BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                  AB 1840
                                                                  Page  1

          Date of Hearing:  May 6, 2014

                            ASSEMBLY COMMITTEE ON HEALTH
                                 Richard Pan, Chair
                    AB 1840 (Campos) - As Amended:  April 10, 2014
           
          SUBJECT  :  Pupil health: vision appraisal.

           SUMMARY  :  Authorizes the use of an eye chart or any other  
          scientifically valid technology to be used for pupil vision  
          screening performed in schools and defines a scientifically  
          valid technology as a technology that has been published in a  
          peer reviewed journal.  

           EXISTING LAW  :  

          1)Requires, upon first enrollment in a California school  
            district of a child at an elementary school, and at least  
            every third year thereafter until the child has completed the  
            eighth grade, the child's vision to be appraised by the school  
            nurse or other authorized person, as specified.  Requires  
            results of the appraisal to be entered in the health record of  
            the pupil.

          2)Requires the vision appraisal to include tests for visual  
            acuity and color vision.  Requires color vision to be  
            appraised once and only on male children in the first grade. 

          3)Permits the vision appraisal to be waived, at the parent's  
            request, by presenting a certificate from a physician, a  
            physician assistant, or an optometrist providing the results  
            of a determination of the child's vision, including visual  
            acuity and color vision.

          4)Requires a report to be made to a child's parent when a visual  
            defect has been noted as a result of the vision appraisal.   
            Requires the report, to request the parent or guardian to take  
            action to correct the defect, and requires the report to be  
            made on a form prescribed by the Superintendent of Public  
            Instruction.  Prohibits the report from including any  
            recommendation suggesting or directing the pupil to a  
            designated individual or class of practitioner for the purpose  
            of curing or correcting any defect referred to in the report.

          5)Establishes the federal Patient Protection and Affordable Care  








                                                                  AB 1840
                                                                  Page  2

            Act (ACA), which among other provisions, imposes new  
            requirements on individuals, employers, and health plans;  
            restructures the private health insurance market; sets minimum  
            standards for health coverage; establishes health benefit  
            exchanges; and, provides financial assistance to certain  
            individuals and small employers.

          6)Requires, under the ACA, health plans, and health insurers  
            that offer coverage in the small group or individual market,  
            both inside and outside of the California Health Benefit  
            Exchange (now called Covered California), to ensure coverage  
            includes the essential health benefits (EHB) package, which  
            includes pediatric vision care.

           FISCAL EFFECT  :  None




           COMMENTS  :

           1)PURPOSE OF THIS BILL  .  According to the author, childhood  
            vision disorders are a prevalent and significant public health  
            problem, yet there is a significant lack of public awareness  
            about the importance of eye care in children and the inability  
            of children to recognize their own vision problems.  The  
            author asserts these problems are heightened in families from  
            economically disadvantaged backgrounds by financial hardship  
            and lack of access to appropriate medical care.  The author  
            states that this bill will help broaden the accessibility to  
            vision screenings because any trained individual can utilize  
            this digital technology to screen students, the results are  
            immediate and digital, and the results indicate whether or not  
            a child would need a follow up eye exam.  More students in  
            low-income, urban, and rural areas would have access to this  
            new digital technology to provide accurate and quick results.   


           2)BACKGROUND  .  

             a)   Photoscreening.  According to the American Academy of  
               Pediatrics (AAP) policy statement, Use of Photoscreening  
               for Children's Vision Screening, photoscreening is a vision  
               screening technique used to screen for amblyogenic factors  
               such as strabismus (lazy eye) and significant refractive  








                                                                  AB 1840
                                                                  Page  3

               errors in one or both eyes in children.  Using a camera or  
               video system, images of the pupillary reflexes  
               (reflections) are obtained.  Other than having to fixate on  
               the appropriate target long enough for the photoscreening,  
               little cooperation is needed from the child.  Data are then  
               analyzed by the evaluator.  Children who do not pass the  
               test may be referred for a complete eye examination.   
               Photoscreening does not represent a single technique or  
               piece of equipment.  Different optical systems can be used  
               for photoscreening.  Each photoscreening system may have  
               its own advantages and disadvantages, and it appears that  
               results published in the literature for one system are not  
               necessarily valid for others.  Studies performed by  
               different investigators using the same photoscreening  
               apparatus may yield a wide range of results.  Likewise, it  
               is not certain that data gathered about different groups of  
               children or different settings can be extrapolated to other  
               groups or settings.  The AAP favors additional research of  
               the efficacy and cost-effectiveness of photoscreening as a  
               vision screening tool.  

