Assembly Standing Committee on Health

We will call together the informational hearing of diversity in California's health workforce today. I want to welcome my colleagues and the esteemed panelists who will be presenting on such an important issue to the State of California.

This afternoon, we have an opportunity to talk about the worst kept secret, that California needs more healthcare professionals than we currently have, that the current workforce does not match the diversity of the state, and that the lack of workforce diversity creates health disparities.

The legislature and the administration have put a lot of time and money into efforts to increase both the workforce as well as its diversity. I'm excited to hear from our presenters today to learn more about our community's needs and what can be done to address them.

With that, I will offer my fellow colleague any opening remarks an opportunity to address. Thank you, Dr. Arambula. With that, we will move forward with the first panel. If you could please come forward.

The California Healthcare Foundation is going to provide us with an assessment of California's health workforce challenges and needs.

Thank you. We'll welcome our colleague, Reginald Jones Sawyer as well. We'll have each member of the panel introduce themselves prior to speaking, and we will begin with Ms. Phillips.

Catherine Phillips, I'm an associate director at the California Healthcare Foundation. Thank you for having me. We have a lot to cover today. If you remember just three things, please hear this.

California does not have enough healthcare workers, and the workforce we have doesn't match our population's ethnicity, their language, or their geography. Investing in education and training programs can help with both of these challenges, and California is making strides.

And a well supported and representative workforce means patients, your family, your friends, your neighbors can receive health care in their home community. Chair Bonta asked me to begin with an overview. There are many challenges impacting California's health workforce.

The two greatest challenges are lack of supply and lack of diversity and representation. California's health workforce shortages have been in the news as people across our state and those with all types of healthcare coverage struggle to find a provider when theirs retires or they move.

And more and more we're getting reports of people having a hard time finding a timely appointment, even from a provider who served them for decades. These shortages are pervasive, and they are widespread.

Five of California's nine geographic regions now fail to meet minimum national standards for the number of primary care providers per capita, and two more are hovering at just above the minimum threshold. Shortages are no longer an issue in just rural communities. They are impacting patients across the state and very likely in your district.

The shortage of primary care providers is a national problem. But California's supply is declining faster than other states. And there are troubling trends in several medical specialties as well, including general surgery, obstetrics, and emergency medicine.

These shortages aren't new, and they weren't sudden. The shortages we are experiencing today are the result of demographic trends. Our clinician workforce is aging, and it's aging much faster than our general population. Today, the median age of a physician in California is 53.

That's 59 in the rural north, and the percentage of providers above 60 continues to increase. So how did we get here? California has underinvested in health and education for decades. While we have world renowned medical institutions and many campuses, they haven't kept pace with our rapidly growing population.

Today, we rank 46th among the 47 states and territories with medical schools for medical school enrollment per capita. And last year, we turned away 75%, 75% of qualified applicants for bachelors of nursing programs because we did not have the capacity to teach them.

We lose students, and especially Latino students, to other states who have greater capacity and only a portion return to us. Several recent factors have made these shortages more pronounced. California's high cost of living is driving healthcare workers to other industries and to neighboring states, and Covid-19 led to burnout early departures, especially in nursing.

I've focused so far on physicians and nurses, but many of these dynamics are occurring across the health professions, including among our critical support staff, such as medical assistants. Last year, for example, the California Primary Care Association, which represents federally qualified health centers, reported increased turnover and longer vacancy times for nearly all positions.

The impact of workforce shortages on community is significant. 11 million Californians, that's more than a quarter of our state's entire population, now live in a federally designated primary care health professional shortage area.

Workforce shortages can impact quality and outcomes, and they create access challenges. No care, long wait times or long drives, While California ranks highly for insurance coverage, we are at the very bottom nationally on many important measures of healthcare quality.

Last year, we ranked 44th in the nation for prevention and treatment and 50th, that's dead last, for children without a medical and dental preventive care visit. While there are many factors associated with quality ratings, workforce limitations are surely apart.

Without a person to see, care is hard to get. In addition to insufficient number of healthcare workers, our current health workforce doesn't reflect the racial, ethnic, or linguistic diversity of our state. And here the numbers are really startling.

Nearly half of California residents identify as Latino or black, yet only 14% of our medical school graduates and less than 9% of our practicing providers do. While these percentages are trending up, they need to move much faster and much further.

The gap is greatest among Latinos, who are underrepresented among every licensed health profession in our state and every region, 47 and all. To reach population parity for physicians, we would need to produce more than 37,000 more Latino physicians.

Today, from all backgrounds, we produce just a little over 1700. Why is diversity and representation so important? Because there are benefits to concordance. When patients share the race or ethnicity of their provider, they report greater trust, greater satisfaction in care.

They have better communication and adherence to treatment, and in some instances, they receive more effective care. The ability to speak the same language with a provider or a healthcare team member further enhances trust and decreases poor clinical outcomes due to miscommunication.

Linguistic skills are important across our country, but they're particularly important in California, where 44% of households speak a language other than English.

Providers of color are also more likely to practice in medically underserved areas and to accept medical. In 2019, leaders from across health, education, labor and government prioritized recommendations to expand and to diversify the health workforce in California.

The final report of the California Future Health Workforce Commission has become a blueprint for action in our state and a role model across the country. And we've seen substantial progress in some areas, many of which we're going to hear from panelists today, including the establishment of the Department of Healthcare Access and Information, who plays a key role in workforce investment and workforce data collection and reporting.

We've seen the expansion statewide of primary care and psychiatry residencies, and the engagement of community health workers, as well as other critical roles such as doulas, peers, and wellness coaches.

These examples highlight the power of state action and the benefits of coordinated and sustained state investment. Our health workforce is critical infrastructure and we need to protect it. Much more is needed. Let me end there. I'll pass it along, and I'll be back on a further panel to speak more about solutions. Thank you.

Great. Thank you so much, Catherine, and thank you so much to the Chair and members for having me today. My name is Kiran Savage-Sangwan. I'm the executive director of the California Pan Ethnic Health Network, or CPEHN. I do have a PowerPoint, but I'll just keep going. It'll get there. As you all know, we live in a very diverse state.

The majority of Californians are people of color, and one in every five Californians is limited English proficient, meaning they speak English less than very well, and our language assistance services are critical.

It's a little delayed.

Kathryn says, okay.

Cool. All right, great. So, as we know, and as was already shared, our healthcare workforce is not representative of the state's diverse population. Particularly striking, again, for the Latino population, 39% of Californians are know, but only 20% of all active health workforce licenses. And even more striking, only 8% of physicians. And Asian and white Californians, when you look at the data, do appear to be sort of overrepresented. But I would put a real caveat, particularly on the Asian population, where we don't have desegregated data.

So we probably do have a real mismatch for smaller Asian and Pacific Islander populations that's masked by our current data. A little over half of all licensed providers speak English only, but those disparities also vary by license type and region and language in particular. And we highlight the data because it is a first step to achieving a more inclusive workforce, is really having that baseline data on patient and provider concordance by language proficiency, disability, sexual orientation, gender identity, and race.

In 2014, we at CPEHN worked to pass what was then AB 212 with the Latino Coalition for a Healthy California, and that did require the Department of Consumer affairs to collect demographic data on allied health professionals and provide that data to what is now HCAI. It did only require data from a limited number of healthcare occupations. So in 2021, we came back, and what became trailer Bill required additional reporting from HCAI around demographic data of registered health professionals under the Department of Consumer Affairs.

So now we are able to sort of take a first look at that data fairly recently, and that's what's contained in our slides here. So here you see a chart that compares the race and ethnicity of the estimated percentage of all active licenses compared to the population percentage for each group.

And again, I would really kind of call out the big caveat in the Asian community that you see here, as well as when you look at the Black and Pacific Islander community, you might say, okay, those are very close, but I think we also have to remember those are very small and dispersed populations. So depending on where those providers are located and where the communities are located, people continue to struggle to find a provider who is concordant. The representation also varies across workforce categories.

So this table is a little busy, but basically green and red, which shows that the percentage point differences between the population and the estimated percentage of active licenses for each of these workforce categories. So the groups in green have a percentage of active licenses that are greater than the population percentage, and the groups in red are the reverse. Right. The percentage of active licenses is less than the population percentage.

This chose a deep dive on behavioral health to sort of take one, and particularly focusing on language, because we know that language concordance in particular is critical to advancing quality behavioral health services. So this looks at languages spoken in the behavioral health workforce and compares them to population estimates for the state. And you can see that API language speakers make up almost 10% of California's population, but only 3.6% of behavioral health providers. Again, not desegregated, but even aggregated like this, we can see the mismatch.

Studies have found that a lack of a diverse mental health workforce, the absence of culturally informed treatment options and stereotypes associated with poor mental health, contributed to limited mental health treatment among people of color. And Kathryn talked a little bit about cultural concordance, which we understand to be a really important part of quality of care in healthcare.

It contributes to patients having positive experiences with their care providers, to improving communication and trust, especially among groups that have experienced discrimination historically and present day, which can in turn improve care and outcomes. And a couple of studies just to highlight about why cultural concordance in healthcare is really so important. One study in Oakland randomized male black patients to male black doctors and male non-black doctors and found that patients were more likely to accept preventive care from a Black doctor.

The researchers estimate that this difference in adherence to care could actually reduce the black-white cardiovascular mortality gap by 19%. A systematic review of studies of language concordance showed that in the majority of studies, patient physician concordance improved care, including patient satisfaction, diagnosis understanding and management of chronic disease such as blood pressure and glycemic control for diabetes patients. Nationally, American Indian and Alaskan native populations have the lowest life expectancy and a high disease burden compared to other races and ethnicities.

Cultural concordance has often been recommended in that community as a way to improve outcomes. I think it's also important to consider workforce diversity from an economic opportunity perspective and to consider workforce solutions that counter racialized poverty. Healthcare is a major economic engine for the state and the largest employer in many communities. It is important that the state ensure that healthcare workers, particularly low-wage workers who are most likely to be people of color, are treated with dignity and paid a living wage.

We at CPEHN routinely speak with healthcare workers who are unable to afford their own health care and skip needed services. And then finally on recommendations. Since 2019, California has invested significant dollars with your leadership in reducing our severe workforce shortages. We've created new reimbursable provider types such as community health workers. But in order to really make best use of targeted investments. We have a couple of recommendations.

One is to recognize and counter the impacts of anti-racial equity initiatives such as Proposition 209 and the recent Supreme Court decision on affirmative action. We have seen the impact of Proposition 209 in terms of diversity in medical education, and so we understand that we have to be creative and we have to think about how to continue to ensure diversity and equity in our higher education and training programs.

Our various departments and agencies should continue to address workforce training needs and open earn and learn programs to a broader, more racially and ethnically diverse pool. And while we understand the currently available data limits in the estimates that HCAI can produce, we're hopeful there will be improvements in data collection methods so that we can see data at a much more granular level for our population.

We also understand that it's not only about training people to become providers, but it's about retaining our healthcare workforce providers, and that providers of color often struggle in both educational and professional settings because of both implicit and explicit racial bias.

