Date of Hearing: May 21, 2020

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 3315

Author:(Eduardo Garcia) – As Introduced Ver:February 21, 2020

SUBJECT: Dentistry: foreign dental schools: applications.

SUMMARY: Repeals recently enacted provisions relating to how foreign dental schools are approved for approved for purposes of license education requirements in California.

EXISTING LAW:

1. Establishes the Dental Board of California (DBC) within the Department of Consumer Affairs (DCA) to regulate the practice of dentistry. (Business and Professions Code (BPC) §§ 1600 et seq.)
2. States that protection of the public shall be the highest priority for the DBC in exercising its licensing, regulatory, and disciplinary functions, and that whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount. (BPC § 1601.2)
3. Authorizes the DBC to grant a license to practice dentistry to an applicant who satisfies certain requirements, including a requirement that satisfactory evidence be provided that the applicant has graduated from a dental school approved by a national accrediting body approved by the board or by the Commission on Dental Accreditation of the American Dental Association. (BPC § 1634.1)
4. Beginning January 1, 2024, requires a school seeking approval as a foreign dental school to have successfully completed the international consultative and accreditation process with the Commission on Dental Accreditation (CODA) of the American Dental Association or a comparable accrediting body approved by the board. (BPC § 1636.4)

THIS BILL:

1. Repeals the requirement that schools seeking approval as a foreign dental school complete the international consultative and accreditation process with CODA beginning January 1, 2024 and restores prior provisions vesting the authority for approving foreign dental schools with the DBC.

FISCAL EFFECT: Unknown; this bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova. According to the author:

To date, the California Dental Board has evaluated and approved the accreditation of two (2) foreign dental schools: De La Salle University in Leon Guanajuato, Mexico in 2002, and the State University of Medicine and Pharmacy “Nicolae Testemitanu” in the Republic of Moldova in 2016. De La Salle University has been a remarkable success. Since its approval, De La Salle has graduated over 300 students, who have passed the required California exams, and many have established practices in low-income communities or are employed by community health clinics like AltaMed. As an example, La Salle graduates are proving dental care in the following communities; Baldwin Park, Bell, Boyle Heights, Chico, Chula Vista, Cudahy, East Los Angeles, El Monte, Fresno, Hemet, Indio, La Puente, National City, Oakland, and Pacoima. The Moldova foreign dental school was recently approved by Dental Board and will graduate its first class in 2021. The Moldova School currently matriculates (61 students), all slated to graduate in years 2021-2024. This disparity in the timeline for accreditation approval (CODA – 8 years; Dental Board - 3 years) imperils the very existence of the LaSalle and Moldova schools, as they now are required to successfully complete the accreditation process under CODA by January 1, 2024. This is an unrealistic deadline that will inevitably result in the loss of accreditation by both of these schools. More importantly, both schools have matriculated students, and intend to continue matriculating students, who now face the prospect of graduating from a non-accredited foreign school, nullifying their hard work and rendering their diplomas worthless

Background.

Statute currently recognizes that “the Legislature recognizes the need to ensure that graduates of foreign dental schools who have received an education that is equivalent to that of accredited institutions in the United States and that adequately prepares the students for the practice of dentistry shall be subject to the same licensure requirements as graduates of approved dental schools or colleges.” The intent of laws authorizing education obtained internationally to count toward California license requirements has historically been focused on ensuring immigrants who have been trained and educated in other countries have access to employment and opportunity upon relocating to California. Various laws aimed at supporting the admission of foreign-trained professionals into the workforce focus particularly on furthering cultural competency and increasing access to care in frequently underserved immigrant communities.

Applicants for licensure as dentists in California are required to submit proof to the DBC that they have met certain education requirements, including a requirement that they have “completed at dental school or schools the full number of academic years of undergraduate courses required for graduation.” For schools located within the United States and Canada, the DBC accepts the findings of the American Dental Association Commission on Dental Accreditation, or CODA, when they approve or reapprove a dental school located within the United States. These schools are accredited and re-evaluated by CODA every seven years.

