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