And so we should be working to ensure that all workplaces and training and educational institutions are actively working to advance diversity, equity and inclusion, and then finally, really making sure that we are providing adequate wages, dignified working conditions and leadership opportunities for allied health professionals such as community health workers, doulas and peer specialists who are filling many of these gaps today. Thank you so much.

Hello. My name is Meron Agonafer. I'm the policy and legislative affairs manager with the California Black Health Network. Thank you for the opportunity to be a part of this distinguished panelists to discuss the impact of the lack of diversity in health workforce on Blacks. This issue has significant implications for our state's overall health and equity. Let's start by looking at some data. According to the US Census Bureau, black individuals comprise around 6.5% of California's population.

However, when we look at the health workforce, the representation of black professionals is Low. A California Healthcare Foundation report found that 3% of physicians are black. The California Board of Registered Nursing 2020 survey of registered nurses reported that 4% of nurses in California are black. The March 29, 2021 published analysis in the New England Journal of Medicine noted that black medical schools had played a significant role in training the current number of black healthcare professionals, enrolling 14.2% of black women 14.9% of black men in 2019.

Without their effort, the percentage of black clinician would be even lower. We hope everyone has seen the report published by the California Healthcare Foundation listening to Black Californians, which presents the disturbing fact that one in four Black Californians avoid care because of fear of being mistreated or disrespected. To address this mistreatment of black patients, California Black Health Network launched the "how do I?" campaign thanks to the generous support of the California Healthcare Foundation.

Our campaign engaged black communities in targeted counties to empower them with the information and resources they need to navigate and advocate for themselves, their friends, their families on how to take action when faced with discrimination in a Doctor's office. The how do I campaign addresses the impact of structural racism in healthcare head on. Through this program, we have learned there is much work ahead to diversify the healthcare workforce. The underrepresentation of black professionals in healthcare perpetuate existing health disparities.

Studies have shown that racial and ethnic commonalities between patients and providers lead to better communication, increased trust, and improved patient satisfaction. When black individuals are unable to see healthcare professionals who share their racial or ethnic background, it can contribute to a lack of trust in the healthcare system, resulting in delayed or poor care. California must expand the number of higher learning institutions committed to addressing disparities in the medical workforce. Charles Drew University is a positive development.

We commend Governor Newson and California Legislature for working together to approve $50 million to construct a facility to house the new medical degree program. 70% of the graduates are people of color and the University accepted its first 60 medical students into the program in 2023. This is one pipeline to expand the number of Black Clinicians and the state should continue to support it. But this is not enough. All medical schools in California must increase their effort to recruit talented and qualified students from underrepresented minorities.

How about the University of California? CBN strongly believes the University of California, as the top state funded higher educational institution, has a vital role to play in expanding the number of black Clinicians. UC has six medical schools which can play an important role in admitting and training black medical professionals.

I would like to bring to your attention an excellent report prepared in September 2020 by the UC Health Sciences Diversity, Equity and Inclusion Task Force, disrupting the status quo, which is geared toward improving diversity through the UC medical school. According to that report, in 2018 and 2019, the percentage of blacks and the UC Health sciences student is nearly at the bottom, just above American Indian Alaskan Native. Fortunately, that report offers critical recommendation to improve UC student diversity and health sciences.

We encourage you to consider working with UC Office of the President for their implementation. Highlights from the task force recommendation include to diversify the applicant pool, they recommend partnering with California Committee colleges, California State universities, historically black colleges and universities. Since they enroll in diverse student body, there are 101 HBCUs in the US and UC can attract, train, mentor, retain top black students from these quality schools.

Expand the prime model, which offers specialized education, training and support for UC medical students who wish to serve underserved populations in urban and rural community. Prime is underfunded and the Legislature should push for deeper investment in this effective program. The UC report also recommends replicating the Prime model for other UC health professions such as nursing, pharmacy and public health. This effort will make an important contribution toward increasing the number of black health professionals.

For behavioral health profession, CBHN is working with Assembly Member Corey Jackson to expand the medical certified peer support services through the California Behavioral Health of Care. We believe this will be more effective than a self-funded county option. A diverse and inclusive black workforce in the healthcare sector will not only lead to improved black patient care, but can offer significant cost savings for California by preventing and managing disease in early stage with culturally competent care.

Thanks to the extensive survey done by California Healthcare Foundation, California blocks have clearly expressed they are more likely to seek care and adhere to treatment plans if the health care is provided by those who look like them and reflect their community. Research led by Sanford University School of Medicine found that Black Men seen by Black doctors agreed to more and more invasive preventive services than those seen by non-black doctors.

This effect seemed to be driven by better communication and more trust, suggesting that improved interactions with black doctors can lead to better adherence to medical recommendations. To conclude, a diverse healthcare workforce brings unique perspectives and experiences that can contribute to innovative approach in healthcare delivery. CBHN urged the Legislator to invest in expanding the medical program at Charles Drew University and to also implement the September 2020 UC Health Sciences Diversity, Equity and Inclusion Task Force recommendation, which embraced supporting and expanding the UC prime program.

I want to thank you, the Chair and Committee Member, for inviting me to speak at this informational hearing. Thank you.

Thank you. And we will welcome Assembly Member Pilar Schiavo and ask if she has any opening remarks for us.

I just wanted to thank the panel, all the panelists who are here today. This is such an important issue. And just from what I'm hearing already, it seems like there's a real problem with the pipeline and it's so frustrating because I think it's really short sighted because we know that these are good jobs, right?

If we're able to put money in upfront to fund training programs, we know that certainly if it's public money, that that public money is going to come back to us because these are good jobs that folks are going to have for the rest of their careers.

And at a time when we know that too many people are underemployed, where they have to have a couple of jobs, especially in communities of color and low-wage and service sector jobs, that these are jobs that typically have retirement plans and living wage jobs where people can actually put their kids through school and keep a roof over their head, that these are exactly the kinds of jobs that we need to be driving folks into and making sure that we create pathways for folks to get into these kinds of jobs in the healthcare field.

I think that one of the things that really concerns me about the recent exodus out of healthcare, which includes a lot of people of color, is that those are things that can be remedied now, right? We can prevent the bleeding. Not to.

Sorry, no pun intended, but we can prevent that through making sure that we're supporting workers in the workplace, that we're appropriately staffing so that people are not carrying an undue burden, which I think is a lot of what has to do with the burnout that's happening within hospitals, at least. And I think that there's a real concern that I have also around travelers and the heavy, heavy use of travelers, which are so expensive in our health care system. And it's not always folks from our community.

They're people from out of state. These are not always people who are coming from our community. So these are not high paid jobs necessarily going back into our communities and not as invested in our communities. And so I think making sure that we're able to staff appropriately with local hires in these good jobs and creating the pathways to be able to get people from our community into good jobs in the healthcare field is incredibly important to me and I know to the Committee here.

So just really happy, thankful to the chair for raising this issue and making sure that we highlight this and keep focused on it. And as we go forward in this legislative session to address the concerns that I know exist. Thank you.

Thank you, Assemblymember. We'll move on now to Dr. Aquino.

Thank you so much. Muy Buenas tardes. Thank you, Chairwoman Bonta and esteemed members of the Committee. It is a pleasure to join you all today. I am Dr. Seciah Aquino and I have the honor of serving as the Executive Director at the Latino Coalition for a Healthy California. At LCHC, we are committed to advancing and protecting Latine and mesoamerican indigenous health through policy change and advocacy. We pride ourselves in translating community solutions into equitable policy and lasting systemic change.

Latines make up a powerful majority in California, comprising 40% of our state's population. That totals a staggering 16 million individuals representing our California pool of patients, consumers, and strong members of the workforce itself. And yet, despite our significant presence, we continue to face systemic challenges that hinder our ability to fully address health inequities in our communities.

The enduring impacts of systemic disenfranchisement and chronic underinvestment, coupled with the aftermath of the recent public health emergency, have led our communities to confront ongoing challenges, including acute Covid-19 cases, long covid, and the socioeconomic aftermath of the pandemic, leaving our collective health status increasingly fragile. One glaring issue that demands our attention is the underrepresentation of Latine healthcare professionals in our workforce.

Despite being a substantial portion of our state population and those utilizing healthcare services, only 6% of primary care physicians and 6% of practicing dentists are Latine. As we dig deeper into the data by region and specialty, the numbers unfortunately continue to dwindle. Additionally, a growing medical pool increases our demand for Latino healthcare professionals. Currently, medical covers 15.28 million people, and over 50% of those enrolled are Latine.

But just this year, with the latest medical expansion, the patient pool has the potential to grow by an estimated 700,000 undocumented adults, a majority of those being Latinos between the ages of 26 through 49. The lack of Latine healthcare professionals poses a major barrier to adequate care for our community. To address this disparity, we must invest in cultivating a healthcare workforce that reflects the diversity of our community.

This entails not only recruiting more Latine healthcare professionals, but also ensuring that they possess varying lived experiences, have language proficiency, and are representative of intersectional identities, including, but not limited to, indigenous Mesoamerican Latines, Afro Latines, LGBTQIA two-s plus undocumented low income, and those from rural communities, only then will we effectively cater to the needs of our diverse Latine community, and today, I'd actually like to expand our definition of healthcare to also include our public health systems.

That is a definition that goes beyond the healthcare delivery system to be inclusive of a safety net that addresses social determinants of health such as our Cal HHS departments, including but not limited to CDSS, the Department of Public Health, and HCAI. In order to serve Californians efficiently and effectively, it is essential to increase our Latine workforce across departments and California State agencies, from directorship roles to senior leadership to management and entry level positions.

Increasing Latine representation will ensure we advance from culturally competent to culturally innate solutions. When we have Latines, indigenous Mesoamericans, Afro Latines, LGBTQIA two s plus and undocumented community members. Leading, implementing and evaluating our programs, we are less likely to overlook the unique challenges and needs of our communities. Our workforce should be a true reflection of our diverse population, and achieving this requires the implementation of intentional interagency strategies aimed at ensuring diversity throughout the entire employee lifecycle. From the initial recruitment phase to retaining talent.

It is imperative that we scrutinize and address the barriers that prevent equitable representation. This entails examining accessibility in the application process, diversifying applicant pools, expanding recruitment networks, scrutinizing hiring practices, and enhancing internal growth and promotion opportunities. We must take a moment to reflect and identify the systems, practices and cultures that perpetuate biases and disparities faced by Latines in our public health workforce.

By deliberately fostering inclusivity and representation in decision making processes, we can effectively bridge existing gaps in our services and policies, thereby fostering a more equitable California for all.

I would be remiss, not to mention a powerful part of our public health workforce here promotores it is important to recognize the great strides we have been making in trying to incorporate promotores into our healthcare delivery system through medical but now it is time that we take this great example and apply it to other safety net programs such as Calfresh, Cal Works and Caliitc.

