BILL ANALYSIS                                                                                                                                                                                                    Ó







         ----------------------------------------------------------------------- 
        |Hearing Date:July 1, 2013          |Bill No:AB                         |
        |                                   |496                                |
         ----------------------------------------------------------------------- 


                      SENATE COMMITTEE ON BUSINESS, PROFESSIONS 
                               AND ECONOMIC DEVELOPMENT
                              Senator Ted W. Lieu, Chair
                                           

                          Bill No:        AB 496Author:Gordon
                        As Amended: June 25, 2013  Fiscal: Yes

        
        SUBJECT:  Medicine:  sexual orientation, gender identity, and gender  
        expression. 
        
        SUMMARY:  Reauthorizes the Task Force on Culturally and Linguistically  
        Competent Physicians and Dentists (Task Force) to advocate for and  
        provide health services to members of language and ethnic minority  
        groups and lesbian, gay, bisexual, transgender and intersex groups.   
        Redefines "cultural and linguistic competency."  Requires that the  
        Task Force report its findings to the Legislature by January 1, 2016.   
        Further requires that training programs for health professionals be  
        formulated in collaboration with medical societies.

        Existing law:
        
        1)Establishes the Office of Health Equity (OHE) within the Department  
          of Public Health to achieve the highest level of physical and mental  
          health for all people, with a focus on socioeconomically  
          disadvantaged populations, including vulnerable and isolated  
          communities.  The OHE seeks to eliminate physical and mental health  
          disparities and inequities and incorporates the functions and  
          missions of the Office of Multicultural Services.  (Health and  
          Safety Code § 152)

        2)Establishes the Medical Board of California (MBC) to regulate  
          physicians and surgeons.  Establishes continuing education (CE)  
          standards for physicians and surgeons.  (Business and Professions  
          Code (BPC) § 2000 et seq.)

        3)Requires that on and after July 1, 2006, all medical CE courses  
          shall contain curricula that include cultural and linguistic  





                                                                         AB 496
                                                                         Page 2



          competency in the practice of medicine. (BPC § 2190.1) 

        4)Establishes the Dental Board of California (DBC) to regulate the  
          practice of dentistry. (BPC § 1600 et seq.)

        5)Establishes the Task Force which was required report its findings to  
          the Legislature on the following topics in 2003:  (BPC § 822)

           a)   Recommendations for a continuing education program that  
             includes foreign language proficiency standards to be acquired to  
             meet linguistic competency;

           b)   Key cultural elements necessary to meet cultural competency by  
             physicians, dentists, and their offices; and,

           c)   The need for voluntary certification standards and  
             examinations for cultural and linguistic competency.

        6)Defines "cultural and linguistic competency" to mean cultural and  
          linguistic abilities that can be incorporated into therapeutic and  
          medical evaluation and treatment, including, but not limited to, the  
          following:  (BPC § 2198.1)

           a)   Direct communication in the patient-client primary language;

           b)   Understanding and applying the roles that culture, ethnicity,  
             and race play in diagnosis, treatment, and clinical care; and,

           c)   Awareness of how the attitudes, values, and beliefs of health  
             care providers, patients, and society influence and impact  
             professional and patient relations.

        7)Establishes the Cultural and Linguistic Physician Competency Program  
          (Program), which is a voluntary program operated by local medical  
          societies of the CMA, with the primary objective of teaching  
          physicians the following:  (BPC § 2198)

           a)   A foreign language at the level of proficiency that initially  
             improves their ability to communicate with non-English speaking  
             patients;

           b)   A foreign language at the level of proficiency that eventually  
             enables direct communication with the non-English speaking  
             patients; and,

           c)   Cultural beliefs and practices that may impact patient health  





                                                                         AB 496
                                                                         Page 3



             care practices and allow physicians to incorporate this knowledge  
             in the diagnosis and treatment of patients who are not from the  
             predominate culture in California.

        This bill:

        1) Reestablishes the Task Force.

        2) Specifies that the Deputy Director of the OHE or his or her  
           designee and the Director of Consumer Affairs or his or her  
           designee shall serve as co-chairs of the Task Force.

        3) Also authorizes additional members to the Task Force including:  1)  
           the Executive Director of the Medical Board of California or his or  
           her designee, 2) the Executive Director of the Dental Board or his  
           or her designee, 3) a member appointed by the Senate Committee on  
           Rules and 4) a member appointed by the Speaker of the Assembly. 

