Existing law provides for the licensure and regulation of various healing arts professions and vocations by boards established within the Department of Consumer Affairs, and establishes the standards for licensure or certification of health professionals. Existing law makes certain violations of specified provisions relating to healing arts by a licensee or registrant a crime.

This bill would require a healing arts board, as defined, to require a licensee or registrant who electronically renews their license or registration to provide to that board the licensees or registrants individual National Provider Identifier, if they have one. The bill would provide that a violation of the bills requirements is not a crime.

Existing law provides for the licensure and regulation of various healing arts professions and vocations by boards established within the Department of Consumer Affairs, and establishes the standards for licensure or certification of health professionals. Existing law makes certain violations of specified provisions relating to healing arts by a licensee or registrant a crime.

This bill would require a healing arts board, as defined, to require a licensee or registrant who electronically renews their license or registration to provide to that board the licensees or registrants individual National Provider Identifier, if they have one. The bill would provide that a violation of the bills requirements is not a crime.

Existing law provides for the licensure and regulation of various healing arts professions and vocations by boards established within the Department of Consumer Affairs, and establishes the standards for licensure or certification of health professionals. Existing law makes certain violations of specified provisions relating to healing arts by a licensee or registrant a crime.

This bill would require a healing arts board, as defined, to require a licensee or registrant who electronically renews their license or registration to provide to that board the licensees or registrants individual National Provider Identifier. Identifier, if they have one. The bill would provide that a violation of the bills requirements is not a crime.

Existing law establishes uniform requirements for the reporting and collection of workforce data from health care-related licensing boards. Existing law requires certain boards that regulate healing arts licensees or registrants to request specified workforce data from their respective licensees and registrants and requires the data to be requested at the time of electronic license or registration renewal, as specified. Existing law provides that a licensee or registrant is not required to provide the specified workforce data as a condition for license or registration renewal, and that those individuals who do not provide that data are not subject to discipline.

This bill would, instead, require certain boards that regulate healing arts licensees or registrants to collect workforce data from their respective licensees or registrants, and would require that data to be required at the time of electronic license or registration renewal, as specified. The bill would, instead, require a licensee or registrant to provide the specified workforce data as a condition for license or registration renewal and would prohibit certain boards, notwithstanding that condition, from denying an application for license or registration renewal solely because the licensee or registrant failed to provide any of the workforce data. The bill would delete the provision that specifies that a licensee or registrant shall not be subject to discipline for not providing that information.

Existing law establishes the Department of Health Care Access and Information and requires the department to maintain a Health Professions Career Opportunity Program to, among other things, implement programs at colleges and universities selected by the department and include in those programs pipeline programs that provide comprehensive academic enrichment, career development, mentorship, and advising in order to support students from underrepresented regions and backgrounds to pursue health careers.

This bill would make technical, nonsubstantive changes to this provision.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1991

Author:(Bonta)

As Amended Ver:July 2, 2024

Majority vote

SUMMARY

Requires all healing arts boards under the Department of Consumer Affairs (DCA) to require their licensees or registrants who electronically renews their license or registration to provide to that board the licensee’s or registrant’s individual National Provider Identifier, if they have one.

Senate Amendments

1. Strike the majority of the contents of the prior bill to narrow the required information to be collected by each board to only require each licensee's or registrant's National Provider Identifier, if they have one.
2. Provide that a violation of the bill’s requirements is not a crime.

COMMENTS

California has long faced significant gaps and inequities in its health care workforce. There has historically been a persistent shortage of accessible health professionals overall, which disproportionately impacts communities with concentrated populations of immigrant families and people of color. A recent study found that between 2010 and 2019, the number of primary care physicians in proportion to population remained largely unchanged nationally. Meanwhile, counties with a higher proportion of minorities saw a decline during that period.

Compounding these issues of access is a significant lack of diversity among health care practitioners, with several minority groups remaining persistently underrepresented within the healing arts. A recent study of data from the American Community Survey and the Integrated Postsecondary Education Data System found that Black, Hispanic, and Native American people are nationally represented across 10 different health professions. As a result, minorities seeking to enter these professions face significant systemic obstacles, and patients who are representative of minority groups or immigrant communities often do not have access to practitioners who possess the cultural or linguistic competence to provide them with appropriate care.

Research cited by the California Health Care Foundation in its 2021 report found that while 39 percent of Californians identified as Latino/x in 2019, only 14 percent of medical school matriculants and 6 percent of active patient care physicians in California were Latino/x. A 2018 study published by the Latino Policy & Politics Initiative at the University of California, Los Angeles found that while nearly 44% of the California population speaks a language other than English at home, many of the most commonly spoken languages are underrepresented by the physician workforce. While the physician community has worked with the Medical Board of California to improve linguistic competency among providers, these efforts have yet to resolve systemic challenges with addressing language barriers in California.

Another issue resulting from underrepresentation in the health professions relates to implicit bias. According to the Stanford Encyclopedia of Philosophy, "implicit bias" can be described as "a term of art referring to relatively unconscious and relatively automatic features of prejudiced judgment and social behavior." In her 2019 book Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do, Dr. Jennifer L. Eberhardt explains that "implicit bias is not a new way of calling someone a racist. In fact, you don't have to be a racist at all to be influenced by it. Implicit bias is a kind of distorting lens that's a product of both the architecture of our brain and the disparities in our society." Dr. Eberhardt goes on to describe how "bias is not limited to one domain of life. It is not limited to one profession, one race, or one country. It is also not limited to one stereotypic association."

In December 2015, the American Journal of Public Health published a systematic review titled Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes. The review concluded that "most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color." Additional published studies suggest that implicit bias in regards to gender, sexual orientation and identity, and other characteristics has resulted in inconsistent diagnoses and courses of treatment being provided to patients based on their respective demographic. These trends take into account not only the characteristics of the person being treated, but those of the licensed professional in correlation to that patient.

The results of implicit bias can have serious consequences in the provision of health care. For example, one frequently cited statistic is that Black women have average maternal mortality rates that are three-to-four times higher than white women. While much of the research and action relating to implicit bias has been focused on the area of law enforcement and police procedure, there has been a growing call to also address the presence of implicit bias in the healing arts professions through additional awareness and training. In 2019, the Legislature enacted Assembly Bill 241 (Kamlager-Dove) to require continuing education courses for physicians and surgeons, nurses, and physician assistants to include the understanding of implicit bias and the promotion of bias-reducing strategies. While implementation of these requirements has undoubtedly had at least some impact on improving health care outcomes for minority patients, education and training is not a substitute for increasing diversity and representation among providers.

In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California's Health Care Workforce. This hearing included perspectives from various stakeholders and public health researchers, along with policymakers who provided updates on the state’s efforts to increase diversity. The background paper for the hearing cited research published in December 2022 by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in a report titled "The Race and Ethnicity of the California Health Care Workforce," which demonstrated that “a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care." As explained in the Health Committee's background paper, underrepresentation in the health care workforce both “contributes to health disparities" and "limits access to high-paying, meaningful professions for underrepresented minorities."

California has attempted to resolve these longstanding issues of representation and access through a number of different approaches. The Legislature has previously enacted and funded loan repayment programs, such as the Dental Corps Loan Repayment Program of 2002, which provided grants to qualifying dentists who agreed to work for at least three years in a clinic or dental practice located in a dentally unserved area, or in which at least 50 percent of patients are from a dentally underserved population. The Health Professions Career Opportunity Program within the Department of Health Care Access and Information (HCAI) similarly supports initiatives designed to enhance diversity and representation in the health professions by awarding grant funding through competitive programs.

As discussed in the Health Committee's background paper, it is often challenging to evaluate the long-term impacts of these programs, as "HCAI does not currently collect longitudinal data that could demonstrate which of these programs are more effective." During sunset review oversight hearings on healing arts boards that were held jointly in 2024 by the Assembly Committee on Business and Professions and the Senate Committee on Business, Professions, and Economic Development, committee members expressed frustration that there was not sufficient data to confirm whether any particular strategy to improve access has been successful. This is in large part due to a lack of consistent data from healing arts licensees to inform policymakers about how many practitioners of particular specialties are providing services in any given area of the state, or about the demographic makeup of those practitioners.

The California Health Workforce Research and Data Center, previously established in 2007 as the Healthcare Workforce Clearinghouse under the prior Office of Statewide Health Planning and Development, serves as California's central source for collection, analysis, and reporting of information on the healthcare workforce employment and educational data trends for the state. As part of its statutory duties, HCAI is mandated to prepare an annual report to the Legislature that accomplishes the following three goals: (1) identifying education and employment trends in the health care professions (2) reporting on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas; and (3) recommending state policy needed to address issues of workforce shortage and distribution.

In 2014, the Legislature enacted Assembly Bill 2102, authored by Assemblymember Phil Ting and co-sponsored by the California Pan-Ethnic Health Network and the Latino Coalition for a Healthy California. The bill required four specified healing arts boards—the Board of Registered Nursing, the Physician Assistant Board, the Respiratory Care Board of California, and the Board of Vocational Nursing and Psychiatric Technicians—to collect and report specific demographic data related to its licensees. Specifically, AB 2102 mandated that the four boards collect the following data from licensees: (1) location of practice, including city, county, and zip Code; (2) race or ethnicity; (3) gender; (4) languages spoken; (5) educational background and (6) classification of primary practice site, such as clinic, hospital, managed care organization, or private practice. In order to implement AB 2102, the DCA and HCAI established an interagency agreement to facilitate the specified data collection and exchange.