We must be intentional to incorporate promotores into payment models and intentionally create jobs and career pipelines for them within our departments and agency. Workforce finally, it is imperative to recognize that the health of our Latine population is intricately linked to the strength of our economy. In 2023, the Latino GDI reached an impressive 682 billion, with key sectors such as education and healthcare, professional and business services, and government playing pivotal roles.

According to the LDC report, California's Latina economy alone would rank as the 21st largest in the world, sitting between the economies of Poland and Switzerland. The economic theory of human capital reinforces the notion that a healthy workforce is a productive workforce, highlighting the crucial interplay between health and economic prosperity. Especially in a year marked by a budget deficit, investing in our Latine workforce is not only a moral imperative, but also a strategic move to bolster the California economy for years to come.

In conclusion, let us not overlook the critical role that Latines play in shaping the present and future of California. By prioritizing their health and representation in the workforce, we not only uphold our moral obligation, but also pave the way for a stronger, more prosperous state. Thank you.

Thank you. We'll move on.

Good afternoon, chair and Members Tara Gamboa-Eastman, Director of Government affairs with the Steinberg Institute. We're an independent, nonprofit Public Policy Institute dedicated to transforming California's mental health and substance use care systems. Today, California is facing a crisis. Substance use rates have skyrocketed. Tens of thousands of people are struggling with addiction and mental illness, unable to access the care that they need. Too many are cycling through our streets, emergency rooms, and jail cells. At the same time, our behavioral health workforce is overwhelmed and understaffed.

As a state, we're already unable to meet the growing demand for behavioral health services due to the workforce shortage. However, attrition across the industry is going to exacerbate this shortage in the years to come. Profession changes workers moving out of state, and retirement are all contributing to the ever growing shortage of professionals to intervene in the mental health and substance use crisis gripping California, we must build our workforce to meet our current and future demand for services. But increasing the sheer number of workers isn't enough.

As we grow our workforce, we must ensure that we're expanding who is a part of it. Right now, our behavioral health workforce does not reflect what California actually looks like. For example, 70% of our medical population are people of color, yet 70% of our medical providers are white. Research has consistently shown that there is greater client satisfaction and better outcomes when clients have access to providers who share their background, life experiences, and language.

To get a handle of this issue, the Steinberg Institute recently developed a program, or tool, excuse me, that estimates current demand and a 10 year estimate of future hiring needs for the behavioral health workforce in California. Leveraging Federal Bureau of Labor Statistics data at the county level, this tool allows the state and individual counties to look at occupation specific needs because of growth in demand and attrition rates.

Based on our estimates, California needs to add approximately 375,000 behavioral health professionals to meet current and growing demand and account for the attrition over the next 10 years. This is around 32,000 people per year across the system of care and professions. When we're thinking about how to diversify our workforce and grow it to meet current and future demands, we can think of short and long term strategies.

In the short term, we can focus on recruiting professionals who can be trained and begin working in the field quickly. Peers, community health workers, and substance use counselors require fewer years of training than many of our other behavioral health professionals and also tend to represent more diverse backgrounds. To address our long term needs, we need to build a pipeline to backfill positions over the next decade.

As our aging workforce continues to retire, we have an opportunity to build a more diversity into our masters and doctors level clinicians. Because these jobs require up to 12 years of education and training, we need to begin recruiting more diverse candidates into our schools of social work, therapy, psychology and psychiatry. Now, recruiting more diverse students will require addressing structural barriers to education, such as the cost of education and unpaid internship requirements.

The state has already taken some step forwards to do this, including offering stipends for social work students and some loan repayment programs. But more must be done to continue to expand access to these programs. To retain a more diverse workforce now and in the future, we're going to have to address issues of pay, burnout and discrimination that drive people out of the profession and make them reluctant to enter in the first place.

The Steinberg Institute will be administering a workforce survey in the coming months where we hope to inform the conversation about what keeps people in the behavioral health workforce. We hope that this qualitative work will help us better understand what we have to do to collectively meet our shared goals of a diverse and stable workforce. Our final research project will include recommendations for short and long term workforce solutions. Thank you so much for holding this important conversation and inviting us to be a part of it.

We're hopeful that together we can continue to address our health, workforce shortages and the lack of diversity in our workforce to provide Californians with the care they deserve. Thank you.

Thank you. And I wanted to welcome our majority leader, Cecilia Aguiar-Curry.

Hi everyone. Thank you very much. Assemblymember Bonta, for putting this on. You struck me on something that drives me nuts. Behavioral health is a really difficult field and many people start with good intentions and they'll do that for quite some time and all of a sudden it doesn't matter if it's retirement or what the pay is, they're just simply burned out. So I think we have to look at this as like, what's a real full time job doing this? Is it a 30 hours week?

Whatever the case, I've just seen it with too many friends and family that have been in this and they just said, I can't go back. They've been offered lots of money to come back and they're not interested in doing it. It's not because they don't love the work, it's just that it weighs a lot on you and I think, how much can your shoulders carry, right? So thank you. And I look forward to hearing more about what everyone's doing, but the data is really important.

Thank you.

I'll jump in with the question and then offer up to my colleagues. So, as I have been taking in what you all have shared, which has been phenomenal, and thank you all for participating in this conversation, there are three issues that we're facing. One issue around just pure scale. I think combined, you offered that there are about 375,000 behavioral health professionals that we need to be able to source in the coming years.

And depending on the framework that you're using, anywhere between 32 to 37,000 professionals across the healthcare system that we need to source. That's a scaling issue of epic proportions, if you really think about it, and also framing that within the context of it being an actual growing field with incredible opportunity. So we have an issue of scale.

You also talked specifically about issues related to pipeline, the sourcing of the educational programs, the certification programs that would allow us to be able to come anywhere near meeting that scale in a way that is feasible. I definitely want to dive into that a little bit with some of your comments. And the third issue is just around retention.

And I will add a sub issue in there that I heard from Dr. Aquino, which is an opportunity to really be able to ensure that we offer payment models that actually support the retention of that pipeline, whether it's around promoting our promotores or ensuring that we're valuing at the right level, particular areas of the profile of a workforce member, like language proficiency and cultural background, cultural context, experience and expertise that should actually be rewarded and acknowledged and valued within our payment scale system.

So that's what I'm gleaning from your very apt presentations. For the sake of time, I would just want to touch into the space of how we ensure that our pipeline is much more robust than it needs to be, and would ask any of the panelists to just contribute to that conversation around how we address supporting our educational institutions and our certification process to bring on more people.

Sure. Thank you for that question, chair. I think it's a really important one. So I would say a couple of things. One is that I think we need to start thinking of our healthcare workforce much more broadly, and we're starting to do that with community health workers, with peers.

These are not new professions, but they haven't been incorporated into our delivery systems in the way that they could be, because I don't think we're ever going to train enough psychiatrists, for example, to get to the numbers we need in terms of who needs behavioral health services. So thinking about who can be a provider much more broadly and the type of training that they need, which is a lot of times, training based on lived experience and training that they can also have on the job. Right.

So we can be sort of doing these things together. I think the other thing that's really important, and Assemblymember Schiavo brought this up, but really thinking this is an intergenerational problem, right? This is not probably going to be solved in my lifetime.

And I think when we think about an intergenerational approach, we start to think about how do we treat our low-wage healthcare workers today, and how can we do better by them so that their children are in a position to go to medical school. Right. To start overcome some of this deeply entrenched poverty in families and so that we can create some of those opportunities. So I really think it's important to look long term.

And then the third and final thing I would say is, I don't have the numbers off the top of my head, but we hear a lot, and there are studies about how many people of color drop out of medical school, for example. Right. We are losing people in ways we don't need to be losing people. If we can really think about how to have that wraparound support and a culture that really values, I think, diversity and equity throughout our training and throughout our healthcare institutions.

I'm sure Assemblymember Dr. Arambula could talk more about his experience. Right. But I think really making sure we're not losing people in ways that we don't need to be as important to.

And if I can just jump in for the Latino community, the trick is to start early, right. If we wait until we have students in University and Medical School to then try to retain them within the pipeline, it's too late. We need to start from elementary school.

Right? Just giving our students this dream that they can achieve and that there will be systems of support that will help them get through each step of the way and see themselves graduating from a professional school at the end. So we need to start partnering with our educational partners to make sure that we can build that infrastructure to help our kids today and our kids to come.

There are three things that come to. My mind when I think about pipeline. And pathway, and they build on each other. And one is the attraction issue. We have a generation of school kids who got STEM. The M was for math, not medicine. So how is it that we can inspire the next generation to want to be caregivers? So that's a piece of it. And the second, exactly as already was shared, was supporting those who show aptitude.

There are incredible programs across the state with postback programs that help those who did go to college but might not have gotten the math or science they need to move on to pharmacy or medicine. There are programs that support high school students who come out showing interest and aptitude, but might need mentorship, might need financial support, might need a hand to show them the way because they come from a first generation college to college family.

And the process of becoming a health professional is long and arduous and they need that navigational support. And that goes all the way to the comments we heard earlier on burnout across the profession. So there's that support across the journey. And third is reducing the barriers that are turnoffs. We have real challenges in our state with licensure, with certification, with things taking too long, with payment barriers.

When we hear a lot from providers about whether it's behavioral health or medicine or others facing moral injury, it's because they don't have the resources they need to deliver the care they know their patient needs. And that's very much about building up a care team that can provide all the different types of social supports that patients benefit from. So I think all three of those pieces are important to make sure you have a healthy pipeline with absolute minimal attrition.

Thank you.

Well, Buenos tardes and I could stay all night, and so I'm appreciative of the chair for holding this hearing and for allowing this conversation to happen. I'm happy to jump in and ask questions, but believe the following panels will have some of the solutions. What I'd like to do is uplift some of the comments that I've heard today, share some of the lived experience that I've been able to have, and really focus on which direction we as a state can go to address this crisis.

Ultimately, I'm going to be asking whether or not we've been providing enough urgency to the crisis that we have while acknowledging that we've made significant strides over the last several years. I'll begin, if I can, with the strategic move to bolster the California economy, and I will bring in lived experience here.

Having a grandfather who never learns to read, sitting here as our first Latino physician, there are barriers that we have in communities to be able to access higher education, and so we have to figure out for our states to make advances, how we're making investments into the people right now who are caring for our community members. And so I struggle with the data points that we're 46 out of 47th in medical school enrollment per capita to believe that we're adequately training enough providers of tomorrow.

And the fact that we have workforce shortages which contribute to poor population health should be an impetus for us as a state to make sure that we're making those investments into our workforces. But we don't have enough workers, and they're not reflected in race and language and geography. And we need to have that better communication so we can establish better trust. I'd like to really ask this panel, are we doing enough, are we bringing enough urgency to this crisis?

And how do we make enough strides so that we're not talking about this a generation from now, but are able to solve this within our lifetimes?

And we'll hear from one or two people so that we can move on to the next panel.

Thank you. I completely agree. I think what we're doing is almost all this crisis after crisis. We'll take it for granted. We're not taking it the attention it deserves, the funding it requires, and that definitely from K-12, we need to invest money. We cannot ignore the fact that so many black and brown communities have really lived in this very much isolation. And the structural racism plays a central role. The social determinant of health play an important role.

