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SB 320

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SENATE THIRD READING
SB 320 (Leyva)
As Amended August 20, 2018
Majority vote

SENATE VOTE: 25-13

Committee Votes Ayes Noes
Health 10-4 Wood, Aguiar-Curry, Bonta, Mayes, Bigelow, Flora,
Carrillo, Limón, McCarty, Waldron
Nazarian, Rodriguez, Santiago,
Thurmond
Higher Education 8-3 Medina, Baker, Arambula, Chávez, Kiley, Patterson
Bloom, Irwin, Levine, Low,
Weber
Appropriations 12-5 Gonzalez Fletcher, Bloom, Bigelow, Brough, Fong,
Bonta, Calderon, Carrillo, Gallagher, Obernolte
Chau, Eggman, Friedman,
Eduardo Garcia, Nazarian,
Quirk, Reyes

SUMMARY: Requires public university student health centers (SHCs), as defined, by January
1, 2022, to offer medication abortion services. Specifically, this bill:

1) Defines the following, for the purposes of this bill:

a) "Commission" as the Commission on the Status of Women and Girls;

b) "Fund" as the College Student Health Center Sexual and Reproductive Health
Preparation Fund;

c) "Grantee" as any qualifying SHC at a public college or university;

d) "Medication abortion readiness" includes, but is not limited to, assessment of each
individual clinic to determine facility and training needs before beginning to provide
abortion by medication techniques, purchasing equipment, making facility improvements,
establishing clinical protocols, creating patient educational materials, and training staff.
Excludes the provision of abortion by medication techniques from this definition; and,
e) "Public university student health center" as a clinic providing primary health care
services to students that is located on the campus of a university within the University of
California (UC) or California State University (CSU) systems.

2) Requires the Commission to administer the Fund, which is continuously appropriated, for the
purposes of providing private moneys in the form of grants to on-campus student health
centers at public and private colleges and universities for medication abortion readiness.
Authorizes the Commission to receive moneys from nonstate entities, including but not
limited to private sector entities and local and federal governme nt agencies.

3) Requires the Commission to utilize fund moneys to do all of the following:
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a) Provide a grant of $200,000 to each public university student health center to pay for the
cost, both direct and indirect, of medication abortion readiness. Allows expenses under
the grants to include, but not be limited to, all of the following:

i) Purchase of equipment used in the provision of abortion by medication techniques;

ii) Facility and security upgrades;

iii) Costs associated with enabling the campus health center to deliver telehealth services;

iv) Costs associated with training staff in the provision of abortion by medication
techniques; and,

v) Staff cost reimbursement and clinical revenue offset while staff are in trainings.

b) Provide a grant of $200,000 to both the UC and CSU to pay for the cost, both direct and
indirect, of the following, for each university system:

i) Providing 24-hour, backup medical support by telephone to patients who have
obtained abortion by medication techniques at a public university student health
center;

ii) One-time fees associated with establishing a corporate account to provide telehealth
services; and,

iii) Billing specialist consultation.

c) Paying itself for the costs, both direct and indirect, associated with administration of the
fund, including the costs of hiring staff, not to exceed $2.4 million; and,

d) Maintaining a system of financial reporting on all aspects of the Fund.

4) Requires each grantee to, as a condition of receiving a grant award from the Fund, participate
in an evaluation of its medication abortion readiness and its provision of abortion by
medication techniques.

5) Specifies that implementation of this bill is contingent upon a total of at least $9.6 million in
private funds being made available to the Fund in a timely manner on or after January 1,
2019, and that nothing in this bill is to be interpreted as requiring a public university to utilize
General Fund moneys or student fees for medication abortion readiness before January 1,
2022.

6) Requires the Commission, working with the SHCs, to assist and advise the public university
SHCs on potential pathways for their SHCs to access public and private payers to provide
funding for ongoing costs of providing medication abortions.

