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, 2023, each student health care services clinic on a California State University or University of California campus 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. The bill would continuously appropriate the moneys in that fund to the commission for grants to these student health care clinics for specified activities in preparation for providing abortion by medication techniques, 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 $10,290,000 in private moneys is made available to the fund in a timely manner on or after January 1, 2020.

The bill would require the commission to submit a report to the Legislature, on or before December 31, 2021, and on or before December 31 of every year thereafter, until December 31, 2026, that includes, but is not necessarily limited to, specified information relating to abortion by medication techniques at these student health clinics.

 UNFINISHED BUSINESS  

Bill No: SB 24

Author: Leyva (D), et al.

Amended: 9/6/19

Vote: 21

SENATE HEALTH COMMITTEE: 7-2, 4/3/19

AYES: Pan, Durazo, Hurtado, Leyva, Mitchell, Monning, Rubio

NOES: Stone, Grove

SENATE EDUCATION COMMITTEE: 5-2, 4/24/19

AYES: Leyva, Durazo, Glazer, McGuire, Pan

NOES: Wilk, Chang

SENATE APPROPRIATIONS COMMITTEE: 4-2, 5/16/19

AYES: Portantino, Bradford, Hill, Wieckowski

NOES: Bates, Jones

SENATE FLOOR: 28-10, 5/20/19

AYES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Dodd, Durazo, Galgiani, Glazer, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener

NOES: Bates, Borgeas, Chang, Grove, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk

ASSEMBLY FLOOR: 44-15, 9/13/19

(ROLL CALL NOT AVAILABLE)

SUBJECT: Public health: public university student health centers: abortion by medication techniques

SOURCE: Access Women's Health Justice

ACLU California

ACT for Women and Girls

California Latinas for Reproductive Justice

NARAL Pro-Choice California

Students United for Reproductive Justice at Berkeley

Women's Policy Institute/Women's Foundation of California

DIGEST:

This bill requires student health centers (SHC) located on a campus within the University of California (UC) or California State University (CSU) that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Requires the California Commission on the Status of Women and Girls (CCSWG) 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 to public university SHCs for medication abortion readiness.

Assembly Amendments

:

1. Delete the requirement that SHCs, as a condition of receiving a grant, participate in an evaluation of its medication abortion readiness and its provision of medication abortion.
2. Permit SHCs to provide medication abortion services through telehealth services.
3. Require CCSWG financial reports to include information from SHCs on their expenditures and activities associated with this bill. Require CCSWG to use Fund moneys to (a) maintain a system of financial reporting on all aspects of the Fund and specify what the reports must include; (b) support implementation of medication abortion readiness by SHCs by specified measures; and (c) pay direct and indirect costs to administer this bill, including costs of the hiring of staff.
4. Prohibit General Fund (GF) moneys from being appropriated, or otherwise provided, to support the Fund or the CCSWG costs to administer this bill.
5. Require CCSWG to assist SHCs in identifying other resources to pay for the costs of medication abortion readiness and for providing for medication abortion.
6. Prohibit this bill from being interpreted as requiring SHCs to bill public programs or health insurance providers to support the costs of providing medication abortion services onsite.
7. Make other technical, clarifying changes.

ANALYSIS:

Existing law:

1. Permits a licensed physician, or 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. [BPC § 2253 and 2725.4]
2. Licenses and regulates clinics, including primary care clinics and specialty clinics such as surgical clinics, by the Department of Public Health.  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. [HSC §1200 and 1206]
3. Establishes the CCSWG and requires CCSWG, among other things, to recommend, develop, prepare, or coordinate materials, projects, or other activities, and to give technical and consultative advice to public or private groups or persons concerned with preventing or minimizing problems brought about by the changing roles and responsibilities of women; and, developing programs to encourage and enable women to be fully contributing members of society. [GOV § 8240, et seq.]

This bill:

1. Requires SHCs located on a campus within the UC or CSU that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Permits this service to be performed by providers on staff at the SHC, through telehealth services, or by providers associated with a contracted external agency.
2. Requires CCSWG to administer the Fund, which is established by this bill for the purposes of providing private moneys to UC and CSU to support medication abortion readiness at SHCs. Permits CCSWG to receive moneys from nonstate entities, including, but not limited to, private sector entities and local and federal government agencies, and to deposit these moneys in the Fund. Continuously appropriates funds to CCSWG for purposes of this bill.
3. Requires CCSWG to utilize Fund moneys to:
   1. Allocate $200,000 to UC and CSU for each SHC to pay for the cost, both direct and indirect, of medication abortion readiness. Defines “medication abortion readiness” to include, but not be limited to, assessment of each individual clinic to determine facility and training needs before beginning to provide medication abortion, purchasing equipment, making facility improvements, establishing clinical protocols, creating patient educational materials, and training staff. Excludes from the definition of “medication abortion readiness” the provision of medication abortion. Requires allowable expenses under these grants to include, but not be limited to:
      1. Purchase of equipment used in the provision of medication abortion;
      2. Facility and security upgrades;
      3. Costs associated with enabling the SHC to deliver telehealth services;
      4. Costs associated with training staff in the provision of medication abortion; and,
      5. Staff cost reimbursement and clinical revenue offset while staff are in trainings.
   2. Allocate $200,000 to both 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 medication abortion at a SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Maintain a system of financial reporting on all aspects of the Fund. Requires financial reports to include, but not be limited to, information from SHCs on their expenditures and activities associated with this bill.
   4. Support implementation of medication abortion readiness by SHCs by measures that may include, but are not limited to:
      1. Assisting student health centers with planning and budgeting;
      2. Coordinating with SHCs to identify training and other resources;
      3. Serving as a liaison between UC and CSU, SHCs, and the Legislature; and,
      4. Collecting, compiling, and analyzing information from SHCs to meet the CCSWG’s reporting requirements.
   5. Pay direct and indirect costs to administer this bill, including costs of the hiring of staff.
4. Requires this bill to be implemented only if, and to the extent that, a total of at least $10,290,000 in private funds is made available to the Fund in a timely manner on or after January 1, 2020.
5. Prohibits GF moneys from being appropriated, or otherwise provided, to support the Fund or the CCSWG costs to administer this bill.
6. Requires CCSWG to assist SHCs in identifying other resources to pay for the costs of medication abortion readiness and for providing for medication abortion.
7. Prohibits this bill from being interpreted as requiring UC or CSU to use GF moneys or student fees for medication abortion readiness or as requiring SHCs to bill public programs or health insurance providers to support the costs of providing medication abortion services onsite.
8. Requires CCSWG, upon request from a SHC, to assist and advise on potential pathways to bill public programs and health insurance to help pay for the costs of providing medication abortion services.
9. Requires CCSWG, on or before December 31, 2021, and on or before December 31 of each year thereafter until December 31, 2026, to submit a report to the Legislature that includes, but is not necessarily limited to, the following, separately for UC and CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;
   3. The total amount of funds received by UC and CSU and 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 SHC.
10. Requires the report and any associated data collection to be conducted in accordance with existing state and federal privacy law, as specified. Makes these reporting requirements inoperative on January 1, 2027.

Comments

1. Author’s statement. According to the author, this bill expands medication abortion services to SHCs on public university campuses. Currently, all SHCs offer some reproductive health services, and many offer comprehensive reproductive health services. Services at most SHCs include pregnancy testing/counseling, contraceptives, sexually transmitted infection (STI) and HIV counseling/testing, and cervical cancer screening/pap tests. Providing these health services on campus ensures that students do not have to travel away from their school and work commitments to receive care. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to 500 public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. Accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success. Students should be able to decide when and if they choose to have a family. By ensuring the provision of medication abortion services on campus, this bill eliminates logistical and financial barriers and allows students to exercise an important constitutional right.
2. Abortion. According to the Center for Disease Control and Prevention (CDC), for the purpose of surveillance, a legal induced abortion is defined as an intervention performed by a licensed clinician that is intended to terminate an ongoing pregnancy. The CDC reports that in 2015, 638,169 legal induced abortions were reported from 49 reporting areas across the U.S. The abortion rate for 2015 was 11.8 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 188 abortions per 1,000 live births. Compared with 2014, the total number, rate, and ratio of reported abortions for 2015 decreased 2%. From 2006 to 2015, the number, rate, and ratio of reported abortions decreased 24%, 26%, and 19%, respectively. In 2015, all three measures reached their lowest level for the entire period of analysis. Women in their twenties accounted for the majority of abortions in 2015 and throughout the period of analysis. The majority of abortions in 2015 took place early in gestation: 91.1% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (7.6%) were performed at 14–20 weeks’ gestation; and, even fewer (1.3%) were performed at ≥21 weeks’ gestation. In 2015, 24.6% of all abortions were early medication abortions (a non-surgical abortion at ≤8 weeks’ gestation).
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 medication abortion. According to a June 2018 Kaiser Family Foundation (KFF) Issue Brief, the most common regimen in the United States involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test. The KFF Issue Brief states that almost one-third of all abortions at eight weeks gestation or less are medication abortions.
4. Medication abortion effectiveness and risks. According to the KFF Issue Brief, Mifeprex is not dispensed by retail pharmacies; rather women can only obtain the drug directly from a medical provider who has received training from the manufacturer about the proper use of the drug.  If the pills are administered at eight weeks’ gestation or less, the pregnancy is terminated successfully 98 out of 100 times, with 0.05% risk of major complications, and an associated mortality rate of less than 1% (0.00063%).  According to the NIH, medication abortion has been proven highly effective, safe and acceptable for abortions occurring up to nine weeks, with efficacy rates up to 98%. Approximately 2% to 5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding.
5. Health care at UC. There are ten universities as part of the UC system and 11 SHCs (UC Hastings Law School has its own SHC), open Monday through Friday, with a 24-hour after-hour counseling service call line. UC SHCs 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 its HSCs, with $164.5 million going towards student health and $45.4 million towards counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected to charge students an annual fee specifically designated to support health care delivery services and/or facilities on campus.

UC requires students to have minimum essential coverage under the Affordable Care Act. 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 a single undergrad and start at about $1,100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including medication abortion, the service is not offered at UC SHCs and students are referred to local family planning clinics for the procedure.

1. Health care at CSU. All 23 CSU campuses have a SHC, providing “basic student health services,” which 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, and students must go off campus to access medications. CSU SHCs are funded through mandatory student fees, which cover basic services. CSU SHCs do not charge students’ insurance policies, are not reimbursed by Medi-Cal for services, and there is no co-pay for a student to visit a SHC. Students may incur additional fees when lab tests must be sent externally, for the actual cost of acquiring vaccines, medications, or health devices, or for augmented services outside of the basic services. All students have access to all services provided by SHCs, no matter their Medi-Cal status or insurance coverage. SHCs provide access to birth control, Plan B, and pregnancy tests, but do not provide ongoing pregnancy-related services. All students are eligible for HIV and STI testing. Some of these services may be provided at no cost to students depending on the capacity for waived testing or onsite lab services. If a service is considered to be beyond the scope of basic care, students may pay a fee-for-service in order to access it at the SHC. Twenty-two campuses have a health facilities fee, which is $19 on average per academic year, and all campuses have a health services fee, which is $320 on average per academic year. 
2. Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The Women's Foundation of California, a co-sponsor of this bill, facilitated two surveys, conducted by UC San Francisco’s ANSIRH, of all 11 UC SHCs and 20 CSU SHCs. The results of the surveys were compiled into two December 2017 reports. Below are selected findings from those reports:
   1. Student access to abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Public transportation is key to abortion accessibility off-campus, as over two-thirds of UC students and one-third of CSU students do not have a car. Twenty-two campuses (62%) 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 such a delay can make a student ineligible for medication abortion.
   2. SHC capacity to provide medication abortion. ANSIRH 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. 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 licensed clinicians, 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.
   3. 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.

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

According to the Assembly Appropriations Committee:

1. Potential one-time GF cost pressures or pressures to increase student health fees at UC and CSU, should readiness costs exceed available private funding. (Although this bill specifies that it does not require an SHC to use GF or student fee revenue for medication abortion readiness before January 1, 2023, compliance with this bill's requirement to offer the service by this date may necessitate their use.)
2. Ongoing GF cost pressures or pressures to increase student health fees, potentially in the hundreds of thousands annually per SHC, to support the provision of medication abortion after 2023. Specifically, the universities indicate ongoing costs associated with equipment maintenance, personnel, liability insurance, medication and telehealth. Some of these costs could be offset by insurance billing, as described in more detail in comment 4), below.
3. One-time costs, likely in the low hundreds of thousands of dollars annually, for the CCSWG to administer the private funding for the provision of medication abortion readiness, provide assistance to SHCs on accessing public and private funding to support ongoing costs of providing medical abortions and prepare an annual report until 2026. Potential one-time GF cost pressures, should CCSWG costs exceed available private funding.
4. Potential, though likely low, state costs to increase Medi-Cal reimbursements, to the extent this bill results in more students accessing medication abortions, and to the extent SHCs bill Medi-Cal for this service.

