WOMEN’S HEALTH: Women in the Health Care Workforce

CAPITOL WEEKLY PODCAST: This Special Episode of the Capitol Weekly Podcast was recorded live at Capitol Weekly’s Conference on Women’s Health which was held on Thursday, September 28, 2023

 This is Panel 3 – WOMEN IN THE HEALTH CARE WORKFORCE

PANELISTS: Melissa D. Bauman, Ph.D., UC Davis Health Women in Medicine and Health Sciences; Beth Malinowski, SEIU California; Sunita Mutha, M.D., Healthforce Center at UCSF; Tanya W. Spirtos, M.D., California Medical Association

Moderated by Angela Hart of KFF Health News

This transcript has been edited for clarity.

TIM FOSTER: Thanks much for tuning in. Angela, I’ll hand it off to you. Thanks so much.

ANGELA HART: Thank you. Thank you, Tim, and thanks everyone for being here. I’m excited for the lively discussion we’re about to have. Just some brief introductions. We have Sunita Mutha. Sunita is Director of the UCSF Healthforce Center. We have Melissa Bauman, Director of Women in Medicine at UC Davis. We have Beth Malinowski, a lobbyist with SEIU California, and we have Tanya Spirtos, President-elect of the California Medical Association. Welcome everyone.

So I just, I want to set up our conversation today. It’s not lost, I’m sure, on all of you who are joining us for the panel, but for the public, I think it’s important to recognize the immense health care landscape we’re in the middle of in California under Governor Gavin Newsom, who has made healthcare a core part of his administration. And under his leadership, we’ve seen extraordinary expansions. We’ve seen expansions in services and benefits, both non-traditional and traditional benefits. We’ve seen a major influx in social services. Of course we’ve seen expansions on population, the number of people who are covered, of course California now is covering or going to cover all undocumented immigrants who are in the state. I’m barely scratching the surface.

“I agree we need more women in healthcare… but I also want to just point out that maybe retaining women in health care workforce is equally, if not more important.” – Melissa Bauman

This governor, I say this all the time, but I think it sets up his perspective… I believe it was to the California Medical Association when he took office in 2019, said, “I am the health care governor. I’m going to be the health care governor.”

And I think, like what he’s done or hate it, think it’s gone aggressively or not far enough, there’s no question that that’s where we are in California today. So, of course, underlying major expansions and benefits and people who are covered, you really need the infrastructure and the staffing to support. And the pandemic just really devastated the state’s health care workforce. And I think, if you look at the disparities, there are many, but the disparities in women in health care are undeniable. And I just wanted to set up our conversation that way and ask –  all of you have really different perspectives, I’d love for you to just talk a little bit about where are more women needed in health care? Quick, and if so, just where specifically. And I’d love to hear from your perspective, your different backgrounds. If you could explain the “Why?” I think that would be a nice setup. I’ll start with, I’d love to start with Melissa, if you could kick it off.

MELISSA BAUMAN: Sure. And thank you for the organizers today. This is, I’ve been able to sit in on some of the previous sessions and enjoyed learning about the changes taking place. So to answer the first part, I think absolutely, there’s a need for more women in health care. Research shows that diverse and representative health care workforce improves not only patients’ access to care, but also outcomes, especially for underserved populations. And that was really touched upon this morning in some of the early panel discussions.

Instead of focusing, so I agree we need more women in healthcare, but instead of thinking how we bring them into the field, which is really important, and as somebody who’s participating in undergraduate education, we can talk about that more later, but I also want to just point out that maybe retaining women in health care workforce is equally, if not more important.

And when we think about the numbers of young women who have come through our pipeline, and I kind of hate the term pipeline, but I’ll use it by default, we’ve had 40%, 50% of our medical students and our biomedical PhD students have been women since the 1990s. But then as you start to look at, in the faculty setting upper ranks or in the hospital setting leadership, you start to see a drop off of women at those higher ranks and in leadership positions, which is where decisions are being made. And so that’s an area that I like to focus on. In addition to filling that pipeline, let’s think about how we keep the women that we have and to make these jobs more workable. So I’ll stop there. We can come back around to some of those points.

AH: Sunita. Thank you.

SUNITA MUTHA: Yes. I, Melissa I think has covered it really nicely that we definitely have enough representation in our pathways into clinical work. And as the intro underscored, when we look at entry-level jobs in health care, 90% or more are occupied by women. And the challenges, I think, are, so where we want more women? I mean, I think we need more people, period. I mean, that is very clear since the pandemic that we need more health care workers. Retention is surely an issue. But I would really agree with Melissa. I think where we need them are two places. One is in roles of leadership where they are vastly underrepresented for the size of faculties even in our academic centers.

The other place that we need them, I think, are in leadership roles in health systems. There again, they’re underrepresented. And the reason for that, which I think you asked Angela, is really that’s where the decision making is done. That is where allocation of resources, investments in new services, in design of new services, all of that really happens in that central location. And I think we do ourselves a disservice not to have the benefit of having women involved in that kind of decision making because where they clearly can contribute and they’re actively in practice. So those are areas that I would underscore, and there are many reasons for what’s happened with the pandemic that I know my colleagues will add to it.

AH: If I could, Sunita, I’m curious if you could, if you have, I would love an example. I wonder if you could provide anything about, for example, what types of decision making might be important at the top that might shape patient care, for example.