Prior to 2015, CODA did not offer an accreditation process for foreign dental schools located outside the United States and Canada, and therefore education programs offered outside those countries could not become approved through the same CODA process. As a result, foreign-trained dental students could not present their degrees to the DBC for purposes of licensure as dentists. Attempts to solve this issue began in the 1970s, when California allowed international graduates who could pass a restorative technique exam performed to qualify to take the state’s licensure exam, without additional education at a CODA-accredited school. However, concerns grew that this process risked licenses being granted to underqualified foreign-trained dentists, and stakeholders engaged in extensive discussions and negotiations to determine what type of alternative accreditation process could be established for purposes of international schools not eligible for accreditation by CODA.

In 1996, AB 1116 (Keeley) was signed into law, creating a new process through which the DBC itself would approve international dental schools not accredited by CODA. According to an issues summary published by the California Dental Association in February 2007:

Although AB 1116 allowed the Dental Board to approve non-CODA accredited schools, the intent has always been for the board’s process to mirror CODA’s to the greatest extent possible. In fact, the Dental Board approached CODA about the possibility of contracting with it to evaluate foreign schools. CODA’s organizational structure at the time prevented the possibility of contracting. Nevertheless, the board utilized CODA accreditation standards in developing their own approval process regulations, and the board has since consistently included former CODA members in its site visits to applicant schools.

The DBC’s investigative process for reviewing applications from foreign dental schools, as outlined in regulations, required schools to meet basic curriculum requirements as well as administrative and programmatic standards to ensure a certain degree of equivalency with schools operating within the United States. An “onsite inspection and evaluation team” appointed by the board was then responsible for making “a comprehensive, qualitative onsite review of each institution that applies for approval.” This review included examining documents, inspecting facilities, auditing classes, and interviewing administrators, faculty, and students. Reviewed schools were required to reimburse the DBC for all reasonable costs incurred by staff and the site team relating to the inspection. The DBC was required to notify the school of whether it has been approved within 225 days of a completed application.

Between 1996 and 2019, only two foreign dental schools were ever approved by the DBC. The first, La Universidad De La Salle Bajío (“De La Salle”) was first approved in 2004 and is located in Leon, Guanajuato, Mexico. The second, the State of Medicine and Pharmacy “Nicolae Testemintanu” of the Republic of Moldova, received a two-year provisional approval in December 2016 and full approval in May 2018. While the DBC has conducted site visits for one other applicant, no other schools were approved over the approximately 23 years.

Over the past several years, policymakers questioned whether continuing to charge the DBC with responsibility for approving foreign dental schools continued to make sense.

In the background paper authored by the Senate and Assembly Business and Professions Committees during the DBC’s sunset review in March 2015, Issue #6 posed the question, “Is the process for approving foreign dental school sufficient? Should the Board consider heavier reliance on accrediting organizations for foreign school approvals if those options become available?” At that time, only De La Salle had ever been approved by the DBC, and the Moldova dental school was struggling to complete its application. While changing the process for approving foreign dental schools was contemplated during the 2015 sunset review, this ultimately did not occur due to a lack of identifiable alternatives to the DBC’s process.

Shortly after the completion of the DBC’s sunset review in 2015, major developments occurred in relation to foreign dental school approval, specifically in the successful establishment of a new process through CODA for foreign dental school approval. In November 2015, the American Dental Association House of Delegates officially established the CODA Standing Committee on International Accreditation, announcing that a review and approval process for foreign dental schools was now available from the same accrediting entity that had long approved schools located within the United States and Canada.

The CODA approval process includes completion of a Preliminary Accreditation Consultation Visit survey (PACV); a site visit and individual consultation; a PACV self-study and consultation visit; and ultimately an application for CODA accreditation. The process is explained in the following flow chart, provided by CODA:

Following the establishment of the CODA accreditation program for international dental schools, the issue of whether authority should be retained by the DBC was raised once again during the board’s sunset review in 2019. In a joint background paper published in February 2019, the committees asked again: “Should the current process by which the DBC approves foreign dental schools continue?” In its formal response to the background paper, the DBC made the following statement: “The DBC believes that the best way to meet the legislature’s need to ensure that graduates of foreign dental schools have received an education that is equivalent to that of accredited institutions in the United States is to require foreign dental schools to successfully complete the CODA international consultation and accreditation process that is currently available to all foreign dental schools.”