SUPPORT: (Verified 9/10/19)

Access Women's Health Justice (co-source)

ACLU California (co-source)

ACT for Women and Girls (co-source)

California Latinas for Reproductive Justice (co-source)

NARAL Pro-Choice California (co-source)

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

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

Insurance Commissioner Ricardo Lara

Lieutenant Governor Eleni Kounalakis

American Academy of Pediatrics California

American Association of University Women – California

American Association of University Women San Jose Branch

American College of Obstetricians and Gynecologists

American Medical Women’s Association

American Nurses Association\California

American Public Health Association, Sexual and Reproductive Health Section

Anti-Defamation League

Associated Student of San Jose State

Associated Students of the University of California

Associated Students of University of California San Diego

Associated Students, Inc., Sacramento State

Berkeley City Council

Bixby Program in Population & Reproductive Health, UCLA

Black Skeptics Los Angeles

Business and Professional Women of Nevada County

Cabrillo College

CalBerkeley Democrats

California Academy of Family Physicians

California Academy of Preventive Medicine

California Commission on the Status of Women and Girls

California Faculty Association

California Medical Association

California National Organization for Women

California Nurses-Midwives Association

California Pan-Ethnic Health Network

California State Student Association

California Voices for Progress

California Women’s Law Center

CARE Advocacy Services, UC Santa Barbara

Center for Relationship Abuse Awareness

Center for Reproductive Rights

Center on Reproductive Rights and Justice, Berkeley Law

Citizens for Choice

City of West Hollywood

Coalition of California Welfare Rights Organizations

Code Blue

Colorado Organization for Latina Opportunity and Reproductive Rights

Democratic Party of Santa Cruz County

Democratic Women’s Club of Santa Cruz County

Equal Rights Advocates

Equality California

Feminist Majority Foundation

Forward Together

Fresno Barrios Unidos

Hollywood Chapter of the National Organization for Women

Ibis Reproductive Health

If/When/How Lawyering Reproductive Justice

IGNITE

Impact Hub Oakland

Indivisible Project

Innovating Education in Reproductive Health

Korean Resource Center

Lawyers Club of San Diego

League of Women Voters of California

Legal Services for Prisoners with Children

Los Angeles Coalition for Reproductive Justice

Los Angeles County Democratic Party

Medical Students for Choice, California Northstate University College of Medicine

Medical Students for Choice, National Office

Medical Students for Choice, Stanford University School of Medicine

Medical Students for Choice, Touro University California College of Osteopathic Medicine

Medical Students for Choice, University of California, Davis, School of Medicine

Medical Students for Choice, University of California, San Francisco

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center for Youth Law

National Council of Jewish Women California

National Council of Jewish Women, Long Beach

National Council of Jewish Women, Los Angeles

National Health Law Program

National Institute for Reproductive Health

National Network of Abortion Funds

National Organization for Women, Hollywood Chapter

National Partnership for Women & Families

National Women’s Health Network

National Women’s Law Center

National Women’s Political Caucus of California

Nevada County Citizens’ for Choice

Our Bodies Ourselves

Peace Over Violence

Pharmacists Planning Services, Inc.

Physicians for Reproductive Health

Planned Parenthood Action Fund of the Pacific Southwest

Planned Parenthood Advocates Pasadena and San Gabriel Valley

Planned Parenthood Affiliates of California

Planned Parenthood California Central Coast

Planned Parenthood Mar Monte

Planned Parenthood of Orange and San Bernardino Counties

Positive Women’s Network-USA

Public Health Justice Collective

Reproductive Health Access Project

Reproductive Health Interest Group, University of California, Los Angeles

Reproductive Rights Network of Santa Cruz County

RHEDI/Reproductive Health Education in Family Medicine

San Diego Coalition for Reproductive Justice

San Francisco Bay Area Physicians for Social Responsibility

Services, Immigrant Rights & Education Network

Sexuality Information and Education Council of the United States

Society of Women Engineers at the University of California, Los Angeles

Stanford Ob/Gyn Student Interest Group

Stonewall Democratic Club

Students for Reproductive Justice, University of California, Santa Barbara

Studio M Visual Design

The SIA Legal Team

Training in Early Abortion for Comprehensive Healthcare

UAW, Local 2865

UAW, Local 5810

Unite for Reproductive & Gender Equity

University of California at Los Angeles Graduate Students

University of California at Los Angeles Reproductive Health Interest Group

University of California Global Health Institute Women’s Health, Gender, and Empowerment Center

University of California Student Association

URGE: Unite for Reproductive & Gender Equity

Voices for Progress

Western Center on Law and Poverty

Women Lawyers of Sacramento

Women’s Catalytic Fund

Women’s Health Specialist of California

Women’s Leadership Project

Young Latinas Aspire

Eleven individuals

OPPOSITION: (Verified 9/10/19)

Americans United for Life

Berkeley College Republicans

California Academy of Preventive Medicine

California Catholic Conference

California Family Council

California ProLife Council and Right to Life Federation

California Right to Life Committee, Inc.

Californians for Life

Center for Bio-Ethical Reform

Concerned Women for America of California

Crusade for Life

Eagle Forum of California

Faith and Public Policy

Life Priority Network

Mike Maggard, Kern County Supervisor 3rd District

Right to Life Kern County

Right to Life of Central California

Spartans for Life San Jose State University

Students for Life at California State University, Fullerton

Students for Life at Fresno State

Students for Life at University of California, Berkeley

Students for Life of America

Tulare-Kings Right to Life

One individual

Prepared by: Melanie Moreno / HEALTH / (916) 651-4111

9/13/19 19:33:27

**** END ****

SENATE THIRD READING

STR Bill Id:SB 24

Author:(Leyva)

As Amended Ver:September 6, 2019

Majority vote

SUMMARY:

Requires public university student health centers (SHCs), on and after January 1, 2023, to offer abortion by medication techniques onsite. Authorizes those services to be performed by providers on staff at the SHC, through telehealth services, or by providers associated with a contracted external agency.

Major Provisions

1. Authorize the Commission on the Status of Women (CSW) to expend private funds to support implementation of medication abortion readiness by public university student health centers by measures that may include, but are not limited to the following:
   1. Assisting student health centers (SHCs) with planning and budgeting;
   2. Coordinating with SHCs to identify training and other resources;
   3. Serving as a liaison between each public university system, SHSs, and the Legislature;
   4. Collecting, compiling, and analyzing information from SHCs to meet the CSW's reporting requirements; and,
   5. Paying direct and indirect costs of the CSW to administer these provisions, including costs of the hiring of staff.
2. Specify that nothing in this bill be interpreted as requiring a SHC to bill public programs or health insurance providers to support the costs of providing abortion by medication techniques onsite.
3. State that it is the intent of the Legislature that both of the following occur:
   1. No General Fund money be appropriated, or otherwise provide, to support the fund or the CSW's costs to administer these provisions; and,
   2. The CSW will assist SHCs in identifying other resources to pay for the costs of medication abortion readiness, and for the costs of providing for abortion by medication techniques.

COMMENTS:

According to the National Institute of Health, 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 medication abortion. The most common regimen in the U.S. involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test.

No SHCs currently provide medication abortion. Neither the University of California (UC) or California State University (CSU) system has taken a position on this bill; however, 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 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.

According to the Author:

This bill expands medication abortion services to SHCs on public university campuses. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to five hundred public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. The author notes that accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success.

Arguments in Support:

ACCESS Women's Health Justice, ACT for Women and Girls, the American Civil Liberties Union of California, California Latinas for Reproductive Justice, NARAL Pro-Choice California, and Students United for Reproductive Justice at UC Berkeley are the cosponsors of this bill. The cosponsors note that currently none of the SHCs at California's public institutions of higher education provide medication abortion services, despite how clinically simple and safe the service is to offer. The cosponsors state that students seeking this basic health care must travel off campus to access it, often with serious logistical and financial barriers.

Arguments in Opposition:

The California Family Council (CFC) is opposed this bill, stating that chemical abortion medication has a notorious reputation for being very painful and traumatic. CFC also states these abortion drugs are only approved for use on pregnancies prior to 10 weeks, and most if not all SHCs are not equipped with the medical equipment or staff necessary to make sure the drugs can be taken safely.

The Department of Finance is opposed to this bill noting that: 1) the CSW does not have the technical expertise nor existing capacity to develop and administer a program of this size, scope, or content, 2) this bill likely creates significant one-time and out-year General Fund (GF) cost pressures for the UC and CSU to comply with the requirements of this bill if: a) sufficient private funding cannot be raised to support readiness grants, b) the costs to comply with this bill's requirements exceed the proposed grant funding; or, c) UC and CSU campuses incur ongoing costs after January 1, 2023; and, 3) this bill would require UC and CSU SHCs to establish medical billing systems and develop medical bill expertise.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Potential one-time GF cost pressures or pressures to increase student health fees at UC and CSU, should readiness costs exceed available private funding. (Although the bill specifies that it does not require an SHC to use GF or student fee revenue for medication abortion readiness before January 1, 2023, compliance with the bill's requirement to offer the service by this date may necessitate their use.)
2. Ongoing GF cost pressures or pressures to increase student health fees, potentially in the hundreds of thousands annually per SHC, to support the provision of medication abortion after 2023. Specifically, the universities indicate ongoing costs associated with equipment maintenance, personnel, liability insurance, medication and telehealth. Some of these costs could be offset by insurance billing, as described in more detail in comment #4, below.
3. One-time costs, likely in the low hundreds of thousands of dollars annually, for the Commission to administer the private funding for the provision of medication abortion readiness, provide assistance to SHCs on accessing public and private funding to support ongoing costs of providing medical abortions and prepare an annual report until 2026. Potential one-time GF cost pressures, should Commission costs exceed available private funding.
4. Potential, though likely low, state costs to increase Medi-Cal reimbursements, to the extent this bill results in more students accessing medication abortions, and to the extent SHCs bill Medi-Cal for this service.

VOTES:

SENATE FLOOR: 28-10-0

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Dodd, Durazo, Galgiani, Glazer, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener

NO: Bates, Borgeas, Chang, Grove, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk

ASM HEALTH: 10-4-1

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Rodriguez, Santiago

NO: Mayes, Bigelow, Flora, Waldron

ABS, ABST OR NV: Ramos

ASM HIGHER EDUCATION: 9-3-0

YES: Medina, Arambula, Bloom, Gabriel, Irwin, Levine, Low, Santiago, Weber

NO: Choi, Kiley, Patterson

ASM APPROPRIATIONS: 13-5-0

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

NO: Bigelow, Brough, Diep, Fong, Obernolte

UPDATED:

VERSION: September 6, 2019

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0002150

SENATE THIRD READING

STR Bill Id:SB 24

Author:(Leyva)

As Amended Ver:June 13, 2019

Majority vote

SUMMARY:

Requires public university student health centers (SHCs), on and after January 1, 2023, to offer abortion by medication techniques onsite. Authorizes those services to be performed by providers on staff at the SHC, or by providers associated with a contracted external agency.

Major Provisions

COMMENTS:

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.

According to the National Institute of Health, 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 medication abortion. The most common regimen in the U.S. involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test.

No SHCs currently provide medication abortion. Neither the University of California (UC) or California State University (CSU) system has taken a position on this bill; however, 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.

According to the Author:

This bill expands medication abortion services to SHCs on public university campuses. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to five hundred public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. The author notes that accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success.

Arguments in Support:

ACCESS Women's Health Justice, ACT for Women and Girls, the American Civil Liberties Union of California, California Latinas for Reproductive Justice, NARAL Pro-Choice California, and Students United for Reproductive Justice at UC Berkeley are the cosponsors of this bill. The cosponsors note that currently none of the SHCs at California's public institutions of higher education provide medication abortion services, despite how clinically simple and safe the service is to offer. The cosponsors state that students seeking this basic health care must travel off campus to access it, often with serious logistical and financial barriers.

Arguments in Opposition:

The California Family Council (CFC) is opposed this bill, stating that chemical abortion medication has a notorious reputation for being very painful and traumatic. CFC also states these abortion drugs are only approved for use on pregnancies prior to 10 weeks, and most if not all SHCs are not equipped with the medical equipment or staff necessary to make sure the drugs can be taken safely. The California Catholic Conference (CCC) opposes this bill and states that no government-funded institution, medical or counseling center, should provide only one set of services. CCC states if this bill is truly about providing choices for female students, the state should then also require and fund life-affirming services on campus.

