BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                    AB 2216


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          ASSEMBLY THIRD READING


          AB  
          2216 (Bonta)


          As Amended  May 27, 2016


          Majority vote


           ------------------------------------------------------------------ 
          |Committee       |Votes|Ayes                  |Noes                |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Health          |19-0 |Wood, Maienschein,    |                    |
          |                |     |Bonilla, Burke,       |                    |
          |                |     |Campos, Chiu,         |                    |
          |                |     |Dababneh, Gomez,      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
          |                |     |Roger Hernández,      |                    |
          |                |     |Lackey, Nazarian,     |                    |
          |                |     |Olsen, Patterson,     |                    |
          |                |     |Ridley-Thomas,        |                    |
          |                |     |Rodriguez, Santiago,  |                    |
          |                |     |Steinorth, Thurmond,  |                    |
          |                |     |Waldron               |                    |
          |                |     |                      |                    |
          |----------------+-----+----------------------+--------------------|
          |Appropriations  |20-0 |Gonzalez, Bigelow,    |                    |
          |                |     |Bloom, Bonilla,       |                    |
          |                |     |Bonta, Calderon,      |                    |
          |                |     |Chang, Daly, Eggman,  |                    |
          |                |     |Gallagher, Eduardo    |                    |








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          |                |     |Garcia, Roger         |                    |
          |                |     |Hernández, Holden,    |                    |
          |                |     |Jones, Obernolte,     |                    |
          |                |     |Quirk, Santiago,      |                    |
          |                |     |Wagner, Weber, Wood   |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
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          SUMMARY:  Establishes the Teaching Health Center (THC) Primary  
          Care Graduate Medical Education Fund (Fund) for purposes of  
          funding primary care residency programs.  Specifically, this  
          bill:  


          1)Establishes the THC Fund in the State Treasury.


          2)Requires the Director of the Office of Statewide Health  
            Planning and Development (OSHPD) to award planning and  
            development grants from the Fund to teaching health centers  
            for the purpose of establishing new accredited or expanded  
            primary care residency programs.


          3)Provides that grants awarded must not be for more than three  
            years and that the maximum award to a teaching health center  
            must not be more than five hundred thousand dollars  
            ($500,000).


          4)Specifies that grants be used to cover the costs of  
            establishing or expanding a primary care residency training  
            program, including costs associated with curriculum  
            development, recruitment, training, and retention of residents  
            and faculty, accreditation by the Accreditation Council for  
            Graduate Medical Education (ACGME), the American Dental  
            Association (ADA), or the American Osteopathic Association  








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            (AOA), faculty salaries during the development phase, and  
            technical assistance.


          5)Requires OSHPD, subject to an appropriation by the  
            Legislature, to award sustaining grants from the Fund to THCs  
            operating primary care residency programs accredited by the  
            ACGME, ADA, or AOA, and requires OSPHD to determine the amount  
            of grants awarded per resident by taking into account the  
            direct and indirect costs of graduate medical education.   
            Requires OSHPD to promulgate emergency regulations to  
            implement this bill.


          6)Makes implementation of this bill subject to an appropriation  
            in the annual Budget Act.


          FISCAL EFFECT:  According to the Assembly Appropriations  
          Committee:


          1)General Fund (GF) cost pressure, ranging from the low millions  
            to over $10 million, to fund primary care residency programs  
            as envisioned by this bill.  The program could be funded at  
            anywhere within this range, as it would scale to the size of  
            the appropriation, but a program smaller in size than the low  
            millions would be limited in effectiveness.  


          2)GF costs to OSHPD to administer the new grant program.  For  
            example, administrative costs of 5% on a $15.5 million program  
            would be around $750,000. 


          3)The California Primary Care Association (CPCA), the sponsor of  
            this bill, has submitted to the budget committees a related  
            budget request for an annual GF investment of $16.5 million GF  
            annually as follows:  $1 million for OSHPD administration, $10  








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            million for creating new programs, and $5.5 million to sustain  
            the existing six programs in Modesto, Fresno, San Bernardino,  
            Redding, Bakersfield, and San Diego.


