CONSENT  

Bill No: AB 743

Author: Eduardo Garcia (D), et al.

Amended: 4/22/19 in Assembly

Vote: 21

SENATE EDUCATION COMMITTEE: 7-0, 6/5/19

AYES: Leyva, Wilk, Chang, Durazo, Glazer, McGuire, Pan

SENATE JUDICIARY COMMITTEE: 9-0, 6/18/19

AYES: Jackson, Borgeas, Durazo, Lena Gonzalez, Jones, Monning, Stern, Umberg, Wieckowski

ASSEMBLY FLOOR: 76-0, 5/2/19 - See last page for vote

SUBJECT: Pupil health: self-administration of prescribed asthma medication

SOURCE: Comite Civico Del Valle, Inc.

DIGEST:

This bill requires a school district to accept the written statement from a physician who is contracted with a binational health plan for the purposes of authorizing a pupil to carry and self-administer prescribed inhaled asthma medication that the pupil needs to administer during the regular schoolday.

ANALYSIS:

Existing law:

1. Requires, in order for a pupil to be assisted by a school nurse or other school personnel, or for the pupil to carry and self-administer prescription inhaled asthma medication, a school district to obtain both a written statement from the physician or surgeon detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer inhaled asthma medication, and a written statement from the parent, foster parent, or guardian of the pupil consenting to the self-administration, providing a release for the school nurse or other designated school personnel to consult with the health care provider of the pupil regarding any questions that may arise with regard to the medication, and releasing the school district and school personnel from civil liability if the self-administering pupil suffers an adverse reaction by taking medication pursuant to this section. (EC § 49423.1)
2. Authorizes, through regulations, a local education agency to establish specifications for the authorized health care provider’s written statement, required as per (1) above, in order to ensure that:
   1. The pupil is clearly identified.
   2. The medication is clearly identified.
   3. The dosage is clearly specified.
   4. The period of time during which the medication is to be taken is clearly specified.
   5. Other information is obtained that is relevant to administering the medication to the pupil, or otherwise assisting the pupil in the administration of the medication.
   6. An amended or new written statement is provided annually and whenever there is a change in the pupil’s authorized health care provider, or a change in the medication, dosage, method by which the medication is required to be taken, or dates or times the medication is to be taken. (California Code of Regulation, Title 5, Section 602)
3. Sets forth, in the Nursing Practice Act, the scope of practice for nursing, which specifically includes the administration of medication. (Business & Professions Code § 2725)
4. Requires a prepaid health plan operating lawfully under the laws of Mexico, that elects to operate a health care service plan in California, to apply for licensure as a health care service plan, and to comply with specified requirements, including that the prepaid health plan offers and sells in California only employer-sponsored group plan contracts exclusively for Mexican nationals legally employed in San Diego or Imperial counties, and for their dependents regardless of nationality. Requires that the health plan pay for, reimburse the cost of, or arrange for the provision or delivery of health care services that are provided or delivered wholly in Mexico, other than for emergency or urgent care services. (Health and Safety Code § 1351.2)

This bill requires a school district to accept the written statement from a physician who is contracted with a binational health plan for the purposes of authorizing a pupil to carry and self-administer prescribed inhaled asthma medication that the pupil needs to administer during the regular schoolday. Specifically, this bill:

1) Requires a school district to accept the written statement from a physician or surgeon who is contracted with a binational licensed health plan.

2) Requires the written statement specified to be provided in both English and Spanish, and shall include the name and contact information for the physician or surgeon.

3) Exempts a school nurse or other school personnel shall from professional review, liability in a civil action, or criminal prosecution for their acts or omissions relating to a pupil self-administering inhaled asthma medication pursuant to the bill’s provisions.

4) Exempts a school district shall from civil liability if a pupil self-administering inhaled asthma medication pursuant to the bill’s provisions suffers an adverse reaction.

Comments

1) Need for the bill. According to the author, “In border towns, entities such as the Imperial County Office of Education (ICOE), County of Imperial and many others offer their employees bi-national insurance. Meaning they can choose to receive health care in the United States or Mexico. Due to the higher cost of health care in the US, several employees opt to receive care for themselves and their children in Mexico.

Current school medical policies and practices fail to recognize the disparity between those afforded the opportunity of having domestic medical coverage and those that have no other choice but to travel to Mexico to receive care. Parents have been told, due to state and school policy, that prescribed medications from Mexico are not allowed.

Therefore, parents are being forced in these cases to seek a second opinion with a US doctor at an additional out of pocket expense. This leaves the potential for children to face a life threatening situation such as asthma if they do not have access to medication prescribed by an out of state doctor. It was brought to our attention that children with asthma have had to be rushed to the hospital because they were restricted access to their inhaler.”

2) High incidence of asthma in border communities. According to the Lucile Packard Foundation for Children’s Health, “asthma is one of the most common chronic diseases among children in the U.S. and a leading cause of hospitalizations and absences from school. Asthma rates vary by region, demographics, environment, physician diagnostic practices, and access to care. Although identifying the impact of independent risk factors for asthma is difficult, low-income and minority children are at disproportionately high risk for severe symptoms, missed school days, and emergency room visits due to asthma. Asthma sufferers often manage symptoms with medication, trigger avoidance, and regular medical monitoring. However, children who face cost barriers to medication or treatment are less likely to have well-controlled asthma than children with access to regular medical care, and may repeatedly be absent from school when their asthma flares up.”