The Department of Finance is opposed to this bill noting that: 1) the Commission does not have the technical expertise nor existing capacity to develop and administer a program of this size, scope, or content; 2) this bill likely creates significant one-time and out-year General Fund cost pressures for the UC and CSU to comply with the requirements of this bill if: a) sufficient private funding cannot be raised to support readiness grants; b) the costs to comply with this bill's requirements exceed the proposed grant funding; or, c) UC and CSU campuses incur ongoing costs after January 1, 2023; and, 3) this bill would require UC and CSU health centers to establish medical billing systems and develop medical bill expertise. The UC and CSU indicate that campus health centers primarily offer triage and preventative services that have not required the implementation of medical billing systems and development of medical bill expertise because the centers are student fee supported.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. One-time costs, likely in the low hundreds of thousands of dollars per SHC, to prepare for offering medication abortions. Potential one-time General Fund cost pressures or pressures to increase student health fees at UC and CSU, should readiness costs exceed available private funding. (Although the bill specifies that it does not require an SHC to use General Fund or student fee revenue for medication abortion readiness before January 1, 2023, compliance with the bill's requirement to offer the service by this date may necessitate their use.)
2. Ongoing General Fund cost pressures or pressures to increase student health fees, potentially in the hundreds of thousands annually per SHC, to support the provision of medication abortion after 2023. Specifically, the universities indicate ongoing costs associated with equipment maintenance, personnel, liability insurance, medication and telehealth. Some of these costs could be offset by insurance billing, as described in more detail in comment #4, below.
3. One-time costs, likely in the low hundreds of thousands of dollars annually, for the Commission to administer the private funding for the provision of medication abortion readiness, provide assistance to SHCs on accessing public and private funding to support ongoing costs of providing medical abortions and prepare an annual report until 2026. Potential one-time General Fund cost pressures, should Commission costs exceed available private funding.
4. Potential, though likely low, state costs to increase Medi-Cal reimbursements, to the extent this bill results in more students accessing medication abortions, and to the extent SHCs bill Medi-Cal for this service.

VOTES:

SENATE FLOOR: 28-10-0

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Dodd, Durazo, Galgiani, Glazer, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener

NO: Bates, Borgeas, Chang, Grove, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk

ASM HEALTH: 10-4-1

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Rodriguez, Santiago

NO: Mayes, Bigelow, Flora, Waldron

ABS, ABST OR NV: Ramos

ASM HIGHER EDUCATION: 9-3-0

YES: Medina, Arambula, Bloom, Gabriel, Irwin, Levine, Low, Santiago, Weber

NO: Choi, Kiley, Patterson

ASM APPROPRIATIONS: 13-5-0

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

NO: Bigelow, Brough, Diep, Fong, Obernolte

UPDATED:

VERSION: June 13, 2019

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001674

Date of Hearing: August 14, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

SBPCA Bill Id:SB 24

Author:(Leyva) – As Amended Ver:June 13, 2019

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

SUMMARY:

This bill requires student health clinics (SHCs) at public universities to offer medication abortion.

Specifically, the bill requires, by January 1, 2023, each SHC on a California State University (CSU) or University of California (UC) campus to offer medication abortion. The bill also establishes the College Student Health Center Sexual and Reproductive Health Preparation Fund and requires the Commission on the Status of Women and Girls (Commission) to administer the fund. The bill’s requirements are to be implemented only if at least $10.29 million in private funding is available in the fund on or after January 1, 2020. The bill specifies that it does not require a public university to use General Fund or student fee revenue for medication abortion readiness before January 1, 2023.

In addition, the bill requires the Commission to provide assistance to SHCs on accessing public and private payers to support the ongoing costs of providing medical abortions and to submit an annual report to the Legislature, beginning December 31, 2021, until December 31, 2026, that includes information related to the provision of medication abortion at SHCs, including information about utilization and funding.

FISCAL EFFECT:

1. One-time costs, likely in the low hundreds of thousands of dollars per SHC, to prepare for offering medication abortions. Potential one-time General Fund cost pressures or pressures to increase student health fees at UC and CSU, should readiness costs exceed available private funding. (Although the bill specifies that it does not require an SHC to use General Fund or student fee revenue for medication abortion readiness before January 1, 2023, compliance with the bill’s requirement to offer the service by this date may necessitate their use.)
2. Ongoing General Fund cost pressures or pressures to increase student health fees, potentially in the hundreds of thousands annually per SHC, to support the provision of medication abortion after 2023. Specifically, the universities indicate ongoing costs associated with equipment maintenance, personnel, liability insurance, medication and telehealth. Some of these costs could be offset by insurance billing, as described in more detail in comment #4, below.
3. One-time costs, likely in the low hundreds of thousands of dollars annually, for the Commission to administer the private funding for the provision of medication abortion readiness, provide assistance to SHCs on accessing public and private funding to support ongoing costs of providing medical abortions and prepare an annual report until 2026. Potential one-time General Fund cost pressures, should Commission costs exceed available private funding.
4. Potential, though likely low, state costs to increase Medi-Cal reimbursements, to the extent this bill results in more students accessing medication abortions, and to the extent SHCs bill Medi-Cal for this service.

COMMENTS:

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 SHCs are funded through a combination of student service fees, income and endowments, and receive little or no state funding. To generate additional student fee revenue to support specific services at SHC, UC campuses have a student referenda process, though the results of a referendum are advisory. For example, UC Berkeley students voted to pass a referendum to expand mental health services at its SHC, which led to a student fee increase and expanded services at that center.

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

1. Medication Abortion. Medication abortion, also known as nonsurgical 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. 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.

Nationally, surveys indicate two universities provide medication abortion at their SHCs: The University of Illinois at Chicago and The College of New Jersey.

Although nothing legally bars California’s SHCs from offering medication abortion, none offer the service. Instead, SHCs indicate they refer their students to other providers for these services, such as community clinics. For example, CSU Sacramento reports having seven requests each year for the last two years for abortion services and indicates the university referred SHC students to outside providers.

1. Private Funding. A consortium of private funders, including the TARA Health Foundation and the Women’s Foundation of California, indicates it already has secured the $10.29 million for medication abortion readiness and associated activities this bill requires. This funding amount was derived from providing the following:
2. $4.6 million the 23 CSU SHCs ($200,000 each) and $2.2 million to the 11 UC SHCs ($200,000 each) to prepare for offering medication abortion. The $200,000 per campus includes funds for staff training, telemedicine services, facilities, supplies and equipment, such as ultrasound machines.
3. $400,000 to the CSU and UC system offices ($200,000 each) to provide systemwide supports for the provision of medication abortion at their respective systems’ SHCs; the $200,000 for each system includes funding for assistance in setting up 24-hour help hotlines and funding for a billing consultant to assist campuses in setting up insurance billing.
4. $3.1 million over five years to the Commission to support four positions and cover operation costs.
5. Insurance Billing. Bill proponents have identified billing insurance as a way to sustain the provision of medication abortion after private funding is exhausted. For example, Medi-Cal reimburses about $550 for a medication abortion and proponents indicate this reimbursement could cover the marginal costs of offering the procedure in the long term. Correspondingly, the proponents intend a portion of private funding to each segment is to support the costs of establishing a billing infrastructure at SHCs.

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

1. Related Legislation. SB 320 (Leyva), of the 2018-19 Legislative Session, was substantially similar to this bill. The bill was vetoed by Governor Brown, who stated:

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.

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

Date of Hearing: June 25, 2019

ASSEMBLY COMMITTEE ON HIGHER EDUCATION

Jose Medina, Chair

SBPCA Bill Id:SB 24

Author:(Leyva) – As Amended Ver:June 13, 2019

SENATE VOTE: 28-10

SUBJECT: Public health: public university student health centers: abortion by medication techniques.

SUMMARY: Requires, on and after January 1, 2023, 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 onsite; and, authorizes those services to be performed by providers on staff at the SHC, or by providers associated with a contracted external agency. 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 for the purposes of providing private moneys in the form of grants to public SHCs for medication abortion readiness.
3. Authorizes the Commission to receive moneys from nonstate entities, including, but not necessarily limited to, private sector entities and local and federal government agencies.
4. Requires the Commission to use fund moneys to do all of the following:
   1. Provide a grant of $200,000 to each public university 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 SHC 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 campus SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Maintain a system of financial reporting on all aspects of the Fund.
5. Specifies that implementation of this bill is contingent upon a total of at least $10,290.000 in private funds being made available to the Fund in a timely manner on or after January 1, 2020, 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, 2023.
6. Requires the Commission, working with the SHCs, to assist and advise the SHCs on potential pathways for SHCs to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
7. Requires the Commission, on or before December 31, 2021, and on or before December 31, of each year thereafter until December 31, 2026, to submit a report to the Legislature that includes, but is not necessarily limited to, all of the following information for each reporting period, separately for the UC and CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by SHC; and,
   3. The total amount of funds granted by the Commission to each UC and CSU campus and each campus’ SHC 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 SHC.
8. Requires the report, as enumerated in (7)(a-c) inclusive, and any associated data collection, to be conducted in accordance with state and federal privacy law, including, but not necessarily limited to, the state Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code), the federal Family Educational Rights and Privacy Act of 1974 (20 U.S.C. Sec. 1232g), and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).
9. States Legislative findings and declarations relating to:
   1. Abortion as a constitutional right and integral part of comprehensive sexual and reproductive health care;
   2. The state’s interest in ensuring that abortion is accessible to those who are seeking to terminate a pregnancy;
   3. The safety of medication abortion;
   4. The financial and logistical barriers that students face when seeking to terminate a pregnancy; and
   5. The Legislature intends that UC and CSU SHCs make medication abortions as accessible and cost-effective for students as possible.

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).
6. Establishes the California Commission on the Status of Women and Girls (Commission) and requires the Commission, in part, to recommend, develop, prepare, or coordinate materials, projects, or other activities, and to give technical and consultative advice to public or private groups or persons concerned with preventing or minimizing problems brought about by the changing roles and responsibilities of women; and, developing programs to encourage and enable women to be fully contributing members of society (Government Code Section 8240, et seq.).

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. General Fund (GF) cost pressures (potentially over $10.3 million, the amount secured in private funds for the grant years) to offset any shortfall in private funds, and if program provisions are implemented successfully, for the potential of ongoing program support after 2023.
2. $10.29 million in budget authority and 4.0 positions for the Commission.
3. Hundreds of thousands dollars for the CSU to provide 24-hour support, support increased campus liability insurance premiums, and equipment purchase and maintenance for their SHCs. Staff notes some of these costs may be covered by a portion of the bill’s $200,000 allocation to each UC and CSU system, however, there remain ongoing GF cost pressures for program implementation post-2023.
4. According to the UC, net total of up to $7.78 million during the grant phase (Fiscal Year (FY) 2019-20, 2020-21, 2021-22, 2022-23) and up to $3.33 million, ongoing (after FY 2022-23), for the UC. These costs include equipment (up to $81,800 in 2019-2023 and $25,000, ongoing); facility reconfiguration up to $380,000 in 2023; personnel costs (up to $430,000 annually until 2023, and up to $245,000 after 2023), medication costs ($6,500 annually) and ongoing); and telehealth services ($26,000 annually).

COMMENTS: Double referral. This bill was passed by the Assembly Committee on Health on June 11, 2019, with a vote of 10 – 4.

Purpose of this bill. According to the author, "Obtaining an abortion is a constitutionally protected right, and college students face numerous barriers when attempting to access this right”. The author argues that, “Denying comprehensive and accessible reproductive care interferes with the well-being and academic success of students and disproportionately impacts students of color and low-income students”.

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. 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.

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.

To note, at least two CSU SHCs do not have a full-time physician on staff.

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 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 (comprised of both CSU and UC campuses) 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% 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.

Arguments in support. According to the California Commission on the Status of Women and Girls, “Medication abortion is safe and extremely effective, with only 3 in 100 patients needing to have a follow-up, in-clinic procedure to complete the abortion”. The Commission contends that, “Medication abortion services, provided on campus, would allow students to seek more robust services from a health center they already know and trust”. Further, the Commission argues that, “This bill will allow students to focus on their future, without the added financial and logistical barriers of seeking reproductive care off campus”.

Arguments in opposition. According to the California Academy of Preventive Medicine (CAPM), “This bill is likely to discourage contraception, which is primary prevention, in favor of just taking a few pills in the event of pregnancy, which will be easier and involve less medication, from 0 to 4 pills/year as compared with a daily birth control pill”. The CAPM contends that, “As the Governor [Brown] noted in his veto message last fall, the bill is totally unnecessary”. Furth the CAPM argues that, “A survey had shown that a specialized, fully equipped abortion clinic is available within 5-7 miles of every Cal State and UC campus. Ultrasound and experienced professionals are available at all”.

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 financial assistance to these centers?

To note, all SHCs are supported entirely by student health fees. 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? 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).

Additionally, Committee Staff understands that the UC and CSU have asked the author for specific amendments to remove references and potential requirements for SHCs to bill; to date, the author has not accepted said amendments.

The author may wish to continue to work with the UC and CSU in order to reach an agreement on whether or not the SHCs will be able to bill, should they have to implement this measure.