Another driver behind the Legislature’s reconsideration of whether the DBC should continue to approval foreign dental schools came from growing concerns about whether the State of Medicine and Pharmacy “Nicolae Testemintanu” of the Republic of Moldova should have been granted approval by the board. Shortly following the school’s full approval, members of the DBC grew concerned that additional details of the Moldova school’s recruitment program and admission standards were not disclosed in the application or to the DBC site evaluation team during the review.

In the DBC’s November 2018 meeting, the board discussed a recently uncovered flyer advertising the Moldova school titled “Become a dentist… while living in Europe!” The flyer was widely distributed in California through “the University of Moldova USA Inc.”—a separate entity operating an admissions office for the Moldova dental school based in Encino, CA. The flyer boasted that the school was “the only Dental School in English outside the United States Fully Approved by the Dental Board of California.” The flyer advertised that applicants to the school in Moldova were not required to have a college degree, or ACT or SAT scores. In addition to the flyer, a “Frequently Asked Questions” page on the University of Moldova USA Inc. site makes various statements clearly intended to recruit United States residents to travel to Moldova to fulfill their dental education requirements before returning to California to practice.

According to the DBC, the relationship between the dental school and the entity in Encino “was never divulged during the site evaluation conducted in October 2016.” It is apparent that the Moldova dental school has actively recruited students in California, promising DBC-approved dental school education (taught entirely in English) without the need for a four-year college degree. Further, the tuition charged to students recruited in the United States appeared to be four times that of Moldovan students.

The DBC discussed the potential misrepresentations by the dental school in Moldova multiple times during its public meetings. In November 2018, the DBC posed a number of questions to the DBC’s official representative, a former state senator; this representative indicated that he would not be able to answer the board’s numerous questions and that school leadership would have to travel to California to provide the requested information. However, no one from the school appeared at the February 2019 board meeting. Finally, leadership for the dental school in Moldova appeared at the DBC’s May 2019 board meeting, where they were questioned extensively about the relationship between the school and the University of Moldova USA Inc.

Ultimately, the DBC’s 2019 sunset bill was amended by the committees to finally transition the responsibility for approving foreign dental schools from the DBC to CODA. These provisions were strongly supported by the DBC itself, which stated openly that it did not feel it had the resources or expertise to effectively review and approve foreign schools, as evidenced by its approval of the dental school in Moldova. While representatives of the University of Moldova USA Inc. opposed the bill, it was not opposed by De La Salle, which was actively going through the CODA accreditation process.

The provisions of the DBC’s 2019 sunset bill required that the board cease accepting new applications from foreign dental schools beginning January 1, 2020, and that the board instead direct schools to CODA to apply for their accreditation. Currently, both foreign dental schools approved by the DBC remain approved until January 1, 2024, by which time they will have to have received CODA accreditation. This date aligns with the DBC’s next sunset review, allowing for the Legislature to consider extending the deadline further in the event that either school reasonably needs more time to receive accreditation. Meanwhile, graduates of a foreign dental school whose programs were approved at the time of graduation remain eligible for licensure by the DBC.

This bill, which the author states is sponsored by the State of Medicine and Pharmacy “Nicolae Testemintanu” of the Republic of Moldova, seeks to strike the changes made by the committees through the DBC’s sunset bill and revert the foreign school approval process back to what it was previously, where the DBC has sole responsibility for approving foreign schools.

Prior Related Legislation. AB 1519 (Low, Chapter 865, Statutes of 2019) enacted language transitioning authority for approving foreign dental schools from the DBC to CODA.