Subsequently, language was included in the omnibus health trailer bill as part of the Budget Act of 2021 consolidating the existing workforce data collection requirements for the four healing arts boards into one section with an expanded list of data points. However, the trailer bill did not require this data to be collected by any additional boards under the DCA; instead, it provided that all other healing arts boards request the information. The trailer bill also expressly provided that licensees could not be required to provide the information as a condition for license renewal, and that they could not be disciplined for failing to provide the information.

This bill would additionally require all healing arts boards to collect each licensee or registrant’s National Provider Identifier, if they have one. A National Provider Identifier is a unique, 10-digit identification number that is used to identify providers in electronic transactions. Access to National Provider Identifier information would assist state policymakers in their goals to increase diversity in the health care workforce by providing a structured and comprehensive way to track and analyze demographic data about healthcare providers. By linking National Provider Identifiers to provider-specific information, policymakers can more easily identify trends and gaps in provider representation across different regions and specialties. This data can highlight areas where underrepresented groups may be concentrated or lacking, enabling targeted initiatives to recruit and retain a more diverse workforce.

The author cites recommendations in a 2019 report by the California Future Health Workforce Commission, which included among its goals an objective to “expand and scale pipeline programs to recruit and prepare students from underrepresented and low-income backgrounds for health careers.” The author believes that collecting National Provider Identifier information for all healing arts licensees will allow legislators and policymakers to more effectively evaluate the success of efforts to improve representation and diversity in the state’s health care professions.

According to the Author

"California faces major shortages of health workers, isn't producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. There are sixteen health care professional oversight boards that "request" workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California's health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended. This information will provide HCAI with data necessary to assess whether or not loan repayment programs intended to increase the diversity of the health workforce, and to encourage providers to serve in underserved areas, are working as intended."

Arguments in Support

The California Pan-Ethnic Health Network supports this bill, writing: "HCAI administers several Loan Repayment Programs that offer financial support to health professionals who agree to provide direct patient care in medically underserved areas. However, California has recently faced major shortages of health workers, not producing enough new workers to meet future needs, and the current health workforce does not match the state's diversity. Reports have also found that Hispanic and Black workers are very underrepresented in the existing health workforce in California. AB 1991 would help support workforce supply and diversity problems to help improve the impacts on health access, quality, and equity in our most underserved communities."

Arguments in Opposition

None on file.

FISCAL COMMENTS

Pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM BUSINESS AND PROFESSIONS: 17-0-1

YES: Berman, Flora, Alanis, Bains, Juan Carrillo, Chen, Dixon, Grayson, Irwin, Jackson, Ward, Lowenthal, McKinnor, Stephanie Nguyen, Pellerin, Soria, Zbur

ABS, ABST OR NV: Sanchez

ASM APPROPRIATIONS: 14-0-1

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Jim Patterson

ASSEMBLY FLOOR: 73-0-7

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Haney, Hart, Holden, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Bauer-Kahan, Megan Dahle, Grayson, Hoover, Mathis, McCarty, Quirk-Silva

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

UPDATED

VERSION: July 2, 2024

CONSULTANT: Robert Sumner / B. & P. / (916) 319-3301 FN: 0004213

 THIRD READING  

Bill No: AB 1991

Author: Bonta (D)

Amended: 7/2/24 in Senate

Vote: 21

SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 12-0, 6/17/24

AYES: Ashby, Nguyen, Alvarado-Gil, Archuleta, Becker, Eggman, Glazer, Menjivar, Niello, Roth, Smallwood-Cuevas, Wilk

NO VOTE RECORDED: Dodd

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 73-0, 5/13/24 - See last page for vote

SUBJECT: Licensee and registrant renewal: National Provider Identifier

SOURCE: Author

DIGEST:

This bill requires health profession licensing boards within the Department of Consumer Affairs (DCA) to require a licensee or registrant who electronically renews their license or registration to provide their individual National Provider Identifier (NDI), if they have one.

ANALYSIS:

Existing law:

1. Establishes the DCA within the Business, Consumer Services, and Housing Agency. (Business and Professions Code (BPC) §§ 100 et seq.)
2. Establishes various boards, bureaus, and other entities within the jurisdiction of the DCA. (BPC § 101)
3. Establishes “healing arts” boards under the jurisdiction of DCA, which includes the following entities:
   1. Acupuncture Board;
   2. Board of Behavioral Sciences;
   3. State Board of Chiropractic Examiners;
   4. Dental Board of California;
   5. Dental Hygiene Board of California;
   6. Medical Board of California;
   7. California Board of Naturopathic Medicine;
   8. California Board of Occupational Therapy;
   9. California Board of Optometry;
   10. Osteopathic Medical Board of California;
   11. California State Board of Pharmacy;
   12. Physical Therapy Board of California;
   13. Physician Assistant Board;
   14. Podiatric Medical Board of California;
   15. Board of Psychology;
   16. Board of Registered Nursing;
   17. Respiratory Care Board of California;
   18. Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board;
   19. Veterinary Medical Board; and
   20. Board of Vocational Nursing and Psychiatric Technicians. (BPC §§ 500 et seq.)
4. Establishes HCAI, previously established as the Office of Statewide Health Planning and Development, vested with responsibilities related to health planning and research development. (Health and Safety Code (HSC) §§ 127000 et seq.)
5. Provides for a Health Professions Career Opportunity Program to increase the number of ethnic minorities in health professional training and minority health professionals practicing in health shortage areas, subject to the appropriation of funds. (HSC §§ 127875 – 127885)
6. Requires HCAI to establish a health care workforce research and data center to serve as the central source of health care workforce and educational data in the state. (HSC § 128050)
7. Requires HCAI to work with the Employment Development Department’s Labor Market Information Division, state licensing boards, and state higher education entities to collect, to the extent available, all of the following data:
   1. The current supply of health care workers, by specialty.
   2. The geographical distribution of health care workers, by specialty.
   3. The diversity of the health care workforce, by specialty, including, but not necessarily limited to, data on race, ethnicity, and languages spoken.
   4. The current and forecasted demand for health care workers, by specialty.
   5. The educational capacity to produce trained, certified, and licensed health care workers, by specialty and by geographical distribution, including, but not necessarily limited to, the number of educational slots, the number of enrollments, the attrition rate, and wait time to enter the program of study. (HSC § 128051)
8. Requires HCAI to prepare an annual report to the Legislature that does all of the following:
   1. Identifies education and employment trends in the health care profession.
   2. Reports on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas.
   3. Recommends state policy needed to address issues of workforce shortage and distribution.
   4. Describes the health care workforce program outcomes and effectiveness. (HSC § 128052)

This bill requires DCA healing arts boards to require licensees and registrants to provide their individual NDI at the time of electronic renewal, if they have one.

Background

Importance of Representation among Health Care Providers. In December 2015, the American Journal of Public Health published a systematic review titled “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes”. The review concluded that “most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color.” Additional published studies suggest that implicit bias in regards to gender, sexual orientation and identity, and other characteristics has resulted in inconsistent diagnoses and courses of treatment being provided to patients based on their respective demographic. These trends take into account not only the characteristics of the person being treated, but those of the licensed professional in correlation to that patient. The results of implicit bias can have serious consequences in the provision of health care. For example, one frequently cited statistic is that Black women have average maternal mortality rates that are three-to-four times higher than white women.

Legislative Efforts to Increase Representation and Improve Healthcare Outcomes

California has attempted to resolve these longstanding issues of representation and access through multiple strategies. For example, the legislature has worked with the MBC to improve cultural and linguistic competency among providers. These efforts, which include collecting foreign language competency from its licensees and administering the Licensed Physicians and Dentists from Mexico Pilot Program, have yet to resolve systemic challenges with addressing language barriers in California.

In 2019, the Legislature enacted AB 241 (Kamlager-Dove, Chapter 241, Statutes of 2019) required continuing education courses for physicians and surgeons, nurses, and physician assistants to include the understanding of implicit bias and the promotion of bias-reducing strategies. While implementing these requirements has had some impact on improving health care outcomes for minority patients, education and training is not a substitute for increasing diversity and representation among providers.

In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California’s Health Care Workforce. This hearing included perspectives from various stakeholders and public health researchers, along with policymakers who provided updates on the state’s efforts to increase diversity. The background paper for the hearing cited research published in December 2022 by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in a report titled “The Race and Ethnicity of the California Health Care Workforce,” which demonstrated that “a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care.” As explained in the Health Committee’s background paper, underrepresentation in the health care workforce both “contributes to health disparities” and “limits access to high-paying, meaningful professions for underrepresented minorities.”

Role of Data Collection and Problem Being Addressed. The California Health Workforce Research and Data Center, established in 2007 as the Healthcare Workforce Clearinghouse under the prior Office of Statewide Health Planning and Development, serves as California’s central source for collection, analysis, and reporting of information on the healthcare workforce employment and educational data trends for the state. As part of its duties, HCAI is mandated to prepare an annual report to the Legislature that accomplishes the following three goals: (1) identifying education and employment trends in the health care professions (2) reporting on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas; and (3) recommending state policy needed to address issues of workforce shortage and distribution.

In addition to the above discussed actions, the Legislature enacted and funded loan repayment programs, such as the Dental Corps Loan Repayment Program of 2002, which provided grants to qualifying dentists who agreed to work for at least three years in a clinic or dental practice located in a dentally unserved area, or in which at least 50 percent of patients are from a dentally underserved population. The Health Professions Career Opportunity Program within HCAI similarly supports initiatives designed to enhance diversity and representation in the health professions by awarding grant funding through competitive programs.

