BILL ANALYSIS Ó AB 376 Page 1 Date of Hearing: April 14, 2015 ASSEMBLY COMMITTEE ON HUMAN SERVICES Kansen Chu, Chair AB 376 (Lopez) - As Amended April 6, 2015 SUBJECT: CalWORKs eligibility: immunizations SUMMARY: Requires counties to access an internet-based computerized information system to verify, when possible, immunization of children under the age of 6 in CalWORKs families. Specifically, this bill: 1)Requires county welfare departments to first search the California Immunization Registry and find no records of immunization prior to requesting applicants for or recipients of CalWORKs to submit vaccination documentation for children not required to be enrolled in school. 2)Stipulates that no continuous appropriation shall be made from AB 376 Page 2 the General Fund to counties in order to implement this act. EXISTING LAW: 1)Establishes in federal law the Temporary Assistance for Needy Families (TANF) program, which provides block grants to states to develop and implement their own state welfare-to-work programs designed to provide cash assistance and other supports and services to low-income families. (42 USC § 601 et seq.) 2)Establishes the state's TANF program, the California Work Opportunity and Responsibility to Kids (CalWORKs) program. CalWORKs provides cash assistance and other supports and services to low-income families and is administered by the counties. (WIC 11200 et seq.) 3)Requires CalWORKs applicants and recipients to provide documentation showing that all children in the assistance unit who are not required to be enrolled in school have received all age appropriate immunizations within 30 to 45 days, as specified. Provides exemptions in cases where it has been determined that immunizations are not medically appropriate, or when an affidavit attesting that immunizations are contrary to the applicant's or recipient's beliefs has been filed with the county welfare department. (WIC 11265.8) 4)Prohibits an aid payment for any adult in the assistance unit if required documentation of immunization is not provided within the specified time period. (WIC 11265.8) 5)Directs the Department of Public Health, in consultation with the Department of Education, to adopt and enforce regulations AB 376 Page 3 to carry out the stated legislative intent to fully immunize appropriate age groups against certain childhood diseases, including diphtheria, measles, mumps, and others, as specified. Allows for certain medical and personal-belief exemptions to immunization requirements, provided documentation is supplied, as specified. (HSC 120325 et seq.) 6)Allows local health officers to, either separately or jointly with other jurisdictions and in conjunction with the Department of Public Health's Immunization Branch, operate immunization information systems containing individuals' vaccination information. Further allows the information in these systems to be shared with specified entities, including with county welfare departments for the purpose of assessing the immunization histories of dependents of CalWORKs participants. States that individuals have the right to refuse the sharing of their information in these systems, and requires that individuals be informed of this right. (HSC 120440) FISCAL EFFECT: Unknown COMMENTS: CalWORKs immunization requirements: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (P.L. 104-193) was the federal law adopting the "welfare reform" of the late 1990s. It created the federal TANF program, which offers block grants to states to design their own welfare programs, provided they meet certain requirements, including establishing work requirements and placing a lifetime limit of five years on receipt of benefits. One of the many provisions contained in PRWORA permits states to create "individual responsibility plans" for participants that may, among other things, require individuals to immunize their children. AB 376 Page 4 Twenty-four states including California require TANF participants to submit documentation of immunization for young children (data as of July 2013). AB 1542 (Ducheny), Chapter 270, Statutes of 1997, created the CalWORKs program as California's implementation of federal welfare reform. Alongside many other changes, this bill added Section 11265.8 to the Welfare and Institutions Code, requiring that all applicants for and recipients of CalWORKs benefits provide documentation that any children in the assistance unit under the age of 6 not required to be enrolled in school have received all age-appropriate immunizations. Applicants and recipients who file an affidavit with the county stating that immunizations are against their beliefs, or who supply documentation stating that it has been medically determined that immunizations are inappropriate, are exempt from this requirement. Applicants and recipients are to be notified of their obligation to provide proof of immunization, and must also receive information on: the relevant childhood immunization schedules, how to obtain immunizations using Medi-Cal or through a county public health clinic or other available sources, as appropriate, and a statement explaining the personal belief exemption. Parents and caretaker relatives are allowed either 30 or 45 days, depending on their individual situations, to supply documentation of immunization; an additional 30 days may be granted if the county finds that good cause exists for not submitting verification in the timeframe allowed. If documentation is not provided within the required time period, a parent's or caretaker relative's needs will not be considered in determining the grant amount for the assistance unit until the required documentation is supplied. For the past three years, the numbers of adults penalized for not providing timely verification of immunization have been: 99,361 (2014), 83,759 (2013), and 109,238 (2012). AB 376 Page 5 California Immunization Registry: All 50 states have immunization registries. The California Immunization Registry (CAIR) is a secure and confidential statewide computerized information system consisting of nine separate regional registries. These regions, most of which are multi-county, cover 57 of California's 58 counties; Imperial County operates its own registry that is not part of the CAIR system. Seven of the nine CAIR regions currently use the same software, while San Diego County and the greater San Joaquin Valley use different software. The current regional structure of CAIR only enables authorized users to access