Date of Hearing: May 1, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1619

Author:(Weber) – As Amended Ver:April 11, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill appropriates $20 million dollars from the General Fund (GF) to the Office of Statewide Health Planning and Development (OSHPD) for the purpose of reducing the shortage of, and disparity in, mental health services across the state by supporting career pipeline programs, recruitment of underrepresented students to pursue mental health careers, college scholarships, and recruitment to practice mental health care in community clinics.

FISCAL EFFECT:

$20 million to OSHPD for programs described in the legislation. OSHPD administrative costs are assumed to be around 5%, or $1 million of the $20 million, with the remaining funds available to provide grant funding. Administrative costs could be higher if new programs are created versus augmenting existing similar programs.

COMMENTS:

1. Purpose. According to the author, studies show students who grew up in underserved areas are more likely to set up practice in those areas when they become physicians, dentists or other health professionals. The author indicates that this bill capitalizes on this trend by providing increased funding and by creating an outreach program to attract and recruit students from low-income and underrepresented communities into mental health professions.
2. Background. The Health Professions Education Foundation is a state non-profit established in 1987 and housed within OSHPD. HPEF administers scholarships and loan repayments programs to health professional students and graduates who are dedicated to providing direct patient care in underserved areas.

State funding allocated for mental health workforce development has decreased, while mental health workforce shortages exist in many practice specialties and geographic areas in California. The Workforce Education and Training (WET) component of the 2004 Mental Health Services Act (Proposition 63, a tax on high-income earners to fund community mental health) set aside $445 million for mental health workforce development, including loan repayment programs, over the past decade. Pursuant to current law, the funding set-aside for the WET program ceased in 2018-19, but the 2018-19 Budget Act provided $10 million one time to continue this program and an additional $1 million to fund psychiatry fellowships at two University of California medical schools.

1. Related Budget Proposal. The governor’s proposed 2019-20 budget includes a $50 million GF investment in the Office of Statewide Health Planning and Development to support behavioral health workforce programs, including targeted funding for the STLRP that would provide loan repayment to psychiatrists.
2. Major Health Workforce Study. The California Future Health Workforce Commission was a recent foundation-supported statewide effort comprised of senior leaders across multiple sectors, including health, education, employment, labor and government. In a report released in January 2019, the commission noted a shortage of behavioral health providers and recommended expanding funding for educational capacity, stipends and scholarships to strengthen the size, distribution and diversity of the behavioral health workforce.
3. Related Legislation. AB 565 (Maienschein), pending referral in the Senate, expands the definition of “practice setting,” for purposes of the STLRP to include a program or facility operated by a county mental health plan.

AB 1759 (Salas), also pending in this committee, appropriates $50 million from the GF to OSHPD to increase the health care workforce in rural and underserved areas.

SB 539 (Caballero), pending in the Senate Appropriations Committee, creates and transfers a specified amount of Mental Health Services Act revenue into the Mental Health Services Workforce Education and Training Account, to be continuously appropriated to the Office of Statewide Health Planning and Development for the purpose of funding the five-year education and training development plan. It also appropriates $70 million from the General Fund for the same purpose.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 23, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1619

Author:Weber – As Amended Ver:April 11, 2019

SUBJECT: Mental health careers: funding.

SUMMARY: Appropriates $20 million dollars from the General Fund (GF) to the Office of Statewide Health Planning and Development (OSHPD) for the purpose of reducing the shortage of, and disparity in, mental health services across the state. Specifically, this bill:

1. Appropriates $20 million dollars from the GF to OSHPD for the purpose of reducing the shortage of, and disparity in, mental health services across the state.
2. Requires the funds to be used for one or more of the following:
   1. Expanding and scaling pipeline programs to recruit and prepare pupils and students, who are from an underrepresented group, for mental health careers;
   2. Recruiting and supporting students enrolled in a postsecondary educational institution, who are from both an underrepresented group and a mental health professional shortage area, to pursue mental health careers;
   3. Supporting scholarships for students enrolled in a postsecondary educational institution who pursue a mental health profession and serve in a mental health professional shortage area; or,
   4. Recruiting and training students enrolled in a postsecondary educational institution, who are from a rural area or a mental health professional shortage area, to practice mental health care in a community health center in that area.
      
3. Defines the following terms:
   
   1. “Mental health professional shortage area” means an area designated as such by the Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services;
   2. “Postsecondary educational institution” means a public or private institution of vocational, professional, or postsecondary education; the governing board of a community college district; the Regents of the University of California; or the Trustees of the California State University;
   3. “Rural area” means a medical service study area (MSSA) with a population density of fewer than 250 persons per square mile and no population center in excess of 50,000 within the area, as determined by OSHPD.
   4. “Underrepresented group” means African-Americans, Native Americans, Hispanic-Americans, or other persons underrepresented in medicine, dentistry, nursing, or other health professions as determined by the Health Professions Education Foundation (HPEF).