SM: Yeah, I mean, I gave one example, which is, decisions about design of new services. So there are so many different directions that we can go when we think about whole person care, which is the intent of CalAIMand much of this work. And in order to do that work, there are decisions that have to be made about location of where services occur, who the partnerships are with. And if you look really broadly at the literature, partnerships and collaborations are by no means only the purview of women, but they are something that we appear to be particularly inclined to look at for solution spaces for making decisions. So I think, if we’re thinking about expanding services for a specialty care, just really ensuring that we are considering the needs of half the population, which we don’t always do when we design services. So I would use that as an example.

AH: For everyone who doesn’t know, you might hear reference to CalAIM today. CalAIM is the California Advancing and Innovating Medi-Cal. It’s a long acronym, but this is Governor Gavin Newsom’s, one of his chief priorities. It’s a $12 billion five year initiative to infuse Medi-Cal with non-traditional social services, things like housing assistance. I believe California is about to approve actually, the federal government’s about to approve, the additional six months of free rent for Medi-Cal patients. So there are 13 groups of non-traditional services, healthy food, asthma remediation… So there’s a lot there. But just so you guys know that that’s the reference too. Tanya, I’d love to hear your perspective on whether you think medicine should be more equally weighted in terms of the gender dynamics we’re seeing.

TANYA SPIRTOS: I want to touch on things that both Melissa and Sunita had said in my response. The good news is that right now, 53% of all medical students are female. So we have had this big gender switch in the last 45 years. So that’s phenomenal. We’ve also now graduated 30% more medical students than we did back in the 1900s. The problem is, in 1997, Congress capped the number of GME slots, which are residency slots. So what we have are these perfectly trained medical students, many of them with master degrees and extra leadership courses, public policy courses, who all of a sudden get ready to match to a program and can’t find a program to take them. So they’re out there with these gigantic loans that they’ve incurred for four years of college and four years of medical school, no way to pay them off and nowhere to get the additional training.

“Even though we’re graduating more women medical students, only one third of our current full-time workforce is women.” – Tanya Spirtos

Now, when Congress limited the number of residency slots in 1997, I wasn’t around for the decision making, so I’m not sure what budget they were trying to balance.

[laughter]

It was rather shortsighted that we can continue to grow medical schools, that we can attract these wonderful, empathetic women, people of all diversities and races, and then have nowhere to train them and nowhere to place them in jobs where they’re desperately needed.

So what we’ve done in California, thankfully, due to the Prop 56 tobacco tax funds, is we’ve managed to set up 975 residency slots in the five years that we’ve been getting that money. And the Governor’s last budget trailer bill also set up another $75 million for next year and the year after that. So in California, we’re able to set up more residency slots, and we’re putting them in areas that are underserved in the Central Valley, because what we all know is where you train is most likely where you’ll meet your spouse, is where you’ll put down roots, and you might/may buy a home.

We definitely do not want more people coming into the urban areas. We’re looking at the Central Valley, we’re looking at, again, along the coast. And all of these residency slots that have been set up through Physicians for a Healthy California, that disperses the funds that are coming through the UC system, they are set up in family practice, internal medicine, OBGYN pediatrics, which are our primary care, not our specialty services. So we’re working to train more residents, but we still need more slots in order to train everybody that’s going through medical school.

The other thing that we’re trying to do to keep people in California, which is frankly higher cost of living compared to the rest of the country, is that we have physician loan forgiveness. And that’s also through the tobacco tax dollars, we can spend a lot of time talking about that. But again, we’re trying to keep them in those jobs for at least five years, pay off their loans, hopefully they’ll stay where their first job was.

And in order to participate in loan forgiveness, at least 30% of their practice has to be Medi-Cal. Again, we’re looking at the underserved population. I think you’re going to eventually ask questions about “how do we retain women in the workforce,” because even though we’re graduating more women medical students, only one third of our current full-time workforce is women. And I think you’ll get to those questions later on, and we can talk about that for at least half an hour.

AH: Wow. One third, did you just say one third? Wow, that’s really staggering.

TS: Of the full-time workforce. So we can talk about what it is that causes women to change their roles, go less full-time. And there’s many things that our society can do to improve retention of all women.

We saw with COVID, women in all workforces, not just health care, had to stay home to take care of children, to take care of families in a greater percentage than men had to. So the way our society treats child rearing, parenting, elder care, we can definitely have a lot more infrastructure support in our society to keep women working full-time.

AH: Beth, you’re of course with SEIU and have a major role in healthcare. You also have a lot of background in healthcare. You, of course, were with the community major, player in the community clinic. So you have, I’m curious if there’s… Sorry, if someone’s… Perfect. I think it’s solved. Okay. There was a little background noise…. I’m curious if there’s anything else that hasn’t been brought up in terms of really looking at the why and the where, if you think that there’s an important point to bring up.

BETH MALINNOWSKI: Really appreciate it. And I want to start by acknowledging, I really agree with the comments made by those that have spoken already. And I’m going to offer you a broader perspective a little bit. So SEIU, we’re proud to represent everyone from future physicians that are interns and residents to IHSS and home care providers, health care workers really in every setting, spectrum of care from clinics to nursing homes and acute care hospitals. And nationally SEIU represents roughly 1 million health care workers. We have a lot to say in this space and would agree with the preface today that women are really the backbone of our health care workforce. And certainly one of the areas we have to take particular focus attention isn’t the space of the physician workforce where as acknowledged, we’re sitting between a third and a quarter of the workforce being women.