1. What is the goal of the legislation? If the goal of this measure is to ensure that all students have access to reproductive rights, instead of mandating the UC and CSU SHCs provide abortion by medication at said SHCs, why not, on a piloted basis, authorize the Fund to provide travel to and from nearby medical centers that provide these services to the students wishing to receive them?

If the goal of this measure is to ensure that all students have access to reproductive rights, but only at their UC or CSU SHCs, the Committee may wish to ask the author if that is the best approach, in lieu of the various policy concerns as enumerated in (1 – 4) inclusive in the Committee Comments section of this analysis.

Prior legislation. SB 320 (Leyva) of 2018, which was vetoed by Governor Brown, was substantially similar to this bill. Governor Brown’s veto message, in part, stated, “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”.

REGISTERED SUPPORT / OPPOSITION:

Support

Access Women's Health Justice
Act for Women and Girls
American Academy Of Pediatrics, California
American Association of University Women (AAUW) San Jose
American Civil Liberties Union (ACLU) of California
American Medical Women's Association
American Nurses Association/California
American Public Health Association
Anti-Defamation League
Associated Students of the University Of California
Bixby Program In Population And Reproductive Health at UCLA
Business and Professional Women of Nevada County
Cabrillo College
California Commission on the Status of Women And Girls
California Faculty Association
California Latinas For Reproductive Justice
California Nurse Midwives Association (CNMA)
California Pan - Ethnic Health Network
California State Student Association
California Women's Law Center
Center for Relationship Abuse Awareness
City of West Hollywood
Code Blue, University of California at Davis School of Medicine
Community Action Fund of Planned Parenthood Orange and San Bernardino Counties
Equal Rights Advocates
Equality California
Feminist Majority Foundation
Fresno Barrios Unidos
Having Our Say Coalition
Hollywood Now
If/When/How: Lawyering For Reproductive Justice
Ignite
Impact Hub Oakland
Lawyers Club of San Diego
League of Women Voters of California
Legal Services for Prisoners With Children
Medical Students For Choice
NARAL Pro-Choice California 
National Abortion Federation
National Association Of Social Workers, California Chapter
National Center for Lesbian Rights
National Center for Youth Law
National Council of Jewish Women
National Council of Jewish Women Long Beach
National Health Law Program
National Partnership for Women & Families
National Women's Health Network
National Women's Law Center
Our Bodies Ourselves
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 California Central Coast
Public Health Justice Collective
Reproductive Health Access Project (RHAP)
RHEDI/Reproductive Health Education in Family Medicine
Sexuality Information And Education Council of the United States (SIECUS)
Society of Women Engineers at UCLA
Stonewall Democratic Club
Students United for Reproductive Justice 
The Women's Foundation of California
Training in Early Abortion For Comprehensive Healthcare
UAW Local 5810
University of California Global Health Institute: Women's Health, Gender, and Empowerment Center Of Excellence Leadership
University Of California Student Association
Voices for Progress
Western Center on Law and Poverty

Opposition

Berkeley College Republicans
California Academy of Preventive Medicine
California Catholic Conference
Fresno Pro-Life Future
Right to Life of Central California
Spartans for Life
Students for Life at Berkeley

1 Individual

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

Date of Hearing: June 11, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 24

Author:(Leyva) – As Amended Ver:April 8, 2019

SENATE VOTE: 28-10

SUBJECT: Public health: public university student health centers: abortion by medication techniques

SUMMARY: Requires public university student health centers (SHCs), on and after January 1, 2023, to offer abortion by medication techniques onsite. Authorizes those services to be performed by providers on staff at the SHC, or by providers associated with a contracted external agency. 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. "SHC" 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 SHCs 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 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 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 SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Maintaining a system of financial reporting on all aspects of the Fund.
      
4. Requires each SHC grantee, as a condition of receiving a grant award from the Fund, to 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 $10.29 million in private funds being made available to the Fund in a timely manner on or after January 1, 2020. Clarifies 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, 2023.
6. Requires the Commission, working with the SHCs, to assist and advise on potential pathways for 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, 2021, and on or before December 31 of each year until December 31, 2026, that includes, but is not necessarily limited to, all of the following information for each reporting period, separately for the UC and the CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by SHC; and,
   3. The total amount of funds granted by the Commission to the university and the university’s SHC 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, by SHC.
8. Requires the report specified in 7) above, and any associated data collection, 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 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. 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. 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:

1. General Fund (GF) cost pressures (potentially over $10.3 million, the amount secured in private funds for the grant years) to offset any shortfall in private funds, and if program provisions are implemented successfully, for the potential of ongoing program support after 2023.
   
2. Costs of $10.29 million in budget authority and 4.0 positions for the Commission.
   
3. Hundreds of thousands dollars for the CSUs to provide 24-hour support, support increased campus liability insurance premiums, and equipment purchase and maintenance for their SHCs. Staff notes some of these costs may be covered by a portion of the bill’s $200,000 allocation to each UC and CSU system, however, there remain ongoing GF cost pressures for program implementation post-2023.
   
4. According to the UCs, net total of up to $7.78 million during the grant phase (fiscal year [FY] 2019-20, 20-21, 21-22, and 22-23) and up to $3.33 million, ongoing (after FY 2022-23), for the UCs. These costs include equipment (up to $81,800 in 2019-2023 and $25,000, ongoing); facility reconfiguration up to $380,000 in 2023; personnel costs (up to $430,000 annually until 2023, and up to $245,000 after 2023), medication costs ($6,500 annually) and ongoing); and telehealth services ($26,000 annually).
   

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill expands medication abortion services to SHCs on public university campuses. The author states that, currently, all UC and CSU SHCs offer some reproductive health services, and many offer comprehensive reproductive health services. The author states that services at most SHCs include pregnancy testing/counseling, contraceptives, sexually transmitted infections and HIV counseling/testing, and cervical cancer screening/pap tests. Providing these health services on campus ensures that students do not have to travel away from their school and work commitments to receive care. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to five hundred public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. The author notes that accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success. The author concludes that by ensuring the provision of medication abortion services on campus, this bill eliminates logistical and financial barriers and allows students to exercise an important constitutional right.
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 Centers for Disease Control and Prevention (CDC), a legal induced abortion is defined as an intervention performed by a licensed clinician that is intended to terminate an ongoing pregnancy. The CDC reports that in 2015, 638,169 legal induced abortions were reported from 49 reporting areas across the U.S.
      
      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 for 2015 was 11.8 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 188 abortions per 1,000 live births. This is the lowest rate ever observed in the U.S.
   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 medication abortion. According to a June 2018 Kaiser Family Foundation (KFF) Issue Brief, the most common regimen in the U.S. involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test. The KFF Issue Brief states that almost one-third of all abortions at eight weeks gestation or less are medication abortions.
      
      According to the KFF Issue Brief, Mifeprex is not dispensed by retail pharmacies; rather women can only obtain the drug directly from a medical provider who has received training from the manufacturer about the proper use of the drug.  If the pills are administered at eight weeks’ gestation or less, the pregnancy is terminated successfully 98 out of 100 times, with 0.05% risk of major complications, and an associated mortality rate of less than one percent (0.00063%).  According to the NIH, medication abortion has been proven highly effective, safe and acceptable for abortions occurring up to nine weeks, with efficacy rates up to 98%. Approximately 2% to 5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding.
   3. Cost and coverage of medication abortion. According to the KFF Issue Brief, on average, a first trimester abortion costs $497, with no significant difference between the average costs of an aspiration abortion and a medical abortion. Most women pay at least some out of pocket costs for their abortion. In 2011, most women seeking first trimester abortion had insurance coverage; however, the majority (69%) did not or could not use it to pay the procedure. of those who did not use their insurance to pay for their abortion, 49% say it was because their insurance did not cover it, and 29% say they did not use it because they were not sure if it was covered.
   4. 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 SHCs 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 in both systems 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.)
   5. 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 $320 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:
      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. ANSIRH 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:
         

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. UC and CSU 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 CDC, 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. ACCESS Women’s Health Justice, ACT for Women and Girls, the American Civil Liberties Union of California, California Latinas for Reproductive Justice, NARAL Pro-Choice California, and Students United for Reproductive Justice at UC Berkeley are the cosponsors of this bill. The cosponsors note that currently none of the SHCs at California’s public institutions of higher education provide medication abortion services, despite how clinically simple and safe the service is to offer. The cosponsors state that students seeking this basic health care must travel off campus to access it, often with serious logistical and financial barriers. The co-sponsors conclude that California remains the bellwether for reproductive health care legislation and must continue to lead the nation in protecting the academic success and well-being of its students.
2. OPPOSITION. The California Family Council (CFC) is opposed this bill, stating that chemical abortion medication has a notorious reputation for being very painful and traumatic. CFC also states these abortion drugs are only approved for use on pregnancies prior to 10 weeks, and most if not all SHCs are not equipped with the medical equipment or staff necessary to make sure the drugs can be taken safely.
   
   The California Catholic Conference (CCC) opposes this bill and states that no government-funded institution, medical or counseling center, should provide only one set of services. CCC states if this bill is truly about providing choices for female students, the state should then also require and fund life-affirming services on campus, and notes that these alternatives are usually offered free of charge. CCC concludes that offering state-funded abortions as the only alternative to pregnancy undermines the ability of a state academic institution to promote the value of diversity and the empowerment of women.
3. PREVIOUS LEGISLATION. SB 320 (Leyva) of 2018 was substantially similar to this bill. SB 320 was vetoed by Governor Brown, who stated, in part: “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.”
4. POLICY COMMENT. According to information provided by the Commission, it estimates staff costs of $542,880 for four positions over the first year of implementation, which it estimated as being the least expensive. The Commission notes that payroll and benefits costs increase annually due to staff merit salary increases in the Executive Branch. Three of the positions end after three years, and one position, the report coordinator extends over the five year reporting requirement. Total payroll for all positions is nearly $2 million and overhead for the positions over the total five year period is approximately $1 million. This amounts to approximately 28 % of the funds being spent on administration. The author may wish to amend the bill to limit the amount of funds that can be spent on administration to 15%, which is more in line with other state agency administration costs, and, if there are any excess funds at the end of the five year period, to require them to be disbursed to SHCs to cover the ongoing costs of providing medication abortion.
5. SUGGESTED AMENDMENT. This bill requires SHCs, as a condition of receiving a grant, to participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques. Another section of the bill requires the Commission to report to the legislature on the same topic. The author may wish to amend the bill to strike the first, duplicative provision.
6. DOUBLE REFERRAL. This bill is double referred; upon passage in this Committee, this bill will be referred to the Assembly Committee on Higher Education.

REGISTERED SUPPORT / OPPOSITION:

Support

ACCESS Women’s Health Justice (cosponsor)

ACLU of California (cosponsor)

ACT for Women and Girls (cosponsor)

California Latinas for Reproductive Justice (cosponsor)

NARAL Pro-Choice California (cosponsor)

Students United for Reproductive Justice at UC Berkeley (cosponsor)

Women’s Foundation of California/Women’s Policy Institute (cosponsor)

Access Women's Health Justice

Act for Women and Girls

American Academy of Pediatrics, California

American Association of University Women – San Jose

American Association of University Women – California

American Civil Liberties Union of California

American Congress of Obstetricians & Gynecologists - District Ix
American Nurses Association/California

American Public Health Association

Anti-Defamation League

Associated Students of the University of California

Bixby Center in Population and Global Reproductive Health at UCLA

Business and Professional Women of Nevada County

California Commission on the Status of Women and Girls

California Faculty Association

California Nurse Midwives Association

California Pan-Ethnic Health Network

California Women's Law Center

Care Advocacy Services at UC Santa Barbara

Center for Relationship Abuse Awareness

City of West Hollywood

Coalition of California Welfare Rights Organizations

Community Action Fund of Planned Parenthood Orange and San Bernardino Counties

Equal Rights Advocates

Equality California

Feminist Majority Foundation

Fresno Barrios Unidos

Hollywood Now

If/When/How: Lawyering For Reproductive Justice

Ignite

Impact Hub Oakland

Lawyers Club of San Diego

League of Women Voters of California

Legal Services for Prisoners with Children

Medical Students for Choice

Medical Students for Choice at UC Davis

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center for Youth Law

National Council of Jewish Women

National Council of Jewish Women Long Beach

National Health Law Program

National Partnership for Women & Families

National Women’s Health Network

National Women’s Law Center

National Women’s Political Caucus of California

Our Bodies Ourselves

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 California Central Coast

Positive Women’s Network – USA

Public Health Justice Collective

Rhedi/Reproductive Health Education in Family Medicine

Society of Women Engineers at UCLA

Stonewall Democratic Society

Students United For Reproductive Justice 

The Women’s Foundation of California

Training In Early Abortion for Comprehensive Health

UAW Local 5810

UC Santa Barbara Associated Students Human Rights Board Students for Reproductive Justice

University of California Global Health Institute: Women’s Health, Gender, And Empowerment

Center of Excellence Leadership

University of California Student Association

Urge

Voices for Progress

Western Center on Law & Poverty, Inc.

