Healthforce
Center atucsr

Research Report

Recovery with Limited
Progress: Impact of
California Proposition 209
on Racial/Ethnic Diversity
of California Medical
School Matriculants, 1990
to 2019

by Alana Pfeffinger, MPH?, Alicia Fernandez, MD?, Manuel
Tapia, MD, MPH®, Francine Rios-Fetchko, BA? and Janet
Coffman, MPP, PhD®

aUCSF Latinx Center of Excellence

bHealthforce Center at UCSF

December 2020

 

Abstract / Overview

Passage of California Proposition 209 in 1996 prohibited the
consideration of race, sex, color, ethnicity, or national origin in
public education, employment and contracting. This brief extends
previous studies of the impact of Proposition 209 on the
racial/ethnic diversity of California medical students by providing
a thirty-year longitudinal assessment (1990 - 2019) of its effects.
Our analyses reveal that while there has some been some
recovery of losses in Latinx and Black/African American
matriculants that occurred immediately after Proposition 209 was
enacted, progress has been limited. We conclude with several
recommendations from the California Future Health Workforce
Commission for key investments to increase racial/ethnic
diversity in California medical schools.

 

The mission of Healthforce Center is to equip health care organizations with the workforce
knowledge and leadership skills to effect positive change. To learn more go to
healthforce.ucsf.edu. The mission of the Latinx Center of Excellence is to improve the
health and healthcare of California through the development of diverse physician leaders
and through research, education and advocacy. To learn more go to latinx.ucsf.edu.

Healthforce Center at UCSF 490 Illinois Street, Floor 11, San Francisco, CA 94143
UCSF LCOE 1001 Potrero Avenue, Building 10, Room 1320B, San Francisco, CA 94110

© 2020 Healthforce Center at UCSF

Latinx Center
of Excellence

UCsp
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 2

Acknowledgements

Development of this brief was made possible through funding from the California Health Care Foundation. We
would like to thank Eric Antebi, Acting Vice President for External Engagement and Director of Communications
Staff at the California Health Care Foundation, and Justin Ewers and Mike Roth of Paschal Roth Public Affairs for
their strategic guidance and feedback on earlier brief drafts. We would also like to thank Amy Quan at Healthforce
Center at UCSF for final copyedit of this report. And finally, we would like to thank the Association of American
Medical Colleges for compiling the data used in this study.

Contents
Acknowledgements 2 Trends in Matriculation to California Medical
Key Findings 3 Schools . . es . '
Trends in Matriculation to California Medical
Background 4 Schools by Race/Ethnicity 7
Programs in Medical Education (PRIME) 4 Trends in Matriculation to California Medical
Holistic Review 4 Schools as a Proportion of the Californian
Growth in First Year Medical Students 5 Population by Race/Ethnicity 11
Demographic Trends in California's Population 5 . .
Discussion 12
Methods 6
Results 7

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 3

Key Findings

The absolute number of Latinx medical student matriculants to California medical schools decreased from
113 (1990) to a low of 92 (1997) immediately following the enactment of Proposition 209 and then
increased over time to 200 (2019). UC medical schools accounted for the majority of growth in Latinx
matriculants.

The proportion of Latinx matriculants in California's medical schools increased from 11 percent (1990) to
14 percent (2019) with a peak of 17 percent in 2016. This overall increase was preceded by a low of 9
percent, following the enactment of Proposition 209.

Because the Latinx population of California grew tremendously during these 30 years, from 26 percent
(1990) to 39 percent (2019) of the population, the number of Latinx medical students has fallen further
behind the numbers needed to provide ethnically concordant care.

Matriculation patterns for Black/African American students are similar to those of Latinx students: a
growth in absolute number of medical students, from 63 (1990) to 121 (2019), yet only a modest change
in the proportion of medical school matriculants overall, moving from 6 percent (1990) to 8 percent
(2019), with a post-Proposition 209 high of 9 percent from 2014 through 2016.