The KidsData Web site, citing data from 2015-16, reports that the rate of children ever diagnosed with asthma is higher in Imperial County (23.2 percent) versus California as a whole (15.2 percent). California Environmental Health Tracking Program data shows 143 per 10,000, asthma-related emergency room visits for children ages 5-17, in Imperial County in 2016, versus 68 per 10,000 such visits for children in California as a whole.

3) Binational health insurance. According to a 2013 study, “Informing public policy toward binational health insurance: Empirical evidence from California,” “binational health insurance (BHI) between the United States and Mexico is a potential way to provide health insurance to the uninsured residing in the United States near the border, particularly uninsured immigrants from Mexico. Many individuals are uninsured, because health insurance premiums are unaffordable. BHI premiums may have the potential to be more affordable than conventional insurance premiums, because Mexico-based health care providers likely have lower reimbursement rates than United States-based providers. The premium savings from binational health insurance (BHI) plans will largely depend on the magnitudes of the provider reimbursement rate differences, as well as the share of enrollees’ health care utilization that takes place Mexico.

Commercial BHI health insurance plans have been available in California since 2000. In 2010, based on the authors’ estimates from contacting BHI plans and evaluating public records, there were approximately 120,000 enrollees within BHI plans.”

Related/Prior Legislation

SB 1266 (Huff, Chapter 321, Statutes of 2014) required school districts, county offices of education, and charter schools to provide emergency epinephrine auto-injectors to school nurses or trained personnel who have volunteered, as specified. Authorized school nurses or trained personnel to use the epinephrine auto-injectors to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an anaphylactic reaction.

SB 1912 (Ashburn, Chapter 846, Statutes of 2004) permitted pupils to carry and auto-injectable epinephrine medication at school, or to receive assistance from school personnel, as specified, if the school district receives written statements, as specified.

AB 2132 (Reyes, Chapter 832, Statutes of 2004) authorized a pupil to carry and self-administer medication, including inhaled asthma medication, or to receive assistance from school personnel, as specified, if the school district receives written statements, as specified.

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

SUPPORT: (Verified 6/21/19)

Comite Civico Del Valle, Inc. (source)

Brawley Elementary School District

Disability Rights California

Meadows Union School District

OPPOSITION: (Verified 6/21/19)

None received

ASSEMBLY FLOOR: 76-0, 5/2/19

AYES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Arambula, Kamlager-Dove, Mullin, Quirk

Prepared by: Brandon Darnell / ED. /

6/21/19 13:58:34

**** END ****

SENATE JUDICIARY COMMITTEE

Senator Hannah-Beth Jackson, Chair

2019-2020 Regular Session

Bill No: AB 743 (Author:Eduardo Garcia)

Version: April 22, 2019

Hearing Date: June 18, 2019

Fiscal: No

Urgency: No

Consultant: CK

SUBJECT

Pupil health: self-administration of prescribed asthma medication

DIGEST

This bill requires a school district to accept the statements of physicians and surgeons who are contracted with certain Mexican health plans in connection with the use of prescription inhaled asthma medication in schools. The bill immunizes school nurses, other school personnel, and school districts from specified liability in connection with a pupil self-administering inhaled asthma medication in accordance with such statements.

EXECUTIVE SUMMARY

A student who is required to take prescribed inhaled asthma medication during the schoolday may carry and self-administer such medication if the school district receives a written statement from a physician or surgeon. The statement must detail the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer the medication. The school district must also obtain a written statement from the adult responsible for the student that consents to the self-administration, authorizes school personnel to contact the health care provider, and releases the school district and school personnel from civil liability if the student suffers an adverse reaction.

This bill requires the school to accept the former statement from a physician or surgeon contracted with a health plan operating under Mexican law, as specified. The bill immunizes school personnel and the school district from liability, as specified, for any acts or omissions relating to the self-administration of such medication based on the statements of such health care providers.

This bill is sponsored by Comite Civico Del Valle. There is no known opposition. The bill passed the Senate Education Committee on a 7-0 vote.

PROPOSED CHANGES TO THE LAW

Existing law:

1. Provides that every person is bound, without contract, to abstain from injuring the person or property of another, or infringing upon any of their rights. (Civ. Code § 1708.)
2. Provides that everyone is responsible, not only for the result of their willful acts, but also for an injury to another caused by their lack of ordinary care or skill in the management of their property or person, except so far as the latter has, willfully or from lack of ordinary care, brought the injury upon themselves. (Civ. Code § 1714(a).)
3. Establishes, through the Government Tort Claims Act (“the Act”), rules of civil liability that apply to public entities and public employees in California. (Gov. Code § 810 et seq.) The Act generally provides that all public entities, state and local, are liable in tort to the extent declared by statute, subject to stated immunities and defenses. (Gov. Code § 815 et seq.) Public employees are liable to the same extent as private persons, subject to various immunities and defenses. (Gov. Code § 820 et seq.)
4. Provides that no physician, psychiatrist, oculist, dentist, dental hygienist, optometrist, otologist, podiatrist, audiologist, or nurse not employed in that capacity by the State Department of Health Services, shall be, nor shall any other person be, employed or permitted to supervise the health and physical development of pupils unless that person holds a services credential with a specialization in health or a valid credential, as specified. (Ed. Code § 49422 (“Section 49422”).)
5. Provides that, notwithstanding Section 49422, any pupil who is required to take, during the regular schoolday, medication prescribed for the pupil by a physician or surgeon, may be assisted by the school nurse or other designated school personnel, or may carry and self-administer inhaled asthma medication if the school district receives the appropriate written statements as follows:
   1. in order for a pupil to be assisted by school personnel, the school district shall obtain both a written statement from the physician or surgeon detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken and a written statement from the parent, foster parent, or guardian of the pupil requesting that the school district assist the pupil in the matters set forth in the statement of the physician or surgeon; or
   2. in order for a pupil to carry and self-administer prescription inhaled asthma medication, the school district shall obtain both a written statement from the physician or surgeon detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer inhaled asthma medication, and a written statement from the parent, foster parent, or guardian of the pupil consenting to the self-administration, providing a release for school personnel to consult with the health care provider of the pupil regarding any questions that may arise with regard to the medication, and releasing the school district and school personnel from civil liability if the self-administering pupil suffers an adverse reaction by taking medication pursuant to this section. (Ed. Code § 49423.1.)
6. Provides that, notwithstanding Section 49422, any pupil who is required to take, during the regular schoolday, medication prescribed for the pupil by a physician and surgeon or ordered for the pupil by a physician assistant, as specified, may be assisted by the school nurse or other designated school personnel or may carry and self-administer prescription auto-injectable epinephrine if the school district receives the appropriate written statements as follows:
   1. in order for a pupil to be assisted, the school district shall obtain both a written statement from the physician and surgeon or physician assistant detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken and a written statement from the parent, foster parent, or guardian of the pupil indicating the desire that the school district assist the pupil in the matters set forth in the statement of the physician and surgeon or physician assistant; or
   2. in order for a pupil to carry and self-administer prescription auto-injectable epinephrine, the school district shall obtain both a written statement from the physician and surgeon or physician assistant detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer auto-injectable epinephrine, and a written statement from the parent, foster parent, or guardian of the pupil consenting to the self-administration, providing a release for the school personnel to consult with the health care provider of the pupil regarding any questions that may arise with regard to the medication, and releasing the school district and school personnel from civil liability if the self-administering pupil suffers an adverse reaction as a result of self-administering medication. (Ed. Code § 49423.)
7. Provides the procedures and guidelines for a prepaid health plan operating lawfully under the laws of Mexico to operate a health care service plan in California. (Health & Saf. Code § 1351.2.)

This bill:

1. Requires a school district to accept the written statement from a physician or surgeon in connection with the authorization of a pupil to carry and self-administer inhaled asthma medication, from a physician or surgeon who is contracted with a health plan licensed pursuant to Section 1351.2 of the Health and Safety Code. This written statement must be provided in both English and Spanish, and include the name and contact information for the physician or surgeon.
2. Provides that a school nurse or other school personnel shall not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for their acts or omissions relating to a pupil self-administering inhaled asthma medication in accordance with the above provision. A school district shall not be subject to civil liability if a pupil self-administering inhaled asthma medication in accordance with the above provision suffers an adverse reaction.

COMMENTS

1. Stated intent of the bill

According to the author:

In border towns, entities such as the Imperial County Office of Education (ICOE), County of Imperial and many others offer their employees bi-national insurance. Meaning they can choose to receive health care in the United States or Mexico. Due to the higher cost of health care in the US, several employees opt to receive care for themselves and their children in Mexico.

Current school medical policies and practices fail to recognize the disparity between those afforded the opportunity of having domestic medical coverage and those that have no other choice but to travel to Mexico to receive care. Parents have been told, due to state and school policy, that prescribed medications from Mexico are not allowed.

Therefore, parents are being forced in these cases to seek a second opinion with a US doctor at an additional out of pocket expense.

This leaves the potential for children to face a life threatening situation such as asthma if they do not have access to medication prescribed by an out of state doctor. It was brought to our attention that children with asthma have had to be rushed to the hospital because they were restricted access to their inhaler.

1. Increasing access to inhaled asthma medication

Currently, a student who is required to take prescribed inhaled asthma medication during the schoolday has two options. The student may be assisted by the school nurse or other designated school personnel, or the student may carry and self-administer such medication. Each option is subject to specific requirements.

For the school personnel to assist the student, specified statements from a physician or surgeon and the adult responsible for the student are needed. This option is not affected by this bill.

Relevant here, in order for a student to be authorized to carry and self-administer the inhaled asthma medication, the school district must obtain two sets of documents. First, the district must receive a written statement from a physician or surgeon. That statement must detail the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the student is able to self-administer the medication.

Second, the school district must also obtain a written statement from the adult responsible for the student that consents to the self-administration, authorizes school personnel to contact the health care provider of the student with any questions that may arise, and releases the school district and school personnel from civil liability if the student suffers an adverse reaction by taking the asthma medication.

