BILL ANALYSIS                                                                                                                                                                                                    Ó






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          |SENATE RULES COMMITTEE            |                       SB 1139|
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                                   THIRD READING 


          Bill No:  SB 1139
          Author:   Lara (D), et al.
          Amended:  4/19/16  
          Vote:     21 

           SENATE HEALTH COMMITTEE:  7-2, 4/13/16
           AYES:  Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
           NOES:  Nguyen, Nielsen

           SENATE APPROPRIATIONS COMMITTEE:  5-2, 5/27/16
           AYES: Lara, Beall, Hill, McGuire, Mendoza
           NOES: Bates, Nielsen
           
           SUBJECT:   Health professionals:  medical residency programs:   
                     undocumented immigrants:  scholarships, loans, and  
                     loan repayment


          SOURCE:    California Pan-Ethnic Health Network
                     Pre-Health Dreamers

          DIGEST:  This bill 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. 









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          ANALYSIS: 
          
          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 Office of Statewide  
            Planning and Development (OSHPD) concerning the funding of  
            those programs.

          2)Establishes the Health Professions Education Foundation (HPEF)  
            within OSHPD.  Requires HPEF to solicit and receive funds from  
            foundations and other private and public sources and to  
            provide financial assistance in the form of scholarships or  
            loans to students in the health professions who are from  
            underrepresented groups. 

          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.  

          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.

          2)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  







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            employment for students in a medical residency training  
            program whose participation is authorized by this section.

          3)Prohibits programs within the HPEF from denying an application  
            based on the citizenship status or immigration status of the  
            applicant.

          4)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.

          5)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)   Loan forgiveness and scholarship programs created  
               through the Mental Health; Services Act;
             g)   The Song-Brown Health Care Workforce Training Act 
             h)   To the extent permitted under federal law, the  
               California State Loan Repayment Program; and, The Mini  
               Grants Program and the California's Student/Resident  
               Experiences and Rotations in Community Health, or  
               CalSEARCH, Program.

          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  







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            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)Statewide shortages of health care providers. 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 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. 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  







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            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  
            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 heard 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,  







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            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  
            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. 


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No


          According to the Senate Appropriations Committee:

          1)Unknown fiscal impact on University of California medical  
            residency programs (General Fund, federal funds, and UC  
            enterprise funds). Under current practice, undocumented  
            immigrants who are authorized to work in the United States and  
            have a social security number can enter a UC residency  
            program. However, the bill would make undocumented immigrants  
            who are not authorized to work in the United States eligible  
            for UC medical residency programs. Medical residents are  
            employees of UC medical centers, rather than students. UC  







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            indicates that if medical residency programs were to admit  
            undocumented immigrants without authorization to work, UC  
            could be in violation of federal law. In addition, because  
            medical residency placements are mostly funded by the federal  
            government, funding would not be available for undocumented  
            medical residents

            In theory, the University could create residency "look-alike"  
            positions that were classified as students, not employees, and  
            were funded without using federal funds. The number of  
            undocumented students who would apply for and be admitted to  
            such a program is unknown. Nationwide, the average Medicare  
            subsidy to hospitals per residency slot is about $110,000 per  
            year. The University would have to cover all the costs of  
            offering such residency slots. Historically, the state General  
            Fund has not been used to support medical residency training.  
            To the extent that UC would allow medical residency training  
            in some form without federal financial support, there would be  
            pressure on the state to provide General Fund support for such  
            programs.

          2)Unknown cost pressure on various programs that provide  
            financial support for medical professionals (various special  
            funds). OSHPD operates several programs that provide financial  
            support for health professionals who agree to provide service  
            in areas that are medically underserved. Under current law and  
            practice, the Office does not allow undocumented individuals  
            to access those programs. By expanding eligibility for those  
            programs, the bill will impose cost pressures on those funds,  
            due to a larger population who would be eligible for existing  
            funds. The size of the impact is not known, because there is  
            limited information available about the number of undocumented  
            individuals who would be eligible for funding under the bill.  
            Based on the current undocumented population in the state and  
            available information about college attendance rates in the  
            undocumented population and the number of college students  
            going into medicine, staff estimates fewer than 50  
            undocumented immigrants are likely to apply for funding per  
            year. (This estimate also assumes a much higher percentage of  
            undocumented would be willing to provide services in medically  
            underserved areas and therefore would be eligible for these  
            programs than is the case for the larger population of health  
            care workers.)








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          SUPPORT:   (Verified5/27/16)


          California Pan-Ethnic Health Network (co-source)
          Pre-Health Dreamers (co-source)
          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
          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 
          National Association of Social Workers 
          National Immigration Law Center
          Services, Immigrant Right, and Education Network
          Stanford University's Latino Medical Student Association
          Western Center on Law & Poverty
          Six Individual Letters


          OPPOSITION:   (Verified5/27/16)




          Californians for Population Stabilization 

          ARGUMENTS IN 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  







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          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 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.







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          ARGUMENTS IN 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. 
          
          
          5/28/16 17:15:03 
          Prepared by:Melanie Moreno / HEALTH /



                                          
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