Black/African American matriculation increased primarily in the UC medical schools. In California's private
medical schools, the proportion of Black/African American students matriculating fell over the 30-year
period, from 6 percent (1990) to 5 percent (2019).

Overall, our analyses indicate that over the last 30 years, there has been insufficient progress in
achieving the required level of diversity within California's medical schools to meet the needs of
California's diverse population (Figure 1).

Figure 1. Growth in California Population and Medical School Matriculation Numbers, 1990 - 2019

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© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 4

Background

In 1995, the Regents of the University of California (UC) approved SP-1 and SP-2, which prohibited the use of
affirmative action, the practice of considering race, religion, sex, color or national origin in admissions,
employment and contracting at UC campuses.' In 1996, Californians passed Proposition 209, an initiative that

prohibited considering individuals' "race, sex, color, ethnicity or national origin' in admissions to all public colleges
and universities, public employment and public contracting.?

Studies that examined the early impact of Proposition 209 (and the SP-1 and SP-2 policies enacted the prior
year) found that they resulted in lower application, acceptance and matriculation rates of Underrepresented in
Medicine (URM) students - who encompass Black/African American, Latinx and Native Americans students - into
California medical schools.?

This brief extends the earlier analyses by providing a longitudinal assessment of the impact of Proposition 209 on
medical student race/ethnicity diversity in California's MD-degree granting medical schools from academic year
1990 - 1991 through academic year 2019 - 2020 (hereafter referred to as 1990 to 2019).

We situate these analyses within four broader contexts:
e Establishment of Programs in Medical Education (PRIME)
e Implementation of holistic review in medical school admissions
e Growth in the number of first-year seats in both public and private medical schools in California
e The changing demographics within the state's population

Programs in Medical Education (PRIME)

The six PRIME programs are innovative medical school programs focus on increasing the number of physicians
committed to caring for the underserved populations of California. The first program was established in 2004 at
UC Irvine and then expanded to three additional campuses in 2007 (UC San Francisco, UC San Diego and UC
Davis).4 The UCLA (in partnership with Charles Drew University) and UC Merced (in partnership with UCSF and
UC Davis) PRIME programs accepted their first cohorts in 2008 and 2011, respectively.* The programs provide
dedicated education and additional training to students to prepare them to meet the needs of medically
underserved populations. The programs have expanded the number of first-year seats at the five UC medical
schools that existed prior to the enactment of Proposition 209 (UC Davis, UCI, UCLA, UCSD, and UCSF). Each of
the six programs (including UC Merced San Joaquin Valley PRIME) has supplemental admissions criteria and
targeted student recruitment. The six programs enrolled a total of 354 medical students in 2018.5 The majority (64
percent) of PRIME students are from racial/ethnic groups that are underrepresented in medicine.®

Holistic Review

Holistic review is a framework for incorporating a wide range of factors into admissions decisions. Colleges and
universities that undertake holistic review take into consideration scores on standardized tests and undergraduate
grade point average (GPA) as well as personal attributes and life experiences that align with the school's
institutional mission and desire to enroll a diverse group of students. Although holistic review does not directly
target students from underrepresented racial/ethnic groups, underrepresented applicants may nonetheless benefit
from additional consideration of their challenges and prior opportunities. In 2010, the Association of American
Medical Colleges issued its "Road Map to Diversity," which encouraged medical schools to adopt holistic review
and provided tools that admissions committees could use to implement it.*® Studies of medical schools that have
implemented holistic review have found that its implementation is associated with an increase in admission of

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 5

students from underrepresented racial/ethnic groups.?"' In 2002, UC Berkeley became the first UC campus to
implement holistic review in the undergraduate admissions process. Holistic review has since been adopted by
five additional UC campuses (UCLA in 2007, UCSD and UCI in 2011, and UC Davis and UC Santa Cruz in 2012).
According to the work of Zachary Bleemer, implementation of holistic review on these undergraduate campuses
increased enrollment of students from underrepresented groups by approximately six percent at each
participating campus. 12

