BILL ANALYSIS Ó
SB 430
Page 1
Date of Hearing: August 13, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 430 (Wright) - As Amended: August 5, 2013
SENATE VOTE : 38-0
SUBJECT : Pupil health: vision examination: binocular
function.
SUMMARY : 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.
Specifically, this bill :
1)Requires, upon first enrollment in a private or public
elementary school, including charter schools, and at least
every third year thereafter until the eighth grade, that a
pupil's vision be examined by a physician, optometrist, or
ophthalmologist.
2)Requires that the examination be consistent with the most
current standard, policy, or guideline adopted by the American
Academy of Pediatrics, the American Academy of Ophthalmology,
or the American Optometric Association.
3)Requires the examination to include tests for visual acuity,
binocular function and color vision, refraction, and eye
health evaluations.
4)Requires the parent or guardian of the pupil to provide the
results of the examination to the school.
5)Exempts from these requirements pupils whose parents or
guardian file a written statement with the school principal
that they adhere to the faith or teachings of any
well-recognized religious sect that depends upon prayer for
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healing in the practice of their religion.
6)Requires schools to refer students who are not eligible for
Medicaid, Children's Health Insurance program coverage, or
California Health Benefit Exchange (Exchange), now called
Covered California, subsidies under the federal Patient
Protection and Affordable Care Act (ACA), or any other health
care service to the county health department or other
appropriate community resources.
7)Provides that a school cannot deny admission to a child
because of a parent's or guardian's failure to obtain the
required eye examination.
8)Requires, if the results of the examination conducted pursuant
to 1) above, are not provided to the school, that the pupil's
vision be appraised by the school nurse or other authorized
person, and that this examination include tests for visual
acuity, color vision, gross external observation of the
pupil's eyes, visual performance, and perception.
9)Clarifies that a school district is not prohibited from
requiring or authorizing a school nurse or other authorized
person to evaluate a pupil's vision for visual acuity, color
vision, or binocular function.
10)Defines "binocular function examination" as, at a minimum,
the evaluation of accommodative ability, sensory and motor
fusion, and ocular motility.
11)Makes the provisions of this bill take effect on July 1,
2014.
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 appraisal referenced in 1) above to include tests
for visual acuity and color vision. Requires color vision to
be appraised once and only on male children in the first
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grade.
3)Permits the appraisal referenced in 1) above to be waived, if
the child's parents so desire, by presenting a certificate
from a physician and surgeon, 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 or guardian
when a visual defect has been noted as a result of the
appraisal referenced in 1) above. Requires the report, if
made in writing, to request the parent or guardian to take
action to correct the defect. Requires the report to be made
on a form prescribed or approved 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 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 Exchange, 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, this bill
makes sure that pupils in California schools are prepared for
the visual rigors of school because the visual system provides
80% of input to the brain. The author states that this bill
is necessary because vision screening using only the eye chart
at 20 feet, one eye at a time, is ineffective in identifying
children who have vision problems at reading distance (close
to their face, not at blackboard distance). It is also
necessary because vision screening at school cannot diagnose
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and provide recommendation for glasses (if needed) before
school. In addition, the author states that this bill is
necessary because it will compel parents to take advantage of
paid-for exams provided through the ACA and subsequent
California legislation for preventative eye care. Finally,
California needs a boost in its academic reputation. Getting
rid of eye-brain issues can make a difference by removing a
barrier to achievement.
The author's background materials reference several studies,
one, a National Institutes of Health study by Gemstone
Foundation found that in four schools (with a total of 997
students) in the Los Angeles Unified School District
(2009-12), 30% to 58% had binocular vision problems.
2)BACKGROUND . According to Covered California, the ACA requires
that all health plans offered in the individual and small
group markets must provide a comprehensive package of items
and services, known as EHBs. Among these benefits are
pediatric services, including dental and vision care. The
requirement for insurance plans to offer EHBs takes effect in
2014. However, this requirement only applies to small group
and individual plans, not to large employers (those with over
100 employees beginning in 2016).
According to the Department of Health Care Services,
California's Child Health and Disability Prevention (CHDP)
Program and Medi-Cal provide pediatric vision services to
eligible children. The Vision Screening guidelines in CHDP
Health Assessment guidelines were updated in 2002 to reference
American Academy of Pediatrics (AAP) policy.
According to the AAP, the American Association of Certified
Orthoptists, the American Association for Pediatric
Ophthalmology and Strabismus, and the American Academy of
Ophthalmology (AAO) policy statement on Eye Examination in
Infants, Children, and Young Adults by Pediatricians
(Pediatrics Vol. 111 No. 4 April 2003), early detection and
prompt treatment of ocular disorders in children is important
to avoid life-long visual impairment. It further states that
children should have an assessment for eye problems in the
newborn period and then at all subsequent routine health
supervision visits . The policy statement recommends that
"all children who are found to have an ocular abnormality or
who fail vision screening should be referred to a pediatric
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ophthalmologist or an eye care specialist appropriately
trained to treat pediatric patients."
