BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    SB 291    
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          |AUTHOR:        |Lara                                           |
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          |VERSION:       |April 6, 2015                                  |
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          |HEARING DATE:  |April 22, 2015 |               |               |
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          |CONSULTANT:    |Reyes Diaz                                     |
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           SUBJECT  :  Mental health:  vulnerable communities

           SUMMARY  :  Requires the Office of Statewide Health Planning and  
          Development to prepare a Mental Health Manpower Plan for the  
          state to assess the needs and available services to meet the  
          mental health needs of Californians, specifically those in  
          vulnerable communities. Expands the definition of "vulnerable  
          communities," as specified; Requires the Department of Health  
          Care Services to include stakeholders in vulnerable communities,  
          as specified, in its meaningful decision making process for  
          purposes of providing technical assistance to specified  
          entities.

          Existing law:
          1.Establishes the Office of Statewide Health Planning and  
            Development (OSHPD) to, among other duties, collect data and  
            disseminate information about the state's health care  
            infrastructure. Requires OSHPD to prepare a Health Manpower  
            Plan for the state to establish standards for and determine  
            the adequacy of policies relating to health care practitioners  
            to serve the needs of the state. 

          2.Establishes the Office of Health Equity (OHE) within the  
            Department of Public Health (DPH) to align state resources,  
            decision making, and programs to establish various goals  
            relating to health. Requires OHE to perform various duties  
            relating to vulnerable communities. 

          3.Defines "vulnerable communities" as, but not limited to: 

                  a.        Women;
                  b.        racial or ethnic groups;
                  c.        low-income individuals and families; 







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                  d.        individuals who are  and have been  
                    incarcerated; 
                  e.        individuals with disabilities;
                  f.        individuals with mental health conditions;
                  g.        children, youth and young adults, and seniors,  

                  h.        immigrants and refugees; 
                  i.        individuals who are limited-English  
                    proficient;
                  j.        lesbian, gay, bisexual, transgender, queer,  
                    and questioning (LGBTQQ) communities; or,
                  aa.       combinations of these populations.

          4.Requires the Department of Health Care Services (DHCS) to  
            provide, to the extent resources are available, technical  
            assistance to county mental health programs and other local  
            mental health agencies, through DHCS staff or by contract, in  
            the areas of program operations, research, evaluation,  
            demonstration, or quality assurance projects. Requires DHCS to  
            utilize a meaningful decision making process that includes  
            local mental health directors and representatives of local  
            mental health boards, as well as other stakeholders as  
            determined by DHCS. 
          
          This bill:
          1.Requires OSHPD to prepare a Mental Health Manpower Plan for  
            the state to assess the needs and services available to meet  
            the mental health needs of Californians, especially those in  
            vulnerable communities. Requires the plan to consist of at  
            least the following elements:

                  a.        Establishment of appropriate standards for  
                    determining the adequacy of supply in the state of  
                    psychologists, psychiatrists, counselors, and other  
                    mental health personnel who may be able to treat  
                    groups in vulnerable communities;
                  b.        Determination of appropriate standards for the  
                    adequacy of supply of the categories in (a.) above; 
                  c.        Determination of the adequacy of the current  
                    and future supply of personnel in (a.) above, taking  
                    into account the sources of supply for that personnel  
                    in the state, the magnitude of immigration of  
                    personnel to the state, and the likelihood of the  
                    continuing immigration;
                  d.        Determination of the adequacy of supply of  








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                    specialties within each category of health personnel  
                    in (a.) above; and,
                  e.        Recommendations concerning changes in  
                    programs, mental health manpower policies, and  
                    licensing statutes needed to meet the state's need for  
                    mental health personnel to serve vulnerable  
                    communities.

          2.Expands the definition of "vulnerable communities" to include  
            individuals who have experienced trauma related to genocide.