I want to offer maybe some additional and initial thoughts on that why. Why do we see some of the challenges of both growing our workforce, which of course we need to do, but also making sure we’re maintaining our existing workforce, especially as it relates to women. And if we take a step back as Tanya was starting to do and think about some of the policy environment that brought us to where we are today, one thing for us to acknowledge is across health care professions, we’ve historically not had the same supports that other more male dominated professions have had, such as construction. So we actually think about…

AH: What kind of supports… Sorry about that, just what kind of supports come to mind?

BM: Yeah, let’s talk about that a little bit. So when we think about construction, we think about the trades. We think about an area of work where you had paid apprenticeship programs. And that really encouraged that person who’s seen as historically the breadwinner for the household to be able to get paid while getting training, and also have a clear guide-way into their future employment.

And historically, we’ve really not had that in health care. We’re starting to see it both federal and state dollars in the past five to 10 years have started to shift that conversation, and certainly when you look at the physician workforce, you do see some funding for our residents and interns. More globally in health care this has been a major challenge that I think we are still needing to overcome. And so that’s an area of both federal and state policy where we can make a difference.

I think when we think about attracting more women into health care, keeping folks in healthcare also through those years where folks are thinking about starting that family, it’s important to acknowledge that the policies really have not been there to do that. And I think I heard one of our other panelists speak to that a little bit already, and just want to draw attention to some of the dialogues that have been happening here in Sacramento where my work is focused. If we look at the legislative session that just wrapped up, you had Senator Menjivar moving a conversation forward through bill vehicle SB 729, regarding treatment of infertility and fertility services. And you might not think this is something that an organization like SEIU might weigh in on, but in fact, we did, we supported this effort. And regrettably, it’s not making its way to the governor’s desk, it was held up in Appropriations.

“The Medical Board, the licensing boards we have, have actually a huge impact in creating an environment that encourages folks to stay committed to their profession.” – Beth Malinowski

But in some ways it could have been seen as a game changer for both our interns and residents with a womb, as well as the rest of the health care workforce, many of whom have to spend reproductive years going through intensive school and training. We’ve seen a statistic from SEIU CIR who represents our interns and residents here at SEIU nationally, that one in four physicians have infertility issues. General populations, it’s more like one in eight is my understanding.

And so this trend I think to some extent relates to this fact that we’ve got so many years of training that leads to early practice and folks being ready to start a family when they might be a little bit older. And with that, their body might have new challenges. And so this is just one example of the types of policy changes we can be making in our state legislatures in places like Sacramento to really influence the environment for our women and future women or women that are in their workforce and trying to choose where they stay and land.

I also want to draw out the regulatory environment. We don’t talk a ton about it, but the Medical Board, the licensing boards we have, have actually a huge impact in creating an environment that encourages folks to stay committed to their profession. So you might think of just kind of procedural activities that happen to keep or maintain their license. The reality is it can actually be a really discouraging environment. And really, our women and persons who have been historically marginalized are those that are most likely to feel disenfranchised by these boards and choose to leave the field, or practice somewhere else, and maybe even a different state, where there might be a different environment of the boards.

And so again, this is an area of policy where we can control here in Sacramento through dialogue that happens around Medical Board sunset and other center review processes for the other boards. So I just wanted to draw out some of those kind of conversation areas that both kind of pivot back to some of the conversations earlier, the conversation around positions, but have implications beyond that. I think the other things are… Oh, sorry, go ahead. Don’t want to take up too much time here.

AH: Oh, no, thank you for bringing up the Medical Board. And their… yeah, it’s a very good point, the Medical Board and their important role in deciding and approving which providers are actually practicing in California.

You guys, I got to say, gosh, I’m so, I’d love to just dive a little bit more into some of the dynamics that Tanya and Beth and I’m sure that you guys touched on about the dynamics that really lead to some of these disparities, these gender disparities. And we have a governor who is a feminist. He was a proud feminist. [chuckle] We have come so far in this country, as we know policy-wise, there are many different factors that really do shape disparity in access to care. And, I don’t know, can you talk about some of the things, some of the reasoning a little bit more deep on gender norms or family pressures, some of these pressures that might make it a little imbalanced? I’d love to hear what you think, Melissa, yeah.

MB: Yeah, thanks. I’ll follow up a little bit from what Beth introduced about the challenges in careers, not only in medicine, but I’ll say STEM, broadly defined, science, technology, engineering, math, medicine, these careers that require significant investment in training. I get asked all the time by our grad students, postdocs, and med students, when’s the best time to start a family? And there’s no great answer to that. My advice, at least we’re asking that question now. Back when I was a postdoc, it was something you whispered about behind closed doors. But our trainees, we talk more openly about this. And I do think that that’s part of a change in climate and culture to show the women in our field, if they want to have a family, “it is possible, and here are some things to consider.”

So for our Women in Medicine and Health Sciences program, we’ve actually started bringing in speakers to talk about fertility planning, to talk about child care and lack thereof. UC Davis Health has made tremendous progress in providing child care. There’s still more work to be done. Also in the space of lactation support. So we have faculty and residents and trainees who come back and they’re breastfeeding. And we need to continue to advocate for lactation support so that we’re not pushing women out of these careers that they’ve invested so much time and effort into training. And then for this short period, and I do reassure individuals going through this with young kids, it’s a short period, it’s transient. It will change over time. And I really care very deeply about supporting that particular period where either they’re planning a family, they’re pregnant, they’re coming back. We can do so much better in that space.

AH: Because that’s when they decide?

MB: Oh, not just that. I think there’s, you know, it’s a complex, there’s no one size fits all.

AH I see.