The AAP Policy Statement on Learning Disabilities, Dyslexia,
and Vision states: vision problems can interfere with the
process of learning; however, vision problems are not the
cause of primary dyslexia or learning disabilities. Scientific
evidence does not support the efficacy of eye exercises,
behavioral vision therapy, or special tinted filters or lenses
for improving the long-term educational performance in these
complex pediatric neurocognitive conditions. Diagnostic and
treatment approaches that lack scientific evidence of
efficacy, including eye exercises, behavioral vision therapy,
or special tinted filters or lenses, are not endorsed and
should not be recommended.
The AAP Technical Review on Learning Disabilities, Dyslexia,
and Vision states: Binocular Vision, true
orthophoria-perfectly straight eyes-occurs rarely; most people
demonstrate a small asymptomatic phoria, a latent deviation,
usually esophoria or exophoria, which should be considered a
normal variant. A study of more than 3000 unselected students
revealed a near phoria in most children. Several studies have
investigated the connection between reading ability and the
binocular and accommodative status of unselected children. No
causal relationship was found between normal variants and
reading/writing difficulties. Manifest strabismus, known as
tropias (e.g. esotropia and exotropia), has also not been
associated with dyslexia.
According to eyeSmart, an informational Website maintained by
the AAO, upon entering school, or whenever a problem is
suspected, children's eyes should be screened for visual
acuity and alignment by a pediatrician, family doctor,
ophthalmologist, optometrist, orthoptist, or person trained in
vision assessment of school-aged children, such as a school
nurse. Nearsightedness (myopia) is the most common refractive
error in this age group and can be corrected with eyeglasses.
If an alignment problem or other eye health issue is
suspected, the child should have a comprehensive exam by an
"Eye M.D."
According to the American Heritage Stedman's Medical
Dictionary, binocular vision is the vision in which both eyes
are used synchronously to produce a single image. According
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to the College of Optometrists in Vision Development, the two
eyes work together as a binocular system and when two eyes
work together well, a person can easily and efficiently
measure the location of objects in relation to his/herself.
Binocular vision makes it easier to ride a bicycle, drive a
car, or direct many other daily activities.
This bill defines "binocular function examination" as, at a
minimum, the evaluation of accommodative ability, sensory and
motor fusion, and ocular motility. According to the
Dictionary of Optometry and Visual Science accommodative
ability is the ability of the eye/s to focus on stimuli at
various distances. The American Optometric Association (AOA)
Clinical Practice guidelines for Pediatric Eye and Vision
Examination define sensory fusion as the ability of the brain
to bring together two sensations with the end result of a
single percept. The pediatric guidelines do not include
definitions for sensory and motor fusion or ocular motility.
The AOA's guideline's for Comprehensive Adult Eye and Vision
Examination define ocular motility as clinically referring to
saccadic (extremely fast voluntary movement of the eyes) and
pursuit eye movements, including fixation maintenance, but not
vergences. Vergences are defined as disjunctive movements of
the eyes in which the visual axes move toward each other with
convergence or away from each other with divergence.
3)SUPPORT . The California Teachers Association (CTA) is the
sponsor of this bill and writes that studies from around the
country confirm that many students with poor or below grade
level reading skills suffer from low "eye-brain coordination"
and often have problems with coordinating their eyes, tracking
and scanning, or re-focusing their eyes rapidly. This
prevents readers from being able to finish reading a line
without stopping or skipping, significantly impairing their
reading and comprehension. CTA believes "healthy children
learn better and school health screenings help to ensure
children are ready to learn." If 1% of current students were
identified and treated, it would result in a greater number of
students succeeding in their educational pursuits. Failure to
identify a correctable condition results in low self-esteem
and minimum academic achievements. This bill could result in
a substantial number of students remaining in school thereby
reducing the number of school drop-outs, and reducing the
achievement gap.
The California Optometric Association writes in support of this
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bill that doctors of optometry are supportive of efforts to
ensure that California's children are healthy, including the
health of their eyes. The California Pan-Ethnic Health
Network (CPEHN) states in support that current vision testing
in schools is limited to using the eye chart for acuity one
eye at a time from 20 feet away. While this is important in
identifying children who may need glasses, it does not address
how well the two eyes work together while reading. Emerging
data show that reading speed and fluency are impacted by poor
eye coordination.