          3.Requires DHCS to include stakeholders in vulnerable  
            communities in its meaningful decision making process, for  
            purpose of providing technical assistance, including:

                  a.        diverse racial, ethnic, cultural, and LGBTQQ  
                    communities;
                  b.        communities that experience trauma related to  
                    genocide;
                  c.        women's health advocates;
                  d.        mental health advocates;
                  e.        health and mental health providers; 
                  f.        community-based organizations and advocates;
                  g.        academic institutions;
                  h.        local public health departments;
                  i.        local government entities; and,
                  j.        low-income and vulnerable consumers.

           FISCAL  
          EFFECT  :  This bill has not been analyzed by a fiscal committee.
           
          COMMENTS  :
          1.Author's statement. According to the author, OSHPD, OHE, DHCS,  
            and other state and local entities have been charged with  
            carrying out various mental health initiatives, yet barriers  
            remain. In particular the Cambodian-American population, which  
            has the largest population in California, still suffers from  
            the effects of the Cambodian Genocide that occurred between  
            1975 and 1979. Their mental health challenges are  
            multigenerational, extending past the elders who were refugees  
            to the youth who are born in the U.S. Unfortunately, the  
            Cambodian community is lumped together, if recognized at all,  
            under the Asian Pacific-Islander category by departments. The  
            current system, where groups are collapsed together in a broad  
            category, disenfranchises people who suffer from trauma  








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            related to genocide. These individuals have unique challenges  
            that cannot be generalized by any other category and,  
            therefore, should be separately assessed. In the absence of  
            laws that highlight this group as a vulnerable population,  
            smaller community and non-profit organizations that serve  
            these individuals are often unable to access funding under the  
            current system. In the interest of continuing the state's goal  
            towards advancing mental health care access, SB 291 will  
            improve institutional access for Californians who have  
            experienced trauma related to genocide by improving  
            stakeholder engagement, service delivery, and ultimately  
            access to mental health services.
            
          2.Health care disparities. According to the Health Services  
            Research Community of the National Institutes of Health,  
            health care disparities refer to differences in access to or  
            availability of facilities and services. Health status  
            disparities refer to the variation in rates of disease  
            occurrence and disabilities between socioeconomic and/or  
            geographically defined population groups. Health disparities  
            have been measured between those of a different race,  
            ethnicity, gender, sexual orientation, age, ability, religion,  
            socioeconomic status, language proficiency, and geographic  
            location. Many racial and ethnic minorities, people with  
            disabilities, and LGBTQQ communities face unique health  
            challenges, have reduced access to health care and insurance,  
            and often have poorer health throughout their lives. For  
            example, research suggests LGBTQQ people and families may face  
            significant challenges associated with health disparities in  
            insurance coverage and access to health care services.

          3.Behavioral health evidence-based/best practice service  
            provision lacking in the state? The Technical Assistance  
            Collaborative/Human Services Research Institute's final report  
            in February 2012, California Mental Health and Substance Use  
            System Needs Assessment, notes that the percent of individuals  
            reported to be receiving an evidence-based practice service  
            was low: only one percent in 2010, down from two percent in  
            2009. It also notes that there is a variability among counties  
            in the use and training of staff in state-of-the-art and  
            evidence-based and recovery-oriented treatment; there is a  
            need to address better preparation of physical health  
            providers to engage and treat people with behavioral health  
            needs; and there is still disproportionate access to  
            behavioral health services on the part of certain ethnic  








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            populations-compounded by the relative lack of cultural and  
            linguistic capacity among providers and practitioners in the  
            state.

          4.Let's Get Healthy Task Force. In May 2012, Governor Jerry  
            Brown established the Let's Get Healthy California Task Force  
            (Task Force) to develop a 10-year plan for improving the  
            health of Californians, controlling health care costs,  
            promoting personal responsibility for individual health, and  
            advancing health equity. The Executive Order directed the Task  
            Force to issue a report with recommendations for how the state  
            can make progress toward becoming the healthiest state in the  
            nation over the next decade. In the report, issued in December  
            2012, the Task Force developed an overarching framework,  
            identifying six goals, organized under two strategic  
            directions: Health Across the Lifespan and Pathways to Health.  
            The Report states that the framework makes clear that health  
            equity should be fully integrated across the entire effort.
          