This bill requires the school to accept the former statement from a physician or surgeon who is contracted with a health plan licensed pursuant to Section 1351.2 of the Health and Safety Code. That statute governs the operation of prepaid health plans operating lawfully under the laws of Mexico who elect to operate a health care service plan in California.

The purpose of requiring statements from such medical professionals is addressed by the sponsor of this bill, Comite Civico Del Valle:

Adequate, affordable, quality health care is a priority for all, regardless of social or economic status. Having Mexico as our southern neighbor allows all residents the opportunity to make this a reality. Most insurance providers who offer medical coverage in our region take full advantage of Mexico’s proximity by including out-of-state health coverage to maximize their earnings. Local agencies, school districts, the private industry, as well as the less fortunate, are all made to travel abroad to receive medical care and savings while insurance providers boost profits. Children’s health should not be put at risk while insurance providers protect their bottom line, simply because their parents’ employer chooses out-of-state coverage for their benefits package; yet this is the situation children face.

If Mexican-based health coverage and medication is acceptable for an industry to offer American beneficiaries, then school policies should be allowed to accept it as well. Currently, school medical policies and practices, with respect to prescribed medications from out-of-state or Mexico, fail to recognize the disparity between those able to afford domestic medical coverage and those made to travel to Mexico to receive medical care. As parents with out-of-state medical coverage have realized, prescribed medications from Mexico are not allowed, nor can be administered, to their children while attending school.

In striving to better serve our community and in the pursuit to promote equitable health for all, Assemblymember E. Garcia hopes to resolve this pressing concern by allowing school districts to accept a pupil’s prescribed medications regardless of state or country for the benefit of the parents, teachers, but most importantly, the children.

1. Qualified immunity

As a general rule, California law provides that everyone is responsible, not only for the result of their willful acts, but also for an injury occasioned to another by their want of ordinary care or skill in the management of their property or person, except so far as the latter has, willfully or by want of ordinary care, brought the injury upon themselves. (Civ. Code § 1714(a).) Immunity provisions are rarely preferable because they, by their nature, prevent an injured party from seeking a particular type of recovery and force injured parties to absorb losses for which they are not responsible. In addition, they disincentivize careful planning and acting. Liability acts not only to allow a victim to be made whole, but to encourage appropriate compliance with legal requirements.

However, the Legislature has, in certain scenarios, approved limited immunity from liability (as opposed to blanket immunities) to promote other policy goals that could benefit the public. Immunities are generally afforded when needed to incentivize certain conduct. Along these lines, this Legislature has, on multiple occasions, enacted legislation that encourages the use of life-saving medications or medical interventions in order to avoid preventable deaths by limiting liability of “Good Samaritans,” as long as certain minimal requirements are met. Examples include protections for use of CPR, Civil Code Section 1714.2; use of an automated external defibrillator, Civil Code Section 1714.21; use of opiate overdose treatment, Civil Code Section 1714.22; use of an epinephrine auto-injector, Civil Code Section 1714.23; providing emergency care at the scene of an emergency, Health and Safety Code Sections 1799.102, 1799.106; and performing emergency rescue services, Health and Safety Code Section 1799.107. In most of those scenarios, however, the qualified immunity does not apply in the case of personal injury or wrongful death which results from the gross negligence or willful or wanton misconduct by the person who renders the care. (See Civ. Code § 1714.21.)

This bill immunizes school personnel and the school district from liability in connection with these new provisions. The bill provides that school personnel shall not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for their acts or omissions relating to a pupil self-administering inhaled asthma medication when done pursuant to statements accepted from physicians or surgeons who are contracted with the Mexican health plans discussed above.

Furthermore, when done in accordance with the provisions allowing statements from physicians or surgeons contracted with Mexican health plans, a school district is also immune from civil liability if a pupil self-administering inhaled asthma medication suffers an adverse reaction.

While providing immunity to school personnel actively assisting with the provision of this medication might raise thornier policy issues, this bill does not present such a situation. These immunity provisions are limited. They only apply in connection with students self-administering this medication and only after the appropriate statements are received from the students’ caregivers and the specified medical professionals. It should be made clear that this immunity only attaches to those situations where the school is relying on statements from physicians or surgeons contracted with the specified health plans. It does not otherwise apply.

SUPPORT

Comite Civico Del Valle (sponsor)

Brawley Elementary School District

Meadows Union School District

OPPOSITION

None known

RELATED LEGISLATION

Pending Legislation: None known

Prior Legislation:

SB 1266 (Huff, Ch. 321, Stats. 2014) requires school districts, county offices of education, and charter schools to provide emergency epinephrine auto-injectors to school nurses or trained personnel who have volunteered, as specified. It also authorizes school nurses or trained personnel to use the epinephrine auto-injectors to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an anaphylactic reaction.

SB 669 (Huff, Ch. 725, Stats. 2013) authorizes a trained pre-hospital emergency medical care person, first responder, or lay rescuer to obtain and use epinephrine auto-injectors to render emergency care to another person, pursuant to specified requirements, and grants them qualified immunity from liability, as specified, unless their conduct in rendering emergency care is grossly negligent.

