well as other existing state mandated benefits including basic health care services:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care.

(HSC § 1367.005 and Insurance Code § 10112.27)

ANALYSIS

This bill requires each student health center on a campus of the University of California and California State University to offer abortion by medication techniques by January 1, 2022. Specifically, this bill:

1. Requires each public university student health center to offer abortion by medication techniques by January 1, 2022.
   
2. Provides that the requirements of this bill are to be implemented only to the extent that sufficient private monies are made available to the Fund.
   

Fund

1. Requires the State Treasurer to establish and administer the Medication Abortion Implementation Fund for the purposes of providing private funds in the form of grants to on-campus student health centers at public and private colleges and universities for the implementation of abortion by medication techniques.
   
2. Authorizes the Treasurer to receive monies from non-state entities, including but not limited to private sector entities and local and federal government agencies, and deposit these monies in the Fund.
   
3. Requires the Treasurer to establish an implementation schedule over the three-year time period that will take into account student health centers that are prepared to begin providing medication abortion in the first, second, or third year based on criteria to be established, which may include whether the clinic has already trained providers and ultrasound machines.
   
4. Requires the Treasurer to use the fund to do all of the following:
   
   1. Provide grants to public university student health centers to pay for the cost, both direct and indirect, of implementing abortion by medication techniques.
      
   2. Hire appropriate individuals or contract with external organization(s) to provide consultation to each public university student health center to establish plans and budgets for implementation of abortion by medication techniques.
      
   3. Hire appropriate individuals or contract with external organization(s) to create and provide appropriate training for staff of each public university student health center.
      
   4. Hire an evaluator with experience in evaluating abortion services, to determine provider, staff, and patient satisfaction and experience with the implementation of abortion by medication techniques at each grantee, as well as report on usage and outcomes.
      
   5. Provide overall coordination of the Fund.
      
   6. Pay itself direct costs and overhead.
      
   7. Maintain a system of financial reporting and accountability.
      
5. Authorizes the Treasurer to directly expend funds for certain aspects of implementation, such as equipment purchases for grantees, if the Treasurer determines that such expenditures would be financially prudent and timely.
   
6. Authorizes the Treasurer to additionally provide grants to student health centers at other public and private postsecondary educational institutions to pay for direct costs associated with implementing abortion by medication techniques. This bill requires the Treasurer to prioritize grants to public university student health centers over grants to student health centers at other public and private postsecondary educational institutions.
   
7. Requires the Treasurer, working with the public university student health centers, to assist and advise on potential pathways for their student health centers to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
   
8. Provides that the monies in the Fund are continuously appropriated to the Treasurer for allocation pursuant to this bill.
   

Advisory Council

1. Requires the Treasurer to establish the Medication Abortion Implementation Advisory Council, in accordance with all of the following:
   
   1. The council is to develop the objectives and priorities of the Fund, actively participate in the overall management of the Fund, and make final recommendations on which student health centers should be funded based on the technical merits of their proposals.
      
   2. The council is to determine the qualifications and scope of work in a request for proposals to select an organization that will provide one-on-one support to each public university student health center for the purposes of creating individual student health center implementation plans, proposals, and budgets.
      
   3. The Treasurer is to work in close collaboration with the council and seek the consent of the council before taking an action different from the action recommended by the council.
      
   4. The council is to consist of at least nine and no more than 11 members representing a range of expertise and experience, appointed by the Treasurer. This bill authorizes individuals and organizations to submit nominations to the Treasurer, and the Treasurer is to solicit nominations from relevant organizations and individuals.
      
   5. Requires the composition of the council to be as follows:
      
      1. Two members from the California non-profit organizations providing supportive services to individuals seeking abortions.
         
      2. Three members who are scientists or clinicians who study or provide abortion by medication techniques.
         
      3. Two members who are currently students at a public university, who have utilized student health services in the past 12 months, and who seek to expand access to abortion by medication techniques on campus.
         
      4. Two members drawn from the ranks of staff and/or providers at a public university student health center.
         
2. Provides that, if the Treasurer appoints more than 9 members, it is the intent of the Legislature that the proportional representation remains substantially the same as in (e).
   
3. Provides that Members of the Council are to serve at the pleasure of the Treasurer, with any vacancies filled by the Treasurer, in consultation with the remaining council members, keeping the proportional representation as set forth in (e).
   
