BILL ANALYSIS Ó
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|Hearing Date:July 1, 2013 |Bill No:AB |
| |496 |
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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
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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
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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
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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:
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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
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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;
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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
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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
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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
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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:
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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.