AB 2132 (Reyes, Ch. 832, Stats. 2004) authorizes a pupil to carry and self-administer medication, including inhaled asthma medication, or to receive assistance from specified school personnel if the school district receives written statements, as specified.

PRIOR VOTES:

Senate Education Committee (Ayes 7, Noes 0)

Assembly Floor (Ayes 76, Noes 0)

Assembly Education Committee (Ayes 6, Noes 0)

**************

SENATE COMMITTEE ON EDUCATION

Senator Connie Leyva, Chair

2019 - 2020 Regular

Bill No: AB 743 Hearing Date: June 5, 2019

Subject: Pupil health: self-administration of prescribed asthma medication.

NOTE: This bill has been double-referred to the Committees on Education and Judiciary. A "do pass" motion should include referral to the Committee on Judiciary.

SUMMARY

This bill requires a school district to accept the written statement from a physician who is contracted with a binational health plan for the purposes of authorizing a pupil to carry and self-administer prescribed inhaled asthma medication that the pupil needs to administer during the regular schoolday.

BACKGROUND

1. Requires, in order for a pupil to be assisted by a school nurse or other school personnel, or for the pupil to carry and self-administer prescription inhaled asthma medication, a school district to obtain both a written statement from the physician or surgeon detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer inhaled asthma medication, and a written statement from the parent, foster parent, or guardian of the pupil consenting to the self-administration, providing a release for the school nurse or other designated school personnel to consult with the health care provider of the pupil regarding any questions that may arise with regard to the medication, and releasing the school district and school personnel from civil liability if the self-administering pupil suffers an adverse reaction by taking medication pursuant to this section. (EC § 49423.1)
2. Authorizes, through regulations, a local education agency to establish specifications for the authorized health care provider’s written statement, required as per (1) above, in order to ensure that:
   1. The pupil is clearly identified.
   2. The medication is clearly identified.
   3. The dosage is clearly specified.
   4. The period of time during which the medication is to be taken is clearly specified.
   5. Other information is obtained that is relevant to administering the medication to the pupil, or otherwise assisting the pupil in the administration of the medication.
   6. An amended or new written statement is provided annually and whenever there is a change in the pupil’s authorized health care provider, or a change in the medication, dosage, method by which the medication is required to be taken, or dates or times the medication is to be taken. (California Code of Regulation, Title 5, Section 602)
3. The Nursing Practice Act sets forth the scope of practice for nursing, which specifically includes the administration of medication.

(Business & Professions Code § 2725)

1. Requires a prepaid health plan operating lawfully under the laws of Mexico, that elects to operate a health care service plan in California, to apply for licensure as a health care service plan, and to comply with specified requirements, including that the prepaid health plan offers and sells in California only employer-sponsored group plan contracts exclusively for Mexican nationals legally employed in San Diego or Imperial counties, and for their dependents regardless of nationality. Requires that the health plan pay for, reimburse the cost of, or arrange for the provision or delivery of health care services that are provided or delivered wholly in Mexico, other than for emergency or urgent care services. (Health and Safety Code § 1351.2)

ANALYSIS

This bill requires a school district to accept the written statement from a physician who is contracted with a binational health plan for the purposes of authorizing a pupil to carry and self-administer prescribed inhaled asthma medication that the pupil needs to administer during the regular schoolday. Specifically, this bill:

1) Requires a school district to accept the written statement from a physician or surgeon who is contracted with a binational licensed health plan.

2) Requires the written statement specified to be provided in both English and Spanish, and shall include the name and contact information for the physician or surgeon.

3) Exempts a school nurse or other school personnel shall from professional review, liability in a civil action, or criminal prosecution for their acts or omissions relating to a pupil self-administering inhaled asthma medication pursuant to the bill’s provisions.

4) Exempts a school district shall from civil liability if a pupil self-administering inhaled asthma medication pursuant to the bill’s provisions suffers an adverse reaction.

STAFF COMMENTS

1. Need for the bill. According to the author, “In border towns, entities such as the Imperial County Office of Education (ICOE), County of Imperial and many others offer their employees bi-national insurance. Meaning they can choose to receive health care in the United States or Mexico. Due to the higher cost of health care in the US, several employees opt to receive care for themselves and their children in Mexico.

Current school medical policies and practices fail to recognize the disparity between those afforded the opportunity of having domestic medical coverage and those that have no other choice but to travel to Mexico to receive care. Parents have been told, due to state and school policy, that prescribed medications from Mexico are not allowed.

Therefore, parents are being forced in these cases to seek a second opinion with a US doctor at an additional out of pocket expense. This leaves the potential for children to face a life threatening situation such as asthma if they do not have access to medication prescribed by an out of state doctor. It was brought to our attention that children with asthma have had to be rushed to the hospital because they were restricted access to their inhaler.”

2) High incidence of asthma in border communities. According to the Lucile Packard Foundation for Children’s Health, “asthma is one of the most common chronic diseases among children in the U.S. and a leading cause of hospitalizations and absences from school. Asthma rates vary by region, demographics, environment, physician diagnostic practices, and access to care. Although identifying the impact of independent risk factors for asthma is difficult, low-income and minority children are at disproportionately high risk for severe symptoms, missed school days, and emergency room visits due to asthma. Asthma sufferers often manage symptoms with medication, trigger avoidance, and regular medical monitoring. However, children who face cost barriers to medication or treatment are less likely to have well-controlled asthma than children with access to regular medical care, and may repeatedly be absent from school when their asthma flares up.”