And I think instead of having that somewhat lip service to the real problem, I hope the Legislature would really take up this issue as a crisis and invest money and take it seriously so that I think, as she put it very nicely in terms of the behavioral health, they're aging, and so the new population, like the black and brown community, can be replaced.

However, where is the priority the state is giving to ensure that the next generation of behavioral health clinicians, doctors, nurses, are black and brown and truly reflect the diversity of California? And I hope the investment also goes behind it so that we're not just giving a lip service and continuously talk about the problem, and we are also putting resource behind it. Thank you.

Thank you so much to our panelists for, for bringing such a robust conversation to us. And we'll move on now to our second panel, which is focused on current efforts to increase workforce diversity in California.

Good afternoon, Madam Chair and Members. Elizabeth Landsberg. I have the honor of serving as HCAI's director, Department of Healthcare Access and Information, and very happy to be here to start talking about some of the solutions.

Okay, so you've seen data, and at HCAI, we absolutely always start with the data and think that that is important. And it's been great to see HCAI data used by some of our other speakers.

As others have already highlighted, the health workforce in California is not evenly distributed in California, and we have particularly significant gaps in the Inland Empire and in the San Joaquin Valley.

So these figures and graphs are for primary care with a white bar representing California population, the darkest blue, physicians next, nurse practitioners, and then PAs. Just want to note that we do publish similar maps for other primary care and behavioral health workforces and see that inequitable distribution with our behavioral health workforce as well as has been noted.

The blue map shows HPSAs, our health professional shortage areas, which are a federally defined unit of analysis to identify work shortages.

And then, so if you compare the map on the left with the blue showing where our health professional shortage areas are, to our map on the right, which shows the urban versus rural areas, you can see that a little more than half of our HPSAs or our health professional shortage areas are rural or partially rural areas.

Though I do want to note, and it's important to note, that there are also certainly urban HPSAs, right? So we know many of our rural areas are medically underserved, but there are certainly urban areas.

As Catherine Phillips from the California Healthcare Foundation noted, 11 million or more than one in four Californians live in a shortage area, and two thirds of those who do are Latinx, black, or Native American.

I'm not going to spend a lot of time on the next couple of slides we have because they're very similar to the data that you've seen. The very important point has been made about the lack of workforce concordance, particularly for the Latinx population.

At HCAI, we're very proud to house California's Health Workforce Research data center through a partnership with the Department of Consumer affairs. We collect data for a wide range of provider types through a survey that's administered at the time of licensure or re-licensure.

So that's a new effort that was passed in the 2021 budget that recast OSHPD as HCAI and has this new data. And so we're very happy to be showing that data and trying to have more and more sophisticated visualizations so that we can really understand and focus our efforts.

In December of 2023, HCAI released dashboards related to race and ethnicity, as well as languages spoken by California's health workforce. So what you see here is a snapshot of the race and ethnicity dashboard.

Kiran already showed you this data showing the most significant disparity for Latinx primary care providers compared to the population. These dashboards are available on HCAI's website and can be analyzed dynamically by workforce category, by license, by name, by region.

So you can decide, I want to specifically look at mental health nurse practitioners in the Fresno area and pull up that data.

We also have the data looking at it over time, and so here it's very hard to see on this little screen, but we do look at the data over time. So this is a 30 year period, and we can see, for example, that darker blue line that's noted. Again, the percentage of Latinx providers is increasing over time.

And again, we have similar data for language concordance, which you have seen, as well as language concordance over time, where again, we're seeing progress, not as much as we need to see and want to see, but some progress over time.

So starting with that data, HCAI's mission is to expand equitable access to quality, affordable health care for all Californians through resilient facilities, actionable information, and the health workforce that each community needs. Every word in that mission statement is very near and important to us.

We have for decades had health workforce development programs, but you all have seen fit. The Administration has agreed that we are facing a workforce shortage and that we need to devote significant resources.

And so we've really been increasing our workforce programs very significantly over time. All of our health workforce programs at HCAI have these three goals, and it's been very important to me that we really have a laser focus on these.

So, first and foremost, to make sure that we are helping develop a health workforce that reflects California in terms of racial and linguistic diversity. We've seen, we have a long ways to go, but it's important for us to stay focused on that also that we develop a workforce that serves medically underserved areas. And so all of our assistance to individuals comes with a service obligation in a medically underserved area.

And then know that it's important, as one in three Californians is on medical, that we're making sure to develop a healthcare workforce that serves the medical population. So those are our three goals. And then we have three big buckets of strategies that we use. The first one you all have focused on already today, which is the pipeline.

We've got to bring more folks in, make them feel that they have the opportunity and are supported to become part of the healthcare workforce, and that's critical to meeting our diversity goals. We also support individuals who need that support. So we have for decades had loan repayment scholarship programs because of the racial wealth gap.

It's really important that we focus on stipends, that we focus on scholarships. Loans only work for folks who can afford to take out those loans to begin with. You'll hear more about some of our programs that we have. We're starting some earn and learn programs for the first time and think it's really important to provide that support.

And then, of course, we do need to expand the educational and training capacity in California. And so we're pleased to provide support to medical schools, to promotora training programs all up and down the health workforce ladder.

We're currently going through a holistic assessment of our tools and application criteria, asking ourselves, do our application criteria best achieve our goals? So we're working with the George Washington Equity Center there to develop. We will be making some changes to some of our application criteria to really hone in and make sure we are meeting our goals.

So with that, I'm very pleased to turn it over to our relatively new but wonderful new workforce deputy director at HCAI, Libby Abbott, who's going to talk in more detail about our particular strategies moving forward.

Thank you, Elizabeth and good afternoon, Madam Chair and Members. Libby Abbott, Deputy Director for the Office of Health Workforce Development. With our remaining time, I'll speak briefly about what we believe are high value strategies for diversifying California's health workforce, including what we are pursuing and implementing as HCAI.

I'll note that many of these solutions reflect what has already been touched on by previous presenters.

So I'll speak about these solutions following the three buckets of HCAI programs that Elizabeth described, starting with programs that fund organizations to build the workforce pipeline. One of the solutions we want to highlight is starting early in the lifecycle of a future health worker before that high school or college student even knows that they might want to become a health worker.

This is critical because sometimes by the time we intervene with a scholarship or a loan repayment program, we are already dealing with a pool of candidates that is less diverse than we would want them to be because our diverse candidates may not have the institutional support, knowledge, access or resources that they need to pursue a career as a health professional.

HCAI invests upstream in what we call pipeline programs, reaching diverse youth to expose them and support them to participate in pathways towards careers in health professions.

Importantly, our pipeline programming offers what we call wraparound supports support to all the extras that will allow individuals to really focus on and succeed in their programs. This can include transportation and caretaker costs, coaching and academic support.

This helps mitigate for any disadvantages that students with less resources might have supporting our progress towards a socioeconomically, racially, and ethnically diverse workforce.

We are also working on integrating funding for wraparound support into our scholarship programs so that likewise, students in undergraduate and graduate programs can cover the cost of life and what it takes to succeed academically.

Next, I'll speak about the bucket of investments supporting individuals pursuing health careers through scholarships, stipends and loaner payments. I'd love to highlight that here. An important solution is investing in the professions that inherently emphasize diversity and lived experience. This includes two professions that HCAI is currently very focused on.

HCAI has $272,000,000 to expand and to support the community health worker, promoter and representative workforce. Community health workers promotes and representatives are by definition representative of the communities that they serve, and these individuals work in a wide range of communities, including Latin, Asian American, black and tribal communities.

And HCAI's funding will go to support the community health workers, promoters and representatives that work across the full range of communities in California.

Through the California Youth Behavioral Health Initiative, HCAI has also received 338,000,000 to stand up a new profession, certified wellness coaches. Certified wellness coaches are meant to plug a gap in the behavioral health workforce that serves our youth and children. We heard from youth they wanted a workforce that looked like them.

So we have worked hard to build diversity, equity and inclusion into the core of the wellness coach role and the programs that we are rolling out to create and support that role, including ensuring partnerships with community colleges and California State universities which reach our most diverse candidates.

I'd like to note that this recommendation is related to the recommendation we heard earlier from Steinberg Institute to invest in provider types that are already quite diverse, such as community health workers, promotories and representatives.

It's worth noting that these workforces may be more diverse because there are fewer educational and career path barriers to entry, which takes us to our next solution. It is important to support and expand professions like community health workers, promotorious representatives, and certified wellness coaches, and make them attractive roles in and of themselves because they fulfill such a critical function in our health system.

But it is equally important that we pay attention to and invest in career progression so that diverse candidates have opportunities to progress from being a certified wellness coach to becoming a licensed social worker, as the slide shows. So that we can ensure that we have appropriate levels of diversity and representation across all levels of the workforce, and not just our low paying or entry level positions.

Following from that, it's essential that we make training economically feasible for all. And that we do that not only through our traditional scholarship and loan repayment mechanisms, but also by funding the complementary pieces related to training and transition to practice, which includes paid internships, apprenticeships, and earn and learn programs.

HCAI has integrated these approaches into our programs, including HCAI's Substance Use Disorder Earn and Learn program. We are also integrating paid internships into our recently launched certified wellness coach programming and will be funding nurse apprenticeship programs. Finally, Elizabeth shared some of the data from our research data center, and we were pleased to see this in other presentations.

I wanted to highlight an example of how important these data are for identifying data driven solutions related to workforce diversification. In November, HCAI released dashboards looking at the educational pathways taken by California's nursing workforce.

We saw that Hispanic and black nurses were significantly more likely to enter the nursing workforce with an associate's degree compared to the rest of the nursing workforce.

And so we saw investing in associate degree nursing programs as an opportunity to directly address some of the concordance issues that we've seen in previous slides by funding and expanding programs that bring diverse nurses into the workforce. For our final bucket, HCAI funds several programs related to expanding educational capacity.

I'll touch on this briefly because I know we have other presenters speaking about this from the educational institution perspective. In our awards related to expanding educational capacity, we do award points and prioritize programs that, for example, develop strategies to recruit and support students from underrepresented communities and which offer support services to students to ensure successful completion of their education.

In this way, HCAI is using its funding to incentivize institutional change in other ways that will support diversification of California's workforce. To close, we just wanted to highlight some ideas on what more is needed to support diversification of California's workforce. Top of mind for us is future forecasting.

It takes years to train a health worker and therefore years to change the composition of our workforce, and so we need to look ahead to know what our future workforce needs are in order to reflect the future composition of our communities. HCAI is currently working on supply and demand modeling for both our behavioral health and our nursing workforces.

We expect from that to have targets by profession type, by region, and ideally by race, ethnicity, and languages spoken to ensure that HCAI's dollars are being targeted to these solutions that will get us to our population concordance that we need in the future.

And finally, I just wanted to address there was a question on the effectiveness of loan repayment programs. In 2023, we conducted an internal analysis of HCAI state loan repayment recipients who were awarded in 2019.

