BILL ANALYSIS �
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
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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
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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.
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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
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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
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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
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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