The KidsData website, citing data from 2015-16, reports that the rate of children ever diagnosed with asthma is higher in Imperial County (23.2 percent) versus California as a whole (15.2 percent). California Environmental Health Tracking Program data shows 143 per 10,000, asthma-related emergency room visits for children ages 5-17, in Imperial County in 2016, versus 68 per 10,000 such visits for children in California as a whole.

3) Binational health insurance. According to a 2013 study, “Informing public policy toward binational health insurance: Empirical evidence from California,” “binational health insurance (BHI) between the United States and Mexico is a potential way to provide health insurance to the uninsured residing in the United States near the border, particularly uninsured immigrants from Mexico. Many individuals are uninsured, because health insurance premiums are unaffordable. BHI premiums may have the potential to be more affordable than conventional insurance premiums, because Mexico-based health care providers likely have lower reimbursement rates than United States-based providers. The premium savings from binational health insurance (BHI) plans will largely depend on the magnitudes of the provider reimbursement rate differences, as well as the share of enrollees’ health care utilization that takes place Mexico.

Commercial BHI health insurance plans have been available in California since 2000. In 2010, based on the authors’ estimates from contacting BHI plans and evaluating public records, there were approximately 120,000 enrollees within BHI plans.”

4) Previous legislation. SB 1266 (Huff, Chapter 321, Statutes of 2014) requires school districts, county offices of education, and charter schools to provide emergency epinephrine auto-injectors to school nurses or trained personnel who have volunteered, as specified. Authorizes school nurses or trained personnel to use the epinephrine auto-injectors to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an anaphylactic reaction.

SB 1912 (Ashburn, Chapter 846, Statutes of 2004) permits pupils to carry and auto-injectable epinephrine medication at school, or to receive assistance from school personnel, as specified, if the school district receives written statements, as specified.

AB 2132 (Reyes, Chapter 832, Statutes of 2004) authorizes a pupil to carry and self-administer medication, including inhaled asthma medication, or to receive assistance from school personnel, as specified, if the school district receives written statements, as specified.

SUPPORT

Brawley Elementary School District

Comite Civico Del Valle, Inc.

Disability Rights California

Meadows Union School District

OPPOSITION

None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 743

Author:(Eduardo Garcia)

As Amended Ver:April 22, 2019

Majority vote

SUMMARY:

Requires a school district to accept the written statement from a physician who is contracted with a binational health plan for the purposes of authorizing a pupil to carry and self-administer inhaled asthma medication that the pupil is required to administer during the regular schoolday.

Major Provisions

1. Requires a school district to accept the written statement from a physician or surgeon, who is contracted with a binational health plan which is licensed in California, for the purposes of authorizing a pupil to carry and self-administer inhaled asthma medication that the pupil is required to administer during the regular schoolday.
2. Requires the written statement to be provided in both English and Spanish and to include the name and contact information for the physician or surgeon.
3. Prohibits the school nurse or other school personnel from being subject to professional review, liable in a civil action, or subject to criminal prosecution for their acts or omissions relating to a pupil self-administering inhaled asthma medication if the pupil suffers an adverse reaction, pursuant to these provisions.
4. Prohibits a school district from being subject to civil liability if a pupil self-administering inhaled asthma medication suffers an adverse reaction, pursuant to these provisions.

COMMENTS:

According to a 2013 study, "Informing public policy toward binational health insurance: Empirical evidence from California," "binational health insurance (BHI) between the United States (U.S.) and Mexico is a potential way to provide health insurance to the uninsured residing in the United States near the border, particularly uninsured immigrants from Mexico. BHI premiums may have the potential to be more affordable than conventional insurance premiums, because Mexico-based health care providers likely have lower reimbursement rates than United States-based providers. Commercial BHI health insurance plans have been available in California since 2000. In 2010 there were approximately 120,000 enrollees within BHI plans."

Asthma is one of the most common chronic diseases among children in the U.S. and a leading cause of hospitalizations and absences from school. Asthma rates vary by region, demographics, environment, physician diagnostic practices, and access to care. The rate of children ever diagnosed with asthma is higher in Imperial County (23.2%) versus California as a whole (15.2%). California Environmental Health Tracking Program data shows 143 per 10,000, asthma-related emergency room visits for children ages 5-17, in Imperial County in 2016, versus 68 per 10,000 such visits for children in California as a whole.

According to the Author:

According to the author, "In border towns, entities such as the Imperial County Office of Education, County of Imperial, and many others offer their employees bi-national insurance, meaning they can choose to receive health care in the United States or Mexico. Due to the higher cost of health care in the U.S., several employees opt to receive care for themselves and their children in Mexico. Current school medical policies and practices fail to recognize the disparity between those afforded the opportunity of having domestic medical coverage and those that have no other choice but to travel to Mexico to receive care. Parents have been told, due to state and school policy, that prescribed medications from Mexico are not allowed. Therefore, parents are being forced in these cases to seek a second opinion with a U.S. doctor at additional out-of-pocket expense."

