BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1139
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|AUTHOR: |Lara |
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|VERSION: |April 4, 2016 |
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|HEARING DATE: |April 13, 2016 | | |
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|CONSULTANT: |Melanie Moreno |
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SUBJECT : Health professionals: medical residency programs:
undocumented immigrants: scholarships, loans, and loan
repayment
SUMMARY :1) Deems eligible any student, including a person without lawful
immigration status and/or a person who is exempt from
nonresident tuition, who meets the requirements for admission to
participate in a medical school program and a medical residency
training program. Prohibits specified grant and loan repayment
and forgiveness programs from denying an application based on an
applicant's citizenship or immigration status. Requires an
applicant, when mandatory disclosure of a social security number
is required, to provide it if one has been issued, or an
individual taxpayer identification number that has been or will
be submitted.
Existing law:
1)Establishes the California Healthcare Workforce Policy
Commission (Commission) and requires the Commission to, among
other things, identify specific areas of the state where unmet
priority needs for primary care family physicians and
registered nurses exist; establish standards for family
practice training programs, family practice residency
programs, primary care physician assistants programs, and
programs that train primary care nurse practitioners; and
review and make recommendations to OSHPD concerning the
funding of those programs that are submitted to the Health
Professions Development Program for participation in the state
medical contract program.
2)Establishes the Health Professions Education Foundation (HPEF)
within OSHPD. Requires t HPEF to solicit and receive funds
from foundations and other private and public sources and to
SB 1139 (Lara) Page 2 of ?
provide financial assistance in the form of scholarships or
loans to students in the health professions who are from
underrepresented groups. Provides that HPEF is governed by a
board consisting of 13 members appointed by the Governor,
Speaker of the Assembly, and Senate Rules Committee.
3)Establishes, under the HPEF, scholarship, loan, and loan
repayment programs for registered nurses, vocational nurses,
geriatric nurse practitioners, clinical nurse specialists, and
mental health professionals who agree to practice for
specified periods of time in underserved areas and in
designated practice settings, as specified.
4)Establishes within OSHPD the Health Professions Education Fund
to receive funds for scholarships and loans to students from
underrepresented groups who are enrolled in or accepted to
schools of medicine, dentistry, nursing, and other health
professions. Provides that moneys in the fund are
continuously appropriated.
This bill:
1)Deems eligible any student, including a person without lawful
immigration status, a person who is exempt from nonresident
tuition, or a person who is both without lawful immigration
status and exempt from nonresident tuition, and who meets the
requirements for admission to participate in a medical school
program and a medical residency training program at any public
or private postsecondary educational institution that offers
such a program.
1)Encourages the University of California to develop a process
for awarding student financial aid that may include, but not
be limited to, grants, scholarships, and stipends, in lieu of
employment for students in a medical residency training
program whose participation is authorized by this section.
2)Prohibits programs within the HPEF from denying an application
based on the citizenship status or immigration status of the
applicant.
3)Requires an applicant, for HPEF programs, when mandatory
disclosure of a social security number (SSN) is required, to
provide his or her SSN, if one has been issued, or an
individual taxpayer identification number (ITIN) that has been
or will be submitted.
SB 1139 (Lara) Page 3 of ?
4)Applies 3) and 4) to the following programs:
a) Programs supported through HPEF;
b) The Registered Nurse Education Fund;
c) The Mental Health Practitioner Education Fund;
d) The Vocational Nurse Education Fund;
e) The Medically Underserved Account for
Physicians;
f) The Steven M. Thompson Medical School
Scholarship Account; and,
g) Loan forgiveness and scholarship programs
created through the Mental Health; Services Act
(MHSA).
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, there are
currently 168 designated medically underserved areas in
California across all 58 counties. Patients in medically
underserved areas face significant challenges to access health
care services. The limited resources and lack of specialty
services in these communities leads to longer waiting times
and longer journeys to appointments. SB 1139 would increase
the number of physicians and health care workers in medically
underserved areas by ensuring that all individuals who wish to
pursue a medical profession may compete for scholarships and
loan repayments available under HPEF, which targets health
professionals who are able to provide culturally and
linguistically appropriate care within medically underserved
areas. Currently the HPEF only allows for the submission of
SSN, which bars undocumented individuals seeking medical
professions from applying. This bill would reduce barriers to
undocumented individuals by enabling an applicant to provide
an ITIN in lieu of a SSN, and prohibit the HPEF from barring
an applicant based on his or her immigration status, while
also addressing service gaps that are desperately needed in
those communities.