        4) Permits the Director of the Department of Consumer Affairs (DCA) or  
           his or her designee in consultation with the OHE to appoint  
           additional members to the Task Force.

        5) Requires the Task Force to hold hearings and convene meetings to  
           obtain input from persons belonging to LGBT and intersex groups in  
           communities that have large populations of LGBT and intersex  
           groups.

        6) Requires the Task Force to report its findings to the Legislature  
           and appropriate licensing boards by January 1, 2016.

        7) Establishes the Program and specifies that it shall be operated by  
           local medical societies of the CMA and monitored by the MBC.

        8) Requires the Program to address the ethnic language minority groups  
           as well as LGBT and intersex groups of interest to local medical  
           societies.

        9) Requires the Program to include direct input from physician groups  
           in Mexico.

        10)Requires training programs to be formulated in collaboration with  
           LGBT and intersex medical societies, among others and specifies the  
           accreditation standards as well as the competency standards for  
           participants.

        11)Specifies the MBC shall convene a workgroup including, but not  





                                                                         AB 496
                                                                         Page 4



           limited to, representatives of affected patient populations,  
           medical societies engaged in program delivery and community clinics  
           to perform a series of participant evaluations. 

        12)Indicates that funding shall be provided by fees charged to  
           physicians who elect to take these educational classes and any  
           other funds that local medical societies may secure for this  
           purpose.

        13)Indicates that local medical societies shall develop a survey which  
           measures the degree of satisfaction with physicians who have taken  
           the educational classes on cultural and linguistic competency and  
           distribute the survey to:

                a)        Language minority patients.

         b) Lesbian gay, bisexual, transgender and intersex patients.

        14)Specifies that local medical societies shall also develop an  
           evaluation survey for physicians to assess the quality of education  
           or training programs on cultural and linguistic competence.

        15)Requires that the information required by these surveys shall be  
           shared with the workgroup established by the MBC.

        16)Amends the definition of "cultural and linguistic competency" to  
           include:

           a)   Understanding and applying the roles that race, sexual  
             orientation, gender identity, and gender expression play in  
             diagnosis, treatment and clinical care;

           b)   Awareness of how attitudes, values and beliefs of society  
             influence and impact professional and patient relations; and,

           c)   Developing behaviors that increase a patient's satisfaction  
             with, and trust in, his or her physicians and health care  
             institutions.


        FISCAL EFFECT:  According to the Assembly Appropriations Committee  
        analysis dated May 1, 2013, the fiscal effect is $110,000 annually for  
        two years.  Approximately half of the costs would come from the  
        Medical Board and half from the Dental Board. 

        COMMENTS:





                                                                         AB 496
                                                                         Page 5



        
       1.Purpose.  This bill is sponsored by  Equality California  .  According  
          to the sponsor, "Lack of provider understanding is a major barrier  
          to adequate healthcare for LGBT people.  LGBT patients often  
          experience inequities in treatment because their doctors or dentists  
          have not received training in cultural competency on LGBT issues,  
          and therefore do not understand the specific needs of or the health  
          disparities impacting the community.  There is no statutory  
          requirement that doctors and dentists receive such training, so most  
          do not.  AB 496 would require the licensed task force members and  
          advocate task force members to provide health services to, or  
          advocate on behalf of, members of language and ethnic minority  
          groups and, in addition, LGBT groups.  The bill would require the  
          task force to report its findings to the Legislature and appropriate  
          licensing boards by January 1, 2016."

       2.Background.

           a)   Barriers to Healthcare for Lesbian, Gay, Bisexual, Transgender  
             and Intersex Individuals.  According to a study, nearly one-fifth  
             of physicians in California have endorsed homophobic viewpoints  
             as recently as the 1990s, with approximately 18% reporting  
             feeling uncomfortable treating gay or lesbian patients.  While  
             attitudes have indeed improved, a national survey in 2002 found  
             that 6% of American physicians still reported discomfort caring  
             for LGBT patients.  Because of the legacy of discrimination  
             and/or expectations of poor treatment, many LGBT patients have  
             reported a reluctance to reveal their sexual orientation or  
             gender identity to their providers, despite the importance of  
             such information for their health care.