From this sample, we saw that 76% of recipients practiced in a health profession shortage area one year after completing their contracts. In 2025, we'll be able to follow up to find out if that trend continues at the three year post contract date.

We are also pursuing an academic partnership currently to look at some of our historical data for scholarships and loan repayment programs to try to understand the relative cost effectiveness of scholarships and loan repayments so that we can understand where to shift our dollars while also addressing some of the equity considerations, which include investing further upstream. Thank you.

Thank you. And we have a very robust panel here and another one coming, so thank you to our panelists for reserving your remarks about five minutes.

And I forgot to push the button. Then I will start with that one. My name is Ilan Shapiro, and thank you so much for the honor, Chair and members for being here. I'm a practicing pediatrician in the community, working in AltaMed for the past eight years. I currently serve as the chief health correspondent and medical affairs officer.

And this is a special thing that we're going to be talking about, the AB 1045 and how that Mexican pilot program where we're bringing Mexican physicians to help in rural and urban areas that are underrepresented. And it's very close to my heart. I am an international medical graduate. I come from a small city called Mexico City, and I have seen the disparities. I have seen absolutely everything.

And when I have served in Illinois, also in Florida, and right now in the past almost 10 years here in California, and when a patient actually comes to me and they hear the language, and not only the language, they feel the culture.

And I can actually talk about vaccines, talk about the tesitos, the teas, the remedies, and actually connect them, not only the parents, but also their kids. That is the future of our communities.

It's kind of the key aspect of where we are going with these type of things. Do we have a solution for absolutely everything? Sadly, no. But I think that we're in a path where bringing right now physicians that actually understand the language, they're culturally concordant, can make a huge difference.

And I'm going to respond a couple of questions that you may have. What about quality? Who is actually measuring this? Where are we going with this? As we know right now, it's very hard for a lot of our patients to actually access primary care services.

And we are on that short list where if we are not creating that pipeline of wellness for our communities, all the stuff that we're doing of expanding medical services is going to be very hard, because we actually need a physician at the end to prescribe that insulin, that physician at the end to prescribe that vaccine, then a lot of these doctors are making a huge difference.

If we put on perspective about the physician shortage, and I share the same feeling with our black physicians, that we're not enough. And when our community actually comes to us and hear us and see us, they are looking for a safe space where they are free.

And most importantly, they are taken care of. Only less than 70% of physicians here in California are Hispanos that talks about a lot of things that we can actually measure it. And we were sharing the numbers on disparities.

How many doctors we need to create from the Hispanic community to be on pair, then, just to give a perspective, it will be 500 years to actually get there. At the pace that we're currently at, then I'm not going to be here for sure. But I think that we can do something right now to make sure that we create that pipeline with these type of things as AB 1045.

In AltaMed, we have been serving the community for the past 55 years, and it's about Latinos, multiethnic, and absolutely anybody that needed help to be there. And that's why it's so important to create these type of pipelines.

And we completely understand the importance of actually creating that from high schools, connecting nurses, connecting the physicians. And also one of the great opportunities that we're having is that family practice in the community residency and has made a huge difference.

Right now, we are having almost 18 residents, and our first class is actually graduating. Then more to come on that one, because we have seen that when they are exposed to the community, and they understand that makes a huge difference.

Moving to our Mexican pilot program, the doctors are certified in many times. This is a law that it's not new. It has been around since 2000. And thank God, since 2021, we reactivated this opportunity. We have 30 physicians practicing from Mexico and California.

And there were a lot of questions regarding if the quality will be better. Are the patients going to feel different? Are they on pair with the system that we have here? And the answer for the three of them is, yes, yes. And afterwards, yes.

When we actually have had independent studies, one from UC Davis, another one from UNAM, and also our internal data that we do a lot of outside consulting, that they come and do surveys for us, the patients actually feel that they have been heard better, they are understood better.

And not only that, but also the quality of the outcomes are starting to trend a little bit higher than all the part of feelings that we had regarding being afraid of what's happening right now.

This proves that in a matter that we can actually regulate in a way where we have CMA, we have the California Medical Board, and also a lot of the accountable clinics that we have, that we have around four clinics, including Altamed, Altura Centers of Health, San Benito Health Foundation, Salina Clinics, where we have all the 30 doctors. We're touching people that were not going to be touched.

If we continue the same path that we're doing, we're going to have more than 28,000 visits per year and totaling in the entirety, more than 300,000 visits that were not going to be touched, people that were not going to be seen, cancers that were not being seen, vaccines for kids that were not going to be given. Then these patients are actually open access to a place that we are having that part.

I can talk about hours regarding this, but the numbers are there gladly to share what we have with UC Davis and also University of Mexico. But the gap is there. And I really want to hone in one thing. Other states are doing a lot of efforts to bring in international medical graduates.

That is not the complete solution for the state. But Tennessee, Arkansas, and other states are already certifying international medical graduates to place them in areas that are needed.

Then understanding that this Mexican pilot project is working, and understanding that other states are already enacting laws that are bringing international medical graduates to help the community of need that are concordant and linguistically competent.

We need to figure out how can we put and use this information that we have. We have patients, we have access. Now we need physicians to actually give that vaccine, prescribe that insulin, and continue having an amazing California state. Thank you so much.

Thank you, Dr. Shapiro. We'll move on to Dr. Henderson.

Thank you very much for the opportunity. My name is Mark Henderson. I'm the Associate Dean of Admissions at UC Davis School of Medicine. I've been in that position for 18 years. Prior to that, I practiced primary care medicine in south Texas near the border. What I'm going to talk about is how the UC Davis School of Medicine became the third most diverse medical school in the United States, right behind Howard University and another minority serving institution. I won't go over.

Let me see if I can advance the slides. This has already been stated. I'll say one thing about this slide, which is that the single best investment we could make is to put more primary care physicians in those dark areas. Let me go back to the map that was shown earlier. Those dark areas that have the poorest health outcomes, these are the HPSAa. The problem is that most medical schools continue to educate specialists, even in California.

UC Davis is the only school that actually graduates a majority of its graduates that go into primary care. Let me see if I can advance the slides. We've said this again, that doctors don't look like California and it's hard to achieve the mission of health equity when there's such gaps. We've spoken about the gaps between the Latino population and the workforce is stunning and it's not getting better fast enough. Now this is an interesting slide.

We did a study three years ago which showed that as medical schools in the United States expanded because everybody's talking about the primary care workforce. So what's the solution? We'll make medical schools bigger. You can look at this slide. Medical schools across this country increased by 50%. They went from 19,000 to over 30,000 slots per year. So you think, okay, that's pretty good. Well, the absolute number of underrepresented students went up.

But actual representation, the percentage of the class, the proportion of the class actually fell by 20% to about 13% of entering medical students are from essentially African American, Latino, Native American communities. So it's actually getting less representative, less diverse, while the country is getting more so.

This is even more disturbing to me. This is the economic distribution of who's in medical school. The gray bars are the top 20th percent of income in this country. The two top gray. So 50% of students in this country come from the top 20th percentile of income. The bottom, the dark rust, that's the bottom 20th percentile. So there's a tenfold difference between wealthy students and I'll say lower income students. An average student, the US median family income is that orange bar.

Okay, so there are very few low income students, very few even middle income students in medical school today. So I think it's not surprising to me. We have so many disparities that when you have poverty cut across all of these health disparities. So there's no way medicine represents society. I think we've said that in multiple different ways. But I want to emphasize economically. This is all before the Supreme Court decision, before that, all of this decrease.

So I think that's why our school made the New York Times last year. I'll talk about what happened at our school over this period of time. So this is the last 25 years since we've been under an affirmative action ban at our school. So this is the percentage of our students entering that are from underrepresented groups. And you can see we're a majority minority school at this point. Keep going. How do we do this?

I think we focused on social accountability in every single thing we do in our admissions process. So I won't go through this, but I'll just state. Our mission is to graduate physicians to meet the health workforce needs of our state, California. 98% of our students come from California. 86%, even after residency, stay in California. We focus on lived experiences of health care, which have already been alluded to.

If you come from a low income family, if you come from a family that's been on Medi-Cal, you understand what's wrong with the system. You understand actually the importance of trust and a lot of the themes we've talked about already, but those are prioritized in our process. Over grades, over test scores, all that stuff is less important. And as a result, the profile of our students is on the right here. 45% of our students are the first in their families to graduate from college.

That's the highest percentage of the United States. Family income, 68,000. Again, that's less than the US median family income. Again, so I think you have economic representation rather than economic segregation, which is what most medical schools have. Of course, that relates to race and ethnicity as we all know. This is the income distribution of UC Davis. Okay, so you can see the median family income is in the orange bar. So most 60% of our students come from the median income or less.

Very different experience of life, very different experience of health care. And again, understanding, empathy for what a lot of our patients go through. Just take two more slides. One thing you have to realize is, I think your mission has to be, it's not just who you bring into your school, it's what you do with them. So we've developed five different pathways within our medical school that each focus on a vulnerable or a health shortage area in our state. I've listed them there.

These are called community health scholars tracks. 30% of our students are in them. 80% of the students in these tracks are from underrepresented communities. One's a rural track. One focuses on federally qualified health centers, the urban underserved. One focuses on the Central Valley. The most recent one, which is funded by PRIME, which is alluded to earlier, focuses on the Native American tribal communities in the state.

So each of these programs has specialized wraparound services, mentoring, financial support, scholarships, so that the students, again, mostly from low income families, have a way to make it through medical school. Again, that starts much earlier than medical school, as was already alluded to. My last slide is the outcomes of those programs. These are what specialties our students go into. Over 64% go into primary care. That's 25 percentage points higher than any other school in California. Why?

Again, because I think they have the lived experience of the lack of primary care and what that means to their families and their communities. So I'll end there. Half of them work in an underserved area. A third work in a rural area. And again, I said this before, 87% practice in California. And we already know how diversity improves health outcomes. And I think that's my last slide. I'm sorry, I went over five minutes.

Thank you so much, Dr. Henderson. Looking forward to hearing more about what I think is certainly a national model. And now we'll move to President Fitzgibbon.

Good afternoon and thank you for the invite today. It's great to speak about our model and share some of our ideas today. And I hope to shed the light on one partial solution and then answer your question about scale. So I'm going to assume that maybe not everyone's familiar with our school. So I'll give you a quick snapshot first. The Kaiser Permanente School of Allied Health Sciences was founded in 1989 in Richmond, California.

And it was a one program, one room, 12 student school at the certificate level. And today we graduate about 350 students a year, everybody from a certificate up to a master's degree. So when I think about scale, I do think about our founders, who started with 12, and the power of the number one in healthcare. All of our programs are in allied health. And I think sometimes allied health is a little bit still misunderstood.

But a good rule of thumb is it's all of the professions that are not a nurse or a doctor. And as I get older, you encounter more and more allied health as a consumer, and you appreciate from the heart that they're very, very important, and they help our physicians make accurate diagnosis and provide quality care. As you can imagine, Kaiser Permanente, since 1989, has found itself short of various allied health professions.