Women’s Catalytic Fund

Oppose

Americans United for Life

Berkeley College Republicans

California Catholic Conference

California Family Council

Californians for Life

Concerned Women for America

Crusade for Life, Inc.

Faith and Public Policy

Fresno Pro-Life Future

Life Priority Network

Right to Life of Central California

Right to Life of Kern County

Students for Life at Berkeley

Students for Life at Fresno State

The National Center for Law & Policy

Tulare-Kings Right to Life, Inc.

Westmont Students for Life

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

 THIRD READING  

Bill No: SB 24

Author: Leyva (D), et al.

Amended: 4/8/19

Vote: 21

SENATE HEALTH COMMITTEE: 7-2, 4/3/19

AYES: Pan, Durazo, Hurtado, Leyva, Mitchell, Monning, Rubio

NOES: Stone, Grove

SENATE EDUCATION COMMITTEE: 5-2, 4/24/19

AYES: Leyva, Durazo, Glazer, McGuire, Pan

NOES: Wilk, Chang

SENATE APPROPRIATIONS COMMITTEE: 4-2, 5/16/19

AYES: Portantino, Bradford, Hill, Wieckowski

NOES: Bates, Jones

SUBJECT: Public health: public university student health centers: abortion by medication techniques

SOURCE: Access Women's Health Justice

ACLU California

ACT for Women and Girls

California Latinas For Reproductive Justice

NARAL Pro-Choice California

Students United For Reproductive Justice at Berkeley

Women's Policy Institute/Women's Foundation of California

DIGEST:

This bill requires student health centers (SHC) located on a campus within the University of California or California State University that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Requires the California Commission on the Status of Women and Girls (CCSWG) to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which is established by this bill for the purposes of providing private moneys to public university SHCs for medication abortion readiness.

ANALYSIS:

Existing law:

1. Permits a licensed physician, or 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. [BPC § 2253 and 2725.4]
2. Licenses and regulates clinics, including primary care clinics and specialty clinics such as surgical clinics, by the Department of Public Health.  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. [HSC §1200 and 1206]
3. Establishes the CCSWG and requires CCSWG, among other things, to recommend, develop, prepare, or coordinate materials, projects, or other activities, and to give technical and consultative advice to public or private groups or persons concerned with preventing or minimizing problems brought about by the changing roles and responsibilities of women; and, developing programs to encourage and enable women to be fully contributing members of society. [GOV § 8240, et seq.]

This bill:

1. Requires SHCs located on a campus within the University of California (UC) or California State University (CSU) that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Permits this service to be performed by providers on staff at the SHC or by providers associated with a contracted external agency.
2. Requires CCSWG 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 to public university SHCs for medication abortion readiness. Permits CCSWG to receive moneys from nonstate entities, including, but not limited to, private sector entities and local and federal government agencies, and to deposit these moneys in the Fund. Continuously appropriates funds to CCSWG for purposes of this bill.
3. Requires CCSWG to utilize fund moneys to:
   1. Provide a grant of $200,000 to each SHC to pay for the cost, both direct and indirect, of medication abortion readiness. Defines “medication abortion readiness” to include, but not be 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 from the definition of “medication abortion readiness” the provision of abortion by medication techniques. Requires allowable expenses under these grants to include, but not be limited to:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the SHC 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 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 SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Maintain a system of financial reporting on all aspects of the Fund.
4. Requires SHC grantees to, as a condition of receiving a grant award, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Requires this bill to be implemented only if, and to the extent that, a total of at least $10,290,000 in private funds is made available to the Fund in a timely manner on or after January 1, 2020.
6. Prohibits this bill from being interpreted as requiring UC or CSU to utilize General Fund (GF) moneys or student fees for medication abortion readiness before January 1, 2023.
7. Requires CCSWG, working with SHCs, to assist and advise on potential pathways to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
8. Requires CCSWG, on or before December 31, 2021, and on or before December 31 of each year thereafter until December 31, 2026, to submit a report to the Legislature that includes, but is not necessarily limited to, the following, separately for UC and CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;
   3. The total amount of funds granted by CCSWG to UC and CSU and 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 SHC.
9. Requires the report and any associated data collection to be conducted in accordance with existing state and federal privacy law, as specified. Makes these reporting requirements inoperative on January 1, 2027.

Comments

1. Author’s statement. According to the author, this bill expands medication abortion services to SHCs on public university campuses. Currently, all SHCs offer some reproductive health services, and many offer comprehensive reproductive health services. Services at most SHCs include pregnancy testing/counseling, contraceptives, sexually transmitted infection (STI) and HIV counseling/testing, and cervical cancer screening/pap tests. Providing these health services on campus ensures that students do not have to travel away from their school and work commitments to receive care. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to 500 public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. Accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success. Students should be able to decide when and if they choose to have a family. By ensuring the provision of medication abortion services on campus, this bill eliminates logistical and financial barriers and allows students to exercise an important constitutional right.
2. Abortion. According to the Center for Disease Control and Prevention (CDC), for the purpose of surveillance, a legal induced abortion is defined as an intervention performed by a licensed clinician that is intended to terminate an ongoing pregnancy. The CDC reports that in 2015, 638,169 legal induced abortions were reported from 49 reporting areas across the U.S. The abortion rate for 2015 was 11.8 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 188 abortions per 1,000 live births. Compared with 2014, the total number, rate, and ratio of reported abortions for 2015 decreased 2%. From 2006 to 2015, the number, rate, and ratio of reported abortions decreased 24%, 26%, and 19%, respectively. In 2015, all three measures reached their lowest level for the entire period of analysis. Women in their twenties accounted for the majority of abortions in 2015 and throughout the period of analysis. The majority of abortions in 2015 took place early in gestation: 91.1% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (7.6%) were performed at 14–20 weeks’ gestation; and, even fewer (1.3%) were performed at ≥21 weeks’ gestation. In 2015, 24.6% of all abortions were early medication abortions (a non-surgical abortion at ≤8 weeks’ gestation).
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 medication abortion. According to a June 2018 Kaiser Family Foundation (KFF) Issue Brief, the most common regimen in the United States involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test. The KFF Issue Brief states that almost one-third of all abortions at eight weeks gestation or less are medication abortions.
4. Medication abortion effectiveness and risks. According to the KFF Issue Brief, Mifeprex is not dispensed by retail pharmacies; rather women can only obtain the drug directly from a medical provider who has received training from the manufacturer about the proper use of the drug.  If the pills are administered at eight weeks’ gestation or less, the pregnancy is terminated successfully 98 out of 100 times, with 0.05% risk of major complications, and an associated mortality rate of less than 1% (0.00063%).  According to the NIH, medication abortion has been proven highly effective, safe and acceptable for abortions occurring up to nine weeks, with efficacy rates up to 98%. Approximately 2% to 5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding.
5. Health care at UC. There are ten universities as part of the UC system and 11 SHCs (UC Hastings Law School has its own SHC), open Monday through Friday, with a 24-hour after-hour counseling service call line. UC SHCs 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 its HSCs, with $164.5 million going towards student health and $45.4 million towards counseling. The source of this funding comes mainly from student service fees. A few campuses have also elected to charge students an annual fee specifically designated to support health care delivery services and/or facilities on campus.
   
   UC requires students to have minimum essential coverage under the Affordable Care Act. 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 a single undergrad and start at about $1,100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including medication abortion, the service is not offered at UC SHCs and students are referred to local family planning clinics for the procedure.
6. Health care at CSU. All 23 CSU campuses have a SHC, providing “basic student health services,” which 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, and students must go off campus to access medications. CSU SHCs are funded through mandatory student fees, which cover basic services. CSU SHCs do not charge students’ insurance policies, are not reimbursed by Medi-Cal for services, and there is no co-pay for a student to visit a SHC. Students may incur additional fees when lab tests must be sent externally, for the actual cost of acquiring vaccines, medications, or health devices, or for augmented services outside of the basic services. All students have access to all services provided by SHCs, no matter their Medi-Cal status or insurance coverage. SHCs provide access to birth control, Plan B, and pregnancy tests, but do not provide ongoing pregnancy-related services. All students are eligible for HIV and STI testing. Some of these services may be provided at no cost to students depending on the capacity for waived testing or onsite lab services. If a service is considered to be beyond the scope of basic care, students may pay a fee-for-service in order to access it at the SHC. Twenty-two campuses have a health facilities fee, which is $19 on average per academic year, and all campuses have a health services fee, which is $320 on average per academic year. 
7. Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The Women's Foundation of California, a co-sponsor of this bill, facilitated two surveys, conducted by UC San Francisco’s ANSIRH, of all 11 UC SHCs and 20 CSU SHCs. The results of the surveys were compiled into two December 2017 reports. Below are selected findings from those reports:
   1. Student access to abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Public transportation is key to abortion accessibility off-campus, as over two-thirds of UC students and one-third of CSU students do not have a car. Twenty-two campuses (62%) 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 such a delay can make a student ineligible for medication abortion.
   2. SHC capacity to provide medication abortion. ANSIRH 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. 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 licensed clinicians, 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.
   3. 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.

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

According to the Senate Appropriations Committee:

• GF cost pressures (potentially over $10.3 million, the amount secured in private funds for the grant years) to offset any shortfall in private funds, and if program provisions are implemented successfully, for the potential of ongoing program support after 2023.
• $10.29 million in budget authority and 4.0 positions for the CCSWG.
• Hundreds of thousands dollars for the CSUs to provide 24-hour support, support increased campus liability insurance premiums, and equipment purchase and maintenance for their SHCs. Appropriations staff notes some of these costs may be covered by a portion of the bill’s $200,000 allocation to each UC and CSU system, however, there remain ongoing GF cost pressures for program implementation post-2023.
• According to the UCs, net total of up to $7.78 million during the grant phase (FY 2019-20, 20-21, 21-22, 22-23) and up to $3.33 million, ongoing (after FY 2022-23), for the UCs. These costs include equipment (up to $81,800 in 2019-2023 and $25,000, ongoing); facility reconfiguration up to $380,000 in 2023; personnel costs (up to $430,000 annually until 2023, and up to $245,000 after 2023), medication costs ($6,500 annually) and ongoing); and telehealth services ($26,000 annually).

SUPPORT: (Verified 5/16/19)

Access Women's Health Justice (co-source)

ACLU California (co-source)

ACT for Women and Girls (co-source)

California Latinas for Reproductive Justice (co-source)

NARAL Pro-Choice California (co-source)

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

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

American Academy of Pediatrics California

American Association of University Women San Jose Branch

American College of Obstetricians and Gynecologists

American Medical Women’s Association

American Nurses Association\California

American Public Health Association, Sexual and Reproductive Health Section

Anti-Defamation League

Associated Student of San Jose State

Associated Students of the University of California

Associated Students of University of California San Diego

Associated Students, Inc., Sacramento State

Berkeley City Council

Business and Professional Women of Nevada County

California Academy of Family Physicians

California Academy of Preventive Medicine

California Commission on the Status of Women and Girls

California Faculty Association

California Medical Association

California Nurses-Midwives Association

California State Student Association

California Voices for Progress

California Women’s Law Center

Center for Relationship Abuse Awareness

Center for Reproductive Rights

Center on Reproductive Rights and Justice, Berkeley Law

Citizens for Choice

City of West Hollywood

Coalition of California Welfare Rights Organizations

Code Blue

Equal Rights Advocates

Equality California

Feminist Majority Foundation

Forward Together

Hollywood Chapter of the National Organization for Women

If/When/How Lawyering Reproductive Justice

IGNITE

Impact Hub Oakland

Innovating Education in Reproductive Health

Korean Resource Center

Lawyers Club of San Diego

League of Women Voters of California

Legal Services for Prisoners with Children

Los Angeles Coalition for Reproductive Justice

Los Angeles County Democratic Party

Medical Students for Choice, California Northstate University College of Medicine

Medical Students for Choice, National Office

Medical Students for Choice, Stanford University School of Medicine

Medical Students for Choice, Touro University California College of Osteopathic Medicine

Medical Students for Choice, University of California Davis School of Medicine

Medical Students for Choice, University of California San Francisco

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center for Youth Law

National Council of Jewish Women California

National Council of Jewish Women, Long Beach

National Council of Jewish Women, Los Angeles

National Health Law Program

National Institute for Reproductive Health

National Organization for Women, Hollywood Chapter

National Partnership for Women & Families

National Women’s Health Network

National Women’s Law Center

National Women’s Political Caucus of California

Our Bodies Ourselves

Pharmacists Planning Services, Inc.

