BILL ANALYSIS Ó
SB 1139
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
1139 (Lara) - As Amended June 21, 2016
SENATE VOTE: 28-11
SUBJECT: Health professionals: medical residency programs:
undocumented immigrants: scholarships, loans, and loan
repayment.
SUMMARY: Makes 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
forgiveness programs from denying an application based on an
applicants' citizenship or immigration status. Specifically,
this bill:
1)Prohibits grant and loan forgiveness programs from denying an
application based on the citizenship status or immigration
status of an applicant.
2)Requires an applicant, for grant and loan forgiveness
programs, when mandatory disclosure of a social security
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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.
3)Applies 1) and 2) above to the following programs:
a) Programs supported through Health Professions
Education Foundation (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,
and,
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.
EXISTING LAW:
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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 the Office of Statewide
Health Planning and Development (OSHPD) concerning the funding
of those programs.
2)Establishes the 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.
FISCAL EFFECT: According to the Senate Appropriations
Committee:
1)Unknown fiscal impact on University of California (UC) 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
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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
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 UC 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 UC 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, OSHPD 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
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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.)
COMMENTS:
1)PURPOSE OF THIS BILL. 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 and the limited resources and lack of specialty
services in these communities leads to longer waiting times
and longer journeys to appointments. The author states this
bill would help to 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 the 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 an 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. The author
contends that, additionally, undocumented students also face
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challenges when applying to medical schools and medical
residency training programs, as their immigration status may
hold precedent over their academic qualifications, prompting
admission personnel to question their eligibility. The author
concludes, to address this barrier, this bill would clarify
the eligibility of undocumented individuals who meet the
requirements to apply to medical schools, and medical
residency training programs.
2)BACKGROUND.
a) Physician supply in California. A 2014 California
HealthCare Foundation (CHCF) report, "California
Physicians: Surplus or Scarcity?" found that the number of
physicians in California increased 39% from 1993 to 2011,
and has outpaced the state's 20% growth rate in the
general population. However, demand for physician
services is expected to increase with the aging of the
state's population and the implementation of the Patient
Protection and Affordable Care Act (ACA). The CHCF report
states that ensuring access to care is also a concern, as
close to one-third of California's physicians are near
retirement age: slightly more than 30% of California
physicians were over the age of 60 - only New Mexico had a
larger proportion of physicians in this age group. The
report also notes Latinos were underrepresented among
physicians. While 38% of the state's population was
Latino, only 4% of physicians were Latinos.
b) Access to healthcare. California is home to the
largest number of primary care physicians and nurse
practitioners in the country. However, the state ranks
23rd in the number of primary care physicians per
resident. The CHCF report states that California has only
35 to 49 primary care physicians per 100,000 Medi-Cal
enrollees. Federal guidelines call for the state to have
60 to 80 doctors per 100,000 patients. The supply of
primary care physicians also varies substantially across
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California's counties. The number of primary care
physicians actively practicing in California counties is,
in too many cases, at the bottom range of, or below, the
state's need. According to 2011 Health Resources and
Services Administration data, 29 of California's 58
counties fall at the lower end or below the needed supply
range for primary care physicians. In other words, half
of Californians live in a community where they do not have
adequate access to the health care services they need.
c) Supreme Court's Decision on Immigration. On June 23,
2016, the Supreme Court announced that it had deadlocked
on the case United States v. Texas, No. 15-674 which
effectively blocked President Obama's immigration plan.
The Deferred Action for Parents of Americans and Lawful
Permanent Residents (DAPA), and Deferred Action for
Childhood Arrivals (DACA) would have shielded from
deportation and/or made eligible for work permits three
categories of unauthorized immigrants:
i) DAPA (parents). Unauthorized parents of children
who are United States citizens or legal permanent
residents born on or before November 20, 2014 would be
shielded from deportation. To qualify parents must have
been in the US since January 1, 2010;
ii) DACA (children). Unauthorized immigrants born after
June 15, 1981 who were brought to the US before their
16th birthday and have been in the country since June 15,
2007; and,
iii) Expanded DACA. Unauthorized immigrants brought to
the US as children before January 2010.
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The status of young people who had qualified for the
initial DACA program, which was created in 2012, was not at
issue in the Supreme Court case. According to a February
2016 Migration Policy Institute report, "Deferred Action
for Unauthorized Immigrant Parents: Analysis of DAPA's
Potential effects on Families and Children," more than 10
million people live in households with at least one
potentially DAPA-eligible adult, and the majority of those
eligible for all of the president's initiatives live in
California, Texas, and New York.
d) 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 U.S. (1.8 million). This
results in an estimated 5,400 new largely underrepresented
minority physicians in the coming decades.
e) 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.
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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.
f) 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:
i) 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 HPEF 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.
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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;
ii) 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, 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
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Resources and Services Administration Bureau of
Clinician Recruitment and Service, National Health
Service Corps (NHSC) and is administered by OSHPD;
iii) 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 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;
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iv) 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;
v) 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;
vi) CalSEARCH.
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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
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 to 2015, 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;
vii) 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, Licensed Marriage and
Family Therapist, marriage and family therapist intern,
Licensed Clinical Social Worker, and Associate Clinical
Social Worker. 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
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for loan repayment. "Qualified facility" is defined
as: (1) a publicly funded facility; (2) a publicly
funded or public Mental Health (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,
viii) Mental Health
Loan Assumption Program (MHLAP). 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
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.
