BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 980
AUTHOR: Pan
AMENDED: June 19, 2013
HEARING DATE: July 3, 2013
CONSULTANT: Marchand
SUBJECT : Primary care clinics: abortion.
SUMMARY : Requires the California Building Standards Commission
to adopt emergency regulations to delete a provision of the 2013
California Building Standards Code that establishes building
standards for primary care clinics that provide abortion
services, and prohibits the Commission from adopting any
building code standards for clinics providing medication or
aspiration abortion services that differ from construction
standards applicable to other primary care clinics.
Existing state statute:
1.Licenses and regulates clinics, including primary care clinics
and specialty clinics such as surgical clinics, by the
Department of Public Health (DPH).
2.Permits DPH to issue a permit to authorize a clinic to offer
one or more special services, which is a type of care for
which DPH has established special standards for ensuring the
quality of care, including birth services and abortion
services.
3.Establishes the California Building Standards Commission
(CBSC), consisting of the Secretary of the State and Consumer
Services Agency, and 10 members appointed by the Governor, as
specified.
4.Requires any building standard adopted or proposed by state
agencies to be submitted to, and approved or adopted by, the
CBSC. Requires building standards adopted by state agencies
and submitted to CBSC to be accompanied by an analysis written
by the state agency that proposes the standards to justify the
approval to the satisfaction of the CBSC.
5.Establishes the Reproductive Privacy Act, which prohibits the
state from denying or interfering with a women's right to
choose or obtain an abortion prior to viability of the fetus,
Continued---
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or when the abortion is necessary to protect the life or
health of the woman. Defines "abortion," for purposes of this
Act, as any medical treatment intended to induce the
termination of a pregnancy except for the purpose of producing
a live birth.
Existing Title 22 regulations (pertaining to the licensing of
health facilities):
1.Requires primary care clinics providing abortion services as a
special service to have adequate and appropriate equipment and
supplies to provide the services offered, including at least
the following: standard gynecological examination table;
pharyngeal suction equipment; oxygen source and mask; surgical
instruments necessary for the performance of the abortion;
emergency medications; and, appropriate intravenous fluids.
2.Requires, in primary care clinics providing abortion services,
a physician certified by the American Board of Obstetrics and
Gynecology or trained in performing abortions to be
responsible for the abortion service, and that only a
physician responsible to the professional director of the
clinic to perform abortions. Requires a licensed nurse to be
present in the clinic when an abortion is performed, and to
have a system operative on a 24-hour basis ensuring
availability of staff for follow-up care or referral of
patients.
3.Requires primary care clinics performing abortion services to
have a floor area which can accommodate the patient, the
equipment and supplies, and the staff required for the
abortion service, and requires a post-abortion recovery area
to be maintained. Requires space for a counseling area to be
maintained, which can be the same area as the post-abortion
recovery area, but must provide privacy for those patients who
request it.
Existing Title 24 regulations (pertaining to building
construction standards),: Requires, effective January 1, 2014,
primary care clinics providing abortion services, in addition to
meeting the minimum requirements for other primary care clinics,
to include the following:
a.A treatment room with a minimum of 120 square feet. Permits
treatment rooms used for aspiration abortion, however, to be
sized as examination rooms;
b.A post-abortion recovery area, with certain specified
clearance and privacy requirements;
AB 980 | Page
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c.A private room or area of at least 60 square feet for
pre-abortion and post-abortion counseling.
This bill:
1.States the intent of the Legislature to preempt, and to render
inoperative, a specific section of the 2013 Triennial Edition
of the California Building Standards Code that establishes
building standards for primary care clinics that provide
abortion services.
2.Prohibits the CBSC, notwithstanding any other law, from
adopting building code standards that establish construction
requirements for primary care clinics that provide medication
or aspiration abortion services that differ from construction
standards applicable to other primary care clinics, as
specified.
3.Requires the CBSC, in conjunction with Office of Statewide
Health Planning and Development (OSHPD), to adopt emergency
regulations to delete a specific section of the 2013 Triennial
Edition of the California Building Standards Code that
establishes building standards for primary care clinics that
provide abortion services, including all cross-references to
that section, as soon as possible. Requires these emergency
regulations, notwithstanding the Administrative Procedures
Act, to become permanent without further regulatory action.
4.Requires the Department of Public Health, no later than July
1, 2014, to repeal specific regulations inconsistent with this
bill, including specified regulations establishing equipment,
supplies, staffing and space requirements for abortion
services in primary care clinics.
FISCAL EFFECT : According to the Assembly Appropriations
Committee analysis (which was to the prior version of this
bill), this bill will have minor, absorbable costs to the CBSC
and OSHPD.