However, as discussed in the Health Committee’s background paper, it is often challenging to evaluate the long-term impacts of these programs, as “HCAI does not currently collect longitudinal data that could demonstrate which of these programs are more effective.”

Discussions with the author’s office revealed that the data point being sought after is the NPI, which is a unique identification number assigned to covered health care providers and requested in an optional survey that may be completed by DCA’s healing arts program licensees and registrants (BPC § 502). However, the survey contains many questions that could be considered sensitive in nature and may discourage a licensee or registrant from participating. The optional nature of the survey does not provide an accurate accounting about the makeup of California’s health workforce, thus making it difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended.

Comments

The author’s office states, “that obtaining the NPI for California’s health care licensees would allow HCAI to evaluate the efficacy of loan programs that waive repayment when the provider works in an underserved area or at a location where the patients predominately represent a an underserved population. A complete evaluation of these programs would demonstrate whether the programs should continue or if alternatives should be considered.”

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

SUPPORT: (Verified 8/6/24)

None received

OPPOSITION: (Verified 8/6/24)

None received

ASSEMBLY FLOOR: 73-0, 5/13/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Haney, Hart, Holden, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Bauer-Kahan, Megan Dahle, Grayson, Hoover, Mathis, McCarty, Quirk-Silva

Prepared by: Yeaphana La Marr / B., P. & E.D. /

8/7/24 14:34:36

**** END ****

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Angelique Ashby, Chair

2023 - 2024 Regular

Bill No: AB 1991 Hearing Date: June 17, 2024

Subject: Licensee and registrant records

SUMMARY:

Requires health professional licensing boards within the Department of Consumer Affairs (DCA) to biennially collect specified workforce data from their licensees and registrants (licensees) as a condition of licensure or renewal. States that a license or renewal denial shall not be based solely on a licensee’s failure to provide the information in the survey. Requires the information collected from licensees to be subsequently provided to the Department of Health Care Access and Information (HCAI).

Existing law:

1. Prohibits including any question relative to an applicant’s race, sex, marital status, or religion in any application blank or form required to be filled in and submitted by an applicant to any department, board, commission, officer, agent, or employee of this state. (Government Code § 8310)
2. Establishes the DCA within the Business, Consumer Services, and Housing Agency. (Business and Professions Code (BPC) §§ 100 et seq.)
3. Establishes various boards, bureaus, and other entities within the jurisdiction of the DCA. (BPC § 101)
4. Establishes “healing arts” boards under the jurisdiction of DCA, which includes the following entities:

a) Acupuncture Board;

b) Board of Behavioral Sciences;

c) State Board of Chiropractic Examiners;

d) Dental Board of California;

e) Dental Hygiene Board of California;

f) Medical Board of California;

g) California Board of Naturopathic Medicine;

h) California Board of Occupational Therapy;

i) California Board of Optometry;

j) Osteopathic Medical Board of California;

k) California State Board of Pharmacy;

l) Physical Therapy Board of California;

m) Physician Assistant Board;

n) Podiatric Medical Board of California;

o) Board of Psychology;

p) Board of Registered Nursing;

q) Respiratory Care Board of California;

r) Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board;

s) Veterinary Medical Board;

t) Board of Vocational Nursing and Psychiatric Technicians.

(BPC §§ 500 et seq.)

1. Requires information retained by each board under the DCA relating to license applicants with criminal records to include the final disposition and demographic information, consisting of voluntarily provided information on race or gender. (BPC § 480(g))
2. Requires the Board of Registered Nursing (BRN), the Board of Vocational Nursing and Psychiatric Technicians (BVNPT), the Physician Assistant Board (PAB), and the Respiratory Care Board of California (RCB) to collect specified workforce data from their respective licensees and registrants for future workforce planning at least biennially, with data collected at the time of electronic license or registration renewal as applicable. (BPC § 502(a)(1))
3. Provides that all other healing arts boards shall request the specified workforce data for future workforce planning at least biennially, with data collected at the time of electronic license or registration renewal as applicable. (BPC § 502(a)(2))
4. Specifies the following information as included within the workforce data collected or requested by healing arts boards:

a) Anticipated year of retirement.

b) Area of practice or specialty.

c) City, county, and ZIP Code of practice.

d) Date of birth.

e) Educational background and the highest level attained at time of licensure or registration.

f) Gender or gender identity.

g) Hours spent in direct patient care, including telehealth hours as a subcategory, training, research, and administration.

h) Languages spoken.

i) National Provider Identifier.

j) Race or ethnicity.

k) Type of employer or classification of primary practice site among the types of practice sites specified by the board, including, but not limited to, clinic, hospital, managed care organization, or private practice.

l) Work hours.

m) Sexual orientation.

n) Disability status.

(BPC § 502(b))

1. Requires each board to maintain the confidentiality of the information it receives from licensees and registrants and to only release information in an aggregate form that cannot be used to identify an individual. (BPC § 502(c))
2. Requires the DCA, in consultation with HCAI, to specify for each board the specific information and data that will be collected or requested. (BPC § 502(d))
3. Requires each board, or the DCA on its behalf, to provide the workforce data it collects to HCAI on a quarterly basis in a manner directed by HCAI, including license or registration number and associated license or registration information. (BPC § 502(e))
4. Prohibits boards from requiring a licensee or registrant to provide the workforce data as a condition for license or registration renewal, or from disciplining licensees or registrants for not providing the information. (BPC § 502(f))
5. Requires the Dental Board of California (DBC) to collect information, if provided by the licensee at the time of initial licensure or renewal, including the licensee’s cultural background and foreign language proficiency. (BPC § 1715.5)
6. Requires the Dental Hygienists Board (DHB) to collect information, if provided by an licensee upon initial licensure or renewal, including the licensee’s cultural background and foreign language proficiency. (BPC § 1902.2)
7. Requires licensed physicians and surgeons to report to the Medical Board of California (MBC), immediately upon issuance of an initial license and at the time of license renewal, information relating to their cultural background and foreign language proficiency, unless the licensee declines to provide that information. (BPC § 2425.3)
8. Requires the Osteopathic Medical Board of California to collect specified information upon initial licensure and renewal, including the licensee’s cultural background and foreign language competency, if reported by the licensee. (BPC § 2455.2)
9. Authorizes the Bureau of Real Estate Appraisers (BREA) to request a licensee to identify their race, ethnicity, sexual orientation, gender, or gender identity; requires BREA to maintain confidentiality of information received, prohibits requiring the information as a condition of licensure or renewal; and authorizes BREA to publish aggregate data to its website. (BPC § 11347)
10. Requires the Board of Registered Nursing to incorporate regional forecasts into its biennial analyses of the nursing workforce and to develop a plan to address shortages. (BPC § 2717)
11. Authorizes the California Architects Board (CAB) to request a licensee to identify their race, ethnicity, sexual orientation, gender, or gender identity; requires CAB to maintain confidentiality of information received, prohibits requiring the information as a condition of licensure or renewal; and authorizes CAB to publish aggregate data to its website. (BPC § 5552.2)
12. Establishes HCAI, previously established as the Office of Statewide Health Planning and Development, vested with responsibilities related to health planning and research development. (Health and Safety Code (HSC) §§ 127000 et seq.)
13. Provides for a Health Professions Career Opportunity Program to increase the number of ethnic minorities in health professional training and minority health professionals practicing in health shortage areas, subject to the appropriation of funds. (HSC §§ 127875 – 127885)
14. Requires HCAI to establish a health care workforce research and data center to serve as the central source of health care workforce and educational data in the state. (HSC § 128050)
15. Requires HCAI to work with the Employment Development Department’s Labor Market Information Division, state licensing boards, and state higher education entities to collect, to the extent available, all of the following data:

a) The current supply of health care workers, by specialty.

b) The geographical distribution of health care workers, by specialty.

c) The diversity of the health care workforce, by specialty, including, but not necessarily limited to, data on race, ethnicity, and languages spoken.

d) The current and forecasted demand for health care workers, by specialty.

e) The educational capacity to produce trained, certified, and licensed health care workers, by specialty and by geographical distribution, including, but not necessarily limited to, the number of educational slots, the number of enrollments, the attrition rate, and wait time to enter the program of study.

(HSC § 128051)

1. Requires HCAI to prepare an annual report to the Legislature that does all of the following:

a) Identifies education and employment trends in the health care profession.

b) Reports on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas.

c) Recommends state policy needed to address issues of workforce shortage and distribution.

d) Describes the health care workforce program outcomes and effectiveness.

(HSC § 128052)

This bill:

1. Provides that healing arts boards under the DCA that are not already required to collect workforce data from their licensees and registrants shall be required to collect that workforce data for future workforce planning at least biennially.
2. Requires a licensee or registrant to provide the workforce data information as a condition for license or registration renewal.

FISCAL EFFECT:

This bill is keyed fiscal by Legislative Counsel. According to the Assembly Committee on Appropriations, this bill creates minor and absorbable costs to DCA and HCAI.

COMMENTS:

1. Purpose. This bill is Author-sponsored. The Author states, “California faces major shortages of health workers, isn’t producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. Health care professional oversight boards request workforce data upon re-licensure which includes an optional survey that is sent to the Department of Health Care Access and Information (HCAI). This bill simply requires a provider to include their National Provider Identifier number in the survey, if they have one. This will let HCAI know if health care providers who agree to work in underserved areas in exchange for loan forgiveness continuing to work in those areas after their service obligation is up, and allow policymakers to determine whether or not loan repayment programs intended to increase the diversity of the health workforce are working as intended.”
2. Background.
   