Arguments in Support:

Supporters state, "If Mexican-based health coverage and medication is acceptable for an industry to offer American beneficiaries, then school policies should be allowed to accept it as well. Currently, school medical policies and practices, with respect to prescribed medications from out-of-state or Mexico, fail to recognize the disparity between those able to afford domestic medical coverage and those made to travel to Mexico to receive medical care. As parents with out-of-state medical coverage have realized, prescribed medications from Mexico are not allowed, nor can be administered, to their children while attending school."

Arguments in Opposition:

Opponents state concerns regarding accurate translations of medical documents, challenges in communicating with the prescribing physician, differing names and dosages of medications between countries, and the fact that a binational health plan may not require that a member have a primary care physician, which is particularly critical for children with asthma, who require ongoing treatment and medication.

FISCAL COMMENTS:

This bill is keyed non-fiscal by the Legislative Counsel.

VOTES:

ASM EDUCATION: 6-0-0

YES: O'Donnell, Kiley, Kalra, McCarty, Smith, Weber

UPDATED:

VERSION: April 22, 2019

CONSULTANT: Debbie Look / ED. / (916) 319-2087 FN: 0000215

Date of Hearing: April 10, 2019

ASSEMBLY COMMITTEE ON EDUCATION

Patrick O'Donnell, Chair

ABPCA Bill Id:AB 743 (

Author:Eduardo Garcia) – As Amended, Ver:April 1, 2019

SUBJECT: Pupil health: medication assistance: written physician statement

SUMMARY: Requires a school district to accept the written statement from a physician or surgeon, who is contracted with a binational health plan which is licensed in California, for the purposes of authorizing a pupil to be assisted by a school nurse or other designated school personnel, or to carry and self-administer inhaled asthma medication that the pupil is required to administer during the regular schoolday. Specifically, this bill:

1. Requires a school district to accept the written statement from a physician or surgeon, who is contracted with a binational health plan which is licensed in California, for the purposes of authorizing a pupil to be assisted by a school nurse or other designated school personnel, or to carry and self-administer inhaled asthma medication, that the pupil is required to administer during the regular schoolday.
2. Makes other technical changes.

EXISTING LAW:

1. Requires, in order for a pupil to be assisted by a school nurse or other school personnel, or for the pupil to carry and self-administer prescription inhaled asthma medication, a school district to obtain both a written statement from the physician or surgeon detailing the name of the medication, method, amount, and time schedules by which the medication is to be taken, and confirming that the pupil is able to self-administer inhaled asthma medication, and a written statement from the parent, foster parent, or guardian of the pupil consenting to the self-administration, providing a release for the school nurse or other designated school personnel to consult with the health care provider of the pupil regarding any questions that may arise with regard to the medication, and releasing the school district and school personnel from civil liability if the self-administering pupil suffers an adverse reaction by taking medication pursuant to this section. (EC 49423.1)
2. Authorizes, through regulations, a local education agency (LEA) to establish specifications for the authorized health care provider’s written statement, required as per (1) above, in order to ensure that:
   1. The pupil is clearly identified.
   2. The medication is clearly identified.
   3. The dosage is clearly specified.
   4. The period of time during which the medication is to be taken is clearly specified.
   5. Other information is obtained that is relevant to administering the medication to the pupil, or otherwise assisting the pupil in the administration of the medication.
   6. An amended or new written statement is provided annually and whenever there is a change in the pupil’s authorized health care provider, or a change in the medication, dosage, method by which the medication is required to be taken, or dates or times the medication is to be taken. (California Code of Regulation, Title 5, Section 602)
3. The Nursing Practice Act sets forth the scope of practice for nursing, which specifically includes the administration of medication. (Business & Professions Code Section 2725)
4. Requires a prepaid health plan operating lawfully under the laws of Mexico, that elects to operate a health care service plan in California, to apply for licensure as a health care service plan, and to comply with specified requirements, including that the prepaid health plan offers and sells in California only employer-sponsored group plan contracts exclusively for Mexican nationals legally employed in San Diego or Imperial counties, and for their dependents regardless of nationality. Requires that the health plan pay for, reimburse the cost of, or arrange for the provision or delivery of health care services that are provided or delivered wholly in Mexico, other than for emergency or urgent care services. (Health and Safety Code Section 1351.2)

FISCAL EFFECT: The Office of Legislative Counsel has keyed this bill as non-fiscal.

COMMENTS:

Need for the bill. According to the author, “In border towns, entities such as the Imperial County Office of Education, County of Imperial, and many others offer their employees bi-national insurance, meaning they can choose to receive health care in the United States or Mexico. Due to the higher cost of health care in the U.S., several employees opt to receive care for themselves and their children in Mexico.

Current school medical policies and practices fail to recognize the disparity between those afforded the opportunity of having domestic medical coverage and those that have no other choice but to travel to Mexico to receive care. Parents have been told, due to state and school policy, that prescribed medications from Mexico are not allowed.

Therefore, parents are being forced in these cases to seek a second opinion with a U.S. doctor at additional out-of-pocket expense.”