PRIOR VOTES :
Assembly Business, Professions, and Consumer Protection:8- 4
Assembly Appropriations: 12- 5
Assembly Floor: 47- 21
COMMENTS :
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1.Author's statement. Under recently approved regulations,
clinics that provide abortion would be held to different
building construction standards than other primary care
clinics. All primary care clinics are local community health
facilities that provide basic and low-risk, yet vital,
services. There is no medical reason to require clinics that
provide medication or early abortion procedures to meet more
rigorous and expensive building standards than other similar
facilities. The risk of infection after an abortion procedure
is extremely low, less than one percent, and there is no
evidence that building standards, like plumbing, impact that
risk.
As millions of additional people come into the health care
system under federal health care reform, more providers and
facilities will be needed to meet the growing demand for
health care. Requiring all primary clinics to be held to the
same building standards (even those providing abortion
services) aligns with the state's goal of increasing access.
This bill will allow primary care clinics, essential health
care access points for many Californians, to open quickly and
more efficiently. California must reduce barriers to care
safely and where appropriate in order to serve the newly
eligible populations in 2014 and beyond.
2.OSHPD building standards and the California Building Standards
Code. OSHPD is the adopting agency for building standards for
health facilities, including clinics. The CBSC, which is
responsible for adopting and publishing the California
Building Standards Code, which is updated every three years,
accepts building standard recommendations from state adopting
agencies related to the types of buildings that fall under
their respective jurisdictions. The 2013 code was recently
adopted, and will take effect on January 1, 2014. Until then,
the 2010 code remains in effect.
New OSHPD 3SE classification. During the process of updating the
building standards code for the 2013 edition, OSHPD proposed a
new subcategory of clinics that would be exempt from certain
requirements that applied to other clinics. Clinics are
referred to in the building codes as OSHPD 3 facilities, and
this new exempted subcategory is called OSHPD 3SE. The OSHPD
3SE classification consists of primary care clinics providing
services that have to meet requirements described in Section
1226.6 of Title 24 of the California Code of Regulations
(clinics that are without treatment rooms and that perform
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5
procedures in examination rooms), as well as rehabilitation
clinics and psychology clinics. Clinics performing abortions
must meet additional requirements described in Section 1226.7
of Title 24, which requires these clinics to have treatment
rooms, as well as other space requirements based on Title 22
regulatory requirements described in existing law above.
However, Section 1226.7 specifically permits treatment rooms
for aspiration abortion to be sized as examination rooms. The
OSHPD 3SE exemption does not apply to clinics that are
required to comply with Section 1226.7. By eliminating
Section 1226.7, with its additional requirements for abortion
services, the authors intent is that those primary care
clinics performing medication and aspiration abortion services
would be treated the same as other primary care clinics, and
would fall under the 3SE exemption.
OSHPD 3SE exemptions. OSHPD proposed that CBSC provide
exemptions from certain requirements in the Mechanical Code
related to ventilation air supply and duct systems, and from
certain requirements in the Plumbing Code related to
disinfection of potable water systems, hot-water-heating
equipment, and minimum vent pipe length. Ultimately, CBSC
only adopted the 3SE exemptions from the Plumbing Code
requirements, and did not adopt the Mechanical Code
exemptions.
3.What are medication abortions and aspiration abortions? The
descriptions below were compiled using information from UCSF
Medical Center's website, as well as Planned Parenthood's
website. Both medication and aspiration abortions are
first-trimester abortions. Second trimester abortions (those
taking place 15 to 23 weeks after the last menstrual period)
use different procedure, known as dilation and evacuation.
Medication abortion. Medical abortion, also known as
non-surgical abortion, is a way to terminate early pregnancy
using medications. A medical abortion can be performed from
the time a woman confirms she is pregnant up until nine weeks
from her last menstrual period. Medications typically include
a combination of two drugs: Mifepristone, also known as
Mifeprex or "RU-486," blocks the action of the hormone
progesterone on the uterus. This causes the lining of the
uterus to shed, as it does during a period, and stops the
growth of the pregnancy. The second medication, Misoprostol,
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also known as Cytotec, causes the uterus to contract and
initiates bleeding and cramping. A medical abortion involves
at least two visits to a doctor's office or clinic: the first
visit includes an exam and counseling, and then the woman is
given the first medication, and told to take the second
medication within the next few days while at home. The woman
returns to the clinic or doctor's office within the next week
or two to ensure the abortion is complete.
Aspiration abortion. Suction aspiration abortion, also known as
surgical abortion, or suction curettage abortion, can be
performed from about six weeks after the woman's last
menstrual period up until about 14 weeks after the last
period. The procedure involves dilating the cervix, often
using a series of increasingly thick rods. The provider may
inject a numbing medication into or near the cervix for this
dilation procedure. Once the cervix is dilated, a tube is
inserted through the cervix into the uterus, and either a
mechanical or electric suction device gently empties the
uterus. Sometimes, an instrument called a curette is used to
remove any remaining tissue that lines the uterus, or to check
that the uterus is empty. When a curette is used, people often
call the abortion a D&C, or dilation and curettage.