Importance of Representation among Health Care Providers. In December 2015, the American Journal of Public Health published a systematic review titled “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes”. The review concluded that “most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color.” Additional published studies suggest that implicit bias in regards to gender, sexual orientation and identity, and other characteristics has resulted in inconsistent diagnoses and courses of treatment being provided to patients based on their respective demographic. These trends take into account not only the characteristics of the person being treated, but those of the licensed professional in correlation to that patient. The results of implicit bias can have serious consequences in the provision of health care. For example, one frequently cited statistic is that Black women have average maternal mortality rates that are three-to-four times higher than white women.

Additionally, research cited by the California Health Care Foundation (CHCF) in its 2021 report “Health Workforce Strategies for California: A Review of the Evidence” found that while 39 percent of Californians identified as Latino/x in 2019, only 14 percent of medical school matriculants and 6 percent of active patient care physicians in California were Latino/x. A 2018 study published by the Latino Policy & Politics Initiative at the University of California, Los Angeles found that while nearly 44 percent of the California population speaks a language other than English at home, many of the most commonly spoken languages are underrepresented by the physician workforce.

Legislative Efforts to Increase Representation and Improve Healthcare Outcomes

California has attempted to resolve these longstanding issues of representation and access through multiple strategies. For example, the legislature has worked with the MBC to improve cultural and linguistic competency among providers. These efforts, which include collecting foreign language competency from its licensees and administering the Licensed Physicians and Dentists from Mexico Pilot Program, have yet to resolve systemic challenges with addressing language barriers in California.

In 2019, the Legislature enacted AB 241 (Kamlager-Dove, Chapter 241, Statutes of 2019) require continuing education courses for physicians and surgeons, nurses, and physician assistants to include the understanding of implicit bias and the promotion of bias-reducing strategies. While implementing these requirements has had some impact on improving health care outcomes for minority patients, education and training is not a substitute for increasing diversity and representation among providers.

In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California’s Health Care Workforce. This hearing included perspectives from various stakeholders and public health researchers, along with policymakers who provided updates on the state’s efforts to increase diversity. The background paper for the hearing cited research published in December 2022 by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in a report titled “The Race and Ethnicity of the California Health Care Workforce,” which demonstrated that “a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care.” As explained in the Health Committee’s background paper, underrepresentation in the health care workforce both “contributes to health disparities” and “limits access to high-paying, meaningful professions for underrepresented minorities.”

Role of Data Collection and Efforts to Collect Data. In addition to previously discussed actions, the Legislature enacted and funded loan repayment programs, such as the Dental Corps Loan Repayment Program of 2002, which provided grants to qualifying dentists who agreed to work for at least three years in a clinic or dental practice located in a dentally unserved area, or in which at least 50 percent of patients are from a dentally underserved population. The Health Professions Career Opportunity Program within HCAI similarly supports initiatives designed to enhance diversity and representation in the health professions by awarding grant funding through competitive programs.

However, as discussed in the Health Committee’s background paper, it is often challenging to evaluate the long-term impacts of these programs, as “HCAI does not currently collect longitudinal data that could demonstrate which of these programs are more effective.”

The California Health Workforce Research and Data Center, established in 2007 as the Healthcare Workforce Clearinghouse under the prior Office of Statewide Health Planning and Development, serves as California’s central source for collection, analysis, and reporting of information on the healthcare workforce employment and educational data trends for the state. As part of its duties, HCAI is mandated to prepare an annual report to the Legislature that accomplishes the following three goals: (1) identifying education and employment trends in the health care professions (2) reporting on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas; and (3) recommending state policy needed to address issues of workforce shortage and distribution.

The Legislature enacted AB 2102 (Ting, Chapter 420, Statutes of 2014) to require the BRN, PAB, RCB, and BVNPT to collect and report specific demographic data related to its licensees. Specifically, AB 2102 mandated that the four boards collect the following data from licensees: (1) location of practice, including city, county, and zip Code; (2) race or ethnicity; (3) gender; (4) languages spoken; (5) educational background and (6) classification of primary practice site, such as clinic, hospital, managed care organization, or private practice. Through an interagency agreement, DCA reports specified data to HCAI. Subsequent legislation to replace the individual program data collection requirements with a single statute applicable to all healing arts boards, which also would have added sexual orientation data to the required information to be collected and reported, were unsuccessful.

AB 133 (Committee on Health, Chapter 143, Statutes of 2021) added BPC § 502, which authorizes all DCA healing arts boards to request specified licensee demographic data and report that data to HCAI, while preserving the confidentiality of the licensee by reporting the data in an aggregate format. The optional survey includes information that could be considered sensitive, such as gender or gender identity, sexual orientation, disability status, and race or ethnicity. The survey also requests non-sensitive information such as the licensee’s work hours, location of practice (city, county, and zip code) and National Provider Identifier (NPI).

Problem Being Addressed by this Bill. There are sixteen health care professional oversight boards that request workforce data specified by BPC § 502, but do not require the data to be reported as condition as licensure. Without accurate information about the makeup of California’s health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended. To obtain the data necessary to properly evaluate these programs, this bill would have required licensees to complete the survey as a condition of licensure or renewal and would have removed a prohibition that prevents boards from seeking disciplinary action against a licensee who does not provide the information.

This bill was subsequently amended to state that a board shall not deny an application for license or registration renewal solely because the licensee or registrant failed to provide any of the information in the survey. Amendments did not restore the prohibition against disciplinary action. Therefore, the bill currently retains that when a licensee does not provide the information, the licensing board could use that failure as factor in making a license or renewal determination.

Discussions with the author’s office revealed that the single data point being sought after is the NPI, which is included in the current optional survey. According to the Centers for Medicare & Medicaid Services, an NPI is a unique identification number assigned to covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use NPIs in administrative and financial transactions adopted under the Health Insurance Portability and Accountability Act (HIPAA). As outlined in federal regulations, covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.^[1]

The NPI is a number that is frequently required to be given out by providers who have a number. The author’s office states that obtaining the NPI for California’s licensees would allow HCAI to evaluate the efficacy of loan programs that waive repayment when the provider works in an underserved area or at a location where the patients predominately represent a an underserved population. A complete evaluation of these programs would demonstrate whether the programs should continue or if alternatives should be considered. In addition to meeting the author’s data collection goal, requiring the NPI would not be a violation of prohibitions against the state requiring any question relative to an applicant’s race, sex, marital status, or religion in any application blank or form required to be filled in and submitted by an applicant to any department, board, commission, officer, agent, or employee of this state.

1. Related Legislation. AB 2862 (Gipson of 2024) would require boards under the DCA to prioritize African American applicants seeking licenses, especially applicants who are descended from a person enslaved in the United States. (Status: This bill is pending in the Senate Committee on Business, Professions and Economic Development.)

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) consolidated workforce data collection requirements and requires all healing arts boards to request, if not require, that data.

AB 1236 (Ting of 2021) would have consolidated workforce data collection requirements and required all healing arts boards to collect that data. This bill died on the inactive file of the Assembly Floor.

AB 2704 (Ting of 2020) would have consolidated workforce data collection requirements and required all healing arts boards to collect that data. This bill was not set for a hearing in the Assembly Committee on Business and Professions.

SB 1575 (Committee on Business, Professions and Economic Development, Chapter 456, Statutes of 2019) required the DHB to collect, if reported by a licensed dental hygienist upon initial licensure or renewal, specified information, including the licensee’s cultural background and foreign language proficiency.

AB 2102 (Ting, Chapter 420, Statutes of 2014) required the BRN, PAB, RCB, and BVNPT to collect and report specific demographic data relating to its licensees, subject to a licensee’s discretion to report his/her race or ethnicity at least biennially at the time of issuing an initial license or renewal license.

SB 1575 (Committee on Business, Professions and Economic Development, Chapter 799, Statutes of 2012) required licensed dentists to report specified information to the DBC, upon initial licensure and any subsequent application for renewal, including information regarding the licensee’s cultural background and foreign language proficiency if reported by the licensee.

AB 1070 (Hill, Chapter 505, Statutes of 2009) required licensed physicians and surgeons to report specified information to the MBC upon issuance of an initial license and at the time of license renewal, including information relating to their cultural background and foreign language proficiency unless the licensee declines to provide that information.

SB 620 (Wiggins, Chapter 602, Statutes of 2009) required the OMBC to collect specified information upon a licensed osteophathic physician and surgeon’s initial licensure and renewal, including the licensee’s cultural background and foreign language competency, if reported by the licensee.

1. Arguments in Support. The Board of Behavioral Sciences writes, “Requiring, instead of requesting, this data would help to ensure that the data gives as accurate a picture as possible regarding the population of health care providers in the state. The Department of Health Care Access and Information (HCAI) relies on this data to ensure that their loan repayment and scholarship programs are working as intended. Additionally, this data can be a helpful tool for the Board when making policy decisions, and strengthening its accuracy will allow the Board to rely on it further.”
   
   The California Pan-Ethnic Health Network writes in support, “HCAI administers several Loan Repayment Programs that offer financial support to health professionals who agree to provide direct patient care in medically underserved areas. However, California has recently faced major shortages of health workers, not producing enough new workers to meet future needs, and the current health workforce does not match the state's diversity. Reports have also found that Hispanic and Black workers are very underrepresented in the existing health workforce in California. AB 1991 would help support workforce supply and diversity problems to help improve the impacts on health access, quality, and equity in our most underserved communities.”
   