             A reluctance or fear to come out contributes to ongoing health  
             disparities.  According to the Health People 2010 Companion  
             Document for LGBT Health survey, LGBT youth are two to three  
             times more likely to commit suicide and/or be homeless; lesbians  
             are less likely to get preventative cancer services; and  
             transgender individuals have a higher prevalence of HIV/STDS,  
             victimization and mental health issues.

             In 2011, both the Institute of Medicine (IOM) and the Health and  
             Human Services recognized the need for training in culturally  
             competent care for LGBT individuals.  In its report, The health  
             of Lesbian, Gay, Bisexual and transgender People: Building a  
             Foundation for Better Understanding, the IOM, whose mission is to  
             be an independent and objective "adviser to the nation to improve  
             health," stated:  "With respect to the healthcare provided to  





                                                                         AB 496
                                                                         Page 6



             LGBT people, a number of structural barriers result from  
             providers' lack of training in the health needs of LGBT  
             patients."

             Stigma can have lifelong repercussions, continuing to affect  
             Americans as they age. According to a study, LGBT adults were  
             more likely to report being lonely, depressed and having a  
             disability.  The study also found that 8 in 10 LGBT adults  
             reported being verbally and/or physically assaulted, threatened  
             with violence or with being "outed."  Furthermore, one in five  
             LGBT adults had not told their health care provider about their  
             sexual orientation, and some LGBT adults reported being turned  
             away by a health care provider after they disclosed their sexual  
             orientation.

             The transgender community, in particular, faces unique  
             challenges.  Negative attitudes toward transgender individuals  
             still prevail, with DSM-IV classifying "gender identity disorder"  
             as a mental illness.  In studies, the transgender community face  
             rates of suicidal ideation and attempts ranging from 16-37% and  
             27% have reported being a victim of violence.  Furthermore, a  
             national survey found about 19% of transgender men and women  
             report being refused medical care and 28% delayed medical care  
             due to their gender non-conforming status.  The lack of health  
             insurance or coverage, in addition to uninformed medical  
             providers, is still a continuing problem for transgender people.

           b)   Task Force on Culturally and Linguistically Competent  
             Physicians and Dentists. In 2000, Governor Davis signed Assembly  
             Bill 2394 (Firebaugh, Chapter 802, Statues of 2000) which  
             established the Task Force on Culturally and Linguistically  
             Competent Physicians and Dentists.  In their approval of AB 2394,  
             the Legislature and the Governor acknowledged the need for  
             California's health care delivery system to evolve in order to  
             meet the needs of California's diverse populations.   
             Specifically, AB 2394 required the Task Force to:

                         Develop recommendations for a continuing education  
                  program that includes language proficiency standards of  
                  foreign language to be acquired to meet linguistic  
                  competency;

                         Identify the key cultural elements necessary to meet  
                  cultural competency by physicians, dentists and their  
                  office;






                                                                         AB 496
                                                                         Page 7



                         Assess the need for voluntary certification  
                  standards and examinations for cultural and linguistic  
                  competency;

                         Hold hearings to obtain input from persons belonging  
                  to language and ethnic minority groups to determine their  
                  needs and preferences for having culturally competent  
                  medical providers, and;

                         Report its finding to the Legislature and  
                  appropriate licensing boards within two years after creation  
                  of the Task Force. 

             The Task Force was comprised of 37 members, including  
             representatives from state government and licensing boards,  
             community clinics, consumer advocacy groups, representative of  
             immigrant, Latino and Asian communities and other key  
             stakeholders.  AB 2394 also created a Subcommittee of the Task  
             Force which was chaired by the Director of the Department of  
             Health Services, Diana Bonta.  The Subcommittee's purpose was to,  
             "examine the feasibility of establishing pilot program that would  
             allow Mexican and Caribbean licensed physicians and dentists to  
             practice in nonprofit community health centers in California's  
             medically underserved areas."  The Subcommittee submitted a  
             report to the Legislature in July of 2001.  The subcommittee was  
             comprised of:  The Director of the Department of Health Services,  
             the Executive Director of the Medical Board of California, the  
             Executive Officer of the Dental Board of California and the  
             director of the Office of Statewide Health Planning and  
             Development.  There were advocates for licensed physicians and  
             dentists and representatives of nonprofit clinic associations.

