BILL ANALYSIS                                                                                                                                                                                                    

                                                                     AB 376

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          Date of Hearing:   April 14, 2015


                                  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  

          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  


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            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  


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            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  

          FISCAL EFFECT:  Unknown


          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. 


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          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). 


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          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. 


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          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  


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          navigation of the CalWORKs eligibility and redetermination  
          process and, ultimately, reduce the number of families facing  
          reduced grant amounts resulting from tardy submission of  

          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:  


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          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 not  
          12     been filed with the county welfare department, the  The  
          county shall
          13    verify on behalf of any applicant or recipient required to  
          14    documentation  that  the immunizations have been performed   
          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  
          18    pursuant to Section 120440 of the Health and Safety Code.  
          If the
          19    registry does not contain records of these immunizations,  
          20    county shall require the applicant or recipient to provide
          21    documentation that the immunizations have been performed  ,  
          22     are 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 been  medicially   medically
          23    determined that an immunization is not appropriate within  
          30 days
          24    of the determination of eligibility for Medi-Cal benefits  


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          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  
          4 financial redetermination of eligibility for aid under this  

          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,  


          Coalition of California Welfare Rights Organizations, Inc. -  

          California Alternative Payment Program Association (CAPPA)

          California Immigrant Policy Center

          San Diego Hunger Coalition 

          Western Center on Law and Poverty 


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          None on file.

          Analysis Prepared by:Daphne Hunt / HUM. S. / (916) 319-2089