Growth in First Year Medical Students

Six new medical schools opened in California over the last 30 years, all but one in the last decade (Appendix A).
Of these six medical schools, three are MD-degree granting programs and are included in these analyses. [See
note for details on the three schools not included.'] The University of California opened a sixth medical school on
the UC Riverside campus that enrolled its first class in 2013. California Northstate University College of Medicine,
a private, for-profit school located in Sacramento County, began admitting students in 2015. California University
of Science and Medicine, a private, not-for-profit university in San Bernardino County, enrolled its first students in
2018. The opening of these new medical schools, coupled with the modest growth of enrollment at UC campuses
associated with the PRIME programs, has created opportunities for additional enrollment in California medical
schools.

Demographic Trends in California's Population

There were substantial changes in the population demographics of California from 1990 to 2019. In 1990, Whites
constituted 57 percent of the state's population and Latinx 26 percent. In 2014, the Latinx population surpassed
Whites to become the largest ethnic group in California.*? In 2018, the racial/ethnic breakdown of the California
population was as follows: 39 percent Latinx, 37 percent White, 15 percent Asian, 6 percent Black/African
American, 3 percent multiracial and <1 percent American Indian or Pacific Islander'® (Figure 2). There has also
been substantial growth in the Asian population during this period, though not to the same extent as the Latinx
population.

' One new allopathic (MD-granting) medical school, the Kaiser Permanente Bernard J. Tyson School of Medicine, is not included because it
did not begin enrolling students until the fall of 2020. Two osteopathic medical schools, Touro University California and California Health
Sciences University, which enrolled their first classes in 1997 and 2020, respectively, are also not included in this analysis.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 6

Figure 2. California's Population by Race/Ethnicity, 1970 - 2018

  

100 , : 7
(=)
: : 15
= 80 | 12
x 26 @ Multiracial
5 @ American Indian and Other
@ 60 | 39 @  Black/ African American
3 @ Asian and Pacific Islander
o. 40 | aa = Latinx
5 .
© ey ® White
& 20 |
5 Ey
0 + : :
1970 1980 1990 2000 2018
Year

Source: California Department of Finance 1970 - 2000; American Community Survey 2018. Accessed Johnson,
H., McGhee, E., and Mejia, M.C. (2020, April). California's Population. Public Policy Institute of California.
https://Awww. ppic.org/publication/californias-population/ 1

Methods

We obtained data from the Association of American Medical Colleges (AAMC) on all matriculants to California
MD-granting medical schools by race/ethnicity and medical school ownership (private or public) for the academic
years of 1990 - 1991 through 2019 - 2020. We assessed yearly trends in total counts (absolute numbers) and in
proportions of matriculants by race/ethnicity to California medical schools. Additionally, we looked at the ratio of
matriculants per 100,000 population by race/ethnicity for the years of 1990, 2000, 2010 and 2019 using
population data from the US Census and American Community Survey.

Individuals were included in the total count for a racial/ethnic group if they indicated the group either "alone" or "in-
combination" on the Electronic Residency Application Service (ERAS) AAMC medical school application form. ' In-
combination refers to those individuals that selected multiple race/ethnicity groups, and therefore, would be
counted more than once for each racial/ethnic group. In these analyses, we focused on the following racial/ethnic
groups: Latinx, Black/African American, White and Asian. ':'" To assess trends in matriculation, we used
unduplicated numbers of total matriculants by academic year.

i Prior to 2002, the AAMC only allowed individuals to select one race/ethnicity category. From 2002 to 2012, the AAMC changed their
methodology for collecting race/ethnicity data by asking two questions - one question allowed applicants to select the race or races with which
they identified and the second question about Hispanic, Latino or Spanish origin. In 2013, the AAMC started using a single question that
displays all the race and Hispanic, Latino or Spanish origin categories that an individual could select and allows individuals to select more than
one race/ethnicity.

ii The corresponding graphs for White and Asian medical school matriculants are available in Appendix C.