And therefore, we jump in and educate our train our own to fill some of those deficits. We made the choice about seven years ago to become regionally accredited so that we could grant a degree all the way up to a doctoral degree. And if you went to our school and decided to go on and become a physician or a nurse or get a second degree that our credits would transfer. We're lucky to have a very, very diverse student body. It's not by accident.

And as I mentioned, our founders could have built the school anywhere, but they built it in Richmond, California. We're embedded in the community there. We work closely with all of the local high schools. And as the previous panelists suggested, we start these conversations early. What is allied health, and how much does it cost, and how much is tuition, and what type of choices do I have locally in my community? We are open to the public.

There is a perception that our school, you have to work for Kaiser Permanente. That's not actually correct. So we're open to the public. And not all of our graduates go to work for KP. About two out of three do. One of the reasons is there's such a scramble for allied health talent across California that other employers come and offer our graduates jobs, sometimes at the graduation ceremony. One of the questions I think that has been asked about is, how could we scale up?

And one of the Committee Members mentioned travelers as a healthcare consumer, and I'm not against travelers or contract staff. We use them, obviously, at KP, and they do a great job. But as a patient or a member, when I'm there, I do sort of see it almost as a missed opportunity. How come we couldn't have somebody there training, learning this role that's going to culminate in a great job? And me, myself, I'm an example.

It was always a dream for me to finish my education in California, and I came and I did it, and I'm still here 25 years later. So I don't think I'm going anywhere. So I think when we think about scaling up, we have so many of the ingredients. We have the best hospitals, the best technology, universities and colleges that people dream of going to from all over the world. So how come we haven't been able to make a bigger dent in the deficit of workers.

I think, personally, it's a useful model to think of it as a three legged stool. So you need the patient. For allied health, half of your training is out on the road, and you need to work with real cases, real patients. We're not short there. You need the hospital systems. You need the technology. We've got the best.

The third leg of the stool, I would just ask everyone to think about, and we haven't talked about a lot yet this afternoon is the clinical preceptor or the instructor. And that's kind of like the buddy system. For example, for our rad tech program, it's two years long, but you need 1,850 supervised hours with a qualified person. So, as one of the Committee Members mentioned, if you've been keeping up with health care, that's a big ask.

You're going to shepherd a student through under your license for 1,850 hours. It's a big commitment, and you might have a line of patients out the door. That's almost universally true for all of the allied health professions. That model. So I would just sort of pose that question, what are the incentives or obstacles to encouraging people to precept the next generation? And I think there are some models nationally, other states are wrestling with this as well, and we're happy to provide more information.

Our model, I would say, coincidentally, that the Mayo Clinic and the Cleveland Clinic both have school of health professions, just like the KP school, and they're working on this preceptor challenge as we speak. So I would hope someday, if you think about our school that started in 1989, I think we do. My personal opinion, we do have the ingredients to fill these deficits and become an exporter of healthcare workers. We have all of those ingredients. If we could get everything aligned, and I think that's a future that everybody could buy into. So thank you for the invitation today.

Thank you so much. I'll open it to my colleagues.

I'll begin. Dr. Shapiro. I was shocked, saddened, but already knew the data points regarding how long it would take for us to reach population parity on 500 years, and want to focus my question on Director Landsberg, if we can, because your testimony was that we're moving in the right direction, that we're increasing over time. Is that trajectory going to lead us as a state to take 500 years for us to reach population parity? Is that okay for us?

Or should we be looking towards some of the innovative models that our University of California systems are doing regarding economic integration as a way in which we can change that slope to reach parity quicker.

Of course, it's not ok for it to take anywhere close to that long. And so I think we think we have the right mix of solutions and that it really does take working along every step of that continuum from bringing more folks in, from helping change some of the educational institutions.

I mean, UC Davis is a model, and we have had them come present to our workforce council and know we'd like to see every medical school adopting that holistic approach and bringing in a more racially, linguistically, and socioeconomically diverse student body. We also know, as Libby Abbott talked about, we have to build the professions. As someone earlier noted, we're never going to have enough psychiatrists.

So we're really thrilled to be supporting psychiatric, mental health, nurse practitioners, the wellness coaches, the Community Health Workers, and really thinking about those stackable credentials. So we think all of the solutions are necessary. We will, as Libby noted, be doing more specific forecasting to give more specific answers, which we know is important both to the State and to the Legislature to really understand what is it going to take and how quickly can we get there.

I'll elevate the successes which you've had within your Health Profession Pathway Program as an example of how we can make improvements and help to diversify holistically our workforce. And yet we'll still push to make sure that those solutions are working for all parts of our state.

We heard that there were 11 million people who are in health shortages areas. I come from one of them. I come from a valley where we don't have a medical school to train doctors at all. And it's hard for me to recruit enough doctors to come in and believe that the solution has to be with us growing our own. And so earlier we heard about how there are six UCs that are currently in the process of training, with our newest UC being UC Merced.

Absolutely.

It's a prime opportunity for us to, as a state, making investments that will both diversify our workforce but also support a Hispanic serving institution to make sure that we're providing that training for tomorrow. But I want to focus on something that hasn't been discussed much today, and it really is regarding trust. We've heard the importance of communication, and so I'm questioning that since we can't prioritize admissions based on race, are we able to use language?

Are we able to focus on the fact that those who are multilingual bring a strength to their application? And if it's allowing us to address disparities we have in threshold languages for those who are serving Medi-Cal, wouldn't we be benefited as a system to be prioritizing admissions for those who speak multi languages?

Well, I won't speak for the medical schools, but I will just say from the HCAI perspective, that we absolutely think language is directly tied to the ability to provide services. So language of those spoken is something that we take into account.

Dr. Henderson?

Yeah. No, as it pertains to the Supreme Court decision, absolutely. A skill based criteria like language is absolutely fine. And I think, again, 45% of high school graduates in the state are Latino. Every single public school should be a Hispanic serving school. So I don't. I don't get. When people say, where are we going to get the people from? Are you kidding me? They're everywhere. They're in our local colleges, in our community college. Anyway, I'm talking about Spanish speaking providers.

So, I mean, I came from the south Texas. When I came here, I was blown away how different it was. I came from a place where most of the people were Latino, but most of the physicians and nurses were, too. That's not true here. Anyway, I know it can be done.

I know this is an informational hearing and for us not to talk about bills, but I would be reminiscent if I don't mention AB 2080, dealing with multilingual, and AB 3081 focused on UC Merced medical school funding. Thank you, Madam Chair.

Thank you, Dr. Arambula, Mr. Jones-Sawyer.

Thank you. I'm sorry I missed the beginning. And the others. This is really personal to me as an African American male who had diabetes. When I went in to Kaiser to get diagnosed, they were pushing pills, metformin, lipocyte, and then tried to put me on, having me stick myself with a needle every day. And one day, an African American female nurse pulled me into the room and said, brother, I'm just tired of this.

I'm tired of seeing all these brothers coming in here, and they're pushing all these drugs on you. Your fat ass just needs to lose some weight. And I said it not to be vulgar, but she said it in a way that it got to me, and I understood, and I lost weight. And my A1C is now I'm no longer diabetic. She talked about beans and greens and what to eat, and all of a sudden, I'm eating right.

She knew what my diet should be that pertained to me that I could understand. And I was not getting that from my doctor, who was not of African American culture, to be able to explain that to me. And so that's why my A1C is in the fives now instead of in the tens. And so I'm a firm believer that we've got to get more people that understand the culture a lot better.

The other example I will give you is there was a state Senator here who had problems with their prostate, and he kept putting it over and over again, not getting it taken care of. And I'll say his name, because he went out and he started talking about prostate cancer, and that's Senator Ron Wyden.

And one day, a black Doctor, he was telling him about his prostate problems, and he looked him in the eye and said, brother, you're going to die if you don't take care of that. And for some reason, that just stuck to him. If it wasn't for that black doctor, Ron Wyden would not be with us today. He immediately took care of it.

That's why it's so important to have somebody that can talk to you in a manner sometimes not as delicate as you would like to in your profession, but can get to you and make sure you understand what you need to do. And then on this subject, the need for that is so important.

And if we can start talking about why that is so important, and let's not talk about in a cerebral sense, but break it down so that others will want to come into the profession and want to be able to talk the same way. And on the theme for workforce diversity, my niece is in her final year of medical school at Morehouse, but she has a family. Her mother's a dentist. Her aunts are all teachers, so she has that infrastructure to push her along.

They're in a sorority called Delta Sigma Theta. And there's a family of doctors within that sorority that when she got stuck or when she wasn't doing well in school, somebody would make a phone call and say, help her with this, with anatomy or whatever, and then that family would come in and help her get through that process.

And so if we could create that, you're talking about getting people in, but you also got to have a group of mentors and instructors and other people who can then talk to these young minority students and make sure that they can make it through and give them the kind of buoyance that they need to be able to get through, because, as you know, it's a struggle to get through medical school.

And I know there's a bunch of times where I wasn't sure she was going to make it. Those women were not going to make sure she was not going to fail. And she's graduating this summer because of all those women who stood behind her and made sure she got there.

That point is so important. And I think that's one of the reasons why schools don't change. It's easier to keep doing it the same way and educating the usual suspects. What you're talking about is a family, an auntie. But that's critical. I think that your story about the diabetes, we see that every day when you see a black, even a black medical student. I had a black medical student the other day with a black woman who had all kinds of problems, really having a difficult time.

We got so much farther in that visit because she saw this student said at the end of the visit, said, can she be my doctor? I said, well, she can in about five years. But I'm just telling you, it's trust. We in primary care, we ask people to change their life, change their behavior, take this medicine, do this. If I don't trust you, why am I going to do that, anyway.

The last thing I'll leave you with, there were a bunch of dentists and doctors that went to Meharry, Morehouse, Howard, that were in their third year at my alma mater, USC, and all of a sudden they were in medical school and they were able to complete their undergraduate degree and go to medical school at the same time because we were in a rush in the produce as many dentists and doctors as possible.

And so I think we had a whole bunch of people who became doctors and dentists during that time of African American persuasion because there was that ladder that got them there. And I didn't find out about it until after I had graduated because I probably would have gone to that program, but nobody knew about that. And it was kind of a secret. But the people who did know about it jumped on it and went through the programs, and they all are now retired doctors and dentists. And so I don't know how we're going to replenish that because I think that avenue has been cut off to be able to do that.

There are a couple of groups I mentioned nationally working on diversity and preceptorships as well. So we'd be happy to share that information. But to your point, if you have a preceptor that you're spending 1,800 hours with, that you identify with, it's much more likely you'll finish your degree and go into the workforce.

And if I may share, one of the things that we have loved doing is we partner with the National Medical Fellowships where communities of color actually get access to paid internship during summer. And we love doing that part. The other one is mi mentor, that actually it's very Spanish, but that doesn't mean that it's only Spanish. Then it's actually for anybody that is on that pathway where they need the family, that trust of like no no no, this is the north, don't go that way.