2)Background. Statewide shortages of health care providers
currently exist in several major health professions. Recent
health care workforce research indicates that health
professional shortage, distribution, and diversity issues
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impact access to primary, allied, mental, and dental health
care in California today. The demand for these health care
professions is also forecasted to grow faster than professions
in other industries. Additionally, health care workforce needs
are projected to increase dramatically due to population
aging, growth, and diversity. This existing shortage is
expected intensify as about 4.7 million more Californians have
gained access to health insurance as a result of the
implementation of the Affordable Care Act. Inability to meet
health care workforce needs will have serious adverse
consequences on health access, quality, and cost.
3)Presidential action on immigration. In November 2014,
President Obama announced that the federal Department of
Homeland Security (DHS) would not deport certain undocumented
parents of U.S. citizens and parents of lawful permanent
residents (LPRs). President Obama also announced an expansion
of the Deferred Action for Childhood Arrivals (DACA) program
for youth who came to the United States as children. Under a
directive from the secretary of DHS, these parents and youth
may be granted a type of temporary permission to stay in the
U.S. called "deferred action." Deferred action is a form of
administrative relief from deportation whereby DHS authorizes
a noncitizen to remain in the U.S. temporarily. These
individuals may also apply for an employment authorization
document (a work permit) during the deferred action period. A
grant of deferred action is temporary and does not grant
citizenship or permanent lawful status. However, a person
granted deferred action is considered by the federal
government to be lawfully present for as long as the grant of
deferred action status. These actions are expected to affect
up to 4.4 million people, according to DHS.
The United States Citizenship and Immigration Services (USCIS)
announced that, due to a federal court order, it would not
begin accepting requests for the expansion of DACA on February
18, 2015 as originally planned and has suspended
implementation of Deferred Action for Parents of Americans and
Lawful Permanent Residents (DAPA). The court's temporary
injunction, issued February 16, 2015, does not affect the
existing DACA and individuals can continue to request an
initial grant of DACA or renewal of DACA under the original
guidelines. Separately, the Texas federal court preliminarily
blocked, on procedural grounds, the President's DAPA and
expanded DACA initiatives (but not original DACA) on February
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16, 2015. The Department of Justice appealed this order, and
arguments were heard on July 10, 2015. On November 9, 2015, a
divided panel of the Fifth Circuit Court of Appeals upheld the
lower court's ruling in a 2-1 decision. The following day, the
Department of Justice announced its intention to seek Supreme
Court review of the Fifth Circuit's decision. On January 19,
2016, the Supreme Court agreed to take the case and will hear
oral arguments on April 18th, with a decision being announced
in late June 2016.
4)Impact of DACA on medical schools. According to a perspective
published in the journal Academic Medicine in December 2014,
it is difficult to estimate the full impact of DACA on the
medical school applicant pool as DACA may also increase
undergraduate completion among this group. One estimate in
California indicated that only about 10% to 20% of
undocumented students who graduated from high school enrolled
in college. This is in contrast to the general population in
which the percentage of high school graduates who subsequently
enrolled in college was 68.2% in 2011. Moreover, the national
graduation rate for bachelor's degrees (completion in six
years or less) is about 59%. A low estimate of potential,
undocumented students in medical school can be estimated by
applying current rates of enrollment of undergraduate
education among undocumented students (10%) and subsequent
entry into the field of medicine (about 2%-3%) to estimates of
total DACA potentials in the United States (1.8 million). This
results in an estimated 5,400 new, largely underrepresented
minority physicians in the coming decades. A low estimate,
using the same method but imputing the current, general
graduation rate (59%) to DACA students, puts the number at
about 3,000 potential future physicians.
5)Financial aid for DACA students. According to the Academic
Medicine article, the price tag of a medical education is
extremely high. Financing a medical education is a challenge
for all medical students, but it is particularly difficult for
DACA students because they are legally excluded from receiving
federal financial aid. DACA students may be eligible, however,
to apply for private need- and merit-based scholarships,
private loans, school loans, and institutional aid. Also, some
state laws allow undocumented students to apply for publicly
funded grants. Medical schools can assist DACA students by
offering financial planning advice early on, in order to
prevent financial status from being a prohibitive barrier to
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their matriculation in the face of limited options for
financial assistance. Medical schools can further encourage
students to join their programs by creating flexible and
generous scholarship packages and providing paid
opportunities, such as research positions, within their
programs. Whereas some states expect DACA students to pay more
expensive international student fees for their education, 12
states have passed laws allowing DACA students to qualify for
in-state tuition at public universities, including California
and Texas, the two states with the largest populations of DACA
students.