             b)   Vision screening in California's schools.  A guide  
               developed by the California Department of Education (CDE)  
               titled, "A Guide for Vision Testing in California Public  
               Schools," states that the only people authorized to conduct  
               vision tests include the following:

               i)     Medical practitioners, including a nurse, physician,  
                 ophthalmologist, or optometrist who holds both a license  
                 from the appropriate California board or agency, and a  
                 health and development credential, a standard designated  
                 service credential with a specialization in health, a  
                 health services credential as a school nurse, or a school  
                 nurse services credential;

               ii)    Certificated school district or county employees who  
                 hold a teaching credential and are qualified by training,  
                 including satisfactory completion of six hours of vision  
                 testing, or an accredited college or university course in  
                 vision testing of at least one semester unit; or,
               iii)   Contracting agents who have met the training  
                 requirements specified above and who have been authorized  
                 by the county superintendent of schools in which the  
                 district is located to perform the tests.









                                                                  AB 1840
                                                                  Page  4

           3)SUPPORT  .  Healthier Kids Foundation of Santa Clara County  
            (Foundation) supports this bill and writes that one of the  
            most important visual skills for reading is the ability to  
            coordinate the two eyes together and that an eye chart helps  
            to test vision for distance but not how the eyes team  
            together.  The Foundation further argues that a few states,  
            including Alabama, Florida, and parts of New York have  
            replaced eye charts with photo optic scan cameras in school  
            settings, which are quick, efficient, reliable, and don't  
            require medical professionals to complete screenings.

            California Coverage & Health Initiatives supports this bill,  
            stating early identification and correction of a vision  
            disorder is an essential part of a child's overall health and  
            their ability to learn and this bill will help children by  
            ensuring schools have the capabilities to identify vision  
            problems early by using the most up-to-date technology  
            available.

           4)OPPOSITION  .  The California School Nurses Organization (CSNO)  
            opposes this bill and writes that according to the American  
            Academy of Ophthalmology Instrument-Based Pediatric Vision  
            Screening Policy, evidence based practice does not support the  
            use of instrument based screening in children older than five  
            years of age.  CSNO further argues that while children younger  
            than four years can benefit from instrument-based screening,  
            for children four to four years of age, photoscreening has not  
            been shown to be superior or inferior to visual acuity testing  
            with the use of vision charts.  Finally, CSNO states that  
            current law already permits the use of alternative tests with  
            children who, because of age or special needs, are not able to  
            be tested with an optotype test.

           5)SCREENING LEGISLATION  .  According to the World Health  
            Organization, screening, in medicine, is a strategy used in a  
            population to identify an unrecognized disease in individuals  
            who may not have signs or symptoms.  As such, screening tests  
            are unique in that they are performed on persons apparently in  
            good health.  As a matter of public policy, when contemplating  
            mandating a specific type of screening, the Legislature should  
            consider several things.  Is the proposed screening test  
            effective in accurately identifying a disease?  What are the  
            consequences of a false positive result?  Is there an  
            effective treatment for the disease?  What is the cost of the  
            screening?  What is the cost benefit analysis?  Is there  








                                                                  AB 1840
                                                                  Page  5

            access to treatment for California's diverse population?  The  
            Legislature should also look to information from other  
            organizations, such as the U.S. Preventive Services Task Force  
            and the federal Department of Health and Human Services  
            Secretary's Advisory Committee on Heritable Disorders in  
            Newborns and Children.  These organizations are expert bodies  
            that evaluate available screening processes to ensure that  
            there is evidence that the proposed screen is effective for  
            widespread use.  While there are examples of individuals who  
            have suffered from delayed or missed diagnoses, it is not a  
            given that screening would have prevented the problem or that  
            mandatory screening is always the appropriate solution.