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3)SUPPORT. The California Pan-Ethnic Health Network and the
Pre-Health DREAMERS are the cosponsors of this bill and state
with implementation of the ACA, more Californians than ever
are newly insured but experience shortages of primary care
providers. The cosponsors note that while the state and
federal government have established various workforce
development programs to address the shortage of culturally and
linguistically appropriate health care providers, these
programs often maintain citizenship and immigration
restrictions that bar otherwise qualified and willing
undocumented individuals from participating. The co-sponsors
point out that higher education; undocumented individuals
attending a University of California or California State
University are eligible for in-state tuition and, beginning in
the 2015-2016 academic school year, have access to the state
funded DREAM program. The co-sponsors conclude that HPEF
provides scholarships or loan repayments to health
professionals for providing direct patient care in Medically
Underserved Areas and is funded in large part through health
professional licensing surcharges, and given the need for
culturally and linguistically appropriate providers in
underserved areas; undocumented individuals can serve as key
practitioners to address chronic shortages of medical
professionals.
The Mexican American Legal Defense and Educational Fund supports
this bill and notes that the organization worked on past
legislation to provide professional licenses regardless of
immigration status and believes this bill is the next logical
step in the process to ensure that immigrants are integrated
into California.
Western Center on Law and Poverty, the Latino Medical Student
Association, the California Academy of Family Physicians, and
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many other organizations support this bill, noting that
undocumented providers would be uniquely positioned to serve
diverse and underserved communities and that patients in
underserved areas face significant challenges to access health
care services.
4)RELATED LEGISLATION. SB 826 (Leno) which enacts the 2016-17
Budget clearly demonstrates the Legislatures' commitment to
providing additional funds for graduate medical education by
appropriating $33 million each year for three years, totaling
$100 million as follows:
a) $62 million to support existing primary care residency
slots;
b) $10 million to support the creation of new primary
care physician residency programs;
c) $10 million to fund new primary care residencies slots
at existing residency programs;
d) $17 million to support existing Teaching Health Center
primary care residencies; and,
e) $1 million to support the SLRP.
5)PREVIOUS LEGISLATION.
a) SB 1210 (Lara) Chapter 754, Statutes of 2014,
establishes the California DREAM Loan Program (CDLP) for
purposes of extending loans to students who meet the
requirements established by AB 540 (Firebaugh), Chapter
814, Statutes of 2001, and have financial need, and
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authorizes any campus of the UC and the California State
University to participate, as specified. This bill also
declares the Legislatures' intent that funds be
appropriated to participating institutions annually for
the CDLP; requires that participating institutions
annually contribute discretionary funds as specified, in
their CDLP revolving fund; and entitles each participating
institution to an administrative cost allowance equal to
5% of the loan funds it awards each year.
b) SB 1159 (Lara) Chapter 752, Statutes of 2014,
prohibits licensing boards under the Department of
Consumer Affairs from denying licensure to an applicant
based on his/her citizenship or immigration status, and
requires a licensing board and the State Bar of California
to require, by January 1, 2016, that an applicant for
licensure provide his/her individual ITIN or an SSN for an
initial or renewal license.
c) SB 150 (Lara) Chapter 575, Statutes of 2013,
authorizes a community college district to exempt pupils
attending community colleges as a special part-time
student from paying nonresident tuition.
d) AB 540 qualifies long-term California residents, as
specified, regardless of citizenship status, for lower
"resident" fee payments at the California Community
Colleges and the California State University.
6)TECHNICAL AMENDMENT. In order to clarify the bills intent it
should be amended as follows:
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2064.3. Notwithstanding any other law: law, any student,
including a person without lawful immigration status, a person
who is exempt from nonresident tuition pursuant to Section
68130.5 of the Education Code, or a person who is both without
lawful immigration status and exempt from nonresident tuition
pursuant to Section 68130.5 of the Education Code, who meets
the requirements for admission is eligible 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 and shall not be denied
based on the citizenship status or immigration status of the
applicant. .
REGISTERED SUPPORT / OPPOSITION:
Support
California Pan-Ethnic Health Network (cosponsor)
Pre-Health DREAMERS (cosponsor)
ACCESS Women's Health Justice
ACT for Women and Girls
Alianza
American Academy of Pediatrics, California
American Civil Liberties Union of California
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Asian Americans Advancing Justice
Asian and Pacific Islander Obesity Prevention Alliance
Black Women for Wellness
California Academy of Family Physicians
CaliforniaHealth+Advocates
California Immigrant Policy Center
California Latinas for Reproductive Justice
California Mental Health Connection
California Nurses Association
California Partnership
California Primary Care Association
California Psychological Association
California State Council of the Service Employees International
Union
Cambodian Family Community Center
Central Valley Partnership for Citizenship
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Coalition for Humane Immigrant Rights of Los Angeles
Community Health Partnership of Santa Clara
Council of Mexican Foundations
Courage Campaign
Doctors for America
Educators for Fair Consideration
El Centro Binacional para el Desarrollo Indigena Oaxaqueño
(Fresno, Greenfield)
El Quinto Sol de America
Fathers and Families of San Joaquin Valley
Fresno Center for New Americans
Greenlining Institute
Having Our Say
Health Access California
Inland Empire Immigrant Youth Coalition
Korean Community Center of the East Bay
Korean Resource Center
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Latino Coalition for a health California
Latino Medical Student Association
Madera Coalition
Mexican American Legal Defense and Educational Fund
Mid-City CAN
National Association of Social Workers
Nile Sisters Development Initiative
PALS for Health
Roots Community Health Center
Services, Immigrant Rights, and Education Network
South Asian Network
Southeast Asia Resource Action Center
Stanford University Latino Medical Student Association
Street Level Health Project
United Farm Workers
Venice Family Clinic
Village Connect, Inc.
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Vision y Compromiso
Western Center on Law & Poverty
Two individuals
Opposition
None on file.
Analysis Prepared by:Lara Flynn / HEALTH / (916)
319-2097