BY BRIANNA VACCARI

CV Journalism Collaborative

A number of bills authored by San Joaquin Valley state legislators that aim to ease the region’s shortage of nurses are awaiting California Gov. Gavin Newsom’s approval.

Two bills authored by Merced legislators would create a pilot program for nursing students to earn bachelor’s degrees at their local community college, particularly in disadvantaged communities.

The legislature also approved a handful of other bills from both Democratic and Republican Valley lawmakers that streamline various medical processes in an effort to ease healthcare challenges.

The stack of legislation is a direct response to the sudden closure – and reopening – of Madera Hospital, as well as the devastating and costly toll of the COVID-19 pandemic in the state’s agricultural heartland.

The legislation is particularly important for areas throughout the state that are considered “medically underserved.” The San Joaquin Valley, stretching from San Joaquin County in the north to Kern County in the south, is one such region, with a large population of people living in poverty who also suffer high rates of conditions such as asthma and diabetes, to name a few.

According to a 2022 UC San Francisco study for the state’s Department of Healthcare Access and Information, the San Joaquin Valley had the lowest number of registered nurses per 100,000 people than any other region in the state. There also were fewer advanced practice nurses with higher levels of education here compared to other areas of the state.

On the flip side, this region had an abundance of certified nursing assistants and licensed vocational nurses, positions which require less training and education, according to the study.

While projections show the nursing pipeline soon should begin to catch up with demand statewide, Valley legislators know the healthcare landscape here is far more complicated than the nursing shortage.

“There is so much work to be done in this realm,” said state Assemblymember Esmeralda Soria, D-Fresno. “I think we’re just beginning to tackle some of the challenges here in the more rural areas of the state.”

San Joaquin Valley nursing shortage critical

Based on nursing student enrollment, UC San Francisco projections show California meeting the demand for nurses statewide by 2027.

But that’s not necessarily the case in the San Joaquin Valley.

The 2022 UCSF analysis showed the Valley had an abundance of certified nursing assistants compared to other regions across California. But as the level of required education and training rises for more advanced nursing licenses, the picture of the Valley’s nursing workforce quickly shifted.

The analysis showed the Valley as a region had the highest number of certified nursing assistants per 100,000 residents, at 432. That was higher than the statewide number of 372.8.

But when it came to registered nurses, the Valley had 868.5 per 100,000, the lowest of any other California regions analyzed. Statewide, there were 991.3 registered nurses per 100,000.

The Valley’s number of advanced practice registered nurses also remained among the lowest in the state.

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Here, there are two root causes behind the nursing shortage. Training and supply only addresses one cause, according to Paul Brown, a professor for UC Merced’s Health Services Research and Policy Institute.

The other cause behind the nursing shortage is the Valley’s large proportion of MediCal patients, Brown said.

“Unsurprisingly, places where there’s more private payers and more private insurance means that you have higher salaries, which means that there’s more nurses there and doctors,” he said. “So they tend to congregate where the private payers are, and the Valley doesn’t have as much private payers.”

Proposed pilot program

Assemblymember Soria and Senator Anna Caballero, both Democrats who represent Merced, authored separate bills to create a pilot program for select community colleges to offer baccalaureate nursing degrees.

While the bills are similar, CalMatters reported that key differences in the two pieces of legislation raise questions about how Newsom will reconcile them.

Both legislators said their goal was to make a bachelor’s degree in nursing more accessible for rural areas where transportation and broadband internet aren’t always readily available or reliable. 

The pilot program under Soria’s AB 2104 would focus on the Valley, run until 2031 and would not require national accreditation for the community colleges participating in the program. 

“I represent a district that is very, very rural,” Soria said. “I want to make sure that the people that live in Firebaugh and Mendota also have the ability to get a bachelor’s degree without having to figure out if they’re going to be able to afford it, or be deterred because of transportation costs or housing.”

The community college route also could prevent local aspiring nurses from leaving the Valley altogether, due in part to fierce competition to get into the state university programs, Soria said. When that happens, students are unlikely to return and work here, she said.

One such student, Alex Snyder, currently works as a registered nurse at Community Regional Medical Center in downtown Fresno. 

Snyder said she applied three different times to three different nursing programs at CSUs and was turned away because her 3.8 GPA was too low, and she didn’t test within the 90th percentile on the entrance exam. That’s how competitive the nursing programs are.

“I was not good enough for their campus, so that’s why I applied to Fresno City,” she said.

Snyder attended Fresno City College and Grand Canyon University concurrently to earn her associate and bachelor’s degrees. She paid $10,000 to Grand Canyon University for 11 classes, she said during a hearing for the Assembly Standing Committee on Higher Education.

Snyder’s experience is representative of another trend: Nursing students are turning to more expensive private colleges and universities because cheaper options, such as attending a state school, are compacted.

Now, Snyder plans to pursue her master’s degree at Gonzaga University, a private university in Washington.

Senator Caballero has a bill for a pilot program similar to Soria’s bill. 

