BILL ANALYSIS                                                                                                                                                                                                    






                             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;




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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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            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,  




          AB 980 | Page 6




            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  




          AB 980 | Page 8




            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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