MB: But I say from my vantage point in academic medicine, I see many of our early career faculty and trainees really struggling to figure out what work life, I don’t say balance, I say “integration,” what does that look like? And can they have the life outside of work that they want while maintaining these careers that they’ve invested so much time and effort into training for?

“Our entry-level workforce is 90% female. So these are our medical assistants, our licensed vocational nurses, community health workers. That group, the living wage is quite low” – Sunita Mutha

AH: Yeah, the pandemic really, we saw a lot of the federal money really going toward propping up things that help with that balance. And doing things like paid time off and childcare. And of course, California is trying to do a lot in that space, like TK, for example. But are there the supports that families need, that working moms need to really commit to their careers?

MB: In our country, in my opinion, no.

AH: In California too.

MB: Yeah, no, I think we’re ahead of the game. We’re doing better, it’s still not enough. And that’s my opinion as an individual.

But I think that there’s also lots of, there’s room for improvement. And I have seen a tremendous change in my career in my 20 years at UC Davis Health and seeing the types of supports that we’re bringing in. And the fact that we have groups like our Women in Medicine program where there’s an expanded network and we can talk to one another and provide advice. I didn’t always experience that as a trainee. And I think that that network is also valuable in addition to policy changes and big picture items. I think having the peer mentoring and support network is critical.

AH: I wanna keep this discussion open if you guys have thoughts too. But let me just, I’d like to also just ask you if you could really get into, are we really seeing a lot more women as we talked about in the introduction, in the lower ends of the medical field and men weighted toward the top? I’m just curious if we talk about the why, if there’s any other thoughts you have about how that’s really shifted. Sunita, I haven’t heard from you on this yet.

SM: Yeah, I think there’s an important thing to pull out here that we haven’t yet is that there’s the physician workforce and we can say a little bit more about that. But really our entry-level workforce is 90% female. So these are our medical assistants, our licensed vocational nurses, community health workers. That group, the living wage is quite low for them. So they are doing multiple jobs often to have that. And they may or may not have benefits depending on the number of hours they’re working, if they’re working in an assisted nursing facility or elsewhere.

So I think we’re talking about different populations of people when we’re talking about women in health care. And for them, I think it’s a matter of living wage, honestly, that’s probably the most critical thing for our entry-level workforce is to be able to given… And we saw that very clearly about how lean the structures are. So during COVID, what we saw is who couldn’t come to work, it was often frontline workers. Because of transportation, because of childcare, because of care for aging parents or disabled family members.

And that is different. And so that just shows you how lean and thin our social structures are to be able to support people. Individuals have to figure out individual solutions. And I think that’s where there’s room for system solutions to try to provide better support. You mentioned TK, we talked about childcare. That’s a national conversation. I think that’s different than some of the conversations we were having where for women in leadership in these large systems that several of us have alluded to, the issues there are thinking differently about who is a leader? What are the skillsets that we need? What is the sponsorship that can occur to advance women into leadership roles and to support them?

And then the flexibility, because many of our jobs actually can’t allow for flexibility of work hours, and really having a very different mindset of how do you retain as much talent as you can in our systems to keep people fully employed to the degree that they want to be so that we’re not having the conversation that Tanya raised, which is that a third or a little bit more of the workforce is female, when over 50%, and in some cases, 60% to 70% in some of the professions like pharmacy and dentistry, is female going into the training.

So I think there are policy and system structures that we haven’t built and haven’t invested in. That’s really what’s gonna be needed to keep everyone in the system, and fully employed.

AH: I’m also curious, if you’re a single mom or if you’re a mom with, for example, aging parents in your household and you have ambitious career goals, maybe you wanna go and be an NP, maybe you’re an RNand you wanna go back to medical school. Can you do that? Can you do that in this environment that we’re in? Beth.

BM: Sure, I would say it’s very challenging today, right? I think Sunita and Melissa said it so well. We do not have the social structures in place right now to support those individuals that wanna do just that.

And we know those individuals are there. That’s not in question. We know they’re there. They are throughout our communities, rural and urban, and they don’t have the support. I think the topic that’s been brought up earlier in terms of childcare, care for aging parents, this is real. And while, yes, it is accurate to say our state has made significant investments, we’re just not there yet. I am someone who’s the parent of a TK child, very proud our state offers public TK, but every day I have to stop my day at 12:45. And guess what? An RN can’t do that. Our physician in training cannot do that. Our MA cannot do that. And they certainly can’t do that, go back to work and also then juggle the needs of their parent with dementia, who they have to make sure gets fed and has their medicine in the evening.

So our structures are not in place for this. I do wanna also just uplift Sunita’s particular point around wages, because certainly wages have a domino effect on how you can uplift your whole household and even whole communities. And in many parts of our state, our health care systems are our largest employers. And so when we’re able to uplift that individual and that family, we’re actually having a domino effect to uplift a whole community. And I think there’s an interplay here between these social supports and wages as well.

AH: Tanya, briefly, I have a couple more things that I’d love to get to. Do you have any other thoughts that you haven’t brought up?

TS: I think everything I would say has already been mentioned by one of the other speakers, but I would go back to letting everybody envision this as a pipeline. We’ve got a great pipeline. We’ve got, okay, six roads of freeway heading into a two-road bridge. We’ve done nothing to open that bridge or make the traffic flow easier.

Medicine is great. I mean, we just have made such strides in everything that we can offer to people. We’ve also made the work so much harder. Physicians now spend equal amounts of time on a computer with electronic health records as they spend face-to-face.