Due to small numbers, Pacific Islander and American Indian/Alaska Native analyses have been excluded from the main findings presented in
this brief. Data on trends for American Indian/Alaska Native medical students are contained in Appendix D.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 7

Results

Trends in Matriculation to California Medical Schools

Over the course of the 30-year period from 1990 to 2019, there was a total increase of 431 (+43 percent) first-
year medical students in California (Figure 3). The number of first-year medical students in the six public medical
schools increased by 155, while the number in the five private medical schools increased by 276, accounting for
64 percent of the total gain in student admission seats during this period. Nationwide, the number of first-year
medical students increased by 37 percent during this period."4

Figure 3. Total Number Matriculants to Public and Private California Medical Schools from 1990 - 2019

1,600
1,400 PRIME ack inaugural
Prop 209
4 1,200 sp-1°P Programs
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Academic Year
=@-Private -@-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Trends in Matriculation to California Medical Schools by Race/Ethnicity

Latinx Matriculants

From 1990 to 2019, the number of Latinx matriculants to California medical schools increased from 113 to 200
students, an increase of 87 students (77 percent) (Figure 4). The number of Latinx matriculants to all California
medical schools decreased to a low of 92 (1997), immediately following the enactment of Proposition 209 and
then increased over time to 200 (2019). The number of Latinx matriculants at public medical schools peaked at 98
in 1992, and was followed by a precipitous drop after the enactment of SP-1 and Proposition 209, reaching a low
of 55 students in 2001. Since then, the number of Latinx matriculants at both public schools and private schools
has risen, with public schools enrolling an all-time high of 152 Latinx matriculants in 2016 and private schools
plateauing in recent years at an all-time high of 67 Latinx matriculants in 2018 and 2019.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 8

Figure 4. Number of Latinx Matriculants to Public and Private California Medical Schools from 1990 - 2019

250
UCR Inaugural

o 200 SP-1 PRIME Class
€ Prop 209 Programs
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Academic Year
=@-Private -@-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

While these increases are noteworthy, they need to be contextualized within the increase in total number of first-
year students in California's medical schools during this time. Despite the increase in number of Latinx students,
the proportion of Latinx matriculants is only marginally higher than that of the early 1990s. The proportion of
Latinx matriculants increased from 11 percent in 1990 to 14 percent in 2019, with a peak of 17 percent in 2016.
This overall increase was preceded by decreases following the enactment of Proposition 209, reaching a low of 9
percent in 2001. Overall, these data indicate limited progress toward increasing the proportion of Latinx medical
students in the state.

The proportion of Latinx matriculants at public medical schools increased from 12 percent in 1990 to a high of 16
percent in 1992 and subsequently declined until the early 2000s (Figure 5). Since then, the Latinx proportion has
increased, rising to a high of 20 percent in 2016 and 2017 before falling to 17 percent in 2019, a proportion only
marginally better than that of the pre-Proposition 209 era.

In contrast, the Latinx proportion of matriculants at private medical schools has not rebounded. The proportion of
Latinx matriculants at private schools increased from 10 percent to 12 percent between 1990 and 1995, fell to 7
percent in 1999, peaked at 14 percent in 2008 and then declined and leveled off at 11 percent in 2019.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 9

Figure 5. Proportion of Latinx Matriculants to Public and Private California Medical Schools from 1990 -
2019

25% UCR | |
naugura
SP-1 PRIME 8

Class
20% \ Prop 209 Programs |
15% | | \
. ofct)
10%

5%

% of Matriculants

0%

oO N t+ oO Co oO N t+ oO 0 oO N t+ oO 00
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Academic Year
=-@-Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Black/African American Matriculants

From 1990 to 2019, the number of Black/African American matriculants at California medical schools increased

from 63 to 121 students (92 percent) (Figure 6). Public medical schools accounted for most of this increase: the

number of Black/African American matriculants at public medical schools increased from 41 to 89 students (117
percent). The number of Black/African American matriculants at private medical schools increased from 22 to 32
students (45 percent).