And the other thing is the paid internships that we're offering on summer because a lot of the students actually need that gap year to actually establish, get better grades, understand what's health for them. And everybody wants an internship, but there's not a lot of paid opportunities.

Then we actually open that space where they come with us, they establish a clinical role, they see operational parts of the clinics, nurses, dentists, and that actually makes a familia, family where when they are on those horrible nights where they cannot sleep or they have an exam and everything is like collapsing, someone will call them then. Yeah, I completely agree with that.

Thank you so much for the very rich conversation. And we're going to move on to our next panel. Our next panel, which is focused on increasing the diversity in healthcare work force education and training, will begin with Dr. Ruth Shim, followed by Maynaka Scott and then Catherine Phillips.

Okay. Good afternoon. Thank you so much, Chair Bonta and the other committee members. It's great to be here with you all. I will try to speak very fast. My name is Dr. Ruth Shim. I am the Associate Dean of Diverse and Inclusive Education at UC Davis School of Medicine. I'm also, I discovered today one of the 3% of black physicians in California. And I don't even know, as a psychiatrist, I don't even know what that percentage is for me, but I imagine it's pretty Low.

Okay, so I want to focus on a couple of things. Dr. Henderson preceded me in the previous panel and talked. I thought amazingly about the work that we've done in diversity through our admissions work to increase the diversity of medical students at UC Davis. I'm actually going to talk about three other areas, though. I'm going to focus in on equity, inclusion, and belonging, because we hear about these terms clustered together, DEIB, diversity, equity, inclusion, and belonging.

And once we do such a great job of getting these diverse students into medical school, some of the challenges we see once they get into medical school are that these issues of equity, inclusion and belonging become challenges. So we try to address equity through the curriculum. We try to address inclusion by improving the climate, and then we try to address belonging through policy change. And I'll talk about each of those very briefly.

So if we are going to focus on promoting equity in medical education, we have a number of ways that we do that. We have a curriculum that focuses on health equity. We try to teach students as they come in about the role of equity and inequity in health. We ask that people, there are issues that come up with equity even in education. So one of them is that we had issues related to grading inequities.

We found that our students from minoritized backgrounds were having lower scores on subjective evaluations in their clinical years. And so we had to create a panel to look at why do we see these differences in outcomes between students of color versus other students. We had to implement new policies to address that. We have to support a safe and supportive learning climate, meaning that discrimination that happens within the healthcare system, that that doesn't occur, that students aren't subject to discrimination based on their identities.

We provide support for those experiences of discrimination and harassment, and we try to educate faculty on how to be better at teaching. So one example of how we've tried to address this in improving equity relates to something called the racial justice report card. So there are a lot of ways that medical schools are ranked to see how great they are. You can hear about the US News and World Report rankings based on reputation.

Blue Ridge rankings rank how much research funding you get as a school of medicine. But several students, the White Coats for Black Lives students, working with several of our Administration Members and student National Medical Association. They worked to use a different rating system and a different ranking system that could actually be a better ranking system for medical schools. It's a ranking system on how well does your school do on racial equity and racial justice. So we issued this racial justice report card.

You can see there were several metrics that were used to see how well is UC Davis doing around racial equity issues across the entire health system. So it deals with things like how many minoritized students are represented. You see an A grade, as Dr. Henderson talked about. But then you can see things like faculty representation. We actually do not do as well in terms of having diverse faculty that are there to teach those students.

So you can see the students coming together to look at these representations, to look at these metrics, like marginalized patient population, equal access for all patients. This, I think, is a more accurate and better way to score and track how well isn't our medical students doing and achieving the goals that we are trying to achieve.

I just want to point out here that it says, you notice we didn't receive any score lower than a C. The people that designed this score did not give out d or f scores. I think they were very political in that way. So the lowest grade you can get on the racial justice report card is a C. Okay, so I just want to include this statement here about inclusive medical education.

Its purpose is to demonstrate how including diverse perspectives in general medical education scholarship could prompt reconsideration of basic concepts and the development of richer, more nuanced, and practicable understanding of who medical learners are. And that's really what we're striving to do. We're striving to increase the inclusivity of our medical education, and we are really trying to prevent othering that happens almost naturally in the medical education experience.

"Othering" is defined as a set of dynamics, processes, and structures that engender marginality and persistent inequality across any of the full range of human differences based on group identities. So this is the way that we try to build inclusion within our systems by preventing othering from occurring.

And we also understand that intersectionality exists for many of our students that come into our institution, and that because people have multiple identities that could be oppressed or marginalized, that we have to work extra hard to make sure that they don't experience many of the different ways that they can be discriminated or oppressed against. Some ways that we can do that, we try to include inclusive educational practices. We try to guide our faculty on how to be more inclusive in these educational practices.

It includes things like using pronouns in all interactions, including guidelines for presenting data about race and ethnicity, distinguishing between race, genetics, and genetic ancestry. Suggestions for developing clinical vignettes oftentimes these vignettes are very racist and very biased. And so we try to teach how not to teach clinical stories using racist tropes and medicine. We include guidelines on discussing body size, guidelines on discussing sexuality, suggestions for people with substance use disorders, and guidelines for accessible learning environments.

And so finally, I want to get to this point on belonging, and really, belongingness is really about becoming more antiracist and moving into antiracist organizations. And so how we do that is work that we are trying to do to address some of the ways that structural racism is built into medical education. One of those ways has to do with standardized tests. So for every medical student to graduate and become a physician, they have to pass what is called the USMLE, the United States Medical Licensing examination.

They have to pass step one, step two, and step three. There's a significant number of our students that run into challenges around passing these tests. This leads to the attrition that we sometimes see for students of color in medical school. And I just want to point out this quote, I'm not going to read the whole thing, but basically, Ibram Kendi is talking about how standardized tests, including the USMLE step one, are in fact designed to be structurally racist.

And it leads people, especially, as he says, black and latinx students, to believe that there's something wrong with them rather than something wrong with the tests. So one of the things we have to do is work around some of the barriers that have been put in place that make it difficult or challenging for our students that are trying to become physicians and go back into their communities and serve their communities in California.

The barriers that are kind of innate to the way that we have set up medical education, that makes it challenging for them. Another way that we do that, and I'll end here, is just by talking about equity-centered, trauma-informed education. This is a book that was written by Alex Chevron Burnett, who we have consulted with. She is a consultant and education consultant for k through 12. But actually the same principles apply for equity-centered, trauma-informed education in the k through 12 area that it does, surprisingly, for medical school.

And so if we can adopt some of those practices and principles in the ways that we're educating our medical students, we can do a better job of ensuring that every student that we admit from a diverse and disadvantaged background feels like they belong in our medical school and feels like we support them and know that they're going to be successful providers that are going to do great things and solve these great challenges that we have in the future.

Thank you.

Thank you.

Sorry, I had recommendations. Let me just say my recommendations really quickly. We wanted to talk about enhancing the resources for educational support for medical students across California. Staff support for medical students to increase inclusion and belonging. This relates to supporting students with disabilities and figuring out ways to better support students of lower socioeconomic status. And California medical schools need faculty and administrators with greater expertise in equity-centered, trauma-informed education. Thank you.

Thank you. We'll move on to Scott.

My name is Monika Scott-Davis, and I am the Clinical Supervisor at Roots Community Health. I've been there now for almost five years, and when I first started, it was just three clinicians. And we are located in East Oakland on 90 Eigth Avenue. Predominantly, we're serving African American, Latino community. But as you know, Oakland is a very diverse city, probably one of the most diverse cities.

And when my colleagues and I, we were talking about, like, wow, we wish this could have been a place that we had our internship. And I guess people in the community started feeling the same way. So we were approached by a lot of the academic institutions, like, hey, does Roots have an internship? And students were coming to us and wanting to do their senior thesis with us. So one thing Roots is really good at is meeting the needs of the community. So we started our internship.

We started with one BSW student, and then we had one student who was getting her master's in psychology to become a licensed marriage and family therapist. So that was our first two students. And after that, we developed a whole team, research and development, to help vet the students that were interested in coming to Roots. And we are currently working with about five institutions. We're like Cal State Hayward, most of the local ones, but also a lot of the online institutions have been reaching out to us.

So we have right now about five MOUs in place as the clinical supervisor. It is so important for people, once they get their license, to go in and to become a clinical supervisor, because you're taking on that responsibility of training someone to be a clinician. Folks who are going in to become a licensed marriage and family therapist, or LCSW or LPCC. They are required 3000 hours of experiential hours to transfer from the academic setting to becoming licensed clinicians.

So far, we now have to, after working two years, we have one clinician who has just passed licensure in November. She's also Spanish-speaking. We have three students who have just gained their masters. One student is Farsi speaking, and he is going on to get his CID. So the beauty of folks coming and getting that experience, especially in community-based organizations, is that, yes, it could be tough.

A lot of people do get burnout, but they really know that this is the work that they want to do. And I'm also happy to say that out of the four people, we've also brought them on to our roots team. So our goal is to give them a strong foundation. Whether they stay with us or go out and practice in other areas in the community, we're giving them that strong foundation.

One thing that we just started, which is something that I was very passionate about, our area has a lot of trauma, and so a lot of know, sometimes talk therapy isn't enough for trauma. So Roots was very generous, allowing me to go and study and get certified to become an EMDR therapist. And so our next goal is to work and present EMDR, which is usually a therapeutic modality that's usually given in more affluent communities. We want it to be represented in our black and brown communities.

So that's some of the things we're doing at Roots. I didn't prepare a big PowerPoint, but I'm so passionate about mental health. I came into the field actually doing a career change. I worked in biotech for 18 years and always volunteered working in the community. So this is my calling, and I think it's my colleague's calling. And I was just happy to land here at Roots and for us to be able to start this program.

Thank you for showing how Oakland does it right. Ms. Phillips?

Thank you. Kathryn Phillips, back again from the California Healthcare Foundation. I also had a slide of solutions, but all have been presented. And I think the degree of alignment that you have heard today is incredibly reassuring. So I'd like to spend the final few minutes answering Member Arambula's question on urgency and also pulling the thread on Schiavo's earlier comment on action. We have seen historic investment from Governor Newsom and from the legislature.

And I think there is broad recognition that we are in a healthcare workforce crisis. And more, much more is needed. There are no spot fixes. Our health workforce is infrastructure. It's critical infrastructure. It's the infrastructure of care. And just like our roads or our bridges, we need regular assessment. We need infrastructure upgrades. That's diversity. It's representation. It's the new roles that we heard about earlier from HCAI. And it's a continual process. It's not a one-time fix.

We heard today many examples of programs and efforts that are trying to address our supply side challenges and also to increase diversity, representation, equity and inclusion all are important. And just as Member Schiavo noted, we need help to scale them all. I argue we also need greater coordination as a state. We need to work better together to bring resources to the programs and the communities that need them most. And we need to begin rewarding the institutions that deliver the outcomes our state cares most about.