So I would say that every time the legislators or the government departments think about a new regulation, they should think about, is it going to add more work time to the physicians? If we have to take homework home and do it in the evenings after the kids are in bed or on the weekends, that takes away from our work-life balance. So not everything that is thought of or envisioned in Sacramento makes medicine safer or makes physicians’ lives any better. And if we burn out our health care workers, we lose them from the force. We need to retain them working full-time. We need them to be happy to ascend to leadership positions, and we need them not to retire until they’re in their 70s.

AH: Thank you. Thank you. Wow, 70s, that’s amazing. I pulled some data that I wanna just bring up to you guys. It makes it a little less amorphous. I just wanna bring some numbers up, but I’m doing so to really try to get into, like we talk about health care is such a big field and it’s growing even within that. I’d love to hear your guys’ thoughts about where we’re seeing some of these, where are we seeing… are there specialties, for example, that are more amenable to women? I’m thinking of, or primary care, OB-GYN.

“Statistics now show that men who have women primary care providers also tend to live longer.” – Tanya Spirtos

I have some stats that I’ll pull right now, but right now in California, 38% of doctors, of physicians are women. That’s doctors, that’s not even talking about all the other health care providers. That’s around 45,000 women, 72,000 men. However, I’m just gonna reference the spreadsheet. So if you guys don’t mind, I’m gonna look to my left for a moment.

Thanks for the California Healthcare Foundation who helped me look through some of this data that is really looking at the pipeline, as you mentioned, Tanya.

Things are changing. It looks to be, now, will they stay in California, but things look to be changing. It looks like from 2019 to 2021, so a two-year period, this is for Residents, we’re seeing females go from 45% to 47%; Men from 54% to 52%; Graduates of, medical graduates, medical school graduates, in 2020, 48%, 2022, 51%. Males went from 51% to 48.9%.

So you can see, there’s just, the trend line is shifting a little bit, and I’m just curious if within that shift, perhaps there’s an opportunity to really kind of look within specialty care or regions in California that really lack access to primary care, the Central Valley, the rural north, of course, parts of inner cities. South LA, I spent some time reporting down there, and there’s enormous disparity. Are there specialties or regions where if the pipeline for women coming into the profession is shifting a little bit, are there areas that really need to be focused on? And if so, like, well, I’ll just leave it there for now. I don’t know if anybody wants to jump out. I’d love to hear, yeah, go ahead, Tanya.

TS: I’ll jump into that one first. Yes, obviously, women tend to be more empathetic, tend to spend more time with their patients. Statistics now show that men who have women primary care providers also tend to live longer. Outcomes of surgery…

AH: Say that again, if you don’t mind.

TS: [laughter] Men who have women primary care physicians tend to live longer. So that’s a good sign. Men who are married also tend to live longer.

[laughter]

But anyway, so women tend to go into these primary care [positions], but there also tend to be the less paid reimbursement. You spend the time, but you don’t do the high reimbursement procedures. So right away, you begin to see a difference in the ability of the women physicians to pay back their loans and to accumulate the funds over what may only be 30 or 35 years in the workforce compared to other computer scientists or other even STEM majors. So you have fewer time in the workforce.

We also, because we are not taking positions of leadership, that would have to be on our own time, not reimbursed, that limits how many women will do this. If we trained more women in the Central Valley and in those specialties where we’re desperately needed, we will hopefully then alleviate some of this burden on our emergency rooms and our end care chronic diseases coming in, in a way that could have been fixed many years before if they just had a good primary care. So yes, we need to build up more residency slots. We need to make those early physicians in practice work life easier so they can spend time with patients and do not burn out as quickly, do not cut back on their office hours, do not cut back on their number of years of practice.

AH: So are you saying, Tanya, I wanna make sure I get it, that like primary care and really like trying to beef up the ranks there might ease pressures on different specialties?

TS: Yes. We’ve always known that if every area has enough primary care physicians, you have better general health.

AH: Yeah, that’s interesting.

TS: If you don’t have primary care, those patients are depending on urgent cares and emergency rooms. That gets the wait longer, costs more money, and they end up coming to the emergency rooms in a more advanced stage of ill health. So yes, we need to beef up primary care throughout the entire country, throughout the entire state, and especially in these underserved areas that you referenced.

AH: I asked around some other, I’m curious, I’m gonna throw some other stats at you guys. The specialties and the areas of care are really weighted toward women. I wonder if you guys buy this, and if so, like should this be redistributed perhaps? Pediatrics, OB-GYN, neonatal pre-medicine, and other areas where there’s like more predictable shifts and stuff like that, fewer emergencies – dermatology, anesthesiology. Do you buy that? And if so, like, I don’t know, should there be a policy argument to look at where California is putting its doctors and providers? I don’t want it to only be… It’s not only doctors, it’s NPs and etc… etc…

TS: I think when…

AH: Oh, yeah, go ahead.

TS: When you’re in medical school, you pick an area of specialty that appeals to you. You’re really not thinking about having kids or the way life is gonna run when you’re there. So you pick, for example, OB-GYN because you thrill in delivering babies. You thrill in doing surgery. Then all of a sudden when you’ve got children of your own, that midnight call to come into the hospital and stay there until 6:00 AM with a delivery suddenly doesn’t work with a home-life balance. So I’m not sure that we can get people when they’re very idealistic in medical school and in residency to make the best decisions looking at what we know now with 20/20 hindsight.