ARGUMENTS IN SUPPORT:

El Proyecto del Barrio, Inc. supports this bill. El Proyecto del Barrio, Inc. argues that “we support AB 3315 because the State, through the authority given to the Dental Board of California to accredit foreign dental schools, has been successful in increasing the number of dentists providing dental care in underserved areas. In general, dental provider shortages are well documented. This problem, in the case of low-income and minority populations, is compounded by language, education, cultural and ethnic barriers, as well as a lack of dentists who accept Medicaid.”

Clínica Monseñor Oscar A. Romero (Clinica Romero) also supports this bill. Clinica Romero states: “It is well known that many of our communities lack access to quality dental care, in part due to the shortage of dentists willing to take positions in community clinics like ours, or establish offices in minority low income areas. The accreditation of foreign dental schools by the California Dental Board provides an alternate process to increase the number of dentists willing to work in low income areas. We understand that up until last year, the California Dental Board has the authority to accredit foreign dental schools. AB 3315 will restore the foreign dental school accreditation to the California Dental Board, which in turn will result in an increase of qualified dental professionals providing vital dental care to our community.”

ARGUMENTS IN OPPOSITION:

The California Dental Association (CDA) opposes this bill. The CDA argues that “by shifting the approval process to CODA, foreign dental schools will be held to the same standards evaluated by the same institution as all dental schools in the United States. CODA oversight for foreign dental schools seeking approval in the U.S. is not only more efficient but a superior method to accreditation because graduates will be eligible to apply for licensure in all 50 states and therefore practice anywhere in the country. Additionally, having a single accrediting agency will ensure that all dentists who receive licensure in the U.S. have received training that meets a singular minimum standard.”

The Dental Board of California (DBC) also opposes this bill. According to the DBC, “the Board opposes this bill for the same reason that the Board supported the original change to CODA approval of foreign dental schools. Delegating this responsibility to an organization that specializes in it, allows the Board to focus on its primary duty of protecting California consumers through the administration and enforcement of the Dental Practice Act. Therefore, the Board opposes returning to the previous system.”

POLICY ISSUE(S) FOR CONSIDERATION:

The author makes several arguments for why they believe that the committees erred in their decision to transition authority to CODA. First, the author implies that the prior approval process through the DBC should be considered superior because it was long-standing, having been enacted through AB 1116 (Keeley) back in 1996. However, efforts to transition the approval of foreign dental schools away from the DBC were unsuccessful not due to the success of the DBC, but due to the lack of a process through CODA which now exists.

The author and supporters of the bill make repeated arguments that the prior approval process through the DBC was successful and should be preserved because it resulted in an increase of dental students from Mexico emigrating to California to practice in underserved areas, bringing with them cultural competency. However, the one school located in Mexico that has been approved by the DBC—De La Salle—did not oppose transitioning approval authority away from the DBC, and that school is currently going through the CODA process. The other approved school is located in the Moldova, a former Soviet republic with little representation in underserved California communities. The author has supplied no evidence that graduates of the school in Moldova are more likely to provide services in low-access areas.

Finally, the author has made repeated assertions that the timeline for schools to receive CODA accreditation is “unrealistic,” arguing that the approval process is “eight years.” This claim is easily refuted; the CODA process for approving foreign dental schools was essentially established at the beginning of 2016, and CODA approved its first school (located in Saudi Arabia) in August 2019, making the 8-year claim appear dubious. Further, the timeline provided for in statute allows for the Legislature to consider extending the transition timeline if it appears to be necessitated during the Legislature’s next sunset review of the DBC. There is no urgent reason to reverse changes deemed prudent by the committees at this time; instead, the sponsor of the bill should submit an application for approval through the CODA process and return to the Legislature in the event that it confronts reasonably insurmountable challenges.

REGISTERED SUPPORT:

Altamed Health Services

Arroyo Vista Family Health Center

Clinicas Del Camino Real, Inc.

Clinica Msr. Oscar A. Romero

Dolores Huerta Foundation

El Proyecto Del Barrio, Inc.

South Central Family Health Center

REGISTERED OPPOSITION:

California Dental Association

Dental Board of California

Analysis Prepared by: Robert Sumner / B. & P. / (916) 319-3301