             The Task Force contracted with the University of California at  
             San Francisco to examine what courses and experiences directed  
             toward increasing cultural and linguistic competence are provided  
             by California medical and dental schools and what the content of  
             these courses were.  The study found that medical and dental  
             schools have a large number of hours spent on teaching cultural  
             competence, when measured to include both didactic and clinical  
             and group courses.  The study found that current ethnic diversity  
             of faculty, students and community clinic experiences seemed to  
             contribute to the teaching of cultural competence in these  
             schools.  The study indicated "As the curricula change over time,  
             vigilance is needed to ensure that there is continued teaching in  
             cultural competence and that current talent in this area at the  
             universities is used to enrich the medical and dental school  





                                                                         AB 496
                                                                         Page 8



             curriculum."

             The Task Force issued its recommendations to the Legislature in  
             2003, but it did not take LGBT communities into consideration  
             under its original charge.  The Task Force has been dormant since  
             the 2003 report to the Legislature.

           c)   Cultural Competence.  Cultural competence is defined as a set  
             of skills that allows providers to give culturally appropriate  
             high-quality care to individuals of cultures different from their  
             own and is an important aspect of care (IOM, 1999).  In addition,  
             cultural competence plays a crucial role in understanding,  
             diagnosing and delivering appropriate care to patients.  The  
             ability of physicians and other health care providers to  
             effectively communicate with and to create a welcoming and safe  
             environment for their patients has a demonstrable impact on  
             patient health outcomes.

        1. Arguments in Support.  A broad list of supporters including:  
            Equality California  (sponsor),  The Trevor Project  , the  California  
           Academy of Family Physicians  , the  Asian Americans for Civil Rights  
           & Equality  , the  Black AIDS Institute  ,  Our Family Coalition  , the  
            California Mental Health Directors Association  , the  Gay and Lesbian  
           Community Services Center of Orange County  , Mental Health American  
           of Northern California  , the  National Center for Lesbian Rights  , the  
            Asian & Pacific Islander Wellness Center  ,  San Francisco Eligible  
           Metropolitan Area HIV Health Services Planning Council  ,  The  
           Greenlining Institute  , the  California Pan-Ethnic Health Network  ,  
            Lyon-Martin Health Services  , the  National Asian Pacific American  
           Women's Forum-San Diego Chapter  ,  Asian Pacific Islander  
           Equality-Northern California,  the  L.A. Gay & Lesbian Center  , the   
           Gay & Lesbian Medical Association: Health Professionals Advancing  
           LGBT Equality  and the  California Primary Care Association  similarly  
           write in their support letters, "AB 496 would ensure that the  
           [Cultural and Linguistic Competency Program] also addresses LGBT  
           groups.  The bill would require the training programs to be  
           formulated in collaboration with California-based LGBT medical  
           societies?AB 496 makes clear that LGBT issues should be included in  
           existing cultural competency training for doctors and dentists, and  
           ensures that the LGBT community will be represented on the existing  
           cultural competency task force."

           The  Medical Board of California  also supports the bill when they  
           write, "The previous Task Force on Culturally and Linguistically  
           Competent Physicians and Dentists did not address LGBT cultural  
           competency.  The Board believes that it is important that LGBT  





                                                                         AB 496
                                                                         Page 9



           cultural issues be addressed by providers, as it is important that  
           physicians can provide appropriate care for all patients and  
           cultural competence is an important factor in the physician-patient  
           relationship.  The Board believes this bill will increase LGBT  
           cultural competency for all providers, which will help to ensure  
           that LGBT cultural issues are addressed and that LGBT patients are  
           delivered appropriate care."

           The  AIDS Legal Referral Panel  writes, "Extending cultural  
           competency provisions to members of the LGBT community is not only  
           a medical necessity, but makes common sense.  By addressing the  
           needs of the LGBT community, we can mitigate disease transmission  
           and progression, reduce healthcare costs and increase overall  
           mental and physical well-being for all Californians."

           The  Gay Asian Pacific Alliance  and the  Asian Law Caucus  shares  
           their support when they write, "Asian Americans suffer from health  
           disparities such as disproportionately high rates of cancer, heart  
           disease, stroke and diabetes.  Compounding these health disparities  
           are barriers due to immigration status and the lack of culturally  
           and linguistically appropriate health care for our community.  In  
           order to begin providing inclusive and effective health care for  
           our communities, we must recognize the role that culture,  
           ethnicity, race, sexual orientation, gender identity, and gender  
           expression affect our health outcomes and overall wellbeing."