EXISTING LAW:

1. Establishes the Mental Health Services Act (MHSA), enacted by voters in 2004 as Proposition 63, to provide funds to counties to expand services, develop innovative programs, and integrated service plans for mentally ill children, adults, and seniors through a 1% income tax on personal income above $1 million.
2. Establishes HPEF within OSHPD to develop criteria for evaluating applicants for various scholarships and loan programs.
3. Creates the Steven Thompson Loan Repayment Program (STLRP) within HPEF, which provides for the repayment of educational loans for physicians and surgeons who practice in medically underserved areas (MUA) of the state, as defined.
   
4. Defines an MUA as a federal Health Professions Shortage Area (HPSA) or an area of the state where unmet priority needs for physicians exist as determined by the California Healthcare Workforce Policy Commission. Indicates that HPSAs are designations that indicate health care provider shortages in primary care, dental health, or mental health and these shortages may be geographic-, population-, or facility-based.
   
5. Creates the Medically Underserved Account for Physicians within the HPEF for the primary purpose of providing funding for the STLRP to repay loans per agreements made with physicians, including loan repayments to not exceed $105,000 per individual licensed physician and do not exceed the amount of the educational loans incurred by the physician participant.
   
6. Requires OSHPD and the HPEF to develop guidelines for the selection and placement of STLRP applicants with priority consideration given to applicants best suited to meet the cultural and linguistic needs of patients by meeting such criteria as speaking a Medi-Cal threshold language, being from an economically disadvantaged background, having significant training in culturally and linguistically appropriate service delivery, having three years of experience working in a medically underserved areas or with a medically underserved population, and agreeing to practice in a medically underserved area.
   

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, access to behavioral health care in California was bolstered by the passage of the federal Patient Protection and Affordable Care Act, which allowed states to expand eligibility for Medicaid and broadened the scope of covered behavioral services. However, while there has been progress in expanding access to mental health care, many patients are left unserved due to drastic shortage of mental health care providers currently practicing in California. The author states that studies show that students who grew up in underserved areas are more likely to set up practice in the area when they become physicians, dentists, or other health professionals, and concludes that this bill capitalizes on this trend by providing increased funding, and creating an outreach program to attract and recruit students from low income and underrepresented communities into mental health professions.
   
2. BACKGROUND. According to a February 2019 report from the California Future Health Workforce Commission (Commission), 7 million Californians, the majority of them Latino, African-American, and Native American; already live in HPSAs a federal desig­nation for counties experiencing shortfalls of primary care, dental care, or mental health care providers. These shortages are most severe in some of California’s largest and fastest-growing regions, including the Inland Empire, Los Angeles, and San Joaquin Valley, and in most rural areas.
   1. Mental health in California. Mental health disorders are among the most common chronic illnesses that people face, both in the United States and in California. According to the California HealthCare Foundation’s March 28, 2018, publication, “Many Californians Have Coverage, but Not Care, for Mental Health Conditions,” nearly one in six adults statewide experiences a mental illness of some kind in any given year. One in 24 has a serious mental illness resulting in functional impairment that limits activities of daily life. Children and teenagers also experience mental health disorders at high rates: one in 13 has an emotional disturbance that limits participation in regular activities. California has a statewide suicide rate slightly below the national average, but the suicide rate in the Northern and Sierra region is nearly triple that of Los Angeles County.
      
      While mental illnesses generally can be managed successfully, many people miss out on treatment, with significant differences by race and ethnicity, region, age, and income, with lower income adult Californians disproportionately suffering from serious mental illnesses and lower income children suffering from serious emotional disturbances. Nearly two-thirds (63%) of adults with a mental illness do not receive treatment. Of the one in eight teenagers with depression, only about one-third (30.5%) receive treatment.
   2. HPEF, Workforce Education and Training (WET). The HPEF is a state non-profit established in 1987 and housed within OSHPD. HPEF has awarded more than 16,385 scholarships and loan repayments totaling more than $186.75 million to California health professionals serving in all 58 counties in areas of unmet need. #
      
      The MHSA included a component for WET programs. A 10-year budget allocated $210 million to counties for local WET program implementation and $234.5 million for state administration of WET programs. The WET program aims to remedy the shortage of mental health practitioners in the public mental health system via programs that fund stipends, mental health loan assumption, education capacity, consumer and family member employment, and regional partnerships. Some of these funds went to create the Mental Health Loan Assumption Program, in order to retain qualified professionals working within the Public Mental Health System. Counties determine which professions are eligible for their 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 (LPCCs), LPCC Interns, and Registered or Licensed Psychiatric Mental Health Nurse Practitioners in California. Support, managerial and/or fiscal staff may be eligible.
   3. Governor’s Budget proposal. The Governor’s budget proposes $50 million in one-time General Fund (GF) to expand the mental health workforce. Specifically, OSHPD requests multi-year appropriation authority of $50 million GF beginning in fiscal year 2019-20, through 2024-25, to support mental health workforce development programs. OSHPD does not anticipate the need for any additional legislation to implement the proposal, as the funds will support existing programs. OSHPD proposes to fund the following programs:
      

These programs support mental health professionals in the entire mental health workforce. According to OSHPD, the intent of the $50 million allocation was to support existing programs that provide scholarships and loan repayments to mental health professionals.