           6)RELATED LEGISLATION  .  

             a)   SB 430 (Wright) deletes an existing requirement that  
               upon first enrollment in a California school district of a  
               child at an elementary school, and at least every third  
               year thereafter until the child has completed the eighth  
               grade, the child's vision to be appraised by the school  
               nurse or other authorized person, and replaces it with a  
               requirement that, upon first enrollment in a private or  
               public elementary school, a pupil receive a vision  
               examination from a physician, optometrist, or  
               ophthalmologist and requires that screening to include a  
               test for binocular function, refraction, and eye health.   
               SB 430 is pending in the Assembly Health Committee.

             b)   SB 1172 (Steinberg) would revise the functions to be  
               performed by the school nurse and the classroom teacher  
               during pupil vision screenings in observing a pupil's eyes,  
               appearance, and other factors that may indicate vision  
               difficulties.  SB 1172 would require CDE to adopt  
               guidelines to implement those provisions, including  
               training requirements and a method of testing for near  
               vision.  SB 1172 is currently pending in the Senate  
               Committee on Appropriations.

           7)PREVIOUS LEGISLATION  .  

             a)   AB 1453 (Monning), Chapter 854, Statutes of 2012,  
               establishes California's EHB benchmark, which requires an  
               individual or small group health plan contract or health  
               insurance policy issued, amended, or renewed on or after  
               January 1, 2014 to, at a minimum, include coverage for  








                                                                  AB 1840
                                                                  Page  6

               EHBs, including pediatric vision care. 
                
             b)   SB 606 (Vasconcellos) of 2001 would have required the  
               existing student eye examination to include screening for  
               binocular function, ocular alignment, ocular motility, and  
               near visual acuity.  SB 606 was held on the Assembly  
               Appropriations Committee's suspense file.

             c)   AB 1095 (Wright) of 2001 would have required every  
               student, within 90 days of entering first grade, to undergo  
               a comprehensive eye exam that includes, in addition to  
               ocular health and distance and near visual acuity,  
               additional evaluations of visual skills such as eye  
               teaming, focusing, and tracking that may impact a child's  
               ability to read.  AB 1095 was held in the Senate  
               Appropriations Committee's suspense file.

             d)   AB 1096 (Wright) of 2001 would have established a pilot  
               program for schools scoring in the bottom 20% on state  
               achievement tests to administer to poor readers  
               comprehensive eye screening and remedial vision training.   
               AB 1096 died on the Senate Floor's inactive file.

           8)SUGGESTED AMENDMENTS  .   School nurses and classroom teachers  
            are currently required to observe student's eyes, visual  
            performance, and perception while performing vision screening.  
             This bill allows for the use of an eye chart or any other  
            scientifically valid technology during that screening, however  
            there is no requirement that school nurses or teachers be  
            trained to use the additional technology.  Furthermore,  
            defining scientifically valid technology as a technology that  
            has been published in a peer-reviewed journal appears to be an  
            unworkable definition.  Peer review refers to the scholarly  
            article, not the actual technology.  An article on a specific  
            technology could conclude that the technology is not relevant,  
            and still be peer-reviewed thus allowing the technology to be  
            used in California's schools.  A better definition of  
            scientifically valid would be evidence based.

            The Committee may wish to amend this bill to require CDE to  
            review the Guide for Vision Testing in California Schools,  
            which has not been updated since 2005, and make  
            recommendations for changes to the school vision screening  
            process, including, but not limited to, updating the  
            technology used in school vision screenings, if warranted by  








                                                                  AB 1840
                                                                  Page  7

            the best available evidence, and the training requirements for  
            individuals qualified to perform pupil vision screening.

           REGISTERED SUPPORT / OPPOSITION  :  

           Support 
           
          California Coverage & Health Initiatives
          Healthier Kids Foundation of Santa Clara County
          Prevent Blindness Northern California

           Opposition 
           
          American Academy of Pediatrics, California
          California School Nurses Organization
           

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