4.Related legislation. AB 154 (Atkins) permits nurse
practitioners, certified nurse midwives, and physician
assistants who have completed training and achieved clinical
competency through by Health Workforce Pilot Project No. 171
to perform abortions by aspiration techniques, in adherence to
specified standardized procedures and training, to perform
abortions. AB 154 is set to be heard in Senate Health
Committee on July 3, 2013.
5.Support. According to Planned Parenthood Affiliates of
California (PPAC), the sponsor of this bill, OSHPD recently
proposed changes to update building standard regulations for
the construction of community clinics. These changes align the
state's regulations with national building standards by
exempting most primary care clinics from certain plumbing
standards in order to reduce costs without compromising
patient safety. Unfortunately, PPAC states that OSHPD's
proposal did not include primary care clinics that provide
abortions. Because of this, beginning in 2014, all new primary
care clinics that provide abortion, even when those are
abortion pills or very early abortion procedures) would have
to meet rigorous and expensive construction standards while
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primary care clinics providing other, similar procedures,
would not. PPAC states that there is no medical reason to
discriminate against clinics that provide medication or early
abortion procedures by requiring different plumbing and
ventilation standards. The American Civil Liberties Union
states in support that imposing unequal and burdensome
building standards on clinics providing abortions is a tactic
often used in other states to impede access by making it more
difficult and expensive for reproductive health providers to
open and maintain their facilities. The American College of
Obstetricians and Gynecologists, District IX, states in
support that it opposes legislation or other requirements that
single out abortion services from other outpatient procedures.
The California Primary Care Association states that with
millions more individuals coming into the health care system,
more providers and facilities will be needed to meet the
growing demand for health care. Requiring all primary care
clinics to be held to the same building standards aligns with
the state's goal of expanding access.
6.Opposition. The California Catholic Conference states in
opposition that the claim by this bill's supporters that
medical and aspiration abortions are so safe that they are
basically the same as the services provided by other primary
care clinics is specious and demonstrably false. The
California Catholic Conference states that abortion is neither
a trivial procedure nor a primary care service. Following an
abortion, women can experience complications ranging from
cramping and vaginal bleeding to nausea, vomiting, diarrhea,
chills, or fever - and in rare cases, hemorrhage requiring a
blood transfusion. Concerned Women for America also opposes
this bill, stating that medical facilities must be prepared
for patient complications, including providing appropriately
constructed treatment rooms. Capitol Resource Family Impact
states that it opposes this bill because it allows abortions
to be performed in examination rooms instead of surgical
treatment rooms and eliminates the requirement to provide
post-abortion recovery and counseling areas where privacy is
provided for patients requesting it. The Coalition for Women
and Children states in opposition that the building code that
this bill seeks to delete is not changing or increasing
current requirements for abortion clinics, but leaving in
place requirements that have been proven effective.
7.Should there be special requirements for abortion services in
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primary care clinics? Recent amendments to this bill require
DPH to repeal regulations inconsistent with this bill,
including specified regulations relating to equipment and
supplies, staffing, and space requirements that are applicable
only to abortion services. The author and sponsors state that
at least portions of the staffing regulation are outdated and
do not reflect current law. However, it is unclear to what
extent this regulation is inconsistent with the rest of this
bill, which pertains to facility requirements and ensuring
that primary care clinics do not have to meet different
building standards if they provide medication and aspiration
abortion services. On the other hand, there are other
regulations not specifically repealed by this bill that are
specific to abortion services, including regulations that
specify certain policies and procedures that a clinic must
implement. It is unclear to what extent it is appropriate,
from a health and safety point of view, for there to be
separate, stand-alone requirements for abortion services,
especially given that "abortion services" encompasses a range
of procedures from oral medication to relatively involved
surgical procedures in later stages of pregnancy.
The committee may wish to consider whether, instead of
repealing specified regulations, DPH should be required to
"repeal or revise regulations relating to abortion services in
primary care clinics, including those contained in Article 5
of Chapter 7 of Division 5 of Title 22 of the California Code
of Regulations, to ensure that any requirements specific to
abortion services, if any, are consistent with current medical
standards of care."
SUPPORT AND OPPOSITION :
Support: Planned Parenthood Affiliates of California (sponsor)
American Civil Liberties Union of California
American Congress of Obstetricians and Gynecologists,
District IX
California Family Health Council
California Primary Care Association
NARAL Pro-Choice California
Planned Parenthood Advocacy Project Los Angeles County
Planned Parenthood of the Pacific Southwest
Planned Parenthood Pasadena and San Gabriel Valley
Planned Parenthood of Santa Barbara, Ventura and San
Luis Obispo Counties, Inc.
Six Rivers Planned Parenthood
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Women's Community Clinic
Oppose: California Catholic Conference, Inc.
California Right to Life Committee, Inc.
Capitol Resource Family Impact
Coalition for Women and Children
Concerned Women for America of California
John Paul the Great Catholic University Students for
Life
Life Priority Network
12 individuals
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