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.