Physicians for Reproductive Health

Planned Parenthood Action Fund of the Pacific Southwest

Planned Parenthood Advocates Pasadena and San Gabriel Valley

Planned Parenthood Affiliates of California

Planned Parenthood California Central Coast

Planned Parenthood Mar Monte

Planned Parenthood of Orange and San Bernardino Counties

Positive Women’s Network-USA

Public Health Justice Collective

Reproductive Health Access Project

Reproductive Health Interest Group, University of California Los Angeles

RHEDI/Reproductive Health Education in Family Medicine

San Francisco Bay Area Physicians for Social Responsibility

Sexuality Information and Education Council of the United States

Stanford Ob/Gyn Student Interest Group

Stonewall Democratic Club

Students for Reproductive Justice, University of California Santa Barbara

The SIA Legal Team

Training in Early Abortion for Comprehensive Healthcare

UAW, Local 2865

UAW, Local 5810

Unite for Reproductive & Gender Equity

University of California Global Health Institute Women’s Health, Gender, and Empowerment Center

University of California San Diego Associated Students

University of California Student Association

URGE

Voices for Progress

Western Center on Law and Poverty

Women Lawyers of Sacramento

Women’s Catalytic Fund

Eleven individuals

OPPOSITION: (Verified 5/16/19)

Americans United for Life

Berkeley College Republicans

California Academy of Preventive Medicine

California Catholic Conference

California Family Council

California ProLife Council and Right to Life Federation

California Right to Life Committee, Inc.

Californians for Life

Center for Bio-Ethical Reform

Concerned Women for America of California

Crusade for Life

Eagle Forum of California

Faith and Public Policy

Life Priority Network

Mike Maggard, Kern County Supervisor 3rd District

Right to Life Kern County

Right to Life of Central California

Spartans for Life San Jose State University

Students for Life at California State University Fullerton

Students for Life at Fresno State

Students for Life at University of California Berkeley

Students for Life of America

Tulare-Kings Right to Life

One individual

Prepared by: Melanie Moreno / HEALTH / (916) 651-4111

5/18/19 12:46:58

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

SB 24 (Leyva) - Public health: public university student health centers: abortion by medication techniques

Bill Summary:

Senate Bill 24 would require, by January 1, 2023, public university student health centers to offer abortion by medication. Would establish the College Student Health Center Sexual and Reproductive Health Preparation Fund, and would provide a continuous appropriation to the Commission on the Status of Women and Girls (Commission), including $400,000 to the University of California (UC) and California State University (CSU) and $200,000 to each student health center (SHC).

Fiscal Impact:

• General Fund cost pressures (potentially over $10.3 million, the amount secured in private funds for the grant years) to offset any shortfall in private funds, and if program provisions are implemented successfully, for the potential of ongoing program support after 2023.
• $10.29 million in budget authority and 4.0 positions for the Commission.
• Hundreds of thousands dollars for the CSUs to provide 24-hour support, support increased campus liability insurance premiums, and equipment purchase and maintenance for their SHCs. Staff notes some of these costs may be covered by a portion of the bill’s $200,000 allocation to each UC and CSU system, however, there remain ongoing GF cost pressures for program implementation post-2023.
• According to the UCs, net total of Up to $7.78 million during the grant phase (FY 2019-20, 20-21, 21-22, 22-23) and up to $3.33 million, ongoing (after FY 2022-23), for the UCs. These costs include equipment (up to $81,800 in 2019-2023 and $25,000, ongoing); facility reconfiguration up to $380,000 in 2023; personnel costs (up to $430,000 annually until 2023, and up to $245,000 after 2023), medication costs ($6,500 annually) and ongoing); and telehealth services ($26,000 annually).

For more detail, please see Staff Comments.

Background:

According to the Senate Education Committee’s analysis on the bill and based on responses provided to the committee by the UC and CSU systems:

UCs. There are ten universities as part of the UC system and 11 UC student health centers (SHCs) (UC Hastings Law School has its own SHC), 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. Student fees fund Student Health Insurance Plan (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 $1,100 per quarter for a single graduate student. While students enrolled in SHIP have abortion coverage, including medication abortion, the service is not offered at UC campus health centers and students are referred to local family planning clinics for the procedure.

The UC 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. It spends an aggregate of $210 million in annual operating costs for all eleven health centers, with $164.5 million going towards student health and $45.4 million toward counseling. For students with UC SHIP, campuses are able to bill these students’ insurance plan electronically. For students with any other insurance, the students are charged fee-for-service rates which are paid at the time services are rendered or charged to their university student accounts. Students can waive out of coverage of SHIP with the approval of UC. A little more than 47% of UC students have UC SHIP, 52.3% of UC students waive SHIP coverage with some type of adequate health insurance coverage (i.e., Medi-Cal, TriCare, private insurance). Anthem Blue Cross is the third-party administrator for UC SHIP, and students have access to a worldwide network.

CSU. There are 23 CSU campuses, and each has a health center, open Monday through Friday. All students have access to all services provided by the SHC, no matter their Medi-Cal status or insurance coverage. Basic health services provided by CSU SHCs 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. For reproductive health, California State University (CSU) SHCs also provide access to birth control, Plan B, pregnancy tests but do not provide ongoing pregnancy-related services, and mental health and counseling services.

CSU SHCs are funded through mandatory student fees. Twenty-two campuses have a health facilities fee, which is $19 on average per academic year, and all campuses have a health services fee, which is $320 on average per academic year. The mandatory fees, which are about $269 per student per year, cover basic services, the SHCs do not charge students’ insurance policies, are not reimbursed by Medi-Cal for services, and there is no co-pay for a student to visit a health center. Students may incur additional fees when laboratory tests must be sent externally, for the actual cost of acquiring vaccines, medications, or health devices, or for augmented services outside of the basic services. In addition, medications are charged at-cost, plus the student must pay an administrative cost. An example from Sacramento State indicates birth control ranges from $10 - $20, and emergency contraception, from $20 - $30.

Proposed Law:

This bill includes the following provisions, among others:

• Requires, by January 1, 2023, public university student health centers to offer abortion by medication.
• Requires the Commission to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which will provide private funds as a grant to public university student health centers for medication abortion readiness.
• Provides a continuous appropriation from the fund to the Commission for the following purposes, among others:
  • $200,000 to each public university student health center to pay for the cost, direct and indirect, of medication abortion readiness (e.g., equipment, facility and security upgrades, costs to enable telehealth services, staff training, cost reimbursement).
  • $200,000 to both the UC and CSUs, to pay for the cost to pay for the cost for each university system for items, including, but not limited to: 24-hour, backup medical support by telephone to patients, one-time fees associated with establishing a corporate account to provide telehealth; billing specialist consultation.
  • Maintaining a system of financial reporting.
• Requires each public university student health center grantee, as a condition of grant award, to participate in an evaluation of its medication abortion readiness.
• Conditions the bill’s implementation only if a total of $10.29 million private funds are made available to the College Student Health Center Sexual and Reproductive Health Preparation Fund by January 1, 2020.
• Requires that nothing in the chapter must be interpreted to require a public university to use General Fund or student fees for medication abortion readiness before January 1, 2023.
• Requires, by December 31, 2021, and annually thereafter until December 31, 2026, the Commission to submit a legislative report on specified information and in compliance with state and federal privacy laws. Makes the reporting requirement inoperative on January 1, 2027.

Related Legislation:

1. SB 320 (Leyva, 2018) was substantially similar to this bill. SB 320 was vetoed by Governor Brown, who stated, in part:

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.

Staff Comments:

According to the Commission, a consortium of private funders has secured $10.29 million (special fund) to cover operations costs ($3.1 million over five years) and grant awards ($7.3 million). The Commission anticipates its administrative needs to include:

• 4.0 staff positions, assuming estimated total salary/benefits of $523,000 for the first year, with normal salary increases each additional year.
• Travel, facilities operations, equipment, and information technology.

Proponents provided staff a sample spreadsheet, which assumes a total of $2.2 million to the 11 UC student health centers, and $4.6 million to 23 CSU student health centers, and $400,000 ($200,000 to each UC and CSU system) for help set-up 24-hour back-up clinics, two telemedicine corporate accounts, and a billing consultant

Both the UCs and CSUs provided staff additional detail, which indicate that costs per campus may be higher than the proposed allocation in the bill, and identified implementation issues for further consideration. According to the UC: The UC estimates proposed grants would be insufficient to cover costs in the readiness phase (2019 -2023). We estimate a funding shortfall of $4.6 to $7.8 million across the11 UC student health centers. Beginning January 1, 2023, no source of funding is provided in SB 24. Without funding, the student health centers will incur ongoing costs in the range of $2.2 to $3.2 annually. Unless financing is made available post 2023, by the state or foundation, this cost will fall to students.

For CSUs:

• Equipment costs. Campuses will need to buy equipment to be in compliance. The CSU assumes a cost of $37,556 for ultrasound at each of our campuses (total of $863,788), and additional ongoing maintenance costs.
• Training costs. $10,067 per campus to provide training (total of $231,541).
• Establishing agreements with local hospitals. CSU doctors do not do inpatient care via the CSU, or have hospital admission privileges. Agreements are difficult to negotiate with local hospitals because CSU students are not required to have insurance, and it is unclear who would be responsible for paying the costs associated with the emergency room visit if the student did not have insurance.
• Liability. The CSU’s existing health malpractice insurance would likely cover the costs (settlements, judgements, defense attorney fees and costs), assuming a possibility that underwriters may increase premiums based on the number of claims. For any incident related to SB 24, the CSU would be responsible for the first $5 million of costs. Campus deductibles would range from $35,000 to $900,000, depending on the campus. The remaining costs would be covered by the California State University Risk Management Authority (CSURMA) fund, which is a system-wide pool to support all CSU risk financing operations.
• Billing. The CSU does not currently bill insurance, and it would be extremely costly to move to a billing system. While 12 CSU campuses utilize Family PACT, a publicly-funded, family planning clinical services program administered through the Department of Health Care Services, this is not the same as billing Medi-Cal or private insurers. Insurance-billing is not a viable option for CSU health centers.

-- END --

SENATE COMMITTEE ON EDUCATION

Senator Connie Leyva, Chair

2019 - 2020 Regular

Bill No: SB 24 Hearing Date: April 24, 2019

Subject: Public health: public university student health centers: abortion by medication techniques.

SUMMARY

This bill requires public university student health centers to offer medication abortions to its students by January 1, 2023.

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 the California Commission on the Status of Women and Girls (CCSWG) and requires CCSWG, among other things, to recommend, develop, prepare, or coordinate materials, projects, or other activities, and to give technical and consultative advice to public or private groups or persons concerned with preventing or minimizing problems brought about by the changing roles and responsibilities of women; and, developing programs to encourage and enable women to be fully contributing members of society. (Government code § 8240, et seq.)
4. Licenses and regulates clinics, including primary care clinics and specialty clinics such as surgical clinics, by the Department of Public Health. 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. (HSC §1200 and 1206)

ANALYSIS

This bill:

1. Requires on-campus student health centers within the University of California (UC) or California State University (CSU) that provide primary health care services to students to offer abortion by medication techniques onsite by January 1, 2023. Permits this service to be performed by providers on staff at the student health center or by providers associated with a contracted external agency.
2. Requires the California Commission on the Status of Women and Girls (CCSWG) 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 monies to public university student health centers (SHCs) for medication abortion readiness. This bill permits CCSWG to receive moneys from nonstate entities, including, but not limited to, private sector entities and local and federal government agencies, and to deposit these moneys in the Fund. This bill continuously appropriates funds to CCSWG for allocation to SHCs for medication abortion readiness.
3. Requires CCSWG to utilize fund moneys to:
   1. Provide a grant of $200,000 to each SHC to pay for the cost, both direct and indirect, of medication abortion readiness. This bill defines “medication abortion readiness” to include, but not be 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 from the definition of “medication abortion readiness” the provision of abortion by medication techniques. Requires allowable expenses under these grants include, but are not be limited to:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the SHC 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 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 student health center (SHC);
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Maintain a system of financial reporting on all aspects of the Fund.
4. Requires SHC grantees to, as a condition of receiving a grant award, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Requires this bill to be implemented only if, and to the extent that, a total of at least $10,290,000 in private funds is made available to the Fund in a timely manner by January 1, 2020.
6. Prohibits this bill from being interpreted to mean that University of California (UC) or California State University (CSU) are required to use General Fund moneys or student fees for medication abortion readiness.
7. Requires California Commission on the Status of Women and Girls (CCSWG), working with SHCs, to assist and advise on potential pathways to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
8. Requires CCSWG, by December 31, 2021, by December 31 of each year thereafter until December 31, 2026, to submit a report to the Legislature that includes, but is not necessarily limited to the following, separately for UC and CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;
   3. The total amount of funds granted by CCSWG to UC and CSU and their 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 SHC; and,
9. Requires the report and any associated data collection to be conducted in accordance with existing state and federal privacy law, as specified. Makes these reporting requirements inoperative on January 1, 2027.
10. States legislative findings and declarations relating to:
    1. Abortion as a constitutional right and integral part of comprehensive sexual and reproductive health care.
    2. The state’s interest in ensuring that abortion is accessible to those who are seeking to terminate a pregnancy.
    3. The safety of medication abortion.
    4. The financial and logistical barriers that students face when seeking to terminate a pregnancy.
    5. The intent of the legislature that medication abortion should be accessible, cost-effective, and provided as a basic health service.