6)California workforce development programs. The state currently
operates a number of programs designed to increase the number
of health care professionals practicing in medically
underserved areas:
a) Health Professions Education Foundation (HPEF).
Established in 1987 and housed within OSHPD, HPEF is a
non-profit foundation statutorily created to provide
financial incentives to aspiring and practicing health
professionals. The foundation offers six scholarships
and seven loan repayment programs in several allied
health professions, including nursing, mental health,
dentistry, and medicine. Scholarship programs provide
financial assistance to healthcare students who are
attending a California accredited college or university
and agree to practice in California's underserved
communities upon graduation. Loan repayment programs are
offered to working health professionals to assist in
repayment of their education debt in exchange for a
service obligation. Service obligations are typically
one to three years, and vary depending on the program.
Awards range from $4,000 to $105,000 dependent on
profession and length of service obligation. HPEF has
increased access to care in the state's underserved areas
via 6,693 awards totaling more than $60 million to health
practitioner awardees serving in 57 of the state's 58
counties;
b) California State Loan Repayment Program (SLRP).
Provides educational loan repayment assistance to primary
health care professionals who provide health care
services in federally designated Health Professional
Shortage Areas (HPSAs). Eligible health professionals
include physicians specializing in primary care fields,
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nurse practitioners, certified nurse-midwives, general
practice dentists, registered dental hygienists, clinical
or counseling psychologists, clinical social workers,
licensed counselors, pharmacists, physician assistants,
psychiatric nurse specialists, and marriage and family
therapists. Eligible health professionals must be
employed by or have accepted employment at a SLRP
Certified Eligible Site (which includes rural health
clinics, community health clinics, county facilities, and
federally qualified health centers) and must commit to
providing full-time or half-time primary care services in
a HPSA for a minimum of two years. Health professionals
may receive up to $50,000 in exchange for a two year
full-time service obligation and/or $25,000 for a two
year half-time service obligation; individuals can
receive up to $150,000 over six years at full-time and
$75,00 for half-time. SLRP award amounts are matched by
the site(s) in which the health professional is
practicing, on a dollar-for-dollar basis, in addition to
salary. The SLRP is funded through a grant from the
Health Resources and Services Administration Bureau of
Clinician Recruitment and Service, National Health
Service Corps (NHSC) and is administered by OSHPD;
c) Steven M. Thompson Physician Corps Loan Repayment
Program. This program is available for individuals who
have a valid, unrestricted license to practice medicine
in California as an allopathic or osteopathic physician
and surgeon. This program encourages recently licensed
physicians and surgeons to practice in HPSAs and Primary
Care Shortage Areas (PCSA) in California. Physicians and
surgeons pay an additional $25 fee during initial and
renewal of licensure to fund the program. The program
repays up to $105,000 in educational loans in exchange
for full-time service for a three-year commitment for
those currently employed or who have accepted employment
in an HPSA or PCSA. Priority consideration is given to
applicants who are best suited to meet the cultural and
linguistic needs and demands of patients from medically
underserved populations and who meet one or more of the
following: speak a Medi-Cal threshold language; come from
an economically disadvantaged background; have received
significant training in cultural and linguistically
appropriate service delivery; and have three years of
experience providing health care services to medically
underserved populations or in a medically underserved
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area. Preference is also given to those who agree to
practice in a medically underserved area and who agree to
serve a medically underserved population. Up to 20% of
the available funds may be awarded to program applicants
from specialties outside of the primary care specialties,
including psychiatry, anesthesiology, emergency medicine,
endocrinology and diabetes, general surgery, pediatric
emergency medicine, and child neurology;
d) Song-Brown Program. The Song-Brown Program was
established in 1973 to increase the number of family
physicians in the state and increase the number of family
medicine residency programs. Currently, Song-Brown
provides financial support to family medicine and primary