High incidence of asthma in border communities. According to the Lucile Packard Foundation for Children’s Health, “asthma is one of the most common chronic diseases among children in the U.S. and a leading cause of hospitalizations and absences from school. Asthma rates vary by region, demographics, environment, physician diagnostic practices, and access to care. Although identifying the impact of independent risk factors for asthma is difficult, low-income and minority children are at disproportionately high risk for severe symptoms, missed school days, and emergency room visits due to asthma. Asthma sufferers often manage symptoms with medication, trigger avoidance, and regular medical monitoring. However, children who face cost barriers to medication or treatment are less likely to have well-controlled asthma than children with access to regular medical care, and may repeatedly be absent from school when their asthma flares up.”

A 2010 study by Mérida Palacio and others studied how air pollution was affecting children in the Mexicali area of Baja California. They focused on 258 healthy, non-asthmatic children ages 9 to 12, and found the children lost about 20 percent of their lung capacity during a period when the particle pollution was worse. Mérida said that study, which was presented at a 2010 conference, “shows how much children’s health is suffering. Their lung capacity is diminished, in the long run, reduced lung capacity translates into higher rates of asthma and chronic obstructive pulmonary disease, or COPD, as well as heart disease, strokes and other illnesses.”

The KidsData website, citing data from 2015-16, reports that the rate of children ever diagnosed with asthma is higher in Imperial County (23.2%) versus California as a whole (15.2%).

California Environmental Health Tracking Program data shows 143 per 10,000, asthma-related emergency room visits for children ages 5-17, in Imperial County in 2016, versus 68 per 10,000 such visits for children in California as a whole.

Why use binational health insurance? According to a 2013 study, “Informing public policy toward binational health insurance: Empirical evidence from California”, “binational health insurance (BHI) between the United States and Mexico is a potential way to provide health insurance to the uninsured residing in the United States near the border, particularly uninsured immigrants from Mexico. Many individuals are uninsured, because health insurance premiums are unaffordable. BHI premiums may have the potential to be more affordable than conventional insurance premiums, because Mexico-based health care providers likely have lower reimbursement rates than United States-based providers. The premium savings from BHI plans will largely depend on the magnitudes of the provider reimbursement rate differences, as well as the share of enrollees’ health care utilization that takes place Mexico.

Commercial BHI health insurance plans have been available in California since 2000. In 2010, based on the authors’ estimates from contacting BHI plans and evaluating public records, there were approximately 120,000 enrollees within BHI plans.” (Fulton et. al)

Arguments in support. The Comite Civico Del Valle writes in support, “If Mexican-based health coverage and medication is acceptable for an industry to offer American beneficiaries, then school policies should be allowed to accept it as well. Currently, school medical policies and practices, with respect to prescribed medications from out-of-state or Mexico, fail to recognize the disparity between those able to afford domestic medical coverage and those made to travel to Mexico to receive medical care. As parents with out-of-state medical coverage have realized, prescribed medications from Mexico are not allowed, nor can be administered, to their children while attending school.”

Arguments in opposition. The California School Nurses Organization expresses numerous concerns with this bill’s provision to require schools to accept written statements from a physician licensed in another country as authorization to permit a pupil to be assisted with, or to be allowed to carry and self-administer medication during the school day. These include the following:

• If the written statement is provided in a language other than English, who would provide an accurate interpretation of the medical information contained?
• If the school nurse, or other school personnel, has questions about the medication or treatment of the pupil, how would they contact the medical professional who provided the written statement, to answer such questions?
• Medications in another country may have different names, contain different ingredients, have different dosages or strengths, all of which could impact the ability of the school nurse to care for the pupil’s health.
• A binational health plan may not require that a member has a primary care physician, which is particularly critical for children with conditions such as asthma that require ongoing treatment and medication.

Recommended amendments. Committee staff recommends that the bill be amended as follows:

1. Ensure that a school nurse, or other school personnel, administering, or assisting a pupil with the administration of inhaled asthma medication, based upon an authorization by a medical professional in another country, as authorized by this section, not be subject to professional review, be liable in a civil action, or be subject to criminal prosecution for his or her acts or omissions in administering, or assisting a pupil with the administration of inhaled asthma medication.
2. Ensure that schools and school districts are protected from any liability related to school personnel administering, or assisting a pupil with the administration of inhaled asthma medication, based upon an authorization by a medical professional in another country, as authorized by this section.
3. Clarify that the written statement from the physician be made available to the school in both English and Spanish, and include contact information for the pupil’s physician.

Prior and related legislation.

AB 2132 (Reyes), Chapter 832, Statutes of 2004, authorizes a pupil to carry and self-administer medication, including inhaled asthma medication, or to receive assistance from school personnel, as specified, if the school district receives written statements, as specified.

SB 1266 (Huff), Chapter 321, Statutes of 2014, requires school districts, county offices of education, and charter schools to provide emergency epinephrine auto-injectors to school nurses or trained personnel who have volunteered, as specified. Authorizes school nurses or trained personnel to use the epinephrine auto-injectors to provide emergency medical aid to persons suffering, or reasonably believed to be suffering, from an anaphylactic reaction.

REGISTERED SUPPORT / OPPOSITION:

Support

Comite Civico Del Valle, Inc.

Opposition

California School Nurses Organization

California Teachers Association

Analysis Prepared by: Debbie Look / ED. / (916) 319-2087