          4)Assembly Budget Subcommittee 1 and Senate Subcommittee 3 have  
            each approved $17.5 million GF to support teaching health  
            centers' residency programs in the 2016-17 budget, similar  
            what is proposed by this bill.


          COMMENTS:  According to the author THCs are a proven model for  
          addressing the primary care provider shortage that six of nine  
          California regions face.  The author notes that 40% of THC  
          graduates entering into primary care practice in nonprofit,  
          community health centers in underserved communities as opposed  
          to just 4% of traditional medical residents.  The author  
          concludes that this bill will help ensure California has a  
          sufficient supply of health workforce professionals to serve the  
          needs of our diverse state.


          California ranks 23rd in the number of primary care physicians  
          per resident.  An August 2014 report by the California  
          HealthCare Foundation states that California has only 35 to 49  
          primary care physicians per 100,000 Medi-Cal enrollees.  Federal  
          guidelines call for the state to have 60 to 80 doctors per  
          100,000 patients.  The supply of primary care physicians also  
          varies substantially across California's counties.  According to  
          2011 Health Resources and Services Administration (HRSA) data,  
          29 of California's 58 counties fall at the lower end, or below,  
          the needed supply range for primary care physicians.  In other  
          words, half of Californians live in a community where they do  
          not have adequate access to the health care services they need.   



          The Teaching Health Center Graduate Medical Education (THCGME)  
          program.  THCGME, funded since 2011 and set to expire in 2016,  








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          has increased the numbers of primary care physicians and  
          dentists training to care for underserved populations  
          nationwide.  Without continued federal funding, most of these  
          THCs report that they would be unlikely to continue current  
          residency recruitment and enrollment, threatening the initial  
          program investments and even the viability of the program  
          itself.


          According to a 2015 Robert Graham Center report, "Teaching  
          Health Center GME Funding Instability Threatens Program  
          Viability," residents who train in underserved settings are more  
          likely to continue to practice in similar environments.  The  
          THCGME program supports new and expanded community-based primary  
          care training programs.  Organizations that can qualify to be  
          THCs include federally qualified health centers, rural health  
          clinics, and tribal clinics-all organizations that care for the  
          underserved.  Unlike most other GME payments, funds flow  
          directly to the community-based, ambulatory patient care centers  
          where residents train, instead of teaching hospitals.  The  
          investment of $230 million over five years (2011 to 2015)  
          represents 0.3% of the annual $15 billion federal GME funding  
          that supports more than 120,000 residents in training each year  
          nationwide.  THCGME will expire in 2016 if there is no  
          congressional action to extend it.


          Since their creation under the Patient Protection and Affordable  
          Care Act six THCs have opened in California, however they are in  
          danger of closing due to the uncertain funding.  They are  
          located in Modesto, Fresno, San Bernardino, Redding,  
          Bakersfield, and San Diego.


          CPCA is the sponsor of this bill and states that this bill will  
          help address California's primary care provider shortage by  
          establishing the Fund, providing planning and development grants  
          to THCs for the purpose of establishing new accredited or  
          expanded primary care residency programs, and make available  








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          sustaining grants to ensure the continued operation of  
          accredited THCs.  CPCA estimates that 8,243 additional primary  
          care physicians will be needed in California by 2030, and notes  
          that with dwindling federal support for current THC sites and no  
          federal investment to develop new sites, California must  
          prioritize and demonstrate its commitment to providing access to  
          primary care through a greater investment in the THC model.




          The California Right to Life Committee, Inc. opposes this bill  
          stating that because the definition of a California Primary Care  
          Residency Program includes obstetrics and gynecology, they are  
          assuming that Title X and family planning education will be  
          included in the medical education for the residency program.


          Analysis Prepared by:                                             
          Lara Flynn/ HEALTH / (916) 319-2097  FN: 0003251