Caballero joined Riverside Senator Richard Roth, a Democrat, as an author on his SB 895, which would pilot a similar program throughout the entire state with a focus on underserved communities through 2034. It also would require the colleges to have national accreditation.

During the COVID-19 pandemic, Caballero said healthcare providers across the Valley paid steep prices for visiting nurses. Her goal is to increase access to education for Valley residents who wish to pursue nursing so they can serve the communities they know and come from. 

“I’ve taken classes at the community college, at the CSU level and also at the UC,” Caballero said. “The more that we can educate our public at a reasonable cost within a short driving distance from where people live, the better off our society is going to be.”

The high price for traveling nurses is one reason officials cited for the bankruptcy that led to Madera Community Hospital closing, Soria and Caballero said. The hospital now is on the path to reopening.

Opposition and support

The California State University opposes both of the bills, mostly over the fundamental belief that the role of community colleges is to offer associate degrees, not a bachelor’s or graduate degree. Private colleges also oppose the bills.

Fresno State President Saúl Jiménez-Sandoval wrote a Fresno Bee op-ed arguing that Soria’s bill wouldn’t address the lack of clinical placements in the Valley for nursing students and ultimately wouldn’t produce more nurses. He instead recommended increasing funding and capacity for the associate’s to bachelor’s degree pipeline currently offered at Fresno State and its partner community college campuses.

One of the biggest supporters of Soria’s bill is Carole Goldsmith, chancellor of State Center Community College District, representing four community colleges that serve 58,000 students. She approached both Soria and Caballero about offering bachelor’s degrees for nursing at community colleges.

“We have the clinicals, we have the faculty to step in this moment and help the hundreds of students in Central Valley and across the state wanting to earn a BSN (bachelor of science in nursing degree) and be a part of the solution,” Goldsmith told the Assembly Standing Committee on Higher Education. “AB 2104 is not just educational heresy. It’s not. It’s a pilot. A pilot to be able to help us meet the moment. It’s a beacon of hope for those of us in the Central Valley that face hospital closures, not just Madera, but others.”

Both bills received broad support from community colleges, nursing associations and healthcare providers. Both bills also received bipartisan support in both chambers of the legislature.

Ultimately, Soria said the CSUs and community colleges need not feel like they must compete for students. 

“There is so much need that we can all play a part in filling that need,” she said.

Whether the governor will support the bills remains to be seen. Soria hopes the low fiscal impact of her bill will be a selling point. Caballero compared predicting the governor’s actions to looking into a crystal ball, but the issue remains a priority statewide, she said.

“I know my crystal ball says that he understands this perfectly well because this has been a discussion that we’ve had with the department of health services, and the whole issue of medical professionals in the community is kind of front and center.”

Other bills from Valley lawmakers

The two proposed pilot programs aren’t the only bills from Valley legislators that aim to ease the nursing shortage and other healthcare challenges in the region.

• State Senator Melissa Hurtado, D-Bakersfield, authored a bill that would add an additional consideration to screening tools when considering admission to impacted nursing programs at community colleges.

Currently, if a college’s nursing program’s number of applicants exceeds capacity, it uses a screening tool that takes into consideration multiple criteria to admit students.

Hurtado’s bill, SB 1183 would add an additional factor for consideration: whether an applicant lives in a medically underserved area. The bill is awaiting Newsom’s approval.

• Assemblymember Heath Flora, R-Ripon, authored AB 2578 to allow California residents who are seeking nursing degrees at an out-of-state private school to provide services while they complete their clinical placements. The bill is awaiting additional review before going to the senate.

• Jim Patterson, a Republican assembly member from Fresno, authored AB 2471 to remove the requirement for public health nurses, a specialized registered nurse, to apply and pay a fee to renew their certification. The bill is awaiting approval from the governor.
  
  According to Patterson: “[This bill] addresses the financial barrier to public health nurses by removing provisions related to the renewal of certificates. This change simplifies the certification process, reducing financial barriers for registered nurses and encouraging more individuals to pursue or continue their careers in public health nursing.”

• Another bill awaiting the governor’s signature would allow nonprofit health care providers to enter into a joint powers agreement with public agencies.
  
  AB 2293, authored by Assemblymember Devon Mathis, R-Visalia, replicates an existing legal mechanism for zero-emission transportation systems that allows a registered 501(c) (3) organization to partner with a joint powers agency.
  
  According to Mathis, the bill will provide a flexible solution to increase healthcare services in the state.

• AB 2080 from Assemblymember Joaquin Arambula, D-Fresno, asks the University of California to present an annual enrollment report and posts data on its website regarding students in its medical schools. Arambula authored the bill with another Democratic assembly member from Coachella.

Research shows linguistic and cultural competency of medical professionals can directly impact medical outcomes for patients, according to Arambula. The intent behind the bill is to use student demographics from medical programs to measure language and cultural competency of future medical professionals with the patients they will serve.

Newsom has until Sept. 30 to approve or veto legislation.

This story was reported with assistance from CalMatters’ Digital Democracy database.