STAFF COMMENTS

1. Need for the bill. According to the author, this bill expands medication abortion services to student health centers (SHCs) on public college and university campuses. Currently, all SHCs offer some reproductive health services, while many offer comprehensive reproductive health services. Services at most SHCs include pregnancy testing/counseling, contraceptives, sexually transmitted infection (STI) and HIV counseling/testing, and cervical cancer screening/pap tests. Providing these health services on college campuses ensures that students do not have to travel away from their school and work commitments to receive comprehensive reproductive health care.

According to the author, early pregnancy termination is as clinically easy and safe to provide as the existing services SHCs already offer. Yet, up to 500 public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers.

According to the author, accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success. Students should be able to decide when and if they choose to have a family. By ensuring the provision of medication abortion services on campus, this bill eliminates logistical and financial barriers and allows students to exercise an important constitutional right.

1. Medication abortion. Medication abortion is the use of medications to terminate a pregnancy. According to the National Institute of Health (NIH), ending a pregnancy with a medication abortion is a viable option for women who are less than ten weeks pregnant and would like to have an abortion at home with a less invasive procedure.

According to the American College of Obstetricians and Gynecologists, medication abortion usually involves two visits to a qualified provider. At the first visit, a standard medical evaluation is completed to ensure full eligibility for medication abortion. This includes an ultrasound examination to confirm a pregnancy of a gestational age of ten weeks or less. If the patient is eligible to proceed, the first medication, mifepristone, is provided to the patient by the medical provider during the in-office visit. This medication disrupts the attachment of the pregnancy to the uterus and facilitates the first stages of a medication abortion. Before the patient leaves, the provider reviews the use of additional home medications that will complete the process, provides instructions regarding symptom monitoring, and advises the patient on 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 (ranging from 6-72 hours after mifepristone ingestion). The second medication induces uterine cramping and bleeding, which expels the pregnancy. The bleeding experience is comparable to a heavy menses or miscarriage. A follow-up appointment is strongly recommended to ensure a full completion of the abortion. Most commonly, this includes an in-office visit where ultrasound imaging is used to confirm that the pregnancy has been terminated. Side effects from medication abortion are generally mild, and may include nausea, vomiting, diarrhea, thermoregulatory effects such as sensation of warmth or chills, or headache.

According to the American College of Obstetricians and Gynecologists, the World Health Organization, and the National Academies of Sciences, Engineering, and Medicine - medication abortion is safe and effective. Clinicial studies report that medication abortion is 93-99 percent effective in successfully terminating a pregnancy without the need for subsequent hospitalization – whether due to an incomplete termination of the pregnancy requiring a surgical abortion, or whether due to severe side effects.

1. Medication abortion at student health centers. According to Advancing New Standards in Reproductive Health, all on-campus health centers do provide primary care services, including basic sexual and reproductive health care and contraception. In regards to reproductive health, all on-campus health centers provide emergency contraception on-site or by prescription from a pharmacy.

At present, no student health centers at the University of California (UC), California State University (CSU), or the California Community Colleges (CCC) vide medication abortion. Campus-based health centers currently refer students to local health clinics for such services

1. Student health care center services. UC. There are ten universities as part of the UC system and 11 UC services to student health centers (SHCs) (UC Hastings Law School has its own SHC), 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.

CSU. Each campus of the CSU has a health center, open Monday through Friday. All students have access to all services provided by the SHC, no matter their Medi-Cal status or insurance coverage. Basic health services provided by CSU SHCs 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.

In regards to reproductive health, California State University (CSU) SHCs also provide access to birth control, Plan B, and pregnancy tests but do not provide ongoing pregnancy-related services.

1. Student health Insurance. University of California (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. SHIP includes coverage for abortion, including abortion by medication.

CSU. Health insurance is not mandatory for students at the 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.

1. Cost of care at student health centers. UC. 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 medication abortion, the service is not offered at UC campus health centers and students are referred to local family planning clinics for the procedure.

CSU SHCs are funded through mandatory student fees. Twenty-two campuses have a health facilities fee, which is $19 on average per academic year, and all campuses have a health services fee, which is $320 on average per academic year. The mandatory fees cover basic services, the SHCs do not charge students’ insurance policies, are not reimbursed by Medi-Cal for services, and there is no co-pay for a student to visit a health center. Students may incur additional fees when laboratory tests must be sent externally, for the actual cost of acquiring vaccines, medications, or health devices, or for augmented services outside of the basic services. If a service is considered to be beyond the scope of basic care, students may pay a fee-for-service in order to access it at the SHC.

1. How are campus health centers funded? UC. According to UC, its student health care centers receive little to no state funding. The UC 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. It spends an aggregate of $210 million in annual operating costs for all eleven health centers, with $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.

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.

1. Cost of an abortion. 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. According to the Planned Parenthood website, the out-of-pocket costs for its medication abortion services range between $300 and $800, depending on the patient’s insurance coverage and financial need.
2. Use of the fund. According to the authors, a consortium of funders raised $10.3 million dollars to be provided to the California Commission on the Status of Women and Girls (CCSWG) to support UC and CSU to prepare to provide medication abortion. Each SHC and each of the systems will receive grants of $200,000 to prepare to provide medication abortion. The CCSWG will have funds to hire staff to oversee grant distribution to SHCs, to provide technical assistance, including on billing options, and to gather five years of evaluation data. SHCs can also use some of the funds to increase the contraceptive services available for students.
3. 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 (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. According to the Senate Committee analysis for this bill, 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.

SHC capacity to provide medication abortion. Advancing New Standards in Reproductive Health (ANSIRH) 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 illustrates SHCs’ capacity for implementing medication abortion services given current resources:

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 licensed clinicians, 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.

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.

1. Heard by the Senate Health Committee. This bill was heard by the Senate Health Committee on April 3, 2019, where it passed on a 7-2 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.
2. Prior legislation. SB 320 (Leyva of 2018) was substantially similar to this bill. SB 320 was vetoed by Governor Brown, who stated, in part:

“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.”

SUPPORT

ACCESS Women's Health Justice (co-sponsor)

ACLU California (co-sponsor)

ACT for Women and Girls (co-sponsor)

California Latinas for Reproductive Justice (co-sponsor)

NARAL Pro-Choice California (co-sponsor)

Students United for Reproductive Justice (SURJ) at University of California Berkeley (co-sponsor)

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

American Academy of Pediatrics - California

American Association of University Women - California

American College of Obstetricians and Gynecologists

American Congress of Obstetricians & Gynecologists - District IX

American Medical Women’s Association

American Nurses Association of California

American Public Health Association – Sexual and Reproductive Health Section

Anti-Defamation League

Associated Students, UC Barbara

Associated Students, UC Berkeley

Associated Students, UC San Diego

Associated Students, San Jose State University

Berkeley City Council

Business Professional Women of Nevada County

California Academy of Family Physicians

California Commission on the Status of Women and Girls

California Faculty Association

California Medical Association

California Nurse-Midwives Association

California Women’s Law Center

Center for Relationship Abuse Awareness

Center for Reproductive Rights

Center on Reproductive Rights and Justice

Coalition of California Welfare Rights Organizations

Code Blue, UC Davis School of Medicine

Equal Rights Advocates

Equality California

Feminist Majority Foundation

Forward Together

If/When/How: Lawyering for Reproductive Justice

IGNITE

Innovating Education in Reproductive health

Korean Resource Center

Lawyers Club of San Diego

League of Women Voters of California

Legal Services for Prisoners with Children

Los Angeles Coalition for Reproductive Justice

Los Angeles County Democratic Party

Medical Students for Choice

Medical Students for Choice, California Northstate University College of Medicine

Medical Students for Choice, Stanford University

Medical Students for Choice, Touro University California College of Osteopathic

Medicine

Medical Students for Choice, UC Davis School of Medicine

Medical Students for Choice, UCSF

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center for Youth Law

National Council of Jewish Women, California

National Council of Jewish Women, Long Beach

National Health Law Program

National Institute for Reproductive Health

National Organization for Women (NOW), Hollywood

National Partnership for Women and Families

National Women’s Health Network

National Women’s Law Center

National Women's Political Caucus of California

Ob/Gyn Student Interest Group, Stanford Medical School

Our Bodies Ourselves

Pharmacists Planning Services Inc.

Physicians for Reproductive Health

Planned Parenthood Action Fund, Central Coast

Planned Parenthood Action Fund, Orange and San Bernardino Counties

Planned Parenthood Action Fund, Pacific Southwest

Planned Parenthood Advocates, Pasadena and San Gabriel Valley

Planned Parenthood Affiliates of California

Planned Parenthood, Mar Monte

Positive Women’s Network, USA

Public Health Justice Collective

Reproductive Health Access Project

Reproductive Health Interest Group, UC Los Angeles

RHEDI/Reproductive Health Education in Family Medicine

San Francisco Bay Area Physicians for Social Responsibility

Sexuality Information and Education Council of the United States

Students for Reproductive Justice, UC Santa Barbara

SIA Legal Team

Stonewall Democratic Club

Training in Early Abortion for Comprehensive Health Care (TEACH)

University of California Global Health Institute (UCGHI) Women’s Health, Gender, and Empowerment Center (WHGE-COE)

Unite for Reproductive and Gender Equity (URGE)

University of California Student Association

Western Center on Law & Poverty, Inc.

Women’s Catalytic Fund

10 individuals

OPPOSITION

Americans United for Life

Berkeley College Republicans

California Catholic Conference

California Family Council

California Right to Life Committee, Inc.

Californians for Life

California ProLife Council and Right to Life Federation

Concerned Women for America of California

Faith and Public Policy

Pro-Life San Francisco

Right to Life of Kern County

Right to Life of Central California

Students for Life of America

Students for Life at Berkeley

Students for Life at CSU Fullerton

Students for Life at Fresno State

Tulare-kings Right to Life, Inc.

One individual

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: SB 24

SUBJECT: Public health: public university student health centers: abortion by medication techniques

SUMMARY:

Requires clinics located on a campus within the University of California or California State University that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Requires the California Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund, which is established by this bill for the purposes of providing private moneys to public university student health centers for medication abortion readiness.

Existing law:

1. Permits a licensed physician, or 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. [BPC § 2253 and 2725.4]
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. [HSC §1200 and 1206]
3. Establishes the California Commission on the Status of Women and Girls (CCSWG) and requires CCSWG, among other things, to recommend, develop, prepare, or coordinate materials, projects, or other activities, and to give technical and consultative advice to public or private groups or persons concerned with preventing or minimizing problems brought about by the changing roles and responsibilities of women; and, developing programs to encourage and enable women to be fully contributing members of society. [GOV § 8240, et seq.]

This bill:

1. Requires clinics located on a campus within the University of California (UC) or California State University (CSU) that provide primary health care services to students (referred to as “public university student health centers” under this bill), after January 1, 2023, to offer abortion by medication techniques onsite. Permits this service to be performed by providers on staff at the student health center or by providers associated with a contracted external agency.
2. Requires CCSWG 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 to public university student health centers (SHCs) for medication abortion readiness. Permits CCSWG to receive moneys from nonstate entities, including, but not limited to, private sector entities and local and federal government agencies, and to deposit these moneys in the Fund. Continuously appropriates funds to CCSWG for allocation for purposes of this bill.
3. Requires CCSWG to utilize fund moneys to:
   1. Provide a grant of $200,000 to each SHC to pay for the cost, both direct and indirect, of medication abortion readiness. Defines “medication abortion readiness” to include, but not be 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 from the definition of “medication abortion readiness” the provision of abortion by medication techniques. Requires allowable expenses under these grants to include, but not be limited to:
      1. Purchase of equipment used in the provision of abortion by medication techniques;
      2. Facility and security upgrades;
      3. Costs associated with enabling the SHC 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 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 SHC;
      2. One-time fees associated with establishing a corporate account to provide telehealth services; and,
      3. Billing specialist consultation.
   3. Pay itself for the costs, both direct and indirect, associated with administration of the Fund, including the costs of hiring staff and reporting to the Legislature, not to exceed $3,090,000.
   4. Maintain a system of financial reporting on all aspects of the Fund.
4. Requires SHC grantees to, as a condition of receiving a grant award, participate in an evaluation of its medication abortion readiness and its provision of abortion by medication techniques.
5. Requires this bill to be implemented only if, and to the extent that, a total of at least $10,290,000 in private funds is made available to the Fund in a timely manner on or after January 1, 2020.
6. Prohibits this bill from being interpreted as requiring UC or CSU to utilize General Fund moneys or student fees for medication abortion readiness before January 1, 2023.
7. Requires CCSWG, working with SHCs, to assist and advise on potential pathways to access public and private payers to provide funding for ongoing costs of providing abortion by medication techniques.
8. Requires CCSWG, on or before December 31, 2021, and on or before December 31 of each year thereafter until December 31, 2026, to submit a report to the Legislature that includes, but is not necessarily limited to the following, separately for UC and CSU:
   1. The number of SHCs that provide abortion by medication techniques;
   2. The number of abortions by medication techniques performed at SHCs, disaggregated, to the extent possible, by student health center;
   3. The total amount of funds granted by CCSWG to UC and CSU and their 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 SHC; 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 SHC.
9. Requires the report and any associated data collection to be conducted in accordance with existing state and federal privacy law, as specified. Makes these reporting requirements inoperative on January 1, 2027.