All of the programs supported by the Governor’s $50 million provide financial incentives for mental health professionals to work in underserved areas.

For all programs, there can be two to four times the number of applicants than individuals awarded. Applications for four of the programs open in August 2019.  At that time, OSHPD will understand the demand from mental health professionals to better assess how to allocate funds across the programs to ensure appropriate distribution of funds. OSHPD expects that the $50 million augmented funding, spent at $10 million per year, will allow OSHPD to make a significant difference in the number of awards to mental health professionals.

• 1. The Commission. The Commission, convened by major health philanthropies in 2017, was made up of experts in health care, community health, education, and health policymaking. Its charge was to create a comprehensive strategy with actionable recommendations, to be implemented between 2019 and 2030, to close the significant and growing gap between the health workforce that exists in California today and the one that will be required in the near future. The Commission’s Recommendation 1.5 states:  Expand funding for educational capacity, stipends, and scholarships to strengthen the size, distribution, and diversity of the behavioral health workforce.  This includes investing in scholarships and loan forgiveness programs. The Commission has identified behavioral health as one of their priority professions.
     

1. SUPPORT. The Association of California Healthcare Districts (ACHD) supports this bill and states that Healthcare Districts located in rural and remote areas of the state are continually challenged with recruiting and retaining health professionals to their areas, including mental health providers. Additionally, there is a significant maldistribution of behavioral health providers in the state, creating a challenge for Healthcare Districts to provide such care to their communities. ACHD has historically supported various efforts to remedy workforce and access to care challenges faced by Healthcare Districts in rural and underserved areas of the state. ACHD concludes that this bill will play a critical role in increasing access to much needed mental health care for Californians.
   
2. RELATED LEGISLATION.
   1. AB 565 (Maienschein) expands the definition of “practice setting,” for purposes of the STLRP to include a program or facility operated by a county mental health plan.
   2. AB 850 (Lackey) would establish the California Social Worker Student Loan Repayment Program in OSHPD to provide loan repayment awards to individuals who have completed a bachelor’s degree in social work, have received a student loan in order to meet the costs associated with obtaining that degree, have been employed as a child welfare social worker for five years, and continue to have repayment obligations on the student loan at the end of that five-year employment period. AB 850 would also require that the loan repayment award be equal to 50% of the balance remaining on the student loan at the end of the five-year employment period. AB 850 would also authorize the OSHPD to adopt rules and regulations for the purpose of administering the program and would make its provisions operative only upon appropriate funding, as determined by the OSHPD, being made available by appropriation of the Legislature or other sources. AB 850 is pending in the Assembly Committee on Revenue and Taxation.
   3. AB 1759 (Salas) appropriates $50 million from the GF to OSHPD to increase the health care workforce in rural and underserved areas.
   4. SB 10 (Beall) would require the State Department of Health Care Services to establish, no later than July 1, 2020, a statewide peer, parent, transition-age, and family support specialist certification program, as a part of the state’s comprehensive mental health and substance use disorder delivery system and the Medi-Cal program. SB 10 is currently pending on the Senate Appropriations Committee suspense file.
   5. SB 11(Beall) would require a health care service plan and a health insurer to submit an annual report to the Department of Managed Health Care or the Department of Insurance, as appropriate, certifying compliance with state and federal mental health parity laws. SB 11 is pending a hearing in the Senate Health Committee.
      
   6. SB 12 (Beall) would require the Mental Health Services Oversight and Accountability Commission (MHSOAC), subject to the availability of funds for these purposes, to administer an Integrated Youth Mental Health Program for purposes of establishing local centers to provide integrated youth mental health services. SB 12 would authorize MHSOAC to establish the core components of the program. SB 12 is currently pending on the Senate Appropriations Committee suspense file.
      
   7. SB 539 (Caballero) would, among other provisions, appropriate $70 million from the GF to OSHPD for the purpose of funding the 5-year education and training development plan. SB 539 is pending a hearing in Senate Health Committee.
      
3. POLICY COMMENT. This bill appropriates $20 million from the GF to increase the mental health workforce. AB 1759 (Salas) appropriates $70 million for rural health workforce expansion, and SB 539 (Caballero) includes $70 million to implement the WET plan. The Legislature may wish to consider how these bills, the Governor’s budget proposal, and the Workforce Commissions’ recommendations all work together.
   

REGISTERED SUPPORT / OPPOSITION:

Support

Association of California Healthcare Districts, and Affiliated Entity Alpha Fund

Depression and Bipolar Support Alliance California

National Association of Social Workers, California Chapter

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097