“We do not reimburse well for primary care services. And so I think it’s not surprising if someone looks at that and says it’s a lifestyle that’s really not sustainable in terms of quality of life” – Sunita Mutha

AH: Thank you. Anything else from, yeah, it looks like you wanna say something, Melissa.

MB: Well, I was just gonna follow up. I completely agree. Those are big choices that are made early in one’s career. I will say as the non-physician here, so this is looking from the outside in, but as part of our Women in Medicine program, we have department level representatives in the majority of our 27 different departments here. And as you alluded to, some of our specialties have a higher percentage of women than others.

But I’m hearing, so for example, we have a new departmental liaison in neurosurgery. I’m thrilled that we’re beginning to have more women in neurosurgery. And I hear from our residents how meaningful it is to them to see that we have women in these surgical specialties where women have historically been underrepresented, but sometimes just seeing that one person out ahead of you who’s passionate about this career and making it work, I think that really, that goes a long ways towards shifting climate and culture and being more inclusive, if someone chooses to go into one of these particular fields where women are continuing to be underrepresented.

SM: Yeah, I think I agree. And I would say the economic issues are big drivers of these decisions.

It’s not just what we choose to believe or experience as giving us joy in a particular practice. The reality is primary care is a shorter timeline for finishing training and being able to go into practice. And it is not well reimbursed. So if we really start, that’s true for pediatrics, that’s true for several of the specialties that are predominantly female right now. And I think the thing we have to ask ourselves is, and if we believe, and I completely agree with Tanya, the data supports that if you can do one intervention in health care to improve overall community health, it’s primary care. It’s ensuring that you have enough primary care access. That’s been proven nationally, internationally.

So the issue I think is we don’t, I won’t use the right phrase here, but we starve the system.

We do not reimburse well for primary care services. And so I think it’s not surprising if someone looks at that and says it’s a lifestyle that’s really not sustainable in terms of quality of life or reimbursement given debt. It’s understandable why some of our young trainees choose hospital medicine instead of going into primary care if they’re doing an internal medicine training.

So I think we have to really look at the incentives in our systems and realize that those incentives are quite visible to trainees and they make decisions, economic decisions as well, that determine it. And yes, we need to fill the huge gaps that we have in parts of our state for what we clearly don’t have enough primary care or specialty care. We don’t have more than enough orthopedics, sometimes. But those I think are to me, gender agnostic. And it’s really about getting right people who are really drawn to want to serve the communities and ensuring that they have the supports to be able to stay in those communities. That it’s a viable lifestyle for themselves and their partners. And that means rethinking, I think, how we allocate resources to support our sector.

AH: Thank you. Thank you, Sunita. Of course, California and Governor Newsom this year released a framework. I’m gonna call it a framework for an increase in rates. We’re talking about managed care and Medi-Cal, but I wonder, Tanya, do you think that the MCO and, who knows, there may be an initiative to solidify this down the road. Do you think, two of the areas, if I’m not mistaken, are behavioral health and primary care. Could it make a difference if you raise the rates and could that address this issue?

TS: Absolutely. Absolutely. One of the major problems we’ve had with Medi-Cal is that there was no increase in rates for over 25 years. And for most specialties, none in the last 10 years. So just increasing this MCO tax will increase to almost Medicare rates. And that’s gonna encourage many more people in both urban and rural areas to see patients coming in.

The second wonderful thing that’s happened in the Medi-Cal system is managed care, is that you’re no longer fee for service. So that has also helped us see the entire patient as opposed to just owning little bits and pieces of the patient’s care.

“SEIU California is deeply proud of SB 525 and really the historic agreement it represents to lift the wages of nearly 500,000 health care workers who we believe will be directly affected by this minimum wage increase.” – Beth Malinowski

I’m not sure how we’re gonna fund homelessness or food insecurity through CalAIM, although it’ll be interesting to follow and see what the governor has in mind to try to get people housed and fed because that’s an important part of good health. But we’re very optimistic that this MCO tax is gonna elevate California compared to the rest of the country.

AH: Beth, I wanna ask you, if you have thoughts on that, I’d like to hear it. But I also wonder, there’s also, of course, on Governor Newsom’s desk, a legislation, he will sign or veto it. I guess he can do nothing too, which that’s, I guess, a veto, for a new minimum wage, $25 for healthcare workers, could this help?

BM Yeah, I wanna appreciate both the potential impact here of both the MCO tax, this conversation, as well as SB 525, the bill you’re referencing. If I could just make a quick additional comment on the MCO tax.

I think maybe one of the lesser discussed sections of the MCO agreement relates to funding for workforce directly. So additional investments in graduate medical education, I think there’s still conversations to be had around maybe how we could use those dollars to influence how women are being supported in training and where. But additionally, there’s, for the first time ever, direct dollars for Medi-Cal workforce-related labor management committees.

And so when we think about who the backbone of staff behind our primary care providers are the folks that make sure that that medical office is successful, be it the MA, be it the other team members, the call center staff. For the first time ever, we’re gonna have dedicated Medi-Cal dollars to think about labor management committees that can exist at the organizational level that can really, I think, make a huge difference, especially for retaining our workforce and creating those pipelines so folks are encouraged to stay in the work and get excited to have a full career and not just start off in health care and then leave health care, which I think, again, is happening to our women in the workforce. I do wanna speak to that…

AH: Sorry Beth, I wanna hear about the minimum wage. Sorry, I just, I’m sorry, I always, you guys, for those of you who don’t know, Managed Care Organization, MCO, sorry. Okay, go ahead.