   Mental health of America supports this bill and states, “This bill will help the state address workforce needs by collecting accurate data such as a licensee’s or registrant’s type of employer (i.e. clinic, hospital, managed care organization, or private practice) and anticipated year of retirement. This information can help guide behavioral health workforces' investments and the efficient use of current available staff. For this reason, we support AB 1991(Bonta) and ask for your “aye” vote.”
2. Arguments in Opposition. The California Board of Psychology writes in opposition, “Firstly, by no longer making the workforce data or demographic survey optional, it forces the licensee or registrant to answer private and at times sensitive questions such as, gender or gender identity, race or ethnicity and sexual orientation and provide equally sensitive answers[.] The Board has received previous comments from stakeholders regarding issues in providing what is deemed private and sensitive information and the undue stress or anxiety in providing the requested information caused them. Secondly, since AB 1991 requires the survey to be completed at time of renewal for a license or registration, the Board would have to refer any licensee or registrant to the Board’s Enforcement Unit for possible discipline. This includes licensees or registrants who fail to complete the survey for any reason including personal reasons as required under this proposed law. The Board believes this requirement would be unfair to licensees and registrants who are now forced to complete the survey if they find issue in providing sensitive information that is currently optional to answer.”

The Medical Board of California opposed this bill unless amended, stating, “The survey that asks these questions is only available online and the Board is concerned that, as currently drafted, AB 1991 could lead to a significant number of licensees submitting a paper renewal application. If that were to occur, the Board’s limited resources would be strained, potentially leading to application processing and approval delays. If the Board is unable to process a renewal application before that license expires, the licensee in question will be unable to practice medicine, delaying their patients’ access to care.”

1. Policy Issues and Suggested Amendments.
   

Restore optional survey while requiring only the NPI if the licensees have one. Government Code Section 8310 prohibits including questions about an applicant’s race, sex, marital status, or religion in any application blank or form required to be filled in and submitted by an applicant to any department, board, commission, officer, agent, or employee of this state.

In recognition of the sensitive nature of other data included in the HCAI survey, the author and stakeholders collaborated to restore survey completion as optional while requiring the individual’s NPI to be submitted, if the licensee has one, when renewing their license electronically. Additionally, amendments would remove a statement that failure to submit the data requested by the survey shall not solely be considered cause for denial. In implementation, the NPI would be presented as a field in the online renewal with an option for the licensee to indicate they do not have an NPI. Thus, disciplinary action is not an option and the prohibition from disciplinary action is not necessary to restore. The amendments would further ensure that boards are not in violation of Government Code Section 8310.

Amend BPC § 502 as follows:

(a) Notwithstanding any other law, both of the following apply:

(1) The Board of Registered Nursing, the Board of Vocational Nursing and Psychiatric Technicians of the State of California, the Physician Assistant Board, and the Respiratory Care Board of California shall collect request workforce data from their respective licensees and registrants as specified in subdivision (b) for future workforce planning at least biennially. The data shall be collect requested at the time of electronic license or registration renewal for those boards that utilize electronic renewals for licensees or registrants.

(2) All other boards that are not listed in paragraph (1) that regulate healing arts licensees or registrants under this division shall collect request workforce data from their respective licensees and registrants as specified in subdivision (b) for future workforce planning at least biennially. The data shall be required requested at the time of electronic license or registration renewal for those boards that utilize electronic renewals for licensees or registrants.

(b) In conformance with specifications under subdivision (d), the workforce data collected or required requested by each board about its licensees and registrants shall include, at a minimum, all of the following information:

(1) Anticipated year of retirement.

(2) Area of practice or specialty.

(3) City, county, and ZIP Code of practice.

(4) Date of birth.

(5) Educational background and the highest level attained at time of licensure or registration.

(6) Gender or gender identity.

(7) Hours spent in direct patient care, including telehealth hours as a subcategory, training, research, and administration.

(8) Languages spoken.

(9) National Provider Identifier.

(10) Race or ethnicity.

(11) Type of employer or classification of primary practice site among the types of practice sites specified by the board, including, but not limited to, clinic, hospital, managed care organization, or private practice.

(12) Work hours.

(13) Sexual orientation.

(14) Disability status.

(c) Each board shall maintain the confidentiality of the information it receives from licensees and registrants under this section and shall only release information in an aggregate form that cannot be used to identify an individual other than as specified in subdivision (e).

(d) The Department of Consumer Affairs, in consultation with the Department of Health Care Access and Information, shall specify for each board subject to this section the specific information and data that will be collected or requested pursuant to subdivision (b). The Department of Consumer Affairs’ identification and specification of this information and data shall be exempt until June 30, 2023, from the requirements of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).

(e) Each board, or the Department of Consumer Affairs on its behalf, shall, beginning on July 1, 2022, and quarterly thereafter, provide the individual licensee and registrant data it collects pursuant to this section to the Department of Health Care Access and Information in a manner directed by the Department of Health Care Access and Information, including license or registration number and associated license or registration information. The Department of Health Care Access and Information shall maintain the confidentiality of the licensee and registrant information it receives and shall only release information in an aggregate form that cannot be used to identify an individual.

(f) When renewing their license or registration electronically, (1) Aa licensee or registrant shall be required to provide their individual National Provider Identifier, if they have one, as specified the information listed in paragraph 9 of subdivision (b) as a condition for license or registration renewal.

(2) Notwithstanding paragraph (1), a board described in paragraph (2) of subdivision (a) shall not deny an application for license or registration renewal solely because the licensee or registrant failed to provide any of the information listed in subdivision (b).

(g) This section does not alter or affect mandatory reporting requirements for licensees or registrants established pursuant to this division, including, but not limited to, Sections 1715.5, 1902.2, 2425.3, and 2455.2.

SUPPORT AND OPPOSITION:

Support:

Board of Behavioral Sciences

California Pan - Ethnic Health Network

Mental Health America of California

Opposition:

California Board of Psychology

Medical Board of California

-- END --

1. https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand ↑

ASSEMBLY THIRD READING

ATR Bill Id:AB 1991

Author:(Bonta)

As Amended Ver:April 17, 2024

Majority vote

SUMMARY

Requires all healing arts boards under the Department of Consumer Affairs (DCA) to collect specified workforce data from their licensees and registrants at least biennially as a requirement of license or registration renewal, and requires that information to be subsequently provided to the Department of Health Care Access and Information (HCAI).

Major Provisions

1. Provides that healing arts boards under the DCA that are not already required to collect workforce data from their licensees and registrants shall be required to collect that workforce data for future workforce planning at least biennially.
2. Requires a licensee or registrant to provide the workforce data information as a condition for license or registration renewal.
3. Prohibits healing arts boards from denying an application for license or registration renewal solely because the licensee or registrant failed to provide any of the required workforce data.

COMMENTS

California has long faced significant gaps and inequities in its health care workforce. There has historically been a persistent shortage of accessible health professionals overall, which disproportionately impacts communities with concentrated populations of immigrant families and people of color. A recent study found that between 2010 and 2019, the number of primary care physicians in proportion to population remained largely unchanged nationally. Meanwhile, counties with a higher proportion of minorities saw a decline during that period.

Compounding these issues of access is a significant lack of diversity among health care practitioners, with several minority groups remaining persistently underrepresented within the healing arts. A recent study of data from the American Community Survey and the Integrated Postsecondary Education Data System found that Black, Hispanic, and Native American people are nationally represented across 10 different health professions. As a result, minorities seeking to enter these professions face significant systemic obstacles, and patients who are representative of minority groups or immigrant communities often do not have access to practitioners who possess the cultural or linguistic competence to provide them with appropriate care.

Research cited by the California Health Care Foundation in its 2021 report found that while 39% of Californians identified as Latino/x in 2019, only 14% of medical school matriculants and 6% of active patient care physicians in California were Latino/x. A 2018 study published by the Latino Policy & Politics Initiative at the University of California, Los Angeles found that while nearly 44% of the California population speaks a language other than English at home, many of the most commonly spoken languages are underrepresented by the physician workforce. While the physician community has worked with the Medical Board of California to improve linguistic competency among providers, these efforts have yet to resolve systemic challenges with addressing language barriers in California.

Another issue resulting from underrepresentation in the health professions relates to implicit bias. According to the Stanford Encyclopedia of Philosophy, "implicit bias" can be described as "a term of art referring to relatively unconscious and relatively automatic features of prejudiced judgment and social behavior." In her 2019 book Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do, Dr. Jennifer L. Eberhardt explains that "implicit bias is not a new way of calling someone a racist. In fact, you don't have to be a racist at all to be influenced by it. Implicit bias is a kind of distorting lens that's a product of both the architecture of our brain and the disparities in our society." Dr. Eberhardt goes on to describe how "bias is not limited to one domain of life. It is not limited to one profession, one race, or one country. It is also not limited to one stereotypic association."

In December 2015, the American Journal of Public Health published a systematic review titled Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes. The review concluded that "most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color." Additional published studies suggest that implicit bias in regards to gender, sexual orientation and identity, and other characteristics has resulted in inconsistent diagnoses and courses of treatment being provided to patients based on their respective demographic. These trends take into account not only the characteristics of the person being treated, but those of the licensed professional in correlation to that patient.

