BILL ANALYSIS �
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Date of Hearing: June 14, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AJR 13 (Lara) - As Introduced: June 2, 2011
SUBJECT : Graduate medical education.
SUMMARY : Urges the President and the Congress of the United
States to continue to provide resources to increase the supply
of physicians in California, in order to improve access to care,
particularly for Californians in rural areas and members of
underrepresented ethnic groups, and to consider solutions that
would increase the number of graduate medical education
residency positions to keep pace with the growing numbers of
medical school graduates, and the growing need for physicians in
California.
EXISTING LAW :
1) Provides for the development of a Health Manpower Plan for
California, and requires the Office of Statewide Health
Planning Development (OSHPD) to consult with the California
Healthcare Workforce Policy Commission, health systems
agencies, and other appropriate organizations in the
preparation of this plan.
2) Establishes legislative intent to maintain a Health
Professions Career Opportunity Program to increase the number
of ethnic minorities in health professional training and
practicing in medically underserved areas.
3) Establishes in OSHPD the California Medical and Dental Loan
Repayment Program of California, the Health Professions
Education Foundation and the California Physician Corp
Program, which operates the Steven M. Thompson Physician Corp
Loan Repayment Program.
4) Establishes in OSHPD a health care workforce clearinghouse
to serve as the central source of health care workforce and
educational data in the state.
5) Requires upon initial licensure and renewal physicians to
provide data to the Medical Board of California (MBC) on
specified information including practice status, cultural
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background, and foreign language proficiency. Provides
physicians a "decline to state" response to the cultural
background and foreign language proficiency questions.
Requires the MBC to aggregate the data and report on it
annually.
6) Enacts, in federal law, the Patient Protection and
Affordable Care Act (PPACA) to, among other things, make
statutory changes to expand access to health care coverage
for Americans including calling for health workforce needs
assessment and action plans, changing Medicare Graduate
Medical Education (GME) to expand training in primary and
ambulatory settings, and reauthorizing existing, and creating
new, scholarship and loan repayment programs.
FISCAL EFFECT : None
COMMENTS :
1)PURPOSE OF THIS RESOLUTION . According to the author, in 2010,
President Obama signed into law the PPACA in order to expand
health insurance coverage, reduce health care costs, and
address the growing shortage of physicians. PPACA aims to
specifically address shortages in primary care through
adjustments to the Medicare and Medicaid fee schedules,
re-allotment of unused GME slots, and a suite of grants,
scholarships, loans and loan forgiveness programs. The author
cites findings from multiple studies that suggest the supply
of physicians in California - especially in underserved areas
serving ethnic populations - is inadequate. The author has
introduced this resolution to urge the President and Congress
to increase the supply of physicians and the number of GME
residency positions in California.
2)MBC SURVEY RESULTS . Key findings published in March 2008,
from an analysis of survey responses from 61,861 physicians
who are active in patient care in California and no longer in
training include:
a) Latinos constitute one-third of the state's population
but only 5% of its physicians;
b) California has very few physicians of Samoan, Cambodian,
and Hmong/Laotian ethnicity, and these ethnic groups should
also be recognized as underrepresented in medicine and more
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actively recruited into the profession;
c) Minority physicians in California are much more likely
than white physicians to practice in Medically Underserved
Areas, Health Professions Shortage Areas, communities with
high proportions of minority populations, and low income
communities. This pattern is particularly true for the
traditionally underrepresented physician ethnic groups
(African Americans, Latinos, and Native Americans), but
also holds to a lesser degree for physicians from other
non-white ethnic groups;
d) Over 40% of minority physicians practice in generalist
primary care fields, compared with 30% of white physicians;
and,
e) Nearly one in five physicians in the state reports
fluency in Spanish, including many non-Latino physicians.
In contrast, fluency in Asian languages is largely limited
to physicians of Asian ethnicity.