Beth Malinowski: Our acronym, SUP and Healthcare. I know we used to be remembered, Angela. Oh, it gets all of us. And I do wanna speak to SB 525, right? I don’t know that it’ll have a direct impact on our physician workforce per se, but it will have a tremendous impact on the workforce more broadly, right?

Our estimate, and for those that don’t know, SEIU California is deeply proud of SB 525 and really the historic agreement it represents to lift the wages of nearly 500,000 health care workers who we believe will be directly affected by this minimum wage increase. And she really did this. The final bill represents incredible partnership across the healthcare industry as well.

And what we know, and this was said earlier by Sunita and others in different ways, wages and a pathway to higher wages is one of the factors that has the greatest impact on where someone chooses to work. And women, as we’ve also discussed already today in our session, many of whom now are not only responsible for their own personal budgets, but the budgets of their family, need to really take into account where they work and how that work is valued.

So we believe women will be more likely to stay in health care and undertake the extensive training and ongoing thing that is needed to stay in the field if they have a pathway to the middle class. And that is what for us SB 525 represents.

The UC Berkeley Labor Center did some phenomenal reporting throughout session as they were trying to help all of us think more about the impact of a minimum wage on health care. And the benefits that we understand are, roughly 75% of all women in health care will benefit from this bill. And 76% of all people of color in health care field will benefit from this bill. And that is when you talk about the profession and the range here, we’re talking about medical assistants, CNAs, other service workers that are really critical to the functioning of our health care delivery system.

AH: Yeah, that’s an awesome point. Yeah, you guys, I just wanna, sorry. I just wanna, when we ask about, when we ask this bigger question of like, what can be done to entice more women into medicine? I guess I was having, I was actually talking with a couple of friends and one of them happens to be an NP, one’s a physician assistant. And it just kind of came up casually. This was a couple of weeks ago. And I heard a clear, a compelling case. Like, hell yeah, this would help them, not only stay, but like go further, go seek more training, etc…. I wonder if Melissa or Sunita or Tanya, any of you guys have thoughts on, could this really make a difference?

MB: Sunita, I’ll take a little sidebar answer. And as we’re thinking about how to entice and retain women in health care, I think we also need to acknowledge the gender pay gap in medicine. And we haven’t talked about that specifically yet. But I think that that’s an issue that becomes… as women enter these careers and become more aware or reach my age and you start thinking about retirement sometime in the near future, not 70, whoever said we need to work till 70, we’ll see.

[laughter]

But, there’s decades of research that demonstrate that female physicians across practice type, specialty ranks, etc… earn less than male counterparts. And I think that that’s an area we haven’t touched on yet, but I think that that’s an area where we need to continue to advocate for change as a way of supporting individuals who enter careers in the healthcare profession, so…

AH: Thank you, that’s actually a really good point. Thank you for that.

SM: Yeah, and I’ll say…

AH: Oh, go ahead.

SM: I think the other opportunity here is some of these entry-level positions don’t pay a lot, but they do have career ladders and they have career lattices, which is it may not be a linear pathway, but there is a pathway to go from being a nursing assistant to getting your RN degree to advancing and maybe end up doing a nurse practitioner training. So there are…

AH: Or even look at, sorry, even look at the doulas or the community health centers that are newly covered in California. Sorry, yeah.

SM: Yeah, and I think that’s what people are looking for. They’re looking for vehicles that allow them economic opportunity and growth and professional development. And that’s true in medicine. It’s true in all of these other health professions that we’re sort of touching on. And the one bright light I will say is that our state has made the largest investment in workforce in my professional career.

AH: Is that right?

SM: Like $2 billion that has gone into workforce and workforce writ large. So this is being done at the health care affordability and information department, labor is doing this as well. Those are really significant investments that speak to that this is a priority because workforce is how we actually get to services. And…

AH: Yet, here we are.

SM: And here we are. But I think, yeah, here we are. And this is a problem that has long been coming. We knew the shortages were coming. We’ve talked about this. Healthforce, we’ve talked about this for a long time that we didn’t have anywhere near the workforce that we needed across an entire spectrum because of our aging society and because of how health care has evolved and the kinds of things that we can deliver and do in health care that we couldn’t do before. So this is, money’s never enough, but this level of attention and focus is unprecedented.

And so I think there are bright lights to be hopeful about that we can actually develop the structure, the infrastructure so that people can start at a community college and that you’re not disadvantaged because you don’t come from money in your family to be able to consider a career in health care or a career in medicine or dentistry or whatever it might be. That has, I think, implications for generations. And that is exciting. There’s still a lot of work left to be done, but it’s exciting opportunity.

AH: I think that’s a really good point. And you guys, gosh, there’s so, I feel like we could talk for another way longer, but I do wanna get to a couple of questions. I just wanna say one more thing that we didn’t really talk about, but every, I think the backdrop and why this is so critical, we didn’t really get into this deeply, but it really comes down to patient care, right? Access and proper access. As we’ve seen an increase in chronic disease and homelessness and things that really impact your health, not to mention, I mean, I think there’s more and more focus on medical gaslighting. So do women really play an important role in really advocating yourself as a patient?

There’s a lot of really important issues here that I think really we need to look at the gender balances and who is entering the profession. So one of the questions I wanted to put to you guys, thinking of getting more women into health care, do you have thoughts on recruitment and training programs being started in high schools, even community colleges? I think Sunita.