4)OPPOSITION . AAP, California strongly opposes this bill
because it would legislate the practice of medicine by taking
the decision of whether to refer a child to a subspecialist
for further eye examination out of the hands of the primary
care physician and the family. Instead, having the exam occur
in the child's medical home as part of a comprehensive
evaluation of the child's health allows concerns about vision
and the eyes to be understood in relation to the outcomes in
the exam. Such a comprehensive exam provides the basis for
determining the most informed and accurate diagnoses.
Further, if the pediatrician or other provider observes
findings that require one or more subspecialist's input
(whether for the eyes or other areas), he or she will make the
appropriate referral.
The California School Nurses Organization (CSNO) opposes this
bill because it deletes the school vision screening program in
existing law. School nurses already screen and refer students
for vision acuity problems regularly every three years, and
additionally whenever there is any concern about a pupil's
vision. Such additional school vision screening often
involves distance and near point acuity as well as functional
vision (including binocularity). The students who are
experiencing academic problems are the ones who are most often
additionally screened. If the current mandates in existing
law are removed, then all pupils will lose an important
opportunity to receive school nursing services and many pupils
may not receive any vision evaluation at all. Additionally,
mandating school vision screening only for those students who
have not received an outside vision test would create an
enormous administrative burden for schools.
Kaiser Permanente is opposed to this bill because their health
care providers indicate that the additional vision testing
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procedures it mandates will have very little clinical benefit
and could lead to false positives. It is unnecessary to do
refractions on children who have normal vision and normal
binocular function, which most do. Furthermore, because the
requirements of this bill go well beyond routine and
recommended vision care for children, such services may not be
covered benefits and could lead to out-of-pocket costs for
parents.
5)POLICY CONCERNS . The requirement that schools refer students
who are not eligible for Medicaid, Children's Health Insurance
Program coverage, or Exchange subsidies under the ACA, or any
other health care service to the county health department or
other appropriate community resources seems overly burdensome.
It is unclear how school administrators will know which
children are eligible for what programs. If this bill should
pass this Committee the author may want to consider amending
the bill to clarify that schools should refer students who are
not enrolled in one of the programs above.
Author's amendments, inserted into this bill on August 5, 2013,
require the eye examination in this bill, when performed by a
physician, optometrist, or ophthalmologist, to be consistent
with the most current standards adopted by the AAP, the AAO,
or the AOA and to include binocular function. If a pupil does
not receive that screening, the school will then be required
to screen the pupil for visual acuity and color vision only,
not for binocular function; therefore, children without
healthcare coverage may not necessarily receive binocular
screening.
As currently drafted, this bill presents several problems. It
appears overly broad in its attempt to mandate a specific type
of eye examination for every school aged child, even when
there is no indication it is medically necessary; it creates
additional administrative burdens on schools that will be
required to track which pupils have received the required
exams and which have not, potentially resulting in pupils
receiving duplicative, unnecessary eye examinations; it does
not actually achieve its goal of ensuring all pupils receive
the screening, and, finally, this bill appears to create a new
mandate on families for pediatric binocular vision screening.
The ACA only mandates no-cost coverage for preventive services
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that have a Grade A or B recommendation from the U.S.
Preventive Services Task Force (UPSTF). The vision screening
required in this bill does not meet these criteria and will
not be covered as a preventive service under the ACA.
6)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
access to treatment for California's diverse population? The
Legislature should also look to information from other
organizations, such as the UPSTF 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.
7)DOUBLE REFERRAL . This bill was heard in the Assembly
Education Committee on June 26, 2013, and passed with a 6-0
vote.
8)PREVIOUS LEGISLATION .
a) 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.
b) 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
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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.
c) 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.
d) AB 1453 (Monning), Chapter 854, Statutes of 2012,
established 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
EHBs, including, among other things, pediatric vision care.
REGISTERED SUPPORT / OPPOSITION :
Support
California Teachers Association (sponsor)
Support (previous version)
The Honorable Diane E. Watson, US Congress, Retired
The Honorable Richard J. Riordan, former Mayor, City of Los
Angeles
Advancement Project
California Academy of Preventive Medicine
California Federation of Teachers
California Optometric Association
California Pan-Ethnic Health Network
California State Board of Optometry
California State PTA
Compton Unified School District
Congress of Racial Equality of California
Disability Rights California
Los Angeles County Education Foundation
Los Angeles Tenth District PTA/PTSA
Small School Districts' Association
Willie L. Brown, Jr. Institute
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Three individuals
Opposition
American Academy of Pediatrics, California District IX
California Medical Association
California School Health Centers Association (previous version)
California School Nurses Organization
Kaiser Permanente
One individual
Analysis Prepared by : Lara Flynn / HEALTH / (916) 319-2097