            Betty T. Yee  , Member, Frist District, State Board of Equalization  
           writes in support of this measure, "By incorporating LGBT issues  
           into voluntary training programs for doctors and dentists and  
           redefining cultural competency to address issues relating to sexual  
           orientation, gender identity, and gender expression, AB 496 will  
           begin to develop norms and outcomes within the health field  
           resulting in improved health care for the LGBT community." 

            Planned Parenthood Affiliates of California  similarly supports the  
           bill.  In their letter they note, "As a health care provider,  
           Planned Parenthood has long supported the healthcare needs of LGBT  
           people?Cultural competency plays a crucial role in understanding,  
           diagnosing and delivering appropriate care to patients."

           The  National Association of Social Workers- California Chapter   
           states, "Cultural competence is important if doctors want their  
           patients to feel comfortable discussing medical issues.  If a  
           doctor does not understand issues that are pertinent to the LGBT  
           community, they may not ask medically necessary questions.   
           Furthermore, it is important that patients do not feel that their  





                                                                         AB 496
                                                                         Page 10



           doctor is judging them for their sexual orientation so that they  
           can feel free to express extremely personal information that may  
           have significant bearing on their health."

           The  City of West Hollywood  writes, "The City? is a community with a  
           large LGBT population:  37% of the population in the City is gay,  
           while 3% are bisexual, and 4% are lesbian.  The City Council has  
           sponsored legislation and advocated for state and federal  
           initiatives that strengthen the rights of gay, lesbian bisexual and  
           transgender people?.AB 496 is an important step in equalizing  
           access to health care services for the LGBT community in  
           California."

         4. Arguments in Opposition.  The  California Right to Life Committee   
           opposes the bill.  In their letter they argue, "The CLRC believes  
                                                  that AB 496 is an unnecessary measure and insinuates that the  
           medical and dental professionals are not adequately trained to be  
           sensitive to any special needs of this selected group of patients.   
           This dishonors these professionals and is not needed." 

         5. Prior Related Legislation.   SB 747  (Kehoe, 2012) would have  
           required physicians and surgeons, registered nurses, licensed  
           vocational nurses, psychologists, psychiatric technicians, marriage  
           and family therapists, and clinical social workers, to take at  
           least one CE course that provides instruction on cultural  
           competency, sensitivity, and best practices for providing adequate  
           care to LGBT people.  (  Status  :  The bill was vetoed by the  
           Governor.)

            AB 673  (John A. Pérez, Chapter 639, Statutes of 2011) added  
           consideration of LGBT communities to the duties of the Office of  
           Multicultural Health (which is now part of OHE).

            AB 801  (Diaz, Chapter 510, Statutes of 2003) established the  
           Cultural and Linguistic Physician Competency Program to be operated  
           by local medical societies of the CMA and monitored by MBC.

            AB 2394  (Firebaugh, Chapter 802, Statutes of 2000) created the Task  
           Force on Culturally and Linguistically Competent Physicians and  
           Dentists and requires the Task Force to, among other things,  
           develop recommendations for a CE program.


        SUPPORT AND OPPOSITION:
        
         Support:  





                                                                         AB 496
                                                                         Page 11




        Equality California (sponsor)
        AIDS Legal Referral Panel
        Asian & Pacific Islander Wellness Center
        Asian Americans For Civil Rights & Equality
        Asian Law Caucus
        Asian Pacific Islander Equality- Northern Chapter
        Betty T. Yee- Member, First District, State Board of Equalization
        California Academy of Family Physicians
        California Communities United Institute
        California Mental Health Directors Association
        California Pan Ethnic Health Network
        California Primary Care Association
        City of West Hollywood
        Gay & Lesbian Medical Association: Health Professionals Advancing LGBT  
        Equality
        Gay Asian Pacific Alliance
        L.A. Gay & Lesbian Center
        Lyon-Martin Health Services
        Medical Board of California
        Mental Health American of Northern California
        National Association of Social Workers- California Chapter
        National Center for Lesbian Rights
        Our Family Coalition
        Planned Parenthood Affiliates of California
        San Francisco Eligible Metropolitan Area HIV Health Services Planning  
        Council
        The Black AIDS Institute
        The Gay and Lesbian Community Services Center of Orange County
        The Greenlining Institute
        The National Asian Pacific American Women's Forum
        The Trevor Project
        67 individuals

         Opposition:  

        California Right to Life Committee, Inc.



        Consultant: Le Ondra Clark, Ph.D.