          5.State's current efforts. According to OSHPD's Web site, the  
            passage of Proposition 63, the Mental Health Services Act  
            (MHSA), provided a unique opportunity with funding to increase  
            staffing and other resources that support public mental health  
            programs, increase access to much-needed services, and monitor  
            progress toward statewide goals for serving children,  
            transition age youth, adults and older adults, and their  
            families. California's public mental health system has  
            suffered from a shortage of public mental health workers,  
            maldistribution of certain public mental health occupational  
            classifications, a recognized lack of diversity in the  
            workforce, and underrepresentation of professionals with  
            consumer and family member experience, and of racial, ethnic,  
            and cultural communities in the provision of services and  
            support. To address the public mental health workforce issues,  
            the MHSA included a component for Mental Health Workforce  
            Education and Training (WET) programs. In 2008, the former  
            Department of Mental Health developed the first WET  
            Development Five-Year Plan, which covered the period April  
            2008 to April 2013 and provided vision, values, and mission  
            for state and local implementation of WET programs. In July  
            2012, the MHSA WET programs were transferred to OSHPD, which  
            assumed the responsibility of administering the WET programs  
            and developing the second MHSA WET Five-Year Plan. OSHPD, with  
            advice from stakeholders and approval by the California Mental  
            Health Planning Council, developed the second MHSA WET  








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            Five-Year Plan, which covers the period of April 2014 to April  
            2019 and provides a framework on strategies that state, local  
            government, community partners, education and training  
            institutions, and other stakeholders can enact to further  
            public mental health workforce, education, and training  
            efforts.
            
            DHCS 
            DHCS recently indicated that, beginning in Fiscal Year  
            2015-2016, it will stratify quality measures by demographic  
            factors. Their goal is to focus quality improvement efforts to  
            eliminate heath disparities and improve quality overall. DHCS  
            is in the process of identifying initial measures to conduct  
            this analysis. Another demographic analysis currently  
            conducted by DHCS is the use of managed care plan grievances  
            and appeals data. DHCS is able to determine if an  
            over-prevalence of grievances and/or appeals exists among a  
            specific demographic group. DHCS has previously collected race  
            and/or ethnicity data when conducting the Consumer Assessment  
            of Healthcare Providers and Systems (CAHPS) survey. This  
            survey is a measure of Medi-Cal beneficiary satisfaction. DHCS  
            reports they will continue to conduct this analysis by race  
            and/or ethnicity and use the CAHPS survey to collect  
            additional demographic factors.
               
            Covered California 
            Covered California has stated that one of its missions is to  
            reduce health disparities, and that it recognizes the diverse  
            cultural, language, economic, educational, and health status  
            needs of those they serve. Their ongoing outreach initiatives  
            include efforts to enroll underserved beneficiaries. Covered  
            California runs the Community Outreach Network, which partners  
            with local organizations across the state to provide  
            information, resources, and training. Community Outreach  
            Network partners include organizations devoted to serving  
            at-risk (vulnerable) populations, including immigrants,  
            African Americans, Asians and Asian sub-populations, LGBTQQ,  
            Mexican Americans, Native Americans, and HIV and AIDS  
            patients. Partners distribute materials, provide outreach and  
            enrollment assistance, and are compensated by Covered  
            California for each application that leads to a purchase.  
            Covered California has also awarded $43 million in grants to  
            organizations that have trusted relationships with culturally  
            and linguistically diverse uninsured markets.









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          6.Related legislation. SB 315 (Monning and Hernandez), creates  
            the California Health Access Model Program Two Account within  
            the California Health Facilities Financing Authority Fund for  
            purposes of administering a second competitive grant selection  
            process, in accordance with existing grant provisions, to fund  
            one or more projects designed to demonstrate specified new or  
            enhanced cost-effective methods of delivering quality health  
            care services to improve access to quality health care for  
            vulnerable populations or communities, or both. SB 315 is set  
            for hearing in the Senate Health Committee on April 29, 2015.