The results of implicit bias can have serious consequences in the provision of health care. For example, one frequently cited statistic is that Black women have average maternal mortality rates that are three-to-four times higher than white women. While much of the research and action relating to implicit bias has been focused on the area of law enforcement and police procedure, there has been a growing call to also address the presence of implicit bias in the healing arts professions through additional awareness and training. In 2019, the Legislature enacted AB 241 (Kamlager-Dove) to require continuing education courses for physicians and surgeons, nurses, and physician assistants to include the understanding of implicit bias and the promotion of bias-reducing strategies. While implementation of these requirements has undoubtedly had at least some impact on improving health care outcomes for minority patients, education and training is not a substitute for increasing diversity and representation among providers.

In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California's Health Care Workforce. This hearing included perspectives from various stakeholders and public health researchers, along with policymakers who provided updates on the state's efforts to increase diversity. The background paper for the hearing^[1] cited research published in December 2022 by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in a report titled "The Race and Ethnicity of the California Health Care Workforce," which demonstrated that "a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care." As explained in the Health Committee's background paper, underrepresentation in the health care workforce both "contributes to health disparities" and "limits access to high-paying, meaningful professions for underrepresented minorities."

California has attempted to resolve these longstanding issues of representation and access through a number of different approaches. The Legislature has previously enacted and funded loan repayment programs, such as the Dental Corps Loan Repayment Program of 2002, which provided grants to qualifying dentists who agreed to work for at least three years in a clinic or dental practice located in a dentally unserved area, or in which at least 50% of patients are from a dentally underserved population. The Health Professions Career Opportunity Program within HCAI similarly supports initiatives designed to enhance diversity and representation in the health professions by awarding grant funding through competitive programs.

As discussed in the Health Committee's background paper, it is often challenging to evaluate the long-term impacts of these programs, as "HCAI does not currently collect longitudinal data that could demonstrate which of these programs are more effective." During sunset review oversight hearings on healing arts boards that were held jointly in 2024 by the Assembly Committee on Business and Professions and the Senate Committee on Business, Professions, and Economic Development, committee members expressed frustration that there was not sufficient data to confirm whether any particular strategy to improve access has been successful. This is in large part due to a lack of consistent data from healing arts licensees to inform policymakers about how many practitioners of particular specialties are providing services in any given area of the state, or about the demographic makeup of those practitioners.

The California Health Workforce Research and Data Center, previously established in 2007 as the Healthcare Workforce Clearinghouse under the prior Office of Statewide Health Planning and Development, serves as California's central source for collection, analysis, and reporting of information on the healthcare workforce employment and educational data trends for the state. As part of its statutory duties, HCAI is mandated to prepare an annual report to the Legislature that accomplishes the following three goals: (1) identifying education and employment trends in the health care professions (2) reporting on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas; and (3) recommending state policy needed to address issues of workforce shortage and distribution.

In 2014, the Legislature enacted AB 2102, authored by Assembly Member Phil Ting and co-sponsored by the California Pan-Ethnic Health Network and the Latino Coalition for a Healthy California. The bill required four specified healing arts boards—the Board of Registered Nursing, the Physician Assistant Board, the Respiratory Care Board of California, and the Board of Vocational Nursing and Psychiatric Technicians—to collect and report specific demographic data related to its licensees. Specifically, AB 2102 mandated that the four boards collect the following data from licensees: (1) location of practice, including city, county, and zip Code; (2) race or ethnicity; (3) gender; (4) languages spoken; (5) educational background and (6) classification of primary practice site, such as clinic, hospital, managed care organization, or private practice. In order to implement AB 2102, the DCA and HCAI established an interagency agreement to facilitate the specified data collection and exchange.

Assembly Member Ting subsequently introduced AB 2704 in 2020, which sought to replace the distinct data collection requirements for the four healing arts boards with a single statute requiring data collection for all healing arts boards. The bill was not set for a hearing in this committee. The next year, Assembly Member Ting reintroduced the bill as AB 1236, adding sexual orientation and disability status to the list of required data points. This bill passed this committee but the author ultimately decided to hold the bill on the Assembly floor.

Instead, language was included in the omnibus health trailer bill as part of the Budget Act of 2021 consolidating the existing workforce data collection requirements for the four healing arts boards into one section with an expanded list of data points. However, the trailer bill did not require this data to be collected by any additional boards under the DCA; instead, it provided that all other healing arts boards request the information. The trailer bill also expressly provided that licensees could not be required to provide the information as a condition for license renewal, and that they could not be disciplined for failing to provide the information.

This bill would amend the consolidated data collection law enacted through the trailer bill to require all healing arts boards to collect the workforce data and report it to HCAI. The author cites recommendations in a 2019 report by the California Future Health Workforce Commission, which included among its goals an objective to "expand and scale pipeline programs to recruit and prepare students from underrepresented and low-income backgrounds for health careers." The author believes that providing HCAI with workforce data for all healing arts licensees will allow legislators and policymakers to more effectively evaluate the success of efforts to improve representation and diversity in the state's health care professions.

According to the Author

"California faces major shortages of health workers, isn't producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. There are 16 health care professional oversight boards that "request" workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California's health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended. This information will provide HCAI with data necessary to assess whether or not loan repayment programs intended to increase the diversity of the health workforce, and to encourage providers to serve in underserved areas, are working as intended."

Arguments in Support

The California Pan-Ethnic Health Network supports this bill, writing: "HCAI administers several Loan Repayment Programs that offer financial support to health professionals who agree to provide direct patient care in medically underserved areas. However, California has recently faced major shortages of health workers, not producing enough new workers to meet future needs, and the current health workforce does not match the state's diversity. Reports have also found that Hispanic and Black workers are very underrepresented in the existing health workforce in California. [This bill] would help support workforce supply and diversity problems to help improve the impacts on health access, quality, and equity in our most underserved communities."

The Latino Coalition for a Healthy California also supports this bill, writing: "We urge you to support [this bill], as California faces major shortages of health workers, isn't producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. Specifically, there are 16 health care professional oversight boards that 'request' workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California's health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended."

Arguments in Opposition

None on file.

FISCAL COMMENTS

According to the Assembly Committee on Appropriations, minor and absorbable costs to the DCA and HCAI.

VOTES

ASM BUSINESS AND PROFESSIONS: 17-0-1

YES: Berman, Flora, Alanis, Bains, Juan Carrillo, Chen, Dixon, Grayson, Irwin, Jackson, Ward, Lowenthal, McKinnor, Stephanie Nguyen, Pellerin, Soria, Zbur

ABS, ABST OR NV: Sanchez

ASM APPROPRIATIONS: 14-0-1

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Grayson, Haney, Hart, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Jim Patterson

UPDATED

VERSION: April 17, 2024

CONSULTANT: Robert Sumner / B. & P. / (916) 319-3301 FN: 0002832

1. https://ahea.assembly.ca.gov/media/1665 ↑

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1991

Author:(Bonta) – As Amended Ver:April 17, 2024

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

SUMMARY:

This bill requires all healing arts boards under the Department of Consumer Affairs (DCA) to collect, at least once every two years, specified workforce data from their licensees and registrants as a requirement of license or registration renewal, and requires the boards to provide that information to the Department of Health Care Access and Information (HCAI). This bill also prohibits a board from denying an application for license or registration renewal solely because the licensee or registrant failed to provide any of the information required by this bill.

FISCAL EFFECT:

Minor and absorbable costs to DCA and HCAI.

COMMENTS:

1. Purpose. According to the author:

California faces major shortages of health workers, isn’t producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. There are sixteen health care professional oversight boards that “request” workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California’s health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended. This information will provide HCAI with data necessary to assess whether or not loan repayment programs intended to increase the diversity of the health workforce, and to encourage providers to serve in underserved areas, are working as intended.

1. Background. In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California’s Health Care Workforce. The background paper for the hearing cited research showing “a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care.” As explained in the Health Committee’s background paper, underrepresentation in the health care workforce both “contributes to health disparities” and “limits access to high-paying, meaningful professions for underrepresented minorities.”
   
   The California Health Care Foundation, in its 2021 report “Health Workforce Strategies for California: A Review of the Evidence,” cited research showing that while 39% of Californians identified as Latino/a in 2019, only 14% of medical school matriculants and 6% of active patient care physicians in California were Latino/a. A 2018 study published by the Latino Policy & Politics Initiative at the University of California, Los Angeles found that while nearly 44% of the California population speaks a language other than English at home, many of the most commonly spoken languages are underrepresented by the physician workforce.
   

The omnibus health trailer bill of the Budget Act of 2021 consolidated the existing workforce data collection requirements for four healing arts boards into one section with an expanded list of data points. The trailer bill did not require this data be collected by any additional boards under the DCA; instead, it provided that all other healing arts boards request the information.

1. Prior Legislation.
   
   1. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, consolidates workforce data collection requirements and requires all healing arts boards to request, if not require, that data.
      
   2. AB 1236 (Ting) of 2021 would have consolidated workforce data collection requirements and required all healing arts boards to collect that data. AB 1236 died on the inactive file of the Assembly Floor.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 1991

Author:(Bonta) – As Amended Ver:March 11, 2024

SUBJECT: Licensee and registrant records.

SUMMARY: Requires all healing arts boards under the Department of Consumer Affairs (DCA) to collect specified workforce data from their licensees and registrants at least biennially as a requirement of license or registration renewal, and requires that information to be subsequently provided to the Department of Health Care Access and Information (HCAI).