4. Provides that members of the council are to serve without compensation, but authorizes members to receive reimbursement for travel and other necessary expenses actually incurred in the performance of their official duties.
   

Miscellaneous

1. Requires each grantee, as a condition of receiving a grant award from the Fund, to participate in an evaluation of their implementation of abortion by medication techniques.
   
2. Requires the Treasurer to report to the Legislature, by December 31, 2020, and again by December 31, 2021, the number of public university student health centers which have begun providing medication abortion.
   
3. Defines the following terms:
   
   1. “Council” means the Medication Abortion Implementation Advisory Council.
      
   2. “Fund” means the Medication Abortion Implementation Fund.
      
   3. “Grantee” means any qualifying student health center at a public or private college or university.
      
   4. “Implementation of abortion by medication techniques” includes but is not limited to assessment of each individual clinic to determine facility and training needs prior to beginning to provide medication abortion, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff.
      
   5. “Public university student health center” means a clinic providing primary health care services to students that is located on the campus of a university within the University of California or the California State University systems.
      
4. States findings and declarations relative to the need for medication abortion at on-campus health centers.

STAFF COMMENTS

1. Need for the bill. According to the author, “California public institutions of higher education strive to offer comprehensive reproductive health care for students in on-campus student health centers. Currently, none of the student health care centers at California’s public institutions of higher education provide medication abortion services, despite how clinically simple the service is to offer. In fact, medication abortion is safer and less complicated than much of the care already offered at college health centers, including diabetes management, mental health care, or diagnosis/treatment of sexually transmitted infections. It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a public institution of higher education already has a student health center, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care.”
   
2. Medication abortion. According to the Guttmacher Institute, medication abortion is the use of medications to terminate a pregnancy. Patients are eligible for medication abortion up to 10 weeks gestation. According to the American College of Obstetricians and Gynecologists, medication abortion usually involves two visits to a qualified provider. At the first visit, pregnancy dating is confirmed by ultrasound and a standard medical evaluation is completed to ensure full eligibility for medication abortion. The first medication, mifepristone, is provided to the patient in-office by the medical provider. This medication acts on the attachment of the pregnancy to the uterus. The provider reviews the use of additional home medications that will complete the process and provides instructions regarding symptom monitoring and when to seek medical attention in the rare event that a complication occurs. The patient is then sent home with a second medication, misoprostol, to take at a specified time based on the plan made with the provider (ranging from 6-72 hours after mifepristone ingestion). Misoprostol induces uterine cramping and bleeding, which expels the pregnancy. The bleeding experience is comparable to a heavy menses or miscarriage. Follow-up is recommended to ensure completion of the abortion and can be completed several different ways depending on provider and patient preference. Most commonly, this includes an in-office visit for ultrasound confirmation that the pregnancy has passed. According to the American College of Obstetricians and Gynecologists, the safety and efficacy of mifepristone and misoprostol have been thoroughly evaluated by scientific research; this regimen is very safe and effective 93-99 percent of the time, meaning that 1-7 percent of patients will require a surgical abortion to complete the abortion. Side effects from these medications are mild and can include nausea, vomiting, diarrhea, thermoregulatory effects such as sensation of warmth or chills, or headache.
   
3. On-campus health centers. None of the health centers on campuses of the University of California (UC) or California State University (CSU) provide medication abortion. Campus-based health centers currently refer students to local health clinics for such services. According to Advancing New Standards in Reproductive Health, all on-campus health centers provide primary care services, including basic sexual and reproductive health care and contraception. All on-campus health centers provide emergency contraception on-site or by prescription from a pharmacy.
   
   Health care at CSU. Each campus of the CSU has a health center, providing basic student health services (to students who have paid the campus health fee) that are available Monday through Friday. Basic health services include primary care consistent with skills and scope of staff, basic sexual and reproductive health care and contraception, preventative services such as immunizations, health education, basic x-ray, and referral to off-campus health care providers. Health services vary from campus. For example:
   

• Sacramento State provides urgent care, x-ray, a vision center, and individual and group counseling.
  
• Stanislaus State provides mental health consultation and general women’s and men’s health services.
  

Health care at UC. Each of UC’s 11 campuses have a health center (open Monday through Friday, with a 24-hour after-hour counseling service call line available). These centers provide basic health care services. Health services vary from campus. For example:

• UC Berkeley provides urgent care, lab, optometry, radiology, pharmacy, physical therapy, a specialty clinic (dermatology; ear, nose and throat; podiatry), and social services (counseling, alcohol/drug, eating disorders, relationship violence, sexual violence, transgender/gender identification counseling).
  