7) Requires the Commission to report to the Legislature, on or before December 31, 2020, and
every year thereafter until January 1, 2026, which includes, but is not limited to, all of the
following:
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a) The number of public university student health centers that have begun providing
abortion by medication techniques;

b) The total cost and source of the funds for implementing and providing abortion by
medication techniques performed at each student health center; and,

c) The number of abortions by medication technique performed at each student health
center.

8) Requires the report required pursuant to 7), above, to be conducted in accordance with state
and federal privacy laws.

9) Makes various findings and declarations regarding current law recognizing abortion as a
basic health service, the Legislatures intent that public university SHCs make medication
abortions as accessible and cost-effective for students as possible, and that the National
Academies of Sciences, Engineering, and Medicine have found that prescribing abortion by
medication techniques is no different from prescribing other medications.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1) One-time costs totaling millions of dollars systemwide. UC estimates that in addition to private
funding, it may require additional one-time General Fund (GF) or student fees to cover start-up
costs.

2) Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide,
depending on various factors.

3) One-time costs totaling in the millions of dollars systemwide. CSU indicates private funding
likely would cover the start-up costs on most campuses, but certain variables are unknown and
could drive up costs at some SHCs.

4) Ongoing GF or student fee cost pressures totaling as high as millions of dollars systemwide,
depending on various factors.

5) Potential though likely low state costs to increase Medi-Cal reimbursements.

COMMENTS: According to the author, California public institutions of higher education strive to
offer comprehensive reproductive health care for students in on-campus SHCs, however, currently
none of the SHCs at California's public institutions of higher education provide medication abortion
services, despite how clinically simple the service is to offer. The author states that medication
abortion is safer and less complicated than much of the care already offered at college health centers,
including diabetes management, mental health care, or diagnosis/treatment of sexually transmitted
infections. It is important that college students have access to safe and reliable comprehensive
reproductive health care on campus which should include early pregnancy termination. The author
concludes that if a public institution of higher education already has a SHC, it makes sense that they
provide this health care service within that facility so that students do not have to travel many miles
away from their work and school commitments in order to receive care.

The United States (U.S.) Supreme Court recognized a woman's constitutional right to abortion in
1973 in Roe v. Wade, and subsequent decisions have reaffirmed that right. Despite this
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constitutional protection, access to abortion in the U.S. is becoming more limited. According to
the Guttmacher Institute, the number of abortion-providing facilities declined 3% between 2011
and 2014 (from 1,720 to 1,671). Ninety percent of all U.S. counties lacked a clinic in 2014, and
39% of women of reproductive age lived in those counties. In 2014, 43% of California counties
had no clinics that provided abortions, and 5% of California women lived in those counties.
According to U.S. census data there are almost 4 million women of childbearing age (15 to 44
years of age) in California.

1) Abortion. According to the Guttmacher Institute, more than half of all U.S. abortion patients
in 2014 were in their 20s: patients aged 20 to 24 obtained 34% of all abortions, and patients
aged 25 to 29 obtained 27% of all abortions. White patients accounted for 39% of abortion
procedures in 2014, African Americans for 28%, Hispanics for 25%, and patients of other
races and ethnicities for 9%. Seventy-five percent of abortion patients in 2014 were poor or
low-income and 17% traveled more than 50 miles to obtain an abortion. The three most
common reasons for getting an abortion, cited by three-fourths of patients were: concern for
or responsibility to other individuals; the inability to afford raising a child; and, the belief that
having a baby would interfere with work, school, or the ability to care for dependents. Fifty-
one percent of abortion patients in 2014 were using contraception in the month they became
pregnant.

2) Medication abortion. The U.S. Food and Drug Administration approved the use of
mifepristone for early nonsurgical, or medication, abortion in 2000. Medication abortion is
the termination of a pregnancy until 10 weeks' gestation using a combination of two
medications, mifepristone and misoprostol. The first medication starts the process and the
second medication is used in the privacy of the person's home to start bleeding, which is
similar to a heavy menstrual period. The same combination of medications is also used in
the management of early miscarriage and gives people the option to pass failed pregnancies
at home. Medication abortions accounted for 31% of all nonhospital abortions in 2014, and
for 45% of abortions before nine weeks' gestation.