SM: Yes, and I see Tanya is gonna add to this. I will just say briefly, yes, absolutely. We know that interest and exposure to role models early, as early as you can get, matters in whether or not people, particularly people of color who’ve typically not been represented in health care fields believe that this is actually an option for them. So yes, and I’ll hand it to you, Tanya.

TS: I’ll be speaking at a local medical school next month. Again, trying to paint as great a picture as I can of the entire health care workforce in order to try to get these young women, it’ll be at a women’s high school. I would say we’re doing a really great job with our pipeline of getting people interested. What we need to do is cut back on the cost of their education, especially for the health care professional schools so people don’t end up with huge loans when they finish.

AH: Beyond Prop 56 even?

TS: Even with that, the average medical student right now comes out with a loan of $250,000, okay? Then they start and they have to find a job that offers physician loan forgiveness. And then they have to stay committed in that one place that long. And that will also make them pick a specialty in which they will hopefully get paid more, which rules out most of primary care. So that’s a whole different discussion.

But I think, yes, the pipeline helps, but then once we get people into the pipeline, make sure they succeed through medical school and graduate. Make sure they succeed through residency. Make sure that they can have their children and have enough childcare structure. They continue working full-time and don’t become that two out of three dropout of a full-time workforce. So we’re doing great with our pipelines. We are. We’re reaching out to high schools in disadvantaged areas where people never thought about being a health care worker. We’re bringing them in, but we’ve got to support them now.

Here in my area in Silicon Valley, we have the Peninsula College Fund, which actually pairs people in the community with first-generation college students to help guide them through how to buy a book, how to enroll, how to go to classes for people who are totally lost when they suddenly get into that college environment. So we’re learning to mentor. We need to keep that up. We need to do a better job of it. We need to support the people that are already on the workforce and keep them working as long as they possibly can.

MB: If I could just, I know we’re short on time, just add one follow-up to that. I, for the past 10 years, taught a first-year seminar on the UC Davis undergraduate campus on women in science and medicine. And I find that the students who enroll in my class are often first-generation students who come in with a strong interest in STEM, having not been exposed to all of these amazing careers. And it’s really one of the parts of my job that I find most enjoyable to introduce them through this course to all of the possibilities and to help them begin the process of finding out what really resonates with them. And I think we can do even more of that because it really does make a huge difference when there’s someone here to support those students upon entry into university-level classes and to help them find a path forward.

AH: Another question we have is really looking at efforts to recruit more women, particularly women of color, who are looking for career change opportunities. We a little bit touched on it, but are there efforts that we haven’t talked about that you guys would point to?

BM: Well, let me just offer a quick remark here. One, I really appreciate the comments made by my colleague just now on, how do we support the workforce. The one thing that I’ll offer specifically is the area of High Road training programs and the particular value…

AH: Say that again, Beth. What did you say?

BM: High Road training programs.

AH: High Road, okay.

BM: Yeah, and so when we talk about that, these are pathways that can be a good guidance for someone who’s switching careers or someone who’s new to a field, either of those cases. There’s really setting folks up for success, not only making sure that they’re in a kind of an environment that supports them to their training, but leaves them to being in an employer environment where we know they are gonna receive the payment and support that they need that reflects and respects their work. So I just want to acknowledge that so that could be a really important pathway, both for folks kind of switching careers, both folks first entering health care.

BM: I also, if I could follow up, I think it’s really important that we acknowledge all of the data we’ve been talking about today about the underrepresentation of women at higher ranks in leadership positions. That’s amplified even more when you start looking at the intersection of race and gender and women of color in particular are very underrepresented in these roles. And I think that that’s something that we need to acknowledge and continue to work on.

AH: Does that affect patient care?

MB: As the non-physician, I would say undoubtedly, but I’ll defer [chuckle] to my colleagues.

AH: What do you guys think? I’m curious.

TS: I would say most people will say that they have an immediate sense of comfort when somebody like them walks in to provide healthcare, whether it’s the same gender or whether it’s the same race or ethnicity, there’s a sudden sense of comfort. And only in this state, we have many underrepresented minorities in medicine. We can do a lot better with that.

AH: Thank you. Any other final thoughts?

SM: Yeah, I’ll just say there’s really ample evidence around concordance. So when the clinician providing care mirrors the patient getting care and those studies show diabetes outcomes are better.

AH: Really? Wow.

SM: Likelihood of following recommendations for medications. So there’s really ample evidence that if you get a really good matching to the degree that you can concordance on some level, that there are actually health outcome benefits.

AH: Even diagnoses, I wonder?

SM: I haven’t seen the data for that, but I’ve certainly seen it for other outcomes, including patient satisfaction and communication.

AH: Yeah, interesting. Thank you. Well, any other final thoughts? I think we’re just about at time. I just want to thank everybody for the thoughtful discussion. And you guys make me want to do a bunch of stories now. So, [chuckle] I’m excited.

MB: Thank you for the invitation. This was great.

TS: Yeah, thank you so much.

AH: Bye-bye, thank you.

TF: Thank you all for participating. This is a really interesting discussion.

Thanks to our Women’s Health sponsors: THE CALIFORNIA HEALTH CARE FOUNDATION, THE TRIBAL ALLIANCE OF SOVEREIGN INDIAN NATIONS, WESTERN STATES PETROLEUM ASSOCIATION, KP PUBLIC AFFAIRS, PERRY COMMUNICATIONS, CAPITOL ADVOCACY, LUCAS PUBLIC AFFAIRS, THE WEIDEMAN GROUP and CALIFORNIA PROFESSIONAL FIREFIGHTERS