EXISTING LAW:

1. Establishes the DCA within the Business, Consumer Services, and Housing Agency. (Business and Professions Code (BPC) §§ 100 et seq.)
2. Establishes various boards, bureaus, and other entities within the jurisdiction of the DCA. (BPC § 101)
3. Establishes “healing arts” boards under the jurisdiction of DCA, which includes the following entities:
   1. Acupuncture Board;
   2. Board of Behavioral Sciences;
   3. State Board of Chiropractic Examiners;
   4. Dental Board of California;
   5. Dental Hygiene Board of California;
   6. Medical Board of California;
   7. California Board of Naturopathic Medicine;
   8. California Board of Occupational Therapy;
   9. California Board of Optometry;
   10. Osteopathic Medical Board of California;
   11. California State Board of Pharmacy;
   12. Physical Therapy Board of California;
   13. Physician Assistant Board;
   14. Podiatric Medical Board of California;
   15. Board of Psychology;
   16. Board of Registered Nursing;
   17. Respiratory Care Board of California;
   18. Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board;
   19. Veterinary Medical Board;
   20. Board of Vocational Nursing and Psychiatric Technicians.

(BPC §§ 500 et seq.)

1. Requires information retained by each board under the DCA relating to license applicants with criminal records to include the final disposition and demographic information, consisting of voluntarily provided information on race or gender. (BPC § 480(g))
2. Requires the Board of Registered Nursing, the Board of Vocational Nursing and Psychiatric Technicians, the Physician Assistant Board, and the Respiratory Care Board of California to collect specified workforce data from their respective licensees and registrants for future workforce planning at least biennially, with data collected at the time of electronic license or registration renewal as applicable. (BPC § 502(a)(1))
3. Provides that all other healing arts boards shall request the specified workforce data for future workforce planning at least biennially, with data collected at the time of electronic license or registration renewal as applicable. (BPC § 502(a)(2))
4. Specifies the following information as included within the workforce data collected or requested by healing arts boards:
   1. Anticipated year of retirement.
   2. Area of practice or specialty.
   3. City, county, and ZIP Code of practice.
   4. Date of birth.
   5. Educational background and the highest level attained at time of licensure or registration.
   6. Gender or gender identity.
   7. Hours spent in direct patient care, including telehealth hours as a subcategory, training, research, and administration.
   8. Languages spoken.
   9. National Provider Identifier.
   10. Race or ethnicity.
   11. Type of employer or classification of primary practice site among the types of practice sites specified by the board, including, but not limited to, clinic, hospital, managed care organization, or private practice.
   12. Work hours.
   13. Sexual orientation.
   14. Disability status.

(BPC § 502(b))

1. Requires each board to maintain the confidentiality of the information it receives from licensees and registrants and to only release information in an aggregate form that cannot be used to identify an individual. (BPC § 502(c))
2. Requires the DCA, in consultation with HCAI, to specify for each board the specific information and data that will be collected or requested. (BPC § 502(d))
3. Requires each board, or the DCA on its behalf, to provide the workforce data it collects to HCAI on a quarterly basis in a manner directed by HCAI, including license or registration number and associated license or registration information. (BPC § 502(e))
4. Prohibits boards from requiring a licensee or registrant to provide the workforce data as a condition for license or registration renewal, or from disciplining licensees or registrants for not providing the information. (BPC § 502(f))
5. Requires licensed dentists to report to the Dental Board of California, upon initial licensure and any subsequent application for renewal, the licensee’s practice status and any completed advanced educational program, as well as information regarding the licensee’s cultural background and foreign language proficiency if reported by the licensee. (BPC § 1715.5)
6. Requires licensed dental hygienists to the Dental Hygiene Board, upon initial licensure and any subsequent application for renewal, the licensee’s practice or employment status, as well as information regarding the licensee’s cultural background and foreign language proficiency if reported by the licensee. (BPC § 1902.2)
7. Requires licensed physicians and surgeons to report to the Medical Board of California, immediately upon issuance of an initial license and at the time of license renewal, their practice status and any specialty board certification they hold, along with information relating to their cultural background and foreign language proficiency unless the licensee declines to provide that information. (BPC § 2425.3)
8. Requires licensed osteopathic physicians and surgeons to report to the Osteopathic Medical Board of California, either immediately upon issuance of an initial license or at the time of renewal, as provided, any specialty board certification they hold and their practice status, along with information relating to their cultural background and foreign language proficiency if reported by the licensee. (BPC § 2455.2)
9. Authorizes the Bureau of Real Estate Appraisers to request that a licensee identify their race, ethnicity, sexual orientation, gender, or gender identity. (BPC § 11347)
10. Requires the Board of Registered Nursing to incorporate regional forecasts into its biennial analyses of the nursing workforce and to develop a plan to address shortages. (BPC § 2717)
11. Authorizes the California Architects Board to request that a licensee identify their race, ethnicity, sexual orientation, gender, or gender identity. (BPC § 5552.2)
12. Establishes HCAI, previously established as the Office of Statewide Health Planning and Development, vested with responsibilities related to health planning and research development. (Health and Safety Code (HSC) §§ 127000 et seq.)
13. Provides for a Health Professions Career Opportunity Program to increase the number of ethnic minorities in health professional training and minority health professionals practicing in health shortage areas, subject to the appropriation of funds. (HSC §§ 127875 – 127885)
14. Requires HCAI to establish a health care workforce research and data center to serve as the central source of health care workforce and educational data in the state. (HSC § 128050)
15. Requires HCAI to work with the Employment Development Department’s Labor Market Information Division, state licensing boards, and state higher education entities to collect, to the extent available, all of the following data:
    1. The current supply of health care workers, by specialty.
    2. The geographical distribution of health care workers, by specialty.
    3. The diversity of the health care workforce, by specialty, including, but not necessarily limited to, data on race, ethnicity, and languages spoken.
    4. The current and forecasted demand for health care workers, by specialty.
    5. The educational capacity to produce trained, certified, and licensed health care workers, by specialty and by geographical distribution, including, but not necessarily limited to, the number of educational slots, the number of enrollments, the attrition rate, and wait time to enter the program of study.

(HSC § 128051)

1. Requires HCAI to prepare an annual report to the Legislature that does all of the following:
   1. Identifies education and employment trends in the health care profession.
   2. Reports on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas.
   3. Recommends state policy needed to address issues of workforce shortage and distribution.
   4. Describes the health care workforce program outcomes and effectiveness.

(HSC § 128052)

THIS BILL:

1. Provides that healing arts boards under the DCA that are not already required to collect workforce data from their licensees and registrants shall be required to collect that workforce data for future workforce planning at least biennially.
2. Requires a licensee or registrant to provide the workforce data information as a condition for license or registration renewal.

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

COMMENTS:

Purpose. This bill is sponsored by the author, who is Chair of the Assembly Committee on Health. According to the author:

“California faces major shortages of health workers, isn’t producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. There are sixteen health care professional oversight boards that “request” workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California’s health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended. This information will provide HCAI with data necessary to assess whether or not loan repayment programs intended to increase the diversity of the health workforce, and to encourage providers to serve in underserved areas, are working as intended.”

Background.

California has long faced significant gaps and inequities in its health care workforce. There has historically been a persistent shortage of accessible health professionals overall, which disproportionately impacts communities with concentrated populations of immigrant families and people of color. A recent study found that between 2010 and 2019, the number of primary care physicians in proportion to population remained largely unchanged nationally. Meanwhile, counties with a higher proportion of minorities saw a decline during that period.^[1]

Compounding these issues of access is a significant lack of diversity among health care practitioners, with several minority groups remaining persistently underrepresented within the healing arts fields. A recent study of data from the American Community Survey and the Integrated Postsecondary Education Data System found that Black, Hispanic, and Native American people are nationally represented across 10 different health care professions.^[2] As a result, minorities seeking to enter these professions face significant systemic obstacles, and patients who are representative of minority groups or immigrant communities often do not have access to practitioners who possess the cultural or linguistic competence to provide them with appropriate care.

Research cited by the California Health Care Foundation (CHCF) in its 2021 report “Health Workforce Strategies for California: A Review of the Evidence” found that while 39 percent of Californians identified as Latino/x in 2019, only 14 percent of medical school matriculants and 6 percent of active patient care physicians in California were Latino/x.^[3] A 2018 study published by the Latino Policy & Politics Initiative at the University of California, Los Angeles found that while nearly 44 percent of the California population speaks a language other than English at home, many of the most commonly spoken languages are underrepresented by the physician workforce.^[4] While the physician community has worked with the Medical Board of California to improve linguistic competency among providers, these efforts have yet to resolve systemic challenges with addressing language barriers in California.

Another issue resulting from underrepresentation in the health professions relates to implicit bias. According to the Stanford Encyclopedia of Philosophy, “implicit bias” can be described as “a term of art referring to relatively unconscious and relatively automatic features of prejudiced judgment and social behavior.” In her 2019 book Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do, Dr. Jennifer L. Eberhardt explains that “implicit bias is not a new way of calling someone a racist. In fact, you don’t have to be a racist at all to be influenced by it. Implicit bias is a kind of distorting lens that’s a product of both the architecture of our brain and the disparities in our society.” Dr. Eberhardt goes on to describe how “bias is not limited to one domain of life. It is not limited to one profession, one race, or one country. It is also not limited to one stereotypic association.”^[5]

In December 2015, the American Journal of Public Health published a systematic review titled Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes. The review concluded that “most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color.” Additional published studies suggest that implicit bias in regards to gender, sexual orientation and identity, and other characteristics has resulted in inconsistent diagnoses and courses of treatment being provided to patients based on their respective demographic. These trends take into account not only the characteristics of the person being treated, but those of the licensed professional in correlation to that patient.