immunization data within their defined region; however, look-up access to other regional registries is available to state or county governmental agencies upon request. It is expected that CAIR will eventually allow any CAIR user to access immunization data across the state by integrating its regional databases. This effort, the "CAIR 2.0 Project," is currently underway and integration is expected to be completed by the summer of 2017. Use of CAIR is voluntary. Health care providers are allowed to enter immunization records into a registry, provided the individual or the individual's parent has been notified about the registry and the right to "lock" his or her (or his or her child's) information in CAIR so that no users other than his or her health care provider may access them. Users must sign a confidentiality agreement to access CAIR; a user ID and password are needed to log in to the registry. Authorized users include health care providers and plans, schools, county welfare departments, foster care agencies, family child care homes and child care facilities. Counties were recently polled on their use of CAIR; of the 23 counties that responded, nine currently use it to some extent, but it appears that most seek verification from the client before logging into the system. AB 376 Page 6 Almost 2.9 million children under the age of 6 (96.7% of the total age-group population in the state) have immunization records contained in CAIR, with almost 1.9 million children under the age of 6 (63.5% of the total age-group population) having at least two immunization doses recorded. Need for the bill: According to the author, "this bill will help streamline and simplify an administrative process, which will help families access the supports they need by using current technology to verify immunization records. Currently, CalWORKs requires an applicant or recipient to immunize their minor children and provide proof of immunization. For our most vulnerable populations, this extra step in the process to receive benefits can add to an already stressful situation. This bill would require that the county first review the California State registry of immunizations, which is maintained by the Department of Public Health before asking the family to provide the records. If the registry indicates that the children have not met the immunization requirements, then the county can request verification of immunization." Staff comments: Locating or obtaining immunization documentation, and providing this information to the county, can create an additional set of barriers for families who already face numerous obstacles to securing services and supports as they work to move out of poverty. Using CAIR to verify children's immunization histories before requiring families to locate or obtain related documentation will assist in the AB 376 Page 7 navigation of the CalWORKs eligibility and redetermination process and, ultimately, reduce the number of families facing reduced grant amounts resulting from tardy submission of verification. However, beyond facilitating access to documentation, more could be done to facilitate access to the immunizations themselves. Poverty can be correlated with limited access to a regular source of affordable health care, contributing to reduced access to age-appropriate vaccinations. National data for 2013 from Centers for Disease Control indicate that, for children 19 to 35 months old, 71% living in families with incomes below the poverty level had received specified vaccinations, compared to 80% of those living in families with incomes above the poverty line. Options exist for counties to help families access immunization services, such as requiring counties to provide information on local free vaccination clinics prior to penalizing the family by reducing their grant amount. One example of facilitated access exists in Virginia: there, sanctions may not be imposed on families until the reason for failing to comply with the immunization requirement has been identified and any barriers to accessing immunizations have been removed (45 Code of Virginia 63.2-603). Should this bill move forward, the author may wish to include provisions that further assist CalWORKs applicants and recipients in obtaining necessary vaccinations for their children. Recommended amendments: AB 376 Page 8 1)In order to make clear that parents and caretaker relatives are able to secure a personal-belief exemption at any point prior to immunization documentation being due, committee staff recommends the following amendments to paragraph (a)(2), beginning on page 2 of the bill: 11 (2)If an applicant or recipient has not filed an affidavit has not12been filed with the county welfare department, theThe county shall 13 verify on behalf of any applicant or recipient required to provide 14 documentation thatthe immunizations have been performedeach 15 child in the assistance unit not required to be enrolled in school 16 has received all age-appropriate immunizations by obtaining a 17 report from the California Immunization Registry established 18 pursuant to Section 120440 of the Health and Safety Code. If the 19 registry does not contain records of these immunizations, the 20 county shall require the applicant or recipient to provide 21 documentation that the immunizations have been performed, or22are not medically appropriate,, unless the applicant or recipient has filed an affidavit that the immunizations are contrary to his or her beliefs or supplied documentation that it has beenmediciallymedically 23 determined that an immunization is not appropriate within 30 days 24 of the determination of eligibility for Medi-Cal benefits under AB 376 Page 9 1 Chapter 7 (commencing with Section 14000), or 45 days for 2 applicants already eligible for benefits under Chapter 7 3 (commencing with Section 14000), or within 45 days of a full or 4 financial redetermination of eligibility for aid under this chapter. 2)Additionally, in order to ensure that DSS and the counties have ample time for proper implementation, committee staff further recommends that the bill become effective on July 1, 2016. REGISTERED SUPPORT / OPPOSITION: Support Coalition of California Welfare Rights Organizations, Inc. - sponsor California Alternative Payment Program Association (CAPPA) California Immigrant Policy Center San Diego Hunger Coalition Western Center on Law and Poverty AB 376 Page 10 Opposition None on file. Analysis Prepared by:Daphne Hunt / HUM. S. / (916) 319-2089