3) SHCs. No SHCs currently provide medication abortion. The UC system has SHCs at all 10
campuses as well as Hastings School of Law. All 11 have a physician on staff. UC Hastings
SHC operates nine months a year and for three months physician services are not available.
All UC SHCs have a 24 hour advice nurse line. The CSU system has SHCs on all 23
campuses; each campus has a least one physician on staff and at least one nurse practitioner
and/or physician assistant. About half of CSU SHCs have after-hour nurse advice lines.
CSU students are eligible for health services provided at any CSU campus. All SHCs refer
off-campus for abortion care and most refer for ultrasound (one UC provides on-site
ultrasound) and miscarriage management (three UCs provide on-site miscarriage
management.)

4) Student Healthcare Coverage. UC requires students to have adequate health insurance, the
minimum essential coverage under the federal Patient Protection and Affordable Care Act,
which covers abortion services as part of maternity care. The UC Student Health Insurance
Plan (SHIP) provides medical, pharmacy, dental and vision benefits, as well as mental health
and substance use disorder services. Students who already have adequate health insurance
may apply to waive enrollment in SHIP. Student fees fund SHIP. The 2017-18 student
health premiums range from $2,517.29 to $4,773.29 for graduate students and from
$1,757.75 to $3,324.00 for undergraduate students (depending on campus and other factors.)
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5) CSU does not require students to be insured and no plan is offered through the university.
CSU SHCs are funded entirely through student fees, which are mandatory for all enrolled
students and vary across campuses, with an average cost of $269 per student per year.

6) UC San Francisco School of Medicine, Advancing New Standards in Reproductive
Health (ANSIRH) Issue Briefs. The sponsors of this bill facilitated the completion of two
surveys, conducted by ANSIRH. Surveys were completed by all 11 UC campuses and by 20 of
the 23 CSU campuses. The results of the surveys were compiled into two reports: "Evaluating
University of California and California State University Capacity to Provide Medication
Abortion" and "Assessing Barriers to Medication Abortion Among California's Public University
Students." The reports made the following findings and conclusions:

a) Student access to abortion. "Assessing Barriers to Medication Abortion Among
California's Public University Students," states there are several barriers to students in
obtaining an abortion. Over half (51%) of students are low-income, with 42% of UC
students and 21% of CSU students experiencing food insecurity. Two-thirds of UC
students and one-third of the CSU student body do not have a car, and 62% of the UC
and CSU student body are more than 30 minutes away from the closest abortion provider
via public transportation. ANSIRH contends, for these students, the multiple visits for a
medication abortion requires a minimum of two hours travel by public transportation.
The brief also notes that only 15% of providers closest to university campuses are open
on weekends, students may have to wait an average of a week for the next available
appointment, and ultimately, the delay can make a student ineligible for medication
abortion.

b) SHC capacity to provide medication abortion. "Evaluating University of California
and California State University Capacity to Provide Medication Abortion," notes that in
California any physician or advanced practice clinician trained to do so may provide
medication abortion. The provider must be able to assess the pregnancy duration,
diagnose ectopic pregnancy, and, provide surgical intervention if needed, either
personally or by referral. Required facilities and equipment needed include a private
room for pelvic exams (not required for all medication abortions) and counseling,
ultrasound capability for pregnancy dating and to rule out ectopic pregnancy, on-site
laboratory for urine pregnancy testing, hemoglobin, and Rh Status (or the ability to refer
to a lab), and a 24-hour telephone hotline staffed by clinicians to answer questions and
refer as needed to emergency care. The chart below provides an assessment of SHC
capacity for implementing medication abortion services given current resources:

UCs CSUs
SHC Capacity
(n=11) (n=20)
Require modification of physical space for patient care
0 0
(to have private exam room)
Require licensed physician or clinician on site
0 0
(physician or clinician currently never on site)
Require training in medication abortion
11 20
(including ultrasound training)
Require training in drawing blood and/or on-site lab testing
1 4
(currently unable to perform necessary lab tests on site and
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unable to draw blood to send to outside lab)
Require ultrasound machine 7 18
Require 24-hour nurse telephone line 0 9
Need to develop relationships with community physicians
to provide aspiration services in case of incomplete abortion 11 20
and ongoing pregnancy

As the chart illustrates, while all of the SHCs have the minimum requirements for
medication abortion provision: a private exam room, ability to do pregnancy testing and
counseling, and clinicians who are licensed in the state of California, none of them are
fully equipped to provide medication abortions. All SHCs would need training; even
though a few sites have a clinician trained in abortion care, they are not currently
providing care. Most CSU SHCs would also need an ultrasound machine and nurse
hotline.

7) Concerns. Neither the UC or CSU system has taken a position on this bill; however, the
ANSIRH surveys identified some of their concerns. SHCs are concerned with the need for
follow-up care and back-up care for emergencies, and how medication abortion will continue
to be funded once the grant money is expended. UC SHCs are also concerned about security
issues that may arise if they begin providing abortions on campus, and CSUs are concerned
that, given the infrequency of its use, staff may not be able to maintain the skill necessary to
use an ultrasound machine to accurately determine whether the medication can be
administered safely.

8) Estimated need for medication abortions among college students. According to the
Centers for Disease Control and Prevention in 2014, 652,639 legal induced abortions were
reported from 49 reporting areas. The abortion rate for 2014 was 12.1 abortions per 1,000
women aged 15 to 44 years. Women in their twenties accounted for the majority of abortions
in 2014 and the majority took place early in gestation: 91.5% of abortions were performed at
≤13 weeks' gestation; a smaller number of abortions (7.2%) were performed at 14–20 weeks'
gestation, and even fewer (1.3%) were performed at ≥21 weeks' gestation. In 2014, 22.6% of
all abortions were early medical abortions. The percentage of abortions reported as early
medical abortions increased 110% from 2005 to 2014, with a 1% increase from 2013 to
2014. ANSIRH estimates, based on age- and state-adjusted abortion rates (California's
abortion rate is 34% higher than the national rate) and a range of rates for medication
abortion as a preferred abortion type, that there would be between 322 to 519 medication
abortions each month across the UC and CSU campuses if SHCs offered medication
abortion.

California Latinas for Reproductive Justice (CLRJ) is a co-sponsor of this bill and states that
while Latinas represent over a third of the state's female population, they represent 12% of all
women (25 or older) to complete a Bachelor's degree or higher in California, they are twice as
likely as white women to report having no usual source of care, and to report delaying or
foregoing needed medical care. CLRJ notes that all students who may become pregnant
attending California higher education institutions will benefit from this bill because it will help
foster a supportive environment where students can concentrate on their studies; have truly
comprehensive healthcare; and, avoid the added financial, logistical, and emotional burden of
seeking necessary reproductive healthcare off campus. The American Civil Liberties Union
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(ACLU) supports this bill and states that no public universities in California currently provide
medication abortion services on-campus, and notes that students seeking this basic health care
must travel off-campus; a serious logistical and financial barrier for a first-generation student,
low-income student, or those struggling with debt and rising tuition costs.

The California Catholic Conference, Inc., opposes this bill and states that the bill blatantly
discriminates against students and health care providers who do not support abortion and hold a
pro-life point of view, and that by turning college campuses into a one-stop shop that offers
abortions on-demand without connection to appropriate medical care, this bill discriminates
against women by limiting the information and assistance that they need and deserve. The
Capitol Resource Institute (CRI) is opposed to this bill and states that mandating that abortion by
medication be available at all public universities will cut down the effort, and therefore the
thought, behind making a decision to get an abortion. CRI concludes a student might make a
hasty decision which she later regrets simply because of the availability of an abortion.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004186