The results of implicit bias can have serious consequences in the provision of health care. For example, one frequently cited statistic is that Black women have average maternal mortality rates that are three-to-four times higher than white women. While much of the research and action relating to implicit bias has been focused on the area of law enforcement and police procedure, there has been a growing call to also address the presence of implicit bias in the healing arts professions through additional awareness and training. In 2019, the Legislature enacted Assembly Bill 241 (Kamlager-Dove) to require continuing education courses for physicians and surgeons, nurses, and physician assistants to include the understanding of implicit bias and the promotion of bias-reducing strategies. While implementation of these requirements has undoubtedly had at least some impact on improving health care outcomes for minority patients, education and training is not a substitute for increasing diversity and representation among providers.

In February 2024, the Assembly Committee on Health held an informational hearing focused on Diversity in California’s Health Care Workforce. This hearing included perspectives from various stakeholders and public health researchers, along with policymakers who provided updates on the state’s efforts to increase diversity. The background paper for the hearing^[6] cited research published in December 2022 by the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University in a report titled “The Race and Ethnicity of the California Health Care Workforce,” which demonstrated that “a health workforce that reflects the racial and ethnic diversity of the population can improve access to, quality of, and outcomes of care.”^[7] As explained in the Health Committee’s background paper, underrepresentation in the health care workforce both “contributes to health disparities” and “limits access to high-paying, meaningful professions for underrepresented minorities.”

California has historically attempted to resolve these longstanding issues of representation and access through a number of different approaches. For example, the Legislature has previously enacted and funded loan repayment programs, such as the Dental Corps Loan Repayment Program of 2002, which provided grants to qualifying dentists who agreed to work for at least three years in a clinic or dental practice located in a dentally unserved area, or in which at least 50 percent of patients are from a dentally underserved population. The Health Professions Career Opportunity Program within HCAI similarly supports initiatives designed to enhance diversity and representation in the health professions by awarding grant funding through competitive programs.

As discussed in the Health Committee’s background paper, it is often challenging to evaluate the long-term impacts of these programs, as “HCAI does not currently collect longitudinal data that could demonstrate which of these programs are more effective.” During sunset review oversight hearings on healing arts boards that were held jointly in 2024 by the Assembly Committee on Business and Professions and the Senate Committee on Business, Professions, and Economic Development, committee members expressed frustration that there was not sufficient data to confirm whether any particular strategy to improve access has been successful. This is in large part due to a lack of consistent data from healing arts licensees to inform policymakers about how many practitioners of particular specialties are providing services in any given area of the state, or about the demographic makeup of those practitioners.

The California Health Workforce Research and Data Center, previously established in 2007 as the Healthcare Workforce Clearinghouse under the prior Office of Statewide Health Planning and Development, serves as California’s central source for collection, analysis, and reporting of information on the healthcare workforce employment and educational data trends for the state. As part of its statutory duties, HCAI is mandated to prepare an annual report to the Legislature that accomplishes the following three goals: (1) identifying education and employment trends in the health care professions (2) reporting on the current supply and demand for health care workers in California and gaps in the educational pipeline producing workers in specific occupations and geographic areas; and (3) recommending state policy needed to address issues of workforce shortage and distribution.

In 2014, the Legislature enacted Assembly Bill 2102, authored by Assemblymember Phil Ting and co-sponsored by the California Pan-Ethnic Health Network and the Latino Coalition for a Healthy California. The bill required four specified healing arts boards—the Board of Registered Nursing, the Physician Assistant Board, the Respiratory Care Board of California, and the Board of Vocational Nursing and Psychiatric Technicians—to collect and report specific demographic data related to its licensees. Specifically, AB 2102 mandated that the four boards collect the following data from licensees: (1) location of practice, including city, county, and zip Code; (2) race or ethnicity; (3) gender; (4) languages spoken; (5) educational background and (6) classification of primary practice site, such as clinic, hospital, managed care organization, or private practice. In order to implement AB 2102, the DCA and HCAI established an interagency agreement to facilitate the specified data collection and exchange.

Assemblymember Ting subsequently introduced Assembly Bill 2704 in 2020, which sought to replace the distinct data collection requirements for the four healing arts boards with a single statute requiring data collection for all healing arts boards. The bill ultimately was not set for a hearing in this committee. The next year, Assemblymember Ting reintroduced the bill as Assembly Bill 1236, adding sexual orientation and disability status to the list of required data points. This bill passed this committee but the author ultimately decided to hold the bill on the Assembly floor.

Instead, language was included in the omnibus health trailer bill as part of the Budget Act of 2021 consolidating the existing workforce data collection requirements for the four healing arts boards into one section with an expanded list of data points. However, the trailer bill did not require this data to be collected by any additional boards under the DCA; instead, it provided that all other healing arts boards request the information. The trailer bill also expressly provided that licensees could not be required to provide the information as a condition for license renewal, and that they could not be disciplined for failing to provide the information.

This bill would amend the consolidated data collection law enacted through the trailer bill to require all healing arts boards to collect the workforce data and report it to HCAI. The author cites recommendations in a 2019 report by the California Future Health Workforce Commission, which included among its goals an objective to “expand and scale pipeline programs to recruit and prepare students from underrepresented and low-income backgrounds for health careers.” The author believes that providing HCAI with workforce data for all healing arts licensees will allow legislators and policymakers to more effectively evaluate the success of efforts to improve representation and diversity in the state’s health care professions.

Current Related Legislation.

AB 2862 (Gipson) would require boards under the DCA to prioritize African American applicants seeking licenses, especially applicants who are descended from a person enslaved in the United States. This bill is pending in this committee.

AB 2860 (Garcia) recasts and expands provisions of law relating to the Licensed Physicians and Dentists from Mexico Pilot Program. This bill is pending in the Assembly Committee on Appropriations.

SB 1067 (Smallwood-Cuevas) would require healing arts boards to expedite the licensure process for applicants who intend to practice in a medically underserved area. This bill is pending in the Senate Committee on Appropriations.

Prior Related Legislation.

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) consolidated workforce data collection requirements and requires all healing arts boards to request, if not require, that data.

AB 1236 (Ting) of 2021 would have consolidated workforce data collection requirements and required all healing arts boards to collect that data. This bill died on the inactive file of the Assembly Floor.

AB 2704 (Ting) of 2020 would have consolidated workforce data collection requirements and required all healing arts boards to collect that data. This bill was not set for a hearing in this committee.

AB 2102 (Ting, Chapter 420, Statutes of 2014) required four specified healing arts boards to collect and report specific demographic data related to its licensees.

ARGUMENTS IN SUPPORT:

The California Pan-Ethnic Health Network supports this bill, writing: “HCAI administers several Loan Repayment Programs that offer financial support to health professionals who agree to provide direct patient care in medically underserved areas. However, California has recently faced major shortages of health workers, not producing enough new workers to meet future needs, and the current health workforce does not match the state's diversity. Reports have also found that Hispanic and Black workers are very underrepresented in the existing health workforce in California. AB 1991 would help support workforce supply and diversity problems to help improve the impacts on health access, quality, and equity in our most underserved communities.”

The Latino Coalition for a Healthy California also supports this bill, writing: “We urge you to support AB 1991, as California faces major shortages of health workers, isn’t producing enough new workers to meet future needs, and the current health workforce does not match the diversity of the state. These workforce supply and diversity problems have a major impact on health access, quality, and equity. Specifically, there are sixteen health care professional oversight boards that ‘request’ workforce data but do not require workforce data to be reported as condition as licensure. Without accurate information about the makeup of California’s health workforce, it is difficult to assess whether or not programs designed to improve diversity and increase access to care in underserved areas are working as intended.”

ARGUMENTS IN OPPOSITION:

None on file.

POLICY ISSUE(S) FOR CONSIDERATION:

This bill and current law provide that the workforce data is collected as part of the license renewal process, and this bill would confirm that licensees must report the information as part of their renewal application. However, the intent of the author is not for licensees to be denied renewal of their license simply because they declined to provide all the information required, some of which is arguably personal and sensitive. The author has therefore agreed to clarify that failure to provide the information is not on its own cause for a license renewal to be denied.

AMENDMENTS:

To ensure that licensees are not denied a license renewal simply because they did not provide all or part of the required workforce data, amend subdivision (f) in Section 1 of the bill as follows:

(f)(1) A licensee or registrant shall be required to provide the information listed in subdivision (b) as a condition for license or registration renewal.

(2) Notwithstanding paragraph (1), a board described in paragraph (2) of subdivision (a) shall not deny an application for license or registration renewal solely because the licensee or registrant failed to provide any of the information listed in subdivision (b).

REGISTERED SUPPORT:

California Pan-Ethnic Health Network

Latino Coalition for a Healthy California

REGISTERED OPPOSITION:

None on file.

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

1. Liu M, Wadhera RK. Primary Care Physician Supply by County-Level Characteristics, 2010-2019. ↑

2. Salsberg, Edward et al. “Estimation and Comparison of Current and Future Racial/Ethnic Representation in the US Health Care Workforce.” JAMA network open vol. 4,3 e213789. 1 March 2021. ↑

3. https://www.chcf.org/publication/health-workforce-strategies-california ↑

4. https://latino.ucla.edu/wp-content/uploads/2019/08/The_Patient_Perspective-UCLA-LPPI-Final.pdf ↑

5. Eberhardt, Jennifer L. Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do.  New York: Viking, 2019. ↑

6. https://ahea.assembly.ca.gov/media/1665 ↑

7. Bogucki C, Brantley E, Salsberg E. “The Race and Ethnicity of the California Health Workforce.” Fitzhugh Mullan Institute for Health Workforce Equity. Washington, DC: George Washington University, 2022. ↑