• UC Merced provides mental health consultation, and general women’s and men’s health services.
  

1. Services currently provided beyond basic health care services. The health centers based on the campuses of the University of California (UC) and California State University (CSU) currently provide services beyond basic health care, and prioritize which services to provide at each campus. As described above in #4, those services vary from counseling to specialty clinics. None of the on-campus health centers have chosen to provide medication abortion, even though some appear able (or nearly able) to provide such services.
   
   Should on-campus health centers be required to provide medication abortion while other high-need areas of health care, such as mental health care services, are not a required component of on-campus health care?
   
2. Capacity to provide medication abortion. According to Advancing New Standards in Reproductive Health (see Comment #9), none of the health centers on campuses of the UC or CSU currently have the capacity to immediately provide medication abortion although they all have the minimum requirements for medication abortion (private exam room, ability to do pregnancy testing and counseling, licensed clinicians ). On-campus health centers would need a varying level of funding and support to have the appropriately trained staff, equipment, and procedures necessary to provide medication abortion. This bill proposes to provide funding and support to on-campus health centers by establishing:
   
   1. The Medication Abortion Implementation Fund to provide grants on-campus health centers to pay for the cost, both direct and indirect, of implementing abortion by medication techniques; hire a consultant to each on-campus health center to establish plans and budgets; and, hire a consultant to create and provide appropriate trainings for staff at each on-campus health center.
      
   2. The Medication Abortion Implementation Advisory Council to, among other things, select organizations to provide one-on-one support to each on-campus health center.
      
3. How are campus health centers funded? For CSU, each campus health center is funded entirely through student fees. The fees are mandatory for all enrolled students and vary across campuses, with an average cost of $269 per student per year.
   
   According to UC, its student health care centers receive little to no state funding; the health centers are funded through a combination of funding (varies by campus) including student service fees, referendum-based fees, income, Health Insurance Fund, campus support and endowments.
   
   This bill makes implementation contingent upon sufficient private monies being available to the Fund. Staff recommends an amendment to clarify that implementation is contingent upon private monies being made available to the Fund in an amount sufficient to fund all of the costs for public university student health centers to allow implementation by January 1, 2022, and through 2024, require the Treasurer to consult with the Department of Public Health and the governing bodies of the public universities in making the determination whether funds are sufficient, and prohibit public universities from being required to use state General Fund monies or student fees to support the implementation of this bill.
   
4. Health coverage and costs for abortion. The University of California (UC) requires students to have adequate health insurance, which is minimum essential coverage under the Affordable Care Act. The UC offers its students the Student Health Insurance Plan (SHIP) through each campus, providing medical, pharmacy, dental, and vision benefits, as well as mental and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP, which vary by campus and type of student. Generally, the fees start at about $500 per quarter for an undergraduate student who is single, and start at about $1,100 per quarter for a graduate student who is single. SHIP includes coverage for abortion, including abortion by medication.
   
   Health insurance is not mandatory for students at the California State University (CSU) and no plan is offered through the university. According to Advancing New Standards in Reproductive Health, about half of the CSU student health centers do not bill any insurance program for services rendered and CSU would need help creating a system for billing insurance.
   
   According to Advancing New Standards in Reproductive Health, the average out of pocket costs for medication abortion is $604 for students who do not have health insurance, whose insurance does not cover abortion, or who chose not to utilize their insurance for medication abortion services.
   
5. Report from sponsors. At the request of the Senate Health Committee, the sponsors of this bill facilitated the completion of two surveys, conducted by the University of California San Francisco, School of Medicine, Advancing New Standards in Reproductive Health. Surveys were completed by all 11 UC campuses and by 20 of the 23 CSU campuses. The results of the surveys were compiled into two reports: Evaluating University of California and California State University Capacity to Provide Medication Abortion and Assessing Barriers to medication Abortion among California’s Public University Students. The reports made the following findings and conclusions:
   
   Capacity: The UC is better equipped to implement this bill due to their requirement for students to have adequate health insurance, which covers abortion.
   
   The CSU offers less specialized care and does not require students to have health insurance.
   