We also need bold action, not just incremental progress. What would it look like for all of the UC schools of health to adopt UC Davis's admission process? Other states have made medical school free for primary care. We could do that. Other states hold medical school seats and residency slots for rural students because they know that is the single best way to get people to work and to live and serve rural communities.

Other industries in California have embraced apprenticeship models to help people of color and those without graduate degrees advance through the profession. For example, the California health law program has finished their pilot. That allows paralegals and research assistants who work 10 years in the legal practice to sit for the bar exam, and if they pass that test, they become a lawyer. No law school needed.

Now, that's not appropriate or useful for every health profession, but I think it's a really powerful example of thinking outside the box, doing something innovative to, again, do more than move the needle. I'd like to thank the other panelists and contributors. We've heard a lot today and you all for your interest and your commitment to this topic. Our workforce deserves more. Our patients need care. Thank you.

Thank you. And I really appreciate that we were able to have Dr. Shem and Ms. Scott present before the wonderful wrap-up from HCSF. My question to Dr. Shim and Ms. Scott are, you kind of offered both the pipeline issue and the way that you actually need to restructure not only the admissions process, but the curriculum and complete environment to be able to support people who we want to be represented, and Ms. Scott, you outlined the way in know beautifully.

Again, Oakland is kind of ensuring that we're taking advantage of both the place and space and the providers who are there who are well sought after. From your perspectives, are there anything that you think we need to do? Have HCSF do and HCAI do to be able to support a more embedded, if you will, opportunity for providers, practitioners and for aspiring practitioners.

I think some of the examples about paid internships would be very beneficial. Even when folks are still at the student level. Many of the people who have come to roots for their preceptorship, they're also balancing to work jobs and get this training. And I can remember back in the day, most of my internships were unpaid, which was a big financial hardship. So we need to really support Clinicians financially so that they can come into the workforce.

It's so crucial, especially for behavioral health, to be able to come and see your reflection in your practitioner and where you feel safe. In order to do that, people have to have the means financially to get through your internships and your education. So financial assistance for the students would be very important.

I agree completely with that and I think I remember Dr. Henderson mentioned the data about the socioeconomic status of UC Davis medical students compared to others. And I would say on the day-to-day, the biggest challenges that come up, that get in the way of really smart, talented, highly educated people from being successful, from successfully graduating medical school are those socioeconomic challenges. So more financial support for students even? Again, we think of people going into medicine as being of higher socioeconomic status.

But if you're committed to increasing the diversity of the medical workforce, that means that we would want to be more inclusive of people that come from different socioeconomic backgrounds. And so they will need more financial support, even just the loans that they receive is not enough. So the recommendation for medical school to be free, I think that's a huge thing.

If we look at the data on medical schools so far that have been free, oftentimes the people that go to those schools are of very high socioeconomic status. So the benefits of getting a free tuition to go to medical school isn't really helping out the population that it would really make a huge difference for.

So I would be fully in support of any financial benefits that we can make to make it less burdensome for people to be able to make it through education and health profession schools.

Thank you. And I also want to just appreciate, Ms. Phillips, your analogy to this infrastructure issue. We've had for too long, far too long, an underinvestment in our medical workforce, infrastructure that will actually allow us to be able to lift up these concordant points of innovation throughout our system. So I'm going to be leaving with that idea, certainly, and I will turn that the conversation over to Dr. Arambula.

Thank you, Madam Chair. I'll begin with Dr. Shim. I was really impressed with your DEI and belonging conversation. I can't remember the first time I actually felt like I belonged in medical school. And for many students, I think they have a similar experience.

And so it seems as if we're turning aspiration into action at UC Davis and that there's a glimmer of hope in how to do it effectively, that I'd like to figure out what types of rewarding of institutions that Ms. Phillips was talking about could we do if we would hold up an example of how to do it right? By focusing on supporting students where they're at, by prioritizing admissions, and by making them feel like they belong, we as a state are going to benefit from it.

I'd love to hear how we can address that.

This is very timely because we were having a conversation earlier with our dean in the School of Medicine about what are metrics that we can look at? And one of the things that came up was student satisfaction. So medical students, they are surveyed and surveyed and probably over-surveyed in their experience. But one of the most important metrics that's used to survey them is something called the graduation questionnaire that the American Association of Medical Colleges puts out.

And that graduation questionnaire has questions in it like, did you ever experience in the course of your medical education, were you ever discriminated against based on your race or ethnicity? Did you ever feel like your grade was dependent on your gender, on your sexuality? And we have been working to improve that score because our score, as diverse as we are as a medical school, our score isn't perfect on that.

And, in fact, we're not even, I think, where we need to be in terms of on par with other medical schools who are less diverse than us across the country. So I think there's a way to tie reward to metrics like that, that ask students specifically about what is your experience as you go to medical school? We have lots of surveys that exist, and tying that to a reward process, I think, could be a very effective way of getting at this issue of belonging.

And if we can have more students feel like they belong.

I'd love to have Ms. Phillips jump in, but I feel like, I must mention these changes happened at UC Davis over the last decade. So these problems, while they seem that they're so intractable, oftentimes they can happen when you have leadership at institutions that are focused on providing real solutions. So I'd like to hear how we can reward other institutions to follow that model so we can continue to diversify our workforce.

Yes. Elizabeth Landsberg and Libby Abbott shared earlier about their approach and upcoming changes that will optimize equity in Hkide's awards that it makes to individuals for loan forgiveness, for scholarships. What I was alluding to were dollars to go to institutions. As we think about the need to expand our capacity to train physicians, nurses, pharmacists, and allied health workers, there's an opportunity to think about how resources are distributed and who is going to get the bolus of resources if they become available in the future.

And in the past, we have put most of the burden on the individual to serve MediCal members, to live and work in a medically underserved area. And we have not held our educational institutions accountable for the outcomes they produce.

So the idea, again, under that banner of innovation, and what would really move the needle is to think, is there a way in the future we could award dollars that go to institutions, educational institutions, in a way that preferentially rewards those who produce the outcomes we want, that are training more primary care and psychiatrists that have more first-generation college students, that have more people of color who have more language capacity, et cetera, as a way to balance what we're already doing at the individual level.

That thought I look forward to following the trail because our budget is a reflection of our values and we need to make sure that we're providing the right incentives for these educational institutions to be training the providers of tomorrow that are reflective and concordant with community. Thank you, Madam Chair.

Thank you, Dr. Arambula. With that, we will end our panel discussion and really appreciate all of you coming from far and wide to be with us today and to provide this perspective, we are going to move now into public comment portion of our informational hearing. If you have a desire to make public comment, please come forward. We will give each member of the public as long as they want, apparently, to make comment.

Thank you, Chair Bonta good afternoon. My name is John Shaban, a legislative advocate with the California Nurses Association. Thank you for holding this hearing today. CNA urges California to place greater investment into associates degree and public nursing school programs that support access to the nursing profession for socioeconomically diverse communities. Registered nursing can be a pathway to good union jobs for people from racial, ethnic, cultural, and linguistically diverse communities, rural communities, and other underserved communities.

More affordable than private school programs, community college and associate's degree in nursing programs have been shown to increase diversity in the nursing workforce. By providing a more affordable and accessible pathway into the nursing profession, California can better meet the cultural and language needs of medically underserved patients throughout the state. Importantly, CNA looks forward to continue working with this Committee to address the employer-created crisis of unsafe staffing, moral distress and unsafe working conditions to protect and retain California's diverse nursing workforce and other healthcare workers in safe and healthy jobs.

Thank you so much.

Thank you.

Good afternoon, Madam Chair and members Jessica Moran with the California Dental Association. I will be quick, and Laura said I had a minute and we did send longer-length comments to the committee. So I know, again, dental was not the top priority for today's hearing. But CDA does recognize that the dental workforce is not reflective of California's population. So I just wanted to highlight two initiatives that we are currently working on to increase diversity amongst the workforce.

The first is expanding pathways for dental assistance to remove the barriers for minority populations. So what that looks like is advocating for the RDA licensure exam with the dental board to be offered in different languages other than English. We are also looking at alternative licensure pathways for dental assistants to meet them where they are in life, whether that's on-the-job training where they're able to get paid while they learn, or programs through ROP or adult schools. And alternative education is what it's called.

The second thing that we are working on is making sure that dental students, when they are in dental school, are receiving community-based clinical rotations. So we actually advocated in the budget process two years ago for one-time funding to support these clinical rotations. And UCLA has data on this that really shows that once you expose a dental student to an FQHC or underserved area, they are more likely to go back and serve in those areas after graduation.

So we are committed to working with legislature on innovative ideas and how we can diversify the workforce for all Californians who receive the care they need. Thank you so much.

Thank you so much. Mr. Arambula, do you have any closing? Well, I want to thank everyone for coming out today. This has been a jam packed of incredible insights and information. I think that we will all move forward with. This is an issue that is very personal and important to me. Throughout the course of this panel, I had a bit of an opportunity to reflect on my own experience as a child. A black Latina growing up in the City of New York.

I did not have a doctor of color, ever as a primary physician, a dentist, anyone within the City of New York. And I entered into undergraduate with an intention to be one of the two things that I was allowed to be from my immigrant family. A doctor or a lawyer. Doctor, Lawyer, Doctor, Lawyer, and I got weeded out of Bio 101 and was not able to be a Doctor because I couldn't make it through Biology 101.

And so when I hear about the incredible need for supports that we need in order to be able to sustain, particularly Latino, particularly black and underrepresented people in our medical health professions, I could have been sitting next to Dr. Arambula right here had I had that kind of support. And I really appreciated the focus on the amount of scale, the scale that we need. This is absolutely an infrastructure crisis.

This is absolutely a healthcare crisis, whether you're talking about working and supporting young people, or, quite frankly, dealing with the elderly population that is coming online or addressing the incredible mental health needs that we have throughout all of our communities, and the fact that we are just not meeting the need.

So right now, we have a system, thankfully, where we're set up to be able to provide access, on paper, but not access, and true to the medical providers, that will ensure that every single individual is heard and supported with the best health outcomes that they can possibly have.

I think we have some shining lights of opportunity here presented by UC Davis Medical center and so many others and Oakland Roots, providing the opportunity for us to look at what needs to happen within our medical institutions, and then also what needs to happen just on the ground for frontline workers and in our communities every single day.

So this is an opportunity for us to have one of many conversations around ensuring that we have a workforce that is going to truly meet the needs of every single Californian. I'm thankful to my colleague, Dr. Arambula, and the colleagues who were able to participate from our Health Committee and our wonderful consultant who put this beautiful panel together.

Thank you, Laura, because this is certainly just the start of really being able to be bold, as we were asked to be able to do in our legislation, in our funding, and making the kind of investments that we need to be able to ensure that every Californian is taken care of with the dignity that they need, and that every workforce member within our healthcare community is lifted up and diversified to the great extent that we need, because we know that when we have a diverse workforce, we actually have better care and better outcomes for every individual.

So with that, we'll be doing a lot of work in this space, I believe Dr. Arambula, and and thank you so much for your participation.