3)PHYSICIAN SUPPLY . A June 2009 report published by the
California HealthCare Foundation (CHCF) based on the MBC
survey found that the supply of MD physicians estimated in
California is 17% lower than that estimated from the American
Medical Association (AMA) Data File. Of active patient care
physicians in California, 34% reported that they were in
primary care, 20% fewer than the number estimated from the AMA
data. Only 16 of California's 58 counties fall within the
needed supply estimate for primary care physicians, and in
eight counties the supply is less than half this range. The
number of specialists per 100,000 population is well above the
upper range of most assessments of need, and more than half of
the state's 58 counties are above the bottom estimated need
level for specialists. Rural counties have far fewer
physicians per capita than urban counties; counties in the
Central Valley and Inland Empire are particularly likely to
have a low supply of physicians, and also have higher
proportions of an aging physician primary care workforce.
A June 2010 CHCF report indicates that California's supply of
physicians has been growing faster than the overall population
rising 7% since 1998. However, demand is expected to rise as
the senior population grows, as more individuals obtain health
insurance because of the PPACA and at the same time many
current physicians are nearing retirement age. Only Orange,
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Sacramento, and Greater Bay Area regions currently meet the
recommended supply of primary care physicians. Nearly 30% of
physicians are over 60 years old - more than any other state.
California draws a substantial portion of physicians,
especially primary care physicians, from foreign and
out-of-state medical schools. Family and general practitioner
compensation has been rising but is only 88% of the national
average.
4)PPACA . California has received a $150,000 grant for health
workforce planning through the PPACA. The California
Workforce Investment Board (CWIB) and OSHPD have partnered to
create the Health Workforce Development Council to assess
California's health workforce needs and develop a
comprehensive strategy to meet those needs. California has
also been awarded over $18 million for primary care residency
expansion, $5 million for health professions education for
low-income persons, as well as other grant funding. This
funding was already appropriated in FY 2010. However,
residents enrolled in these programs are not guaranteed to
become primary care physicians and could go into
subspecialties after their family practice, general internal
medicine, and general pediatrics residencies. According to a
health professions expert, many later go on to become
cardiologists and rheumatologists.
Many of the grant funds for workforce in the PPACA have been
authorized, but not appropriated, and are vulnerable in the
budget discussions at the federal level. For example the 2011
Federal fiscal year budget did not contain funding for state
workforce development grants, primary care training
enhancements or state health access grants.
5)RELATED LEGISLATION .
a) AB 589 (Perea) establishes the Steven M. Thompson
Medical School Scholarship Program and account to receive
federal and private funding to promote the education of
medical doctors and doctors of osteopathy, as specified.
AB 589 is pending in the Senate.
b) SB 347 (Rubio) requires, to the extent permitted by
federal law, the Department of Health Care Services to
include in its capitation rates paid to managed health care
plans an amount sufficient for the plans to make GME
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payments to providers contracting with the managed health
care plans. SB 347 is still pending in the Senate Health
Committee.
6)SUPPORT . This resolution is sponsored by the California
Medical Association (CMA). The CMA indicates that this nation
is facing a crisis with regard to the physician workforce and
by 2020 there will be a shortage of 91,500 physicians. By
2025, the CMA says the shortage is projected to be 130,600.
By 2015, California will face a shortage of as many as 17,000
physicians, which does not take into account the expected
increase of 10% more insured in 2015 due to PPACA. CMA also
raises concerns about the high level of debt medical students
face, which is currently over $150,000 and approaching
$750,000 by 2033 if current rates continue. CMA believes this
contributes to student choices of more lucrative specialties
over primary care. CMA also expresses concerns about the
"bottleneck" in U.S. physician training at the residency
stage. CMA indicates that California has only 8.3% of the
country's medical residents. In 2008, California had 9,200
medical residents, significantly below the national average.
The Latino Coalition for a Health California (LCHC) writes
that primary care physicians represent the access point for
many into the health care system but fundamental shortages of
Latino primary care physicians work against increasing access.
Diversity in the healthcare workforce is essential to meet
the needs of patients, and physicians must be able to
effectively communicate in the language of their patients.
LCHC supports the need for more resources in California to
increase the supply of physicians so that they better
represent the populations they serve.
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Association (sponsor)
Latino Coalition for a Healthy California
Opposition
None on file.
Analysis Prepared by : Teri Boughton / HEALTH / (916) 319-2097
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