care residency (Internal Medicine, OB/GYN and Pediatric)
programs, family nurse practitioner programs, primary
care physician assistant training programs, and
registered nurse education programs. Funding is provided
to institutions that provide clinical training and
education in underserved areas, and healthcare to the
state's underserved population;
e) Mini Grants Program (Mini Grants). Provides grants
to organizations supporting underrepresented and
economically disadvantaged students in pursuit of careers
in health care. Organizations receive grants of up to
$15,000 to engage in health career conferences,
workshops, and/or career exploration activities. Since
2005, over $2.2 million has been awarded to support
organizations engaging in these activities serving nearly
56,000 students statewide. In 2014 to 2015, via partial
funding from Mental Health Services Act (MHSA) Workforce
Education and Training, the California Endowment, and the
California State Office of Rural Health, OSHPD awarded 46
Mini Grants to organizations for a sum of $603,706. This
will help support 16,555 students from demographically
underrepresented groups to pursue healthcare careers;
f) California Student/Resident Experiences and
Rotations in Community Health (CalSEARCH. Provides
grants to organizations that support student and resident
rotations from primary care and mental health disciplines
in community clinics, health centers, and public mental
health system sites which expose students, residents and
practitioners to underserved communities. Organizations
awarded receive funding to administer the program and to
provide students, residents, and preceptors and mentors a
small stipend for completing the program. In addition to
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completing a rotation in an underserved area,
participants are also required to complete a community
project. From 2009 to 2012, 150 students and residents
were supported via an American Recovery and Reinvestment
Act grant. In 2014 to2015, via funding from the MHSA
Workforce Education and Training and The California
Endowment, OSHPD granted 12 awards to organizations for a
sum of $317,000 which will help support 92 participants
statewide;
g) Licensed Mental Health Services Provider Education
Program. This program is available to individuals who are
licensed/registered mental health professionals with
either the Board of Behavioral Sciences or the Board of
Psychology. According to OSHPD, the following individuals
qualify for this program: licensed psychologist,
registered psychologist, postdoctoral psychological
fellow/trainee, LMFT, marriage and family therapist
intern, LCSW, and ACSW. These individuals pay an
additional $10 fee during initial and renewal
license/registration to fund the program. For a 24-month
service obligation at a "qualified facility," providing a
minimum of 32 hours of direct patient care, an individual
may receive up to $15,000 for loan repayment. Applicants
can only receive two awards for a total possible award of
up to $30,000 for loan repayment. "Qualified facility" is
defined as: 1) a publicly funded facility, 2) a publicly
funded or public MH facility, or 3) a nonprofit, private
MH facility that contracts with a county MH entity or
facility to provide MH services. Selection of awards is
based on the following criteria: work experience,
cultural and linguistic competence, career goals,
community service, community background, and fluency in a
language other than English. Priority is given to
individuals whose community background and commitment
indicates the likelihood of long-term employment in a
qualified facility even after the service obligation has
ended; and,
h) Mental Health Loan Assumption Program. MHLAP was
created by the MHSA, which provided funding to develop a
loan forgiveness program in order to retain qualified
professionals working within the Public Mental Health
System (PMHS). Through the Workforce Education and
Training component of the Act, $10 million is allocated
yearly to loan assumption awards. An award recipient may
receive up to $10,000 to repay educational loans in
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exchange for a 12-month service obligation in a
hard-to-fill or retain position within the County PMHS.
Counties determine which professions are eligible for
their county's hard-to-fill or retain positions. Some of
the eligible professions include, but are not limited to,
Registered or Licensed Psychologists, Registered or
Licensed Psychiatrists, Postdoctoral Psychological
Assistants, Postdoctoral Psychological Trainees,
Registered or Licensed Marriage and Family Therapists,
Registered or Licensed Clinical Social Workers, Licensed
Professional Clinical Counselors, Licensed Professional
Clinical Counselor Interns, and Registered or Licensed
Psychiatric Mental Health Nurse Practitioners in
California.Support, managerial and/or fiscal staff may be
eligible.