   Visiting clinicians and telemedicine could be models to provide medication abortion at sites that have limited internal capacity.
   
   With adequate funding for training and ultrasound machines, services could be integrated into the health care provided at all of the on-campus health centers. Additional funding would be needed to support implementation of this bill.
   
   Primary area of need is ultrasound and training: Six campuses (both University of California (UC) and California State University (CSU)) have ultrasound machines, and 6 have at least one staff member trained in pregnancy dating.
   
   Transportation and distance to local clinics: Twenty-two campuses (both UC and CSU are more than 30 minutes away from the closest abortion provider via public transportation. For these students, the multiple visits for a medication abortion require a minimum of two hours travel by public transportation.
   

Fifteen campuses are further than 5 miles from the nearest provider. The median time by public transit to the closest provider is 34 minutes one-way. The maximum was 55 minutes for UCs (Davis), and 1 hour 32 minutes for CSUs (Stanislaus). Travel time for 5 campuses is one hour each way.

Time to appointment: Only 15 percent of providers closest to campuses are open on weekends. Students have to wait an average of one week for the next available appointment; cumulative delay can make a student ineligible for medication abortion (must be within the first 10 weeks of pregnancy).

Costs: Paying for an abortion may be a significant financial stressor as students may go to a provider that does not accept their student or other private health insurance, may not want to use their health insurance so they can keep the abortion private, may not have health insurance that covers abortion, or may not have insurance coverage at all.

The average out-of-pocket cost of medication abortion at the providers closest to campuses was $604. On-campus health centers could offer medication abortion at a lower cost because on-campus health centers wouldn’t need to charge to cover facility overhead.

Estimated demand: Based on national statistics on the demand for abortions by women aged 18-24, is it estimated that on average, there will be demand for 10-17 medication abortions per month per UC campus, and 9-15 medication abortions per month per CSU campus.

Concerns of each segment: On-campus health centers are most concerned with the need for follow-up care and back up care for emergencies. UCs are concerned about security and low perceived demand. CSUs are concerned about provider training and the need to prioritize basic services given limited fee-based funding.

https://www.ansirh.org/sites/default/files/publications/files/sb320evaluating-access12-20-17.pdf

https://www.ansirh.org/sites/default/files/publications/files/sb320barriers12-20-17.pdf

1. Fiscal impact. This bill is likely to impose significant costs. According to the sponsors, a range of funders have offered to fund the implementation of this bill. “Funding will be available for equipment, training, payor support, and facility safety assessment.” This bill requires grant funds to be used for direct or indirect costs, consultation, training, evaluation, and authorizes funds to be used for equipment.
   
2. Heard by the Senate Health Committee. This bill was heard by the Senate Health Committee on April 19, 2017, where it passed on a 6-2 vote. Please see that Committee’s policy analysis for a more detailed discussion about the health-related aspects of the provision of medication abortion by on-campus health centers.
   

SUPPORT

ACCESS Women’s Health Justice (co-sponsor)

ACT for Women and Girls (co-sponsor)

California Latinas for Reproductive Justice (co-sponsor)

Women’s Policy Institute (co-sponsor)

All Rise Alameda

American Academy of Pediatrics

American Association of University Women of California

American Civil Liberties Union

American Congress of Obstetricians and Gynecologists, District IX

American Nurses Association/California

Associated Students of the University of California

California Immigrant Policy Center

Californians United for a Responsible Budget

California State Council of the Service Employees International Union

California Voices for Progress

California Women’s Law Center

Center for Reproductive Rights

Citizens for Choice

Coalition of California Welfare Rights Organizations

Economic Development & Justice Giving Circle, Women’s Foundation of California

Equality California

Equal Rights Advocates

Essential Access Health

Fresno Barrios Unidos

Having Our Say Coalition

If/When/How: Lawyering for Reproductive Justice

Innovating Education in Reproductive Health

Korean Community Center of the East Bay

Korean Resource Center

Latino Coalition for a Healthy California

Los Angeles LGBT Center

Maternal and Child Health Access

Medical Students for Choice

Mixteco/Indígena Community Organizing Project

NARAL Pro-Choice California

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center Youth Law

National Council of Jewish Women-California

National Health Law Program

National Network of Abortion Funds

National Partnership for Women & Families

Physicians for Reproductive Health

Planned Parenthood Affiliates of California

Planned Parenthood Mar Monte

Positive Women’s Network – USA

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

South Asian Network

Studio M Visual Design

Training in Early Abortion for Comprehensive Healthcare

Western Center on Law & Poverty

Women’s Foundation of California

Youth Justice Coalition

An individual

OPPOSITION

California Catholic Conference

California Family Council

Californians for Life

California Nurses for Ethical Standards

California ProLife Council

California Right to Life Committee, Inc.