            AB 176 (Bonta), adds DPH to the list of agencies that are  
            required to use additional separate collection categories and  
            other tabulations, and to take additional actions, including  
            posting the demographic data collected on its Internet Web  
            site. Requires the updating of the reporting categories for  
            future decennial censuses. Requires, on or after July 1, 2016,  
            whenever DPH, DHCS, or the Department of Managed Health Care  
            collects ancestry or ethnic origin demographic data of persons  
            for a report that includes specified categories of  
            information, that entity to use the additional separate  
            collection categories and other tabulations for specified  
            Asian groups and Pacific Island groups, and to post the  
            demographic data on its Internet Web site. Requires, on and  
            after July 1, 2016, the Board of Governors of the California  
            Community Colleges, the Trustees of the California State  
            University, and the Regents of the University of California,  
            whenever those entities collect ancestry or ethnic origin  
            demographic data of students for a report that includes  
            student admission, enrollment, completion, or graduation  
            rates, to use specified collection and tabulation categories  
            for Asian, Native Hawaiian, and Pacific Islander groups.  
            Requires each entity specified above to make the demographic  
            data publicly available on the entity's Internet Web site and  
            requires the updating of the reporting categories for each  
            decennial census. AB 176 is scheduled for hearing in the  
            Assembly Health Committee on April 21, 2015.
            
          7.Prior legislation. AB 411 (Pan), of 2013, would have required  
            DHCS, when entering into a new contract with an External  
            Quality Review Organization (EQRO) for the purpose of  
            performing work associated with Medi-Cal managed care  
            programs, to include in the terms of the new contract a  
            requirement that, upon approval of the contract, the EQRO  
            stratify all patient-specific Healthcare Effectiveness Data  








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            and Information Set measures, or their External Accountability  
            Set performance measure equivalent, by certain  
            characteristics, including geographic area and primary  
            language. AB 411 would have required DHCS to publicly report  
            this analysis on its Internet Web site. AB 411 would have  
            provided that its provisions only be implemented to the extent  
            that funding is available. AB 411 was vetoed by the Governor  
            who stated that nothing in current law prevents DHCS from  
            requiring EQROs to provide more detailed data by geography,  
            race, ethnicity, or other demographic attribute. He concluded  
            that if DHCS saw a need or benefit that justifies the costs of  
            procuring this additional data, he was confident that they  
            would procure it.

            AB 209 (Pan), of 2013, would have required DHCS to develop and  
            implement a plan that includes specified components to  
            monitor, evaluate, and improve the quality, accessibility, and  
            utilization of health care and dental services provided  
            through Medi-Cal managed care. This bill would have required  
            DHCS to hold public meetings to report on performance  
            measures, utilization levels, quality and access standards,  
            network adequacy, fiscal solvency, and evaluation standards  
            with regard to all Medi-Cal managed care services and to  
            invite public comments. This bill would have also required  
            DHCS to appoint an advisory committee for the purpose of  
            making recommendations to improve quality and access in the  
            delivery of Medi-Cal managed care services. AB 209 died in the  
            Senate on the third reading file.

          8.Support.  Supporters of this bill argue that there continues  
            to be barriers to accessing mental health services, especially  
            for the Cambodian community, which still suffers from effects  
            of genocide that occurred between the years of 1975 and 1979.  
            They further argue that because many Asian subpopulations get  
            lumped together as Asian Pacific-Islander, groups that have  
            experienced trauma related to genocide are disenfranchised,  
            particularly because of unique challenges. Supporters cite  
            mounting research that shows trauma/stress affects brain  
            development, as well as physical and mental health.

          9.Technical amendment. In current law, OSHPD is already required  
            to develop a Health Manpower Plan for the state. The author  
            may wish to amend this bill to require OSHPD to include in its  
            current responsibility an element for addressing the mental  
            health needs of vulnerable communities, which will include  








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            communities that experience trauma related to genocide in its  
            expanded definition.

          
           SUPPORT AND OPPOSITION  :
          Support:  Cambodian Advocacy Collaborative (sponsor)
                    Families in Good Health
                    Khmer Parent Association
                    Los Angeles Lesbian, Gay, Bisexual, Transgender Center
          
          Oppose:   None received.
          
                                      -- END --