7)Support. The Pre-Health Dreamers state that in California
alone, there are 285 undocumented students in the PHD network
and among them 169 are interested in medicine, 16 in
dentistry, 26 in nursing, six in pharmacy, and many others
interested in allied health professions. PHD states that they
believe that their members can contribute significantly to the
quality of care in California because many are often bilingual
and bi-cultural, and are deeply motivated to give back to
their communities, which are often underserved. The
California Pan-Ethnic Health Network states that undocumented
individuals can serve as key practitioners to address chronic
shortages of medical professionals and they deserve to compete
in state programs that help defray the cost of their training,
especially when their licensing fees support these very
programs. Numerous supporters write that most undocumented
students, including those in the medical field, face major
challenges financing their education because they struggle to
access loans, and do not qualify for federal loan forgiveness
programs. The Asian Law Alliance writes that this bill will
ensure that all individuals who wish to pursue a medical
profession may compete for scholarships and loan repayments
available under HPEF. The National Immigration Law Center
writes that this bill promotes public health by increasing the
pool of qualified health professionals who will provide
culturally and linguistically competent medical services in
underserved areas. The American Academy of Pediatrics,
California states that while this bill underwrites a motion
that is the ethically right thing to do in support of our
medial trainees, it will also further our goals of building a
SB 1139 (Lara) Page 11 of ?
larger, stronger healthcare workforce. The Western Center on
Law and Poverty states that this bill will ensure that all
people, regardless of their immigration status, have access to
the state's scholarship and loan forgiveness programs for
health professionals. Educators for Fair Consideration states
that most undocumented students, including those in the
medical field, face major challenges financing their education
because they struggle to access loans, and do not qualify for
federal loan forgiveness programs. SEIU California writes that
they are committed to working toward comprehensive immigration
reform at the federal level to remove barriers to education
for immigrants, however, until those changes can happen at the
federal level, they support improvement of state law to ensure
that no one is discriminated against based solely on their
immigration status. The California Primary Care Association
writes that clinics cannot provide timely, quality, culturally
competent care if they do not have the health care workforce
needed to provide that care and that this bill w California
Pan-Ethnic Health Network il provide for health professional
students who plan to practice in the underserved communities
of California.
8)Opposition. Californians for Population Stabilization writes
that there is a limited amount of money available for
scholarship and loan forgiveness programs, and giving those
funds to illegal immigrants simply reduces the pool available
to legal students. CAPS further asserts that the State of
California has done an abysmal job of maintaining
infrastructure, protecting open spaces, and providing quality
public education, and much of its failure is due to the flood
of illegal immigration that has overwhelmed the state.
9)Amendments. The author has agreed to take the following
amendments:
(b) A program within the Health Professions Education
Foundation A program listed in (d) shall not deny an
application based on the citizenship status or immigration
status of the applicant.
(c) For any program within the Health Professions Education
Foundation listed in (d) , when mandatory disclosure of a
social security number is required, an applicant shall provide
his or her social security number, if one has been issued, or
an individual tax identification number that has been or will
be submitted.
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(d) This section shall apply to all of the following:
(1) Programs supported through the Health Professions
Education Fund pursuant to Section 128355.
(2) The Registered Nurse Education Fund created pursuant to
Section 128400.
(3) The Mental Health Practitioner Education Fund created
pursuant to Section 128458.
(4) The Vocational Nurse Education Fund created pursuant to
Section 128500.
(5) The Medically Underserved Account for Physicians created
pursuant to Section 128555.
(6) The Steven M. Thompson Medical School Scholarship Account
created pursuant to Section 128580.
(7) Loan forgiveness and scholarship programs created pursuant
to Section 5820 of the Welfare and Institutions Code.
(8) The Song-Brown Program created pursuant to 128200.
(9) To the extent permitted under federal law, the California
State Loan Repayment Program authorized under the U.S. Public
Health Services Act Title III, Section 3381(a)-(1) (42 U.S.C.)
Section 254q-1(a)-(i).
(10) The Mini Grants Program and the CalSEARCH Program created
pursuant to Section 127885.
SUPPORT AND OPPOSITION :
Support: California Pan-Ethnic Health Network (sponsor)
Pre-Health Dreamers (sponsor)
American Academy of Pediatrics
American Civil Liberties Union of California
Asian Law Alliance
California Immigrant Policy Center
California Mental Health Connection
California Primary Care Association
California State Council of the Service Employees
International Union (SEIU)
Community Health Partnership
Courage Campaign
Department of Medicine at the University of
California, Irvine
Doctors for America
Educators for Fair Consideration
The Greenling Institute
Having Our Say Coalition
Health Access California
Inland Empire Immigrant Youth Coalition
Latino Medical Student Association
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National Association of Social Workers
National Immigration Law Center
Services, Immigrant Right, and Education Network
(SIREN)
Stanford University's Latino Medical Student
Association
Western Center on Law & Poverty
Six Individual Letters
Oppose: Californians for Population Stabilization
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