Figure 6. Number of Black/African American Matriculants to Public and Private California Medical Schools
from 1990 - 2019

 

140
120 UCR Inaugural
Y Class
100 SP-1 PRIME
$s Prop 209 Programs
2 80
8
s 60
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a a a a a N N N N N N N N N N
Academic Year
=@- Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 10

Despite the relatively large increase in the number of Black/African American matriculants, there was only a small
increase in the proportion of Black/African American matriculants to California medical schools, from 6 percent in
1990 to 8 percent in 2019 (Figure 7), with a post-Proposition 209 high of 9 percent from 2014 through 2016. This
small change was preceded by a low of 5 percent (1997) following the enactment of Proposition 209, a proportion
that remained relatively constant through 2006. Public medical schools accounted for much of the increase in the
proportion of Black/African American matriculants. The proportion of Black/African American matriculants in
California's public medical schools peaked at 10 percent in 1993 and, except for a low of 4 percent in 2011,
fluctuated between 5 percent and 9 percent until 2013, after which there was a general upward trend. By 2019,
Black/African American students constituted 11 percent of matriculants at public medical schools - only
marginally better than the percentage in the pre-Proposition 209 era. In contrast, the proportion of Black/African
American matriculants at California's private schools dropped from 6 percent to 5 percent over this 30-year
period.

Figure 7. Proportion of Black/African American Matriculants to Public and Private California Medical
Schools from 1990 - 2019

12% SP-1 UCR Inaugural
Prop 209

PRIME Class
10% Programs J L
: \
6% \
A% ee

2%

% of Matriculants

0%

oO N t+ wo co oO N t+ wo [oe] oO N t+ wo 00
a oO) oO) oO) oa oO oO Oo oO oO a a a a a
An Dn DH HD HAH CG SO So 0 0 Oo 86 oO
a ol a a a N N N N N N N N N N
Academic Year
=-@-Private -@-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Asian Matriculants

The number of Asian matriculants increased from 291 matriculants in 1990 to 573 in 2019 (96 percent). The
proportion of Asian matriculants increased from 29 percent in 1990 to 40 percent in 2019 (Appendix C). With
respect to public medical school matriculants, the proportion of Asian matriculants reached a low point of 27
percent in 1992 and then rose to a high of 44 percent in 2005. In 2013, the proportion of Asian medical students
matriculating to California private medical schools surpassed that of public schools, a trend that has continued
through 2019.

White Matriculants

Among Whites, the number of matriculants to a California medical school increased by 3 percent, from 500 in
1990 to 514 in 2019. However, the proportion of matriculants decreased from 50 percent in 1990 to 36 percent in
2019 (Appendix C). At California public medical schools, following SP-1 there was an initial increase in White
matriculants from 46 percent in 1995 to 54 percent in 2006. Since 2006, there has been a general downward
trend in both the number and proportion of White matriculants to California public medical schools. Since 2013,

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 11

Whites have ceased to constitute the largest racial/ethnic group among matriculants to California's private
medical schools.

Trends in Matriculation to California Medical Schools as a Proportion of the Californian Population by
Race/Ethnicity

Figure 8. Matriculants to California Medical Schools per 100,000 Californians by Race/Ethnicity

 

 

12
S 10
2
S 8
o
ao 6
a
w
5 4
a 2
0
1990 2000 2010 2019
Year
=@€-=(atinx =-®-Black Asian =@< White

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation and US
Census 1990 and 2000 data and American Community Survey, 2010 and 2019.

Latinx Matriculants

While the number of Latinx matriculants to California medical schools has increased, the growth has not been
proportional to the growth of the Latinx population in California. From 1990 to 2019, the Latinx population grew by
106 percent from 7,557,550 to 15,574,882 (Figure 8). In 2014, the Latinx population became the largest
racial/ethnic group in California, surpassing Whites.

In 1990, there were 1.49 Latinx matriculants to California medical schools per 100,000 Latinx Californians. In
2000, the ratio decreased to a low of 0.88 Latinx matriculants/100,000. The ratio was higher by 