BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 1139| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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. SB 1139 Page 2 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 SB 1139 Page 3 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 SB 1139 Page 4 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 SB 1139 Page 5 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, SB 1139 Page 6 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 SB 1139 Page 7 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.) SB 1139 Page 8 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 SB 1139 Page 9 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. SB 1139 Page 10 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 / ****END****