FISCAL EFFECT: This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, this bill expands medication abortion services to SHCs on public university campuses. Currently, all SHCs offer some reproductive health services, and many offer comprehensive reproductive health services. Services at most SHCs include pregnancy testing/counseling, contraceptives, sexually transmitted infection (STI) and HIV counseling/testing, and cervical cancer screening/pap tests. Providing these health services on campus ensures that students do not have to travel away from their school and work commitments to receive care. Although early pregnancy termination is as clinically easy and safe to provide as the services SHCs already offer, up to 500 public university students currently must leave campus each month to access medication abortion, resulting in delayed care as well as travel and cost barriers. Accessing medication abortion services on campus will allow students to remain focused on their studies, helping to improve academic success. Students should be able to decide when and if they choose to have a family. By ensuring the provision of medication abortion services on campus, this bill eliminates logistical and financial barriers and allows students to exercise an important constitutional right.
2. Abortion. According to the Center for Disease Control and Prevention (CDC), for the purpose of surveillance, a legal induced abortion is defined as an intervention performed by a licensed clinician that is intended to terminate an ongoing pregnancy. The CDC reports that in 2015, 638,169 legal induced abortions were reported from 49 reporting areas across the U.S. The abortion rate for 2015 was 11.8 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 188 abortions per 1,000 live births. Compared with 2014, the total number, rate, and ratio of reported abortions for 2015 decreased 2%. From 2006 to 2015, the number, rate, and ratio of reported abortions decreased 24%, 26%, and 19%, respectively. In 2015, all three measures reached their lowest level for the entire period of analysis. Women in their twenties accounted for the majority of abortions in 2015 and throughout the period of analysis. The majority of abortions in 2015 took place early in gestation: 91.1% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (7.6%) were performed at 14–20 weeks’ gestation; and, even fewer (1.3%) were performed at ≥21 weeks’ gestation. In 2015, 24.6% of all abortions were early medication abortions (a non-surgical abortion at ≤8 weeks’ gestation). The percentage of abortions reported as early medication abortions increased 114% from 2006 to 2015, with an 8% increase from 2014 to 2015. 
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 medication abortion. According to a June 2018 Kaiser Family Foundation (KFF) Issue Brief, the most common regimen in the United States involves the use of two different medications: Mifepristone, sold under the brand name Mifeprex, and misoprostol. Mifepristone blocks progesterone, a hormone essential to the development of a pregnancy. Misoprostol, taken 24 to 48 hours later, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit is scheduled a week or two later to confirm the pregnancy was terminated via ultrasound or blood test. The KFF Issue Brief states that almost one-third of all abortions at eight weeks gestation or less are medication abortions.
4. Medication abortion effectiveness and risks. According to the KFF Issue Brief, Mifeprex is not dispensed by retail pharmacies; rather women can only obtain the drug directly from a medical provider who has received training from the manufacturer about the proper use of the drug.  If the pills are administered at eight weeks’ gestation or less, the pregnancy is terminated successfully 98 out of 100 times, with 0.05% risk of major complications, and an associated mortality rate of less than one percent (0.00063%).  According to the NIH, medication abortion has been proven highly effective, safe and acceptable for abortions occurring up to nine weeks, with efficacy rates up to 98%. Approximately 2% to 5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding.
5. Insurance coverage for medication abortion. According to the KFF Issue Brief, on average, a first trimester abortion costs $497, with no significant difference between the average costs of an aspiration abortion and a medical abortion. Most women pay at least some out of pocket costs for their abortion. In 2011, most women seeking first trimester abortion had insurance coverage; however, the majority (69%) did not or could not use it to pay the procedure. Of those who did not use their insurance to pay for their abortion, 49% say it was because their insurance did not cover it, and 29% say they did not use it because they were not sure if it was covered.
6. Health care at UC. There are ten universities as part of the UC system and 11 SHCs (UC Hastings Law School has its own SHC), 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 medication abortion, 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” (as defined under the CSU Executive Order 943), which 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. CSU SHCs are funded through mandatory student fees. The mandatory fees cover basic services, the SHCs do not charge students’ insurance policies, are not reimbursed by Medi-Cal for services, and there is no co-pay for a student to visit a health center. Students may incur additional fees when laboratory tests must be sent externally, for the actual cost of acquiring vaccines, medications, or health devices, or for augmented services outside of the basic services. All students have access to all services provided by the SHC, no matter their Medi-Cal status or insurance coverage. SHCs provide access to birth control, Plan B, and pregnancy tests but do not provide ongoing pregnancy-related services. All students are eligible for HIV testing and STI testing. Some of these services may be provided at no cost to students depending on the capacity for waived testing or onsite lab services. If a service is considered to be beyond the scope of basic care, students may pay a fee-for-service in order to access it at the SHC. Twenty-two campuses have a health facilities fee, which is $19 on average per academic year, and all campuses have a health services fee, which is $320 on average per academic year. 
8. Advancing New Standards in Reproductive Health (ANSIRH) Issue Briefs. The Women's Foundation of California, a co-sponsor of this bill, facilitated two surveys, conducted by UC San Francisco’s ANSIRH, of all 11 UC SHCs and 20 of the 23 CSU SHCs. The results of the surveys were compiled into two December 2017 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.” Below are findings from those reports:
   1. Student access to abortion. Over half (51%) of students are low-income, with 42% of UC students and 21% of CSU students experiencing food insecurity. Public transportation is key to abortion accessibility off-campus, as over two-thirds of UC students and one-third of CSU students do not have a car. Twenty-two campuses (62%) 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 such a delay can make a student ineligible for medication abortion.

• 1. SHC capacity to provide medication abortion. ANSIRH 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 illustrates SHCs’ capacity for implementing medication abortion services given current resources:
     

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 licensed clinicians, 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.

1. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Committee on Education.
   
2. Prior legislation. SB 320 (Leyva of 2018) was substantially similar to this bill. SB 320 was vetoed by Governor Brown, who stated, in part: “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.”
3. Support. Numerous supporters write that currently none of the SHCs at California’s public universities provide medication abortion services, despite how clinically simple the service is to offer. Students seeking this basic reproductive health care must travel off campus to access abortion care - often with serious logistical and financial barriers. Students at California’s public universities face several additional barriers to obtaining an abortion. According to recent studies at UCSF, over half (51%) of students across the UC and CSU systems are low-income (defined as qualifying for a Pell Grant), 21% of CSU students are food insecure and 9% suffer housing displacement such as homelessness, and 42% of UC students experience low or very low food security. For those students, paying out-of-pocket at a clinic, securing reliable transportation, missing school and work to determine their options and get to the clinic are huge burdens. Supporters state that after a student identifies a clinic, they will have to wait an average of a week for an appointment at the closest clinic to campus. 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. Making abortion services available at student health clinics would minimize the disruption for students who become pregnant and make basic healthcare available to all. California is the bellwether for reproductive health care legislation and should lead the nation in protecting the academic success of our students. Supporters contend that California is the bellwether for reproductive health care legislation and should lead the nation in protecting the academic success of our students.
4. Opposition. Faith and Public Policy states that this bill needs to include a specific exclusion against the use of state general funds, university funds, and student fees for this abortion expansion effort. Californians for Life write this bill is a pro-abortion effort which does nothing to help pregnant students on campus find the comprehensive resources they need in order to have real choices, real options, other than abortion, abortion, and more abortion. Crusade for Life writes that this bill does not meet the legitimate duty of governments, which is to secure the right to life as clearly expressed in the Declaration of Independence, an organic document of our nation.
5. Policy comments.
   1. This bill provides funding for medication abortion readiness, but does not contain detail on how SHCs will pay for these services once they have the necessary capacity and are required to offer medication abortion. The author may wish to amend this bill to provide for a reimbursement mechanism so that student fees are not affected, given that currently, SHCs are solely funded through student fees.
   2. This bill permits CCSWC to use up to approximately $3 million to administer the medication abortion readiness grant program, which is approximately 30% of total funding for the program. In comparison to what other state departments, commissions, and offices budget to administer programs of this size and scope, this seems disproportionate. For example, through the 2018-19 Budget, DPH’s Black Infant Health/Perinatal Equity Initiative received $8 million to fund up to 15 counties to add a medical/social model to their existing Black Infant Health programs. The Budget set aside up to $800,000 for overhead. This bill should be amended to either cap the funding to CCSWC in line with other state programs of this nature or to delete the allocation for administrative funding and permit the funders and CCSWC to negotiate overhead through the contracting process.

SUPPORT AND OPPOSITION:

Support: Access Women's Health Justice (co-sponsor)

ACLU California (co-sponsor)

ACT for Women and Girls (co-sponsor)
California Latinas For Reproductive Justice (co-sponsor)
Students United For Reproductive Justice at Berkeley (co-sponsor)

NARAL Pro-Choice California (co-sponsor)

Students United for Reproductive Justice at Berkeley (co-sponsor)
Women's Policy Institute/Women's Foundation of California (co-sponsor)

American Academy of Pediatrics California

American Association of University Women District IX

American College of Obstetricians and Gynecologists

American Nurses Association\ California

American Public Health Association, Sexual and Reproductive Health Section

Anti-Defamation League

Associated Students of UC San Diego

Associated Students of the University of California

Berkeley City Council

Business and Professional Women of Nevada County

California Academy of Family Physicians

California Commission on the Status of Women and Girls

California Faculty Association

California Medical Association

California Nurses-Midwives Association

California Voices for Progress

California Women’s Law Center

Center for Relationship Abuse Awareness

Center for Reproductive Rights

Citizens for Choice

Coalition of California Welfare Rights Organizations

Code Blue

Equal Rights Advocates

Equality California

Feminist Majority Foundation

Hollywood Chapter of the National Organization for Women

If/When/How Lawyering Reproductive Justice

Impact Hub Oakland

Innovation Education in Reproductive Health

Korean Resource Center

Lawyers Club of San Diego

League of Women Voters of California

Legal Services for Prisoners with Children

Los Angeles Coalition for Reproductive Justice

Medical Students for Choice, National Office

Medical Students for Choice, California Northstate University College of Medicine

Medical Students for Choice, Stanford University School of Medicine

Medical Students for Choice, Touro University CA College of Osteopathic Medicine

Medical Students for Choice, UC Davis School of Medicine

Medical Students for Choice, UCSF

National Abortion Federation

National Association of Social Workers, California Chapter

National Center for Lesbian Rights

National Center for Youth Law

National Council of Jewish Women CA

National Council of Jewish Women, Long Beach

National Health Law Program

National Partnership for Women & Families

National Women’s Health Network

National Women’s Law Center

Our Bodies Ourselves
Pharmacists Planning Services, Inc.

Physicians for Reproductive Health

Planned Parenthood Action Fund of the Pacific Southwest

Planned Parenthood Advocates Pasadena and San Gabriel Valley

Planned Parenthood Affiliates of California

Planned Parenthood California Central Coast

Planned Parenthood Mar Monte

Planned Parenthood of Orange and San Bernardino Counties

Positive Women’s Network-USA

Public Health Justice Collective

Reproductive Health Access Project

RHEDI/Reproductive Health Education in Family Medicine

San Francisco Bay Area Physicians for Social Responsibility

Sexuality Information and Education Council of the United States

Stonewall Democratic Club

The SIA Legal Team

Training in Early Abortion for Comprehensive Healthcare

UCSD Associated Students

Unite for Reproductive & Gender Equity

University of California Student Association

URGE

Voices for Progress

Western Center on Law and Poverty

Women’s Catalytic Fund

Women Lawyers of Sacramento

Eleven individuals

Oppose: California Catholic Conference

California Family Council

Californians for Life

Crusade for Life

Berkeley College Republicans

Faith and Public Policy

Life Priority Network

Right to Life of Central California

Students for Life at UC Berkeley

One Individual