Capitol Resource Institute

Chico State Students for Life

Concerned Women for America

Crusaders for Life, Kolbe Academy and Trinity Prep

Faith and Public Policy

Fresno State Students for Life

Right to Life of Central California

Right to Life of Kern County

Salt & Light Citizenship Ministry

Salt & Light Council

Students for Life at Berkeley

Numerous individuals

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 320

SUBJECT: Public health: public postsecondary education: student health insurance plans: on-campus student health centers: abortion by medication techniques

SUMMARY:

Requires student health care plans offered by California State University (CSU) or California Community Colleges (CCC) campuses to cover abortions. Requires on-campus health centers operated on CSU and CCC campuses to offer medication abortion and abortion counseling to its students, as specified. Requires the University of California, as a condition for the use of state funds, as specified, to include coverage for abortions and to provide medication abortion and abortion counseling, as specified.

Existing law:

1. Provides for the regulation of health plans by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), except that a plan directly operated by a bona fide public or private institution of higher learning which directly provides health care services only to its students, faculty, staff, administration, and their respective dependents is exempt from the Knox-Keene Act. Provides for the regulation of health insurers by the California Department of Insurance (CDI) under provisions of the Insurance Code.
   
2. Requires Knox-Keene Act, regulated health plans to cover basic health care services such as physician, inpatient and ambulatory services. Requires CDI regulated non-grandfathered small and individual health insurance policies to provide these same basic health care services in compliance with California essential health benefits (EHB) requirements.
   
3. Establishes as EHBs the Kaiser Small Group HMO plan along with the following ten federally mandated benefits under the Patient Protection and Affordable Care Act (ACA) as well as other existing state mandated benefits including basic health care services:
   1. Ambulatory patient services;
   2. Emergency services;
   3. Hospitalization;
   4. Maternity and newborn care;
   5. Mental health and substance use disorder services, including behavioral health treatment;
   6. Prescription drugs;
   7. Rehabilitative and habilitative services and devices;
   8. Laboratory services;
   9. Preventive and wellness services and chronic disease management; and,
   10. Pediatric services, including oral and vision care.

This bill:

1. Requires a student health insurance plan offered by a campus of CSU or CCC to include coverage of abortion in that plan.
2. Requires the University of California (UC), as a condition for the use of state funds for purposes of providing health insurance coverage for its students, to include coverage of abortion as part of the student health insurance plan.
3. Requires CSU or CCC campuses that operate an on-campus health care center to offer abortion by medication techniques and scientifically accurate abortion counseling services to its students.
4. Requires each UC campus that has an on-campus health care center, as a condition for the use of state funds for purposes of operating on-campus health care centers, to offer abortion by medication techniques and scientifically accurate abortion counseling services to its students.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, many California public institutions of higher education already offer comprehensive reproductive health services for student at their on-campus student health centers. These services include pregnancy options counseling, contraceptives and other health related services. It is important that college students have access to safe and reliable reproductive health care on campus which should include early pregnancy termination. If a UC, CSU or CCC already has a student health center, it makes sense that they provide this health care service within that facility so that students do not have to travel many miles away from their work and school commitments in order to receive care. SB 320 will help to improve the academic success of students and, if a pregnant student wishes, she will be able to receive this health care service with limited financial or logistical barriers. Early pregnancy termination is a constitutionally protected right and college aged women should not have to wait additional time or travel long distances when they may have already decided to end their pregnancy. The author firmly believes that women should have control over their bodies and when they choose to incorporate a family into their lives.
   
2. Abortions. The Center for Disease Control and Prevention (CDC) defines a legal induced abortion has an intended termination of an ongoing pregnancy performed by a licensed clinician, such as physician, nurse-midwife, nurse practitioner, or physician assistant. The CDC reports that in 2013, over 664,435 legal abortions were performed in the U.S. During this period, women in their 20s accounted for the majority of abortions and had the highest abortion rate. Specifically in 2013, women aged 20-24 accounted for 32.7% of abortions, while women aged 25-29 accounted for 25.9% of all abortions.
   
3. Medication abortion. According to the National Institute of Health (NIH), ending a pregnancy with medications is an option for women who are less than ten weeks pregnant and would like to have an abortion at home with a less invasive procedure. A health care professional confirms via ultrasound a pregnancy of ten weeks gestation or less, indicating that the woman may be eligible for medical abortion. The two-pill process leads to a result similar to a miscarriage. The first drug, Mifepristone, also called the abortion pill, is taken at the health care provider’s office or clinic, stopping the release of the hormone progesterone, which breaks down the uterus lining, discontinuing the pregnancy. Between six to 72 hours later, as determine by their health care provider, the patient takes Misoprostol at home. This drug causes the uterus to contract and empty, leading to heavy bleeding and tissue discharge, comparable to a miscarriage. The bleeding can last up between four to six hours, with very rare cases lasting up to four weeks. Common side effects of the abortion medication include nausea, cramps, vomiting, fevers, chills, diarrhea, and headaches. While uncommon, more serious problems may occur, such as an incomplete abortion, where portions of the uterine lining are not discharged. In this case, a health care provider performs an in-clinic surgical abortion to complete the process, with a seven to 14 day follow-up visit.
4. Medication abortion effectiveness, risks, and cost. According to the NIH, medication abortions are effective for 98 out of 100 women who are less than eight weeks pregnant. For women who are eight to nine weeks pregnant, it is effective 96 out of 100 times. Between nine to ten weeks of pregnancy, the medication abortion works 93 out of 100 times. For those women for whom the medical abortion is not immediately effective, a surgical procedure to terminate the pregnancy or to stop heavy bleeding may be necessary. The drug is not recommended for use for pregnancies of 10 weeks or more. Serious infection can occur in about 1 in 1,000 women, and deaths due to these infection occurs in less than 1 per 100,000 women. Antibiotics are often prescribed in addition to the abortion medication to lower the risk of infections. According to the Guttmacher Institute, the national average cost of an early medication abortion was $504 in 2011.
5. Health coverage for abortions. According to DMHC, through the Knox-Keene Act requirement for coverage of basic health care services and the California Constitution, health plans are prohibited from discriminating against women who choose to terminate a pregnancy. Thus all health plans must treat maternity services and legal abortion neutrally. Exclusions and limitations are also incompatible with both the California Reproductive Privacy Act and multiple California judicial decisions that have unambiguously established under the California Constitution that every pregnant woman has the fundamental right to choose to either bear a child or to have a legal abortion.
   
   Health plans and insurers are also required to cover all Food and Drug Administration (FDA)-approved contraceptive drugs, devices, and other products for women, including all FDA-approved contraceptive drugs, devices, and products available over the counter, as prescribed by the enrollee’s or insured’s provider; voluntary sterilization procedures; patient education and counseling on contraception; and, follow-up services related to the drugs, devices, products, and procedures, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal. Because California’s EHB benchmark plan covers medication abortions all non-grandfathered individual and small group health plan and health insurance policies must also cover medication abortions. Under Medi-Cal, medication abortion is covered through the 70^th day of gestation.
6. Health care at UC. There are 11 universities as part of the UC system, each with their own health center (open Monday through Friday, with a 24-hour after-hour counseling service call line available). These centers provide basic student health care with physicians and nurses on staff. According to UC, its student health care centers receive little to no state funding. It spends an aggregate of $210 million in annual operating costs for all eleven health centers, $164.5 million going towards student health and $45.4 million toward counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected, through the Health Service Referenda, to charge themselves an annual fee specifically designated to support health care delivery services and/or facilities on campus.
   
   UC requires students to have adequate health insurance, which is minimum essential coverage under the Affordable Care Act (ACA). The UC system offers its students the Student Health Insurance Plan (SHIP) through each campus, providing medical, pharmacy, dental, and vision benefits, as well as mental and substance use disorder services. Students who already have adequate health insurance may apply to waive enrollment in SHIP. Student fees fund SHIP, which vary by campus and type of student. Generally, the fees start at about $500 per quarter for a single undergrad and start at about $1100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including abortion by medication, the service is not offered at UC campus health centers and students are referred to local family planning clinics for the procedure.
7. Health care at CSU. All 23 CSU campuses have a health center, providing basic student health services that are available Monday through Friday. Basic health services include primary care consistent with skills and scope of staff, family planning services excluding surgical procedures, preventative services such as immunizations, health education, basic x-ray, and referral to off-campus health care providers. Not all campuses have their own pharmacy unit, sending students off campus to drug stores to pick up medications. Each health center is funded independently by campus through students fees. The fees vary across campuses, with an average cost of $269 per student per year going towards health care services and $20 per student per year going towards the health facilities. Health insurance is not mandatory for students at CSU and no plan is offered through the university.
8. Health care at CCC. There are 113 community colleges in California as part of the CCC System. According to the CCC’s Chancellor’s Office, 70 community colleges have a health center. Similar to CSU, the health centers are funded by its students’ fees. The health centers offer “basic clinical care” (which is described as assessment, intervention and referral; first aid and basic emergency care; health appraisal; and, communicable disease control) as well as mental health services (described as crisis management, short-term psychological counseling, alcohol/drug counseling, eating disorders counseling, stress management, suicide prevention, sexual harassment/assault recovery counseling program, and mental health assessment) from Monday through Friday. On average, about one third of health center staff consists of registered nurses, 14% are nurse practitioners, 4% are physicians, and 4% are licensed mental health professionals. Health insurance is not mandatory for students (except for international students) and the CCCs do not offer health insurance through their campuses.
9. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Committee on Education.
   
10. Support. Numerous supporters state that this bill will increase access to reproductive health services to students at California’s public universities and colleges by providing medication abortion at student health centers that receive state funding. Supporters contend that throughout the state, most public colleges and universities do not currently provide medication abortion on campus. For this reason, students seeking this basic reproductive health care must travel off campus to access abortion care--often with serious logistical and financial barriers. Some students must travel more than four hours to find the nearest provider. This is especially important for first-generation students, low-income students, students who are parenting, students struggling with debt and rising tuition, and others who are already overcoming obstacles to pursue their dreams. For those students, paying out-of-pocket at a clinic, trying to find a ride or take a bus to the clinic, missing school and work to figure out their options and get to the clinic, are huge burdens. Supporters state that this bill will manage the obstacles to care by requiring on-campus health centers at UC, CSU, and CCC stock FDA-approved medications used for the provision of medication abortion, which is safe, effective, and simple to provide. Public universities and colleges that have health centers are staffed by a variety of providers that can dispense the medication.
11. Opposition. California Catholic Conference, Inc. writes that this bill mandates school health clinics to provide chemical abortificatients to female students without requiring clinics to connect with students with the proper care and follow-up treatment that traditional medical staff and professional health care would ensure. California Family Council writes that this bill lowers health and safety standards for the mothers, as this drug may cause physical and psychological pain. Californians for Life states that pregnant students deserve assistance, resources, and support to complete their education goals, not abortions. California Right to Life Committee, Inc. states that women’s mental or physical health is not advanced by abortions, surgical or medication techniques. The California Resource Institute states that mandating that abortions by medications be available at all UCs will cut down the effort, and therefore thought, behind making a decision about abortion. The Faith and Public Policy of Calvary Chapel Chino Hills questions why the state would forfeit funds for abortions when California colleges are facing tuition hikes on a yearly basis, while the proposed abortion pill costs $500.
    
12. Policy comments.
    1. What problem is this bill attempting to solve? The author and supporters state that this bill is necessary, in part, so that students do not have to travel far distances to receive abortions. However, no data, except some anecdotal estimates, has been provided to support the assertion that access to this service is currently limited.
    2. Capacity. It is unclear whether these institutions, particularly community colleges and CSU campuses, have the ability to provide these services given how their health centers are set up.  In the case of community colleges, most of those health centers only offer very basic services, such as first aid and assessment and referral functions. With regard to UC health centers, according to UC, none are equipped to offer abortion services. However, each student center has relationships with OB/GYNs in the community to ensure access to these services.
    3. Impact on student fees. Because campus health centers are all funded through fees on students, this bill may result in either shutting down the centers or substantial increases in student fees to pay for the additional services due to new staffing and equipment necessary to provide them.
    4. State funding for UC SHIP. This bill requires UCs, as a condition for using state funds to provide health coverage, to cover abortions. However, coverage for abortions is already included in the program as it is required to meet the ACA’s minimum essential coverage standards, and the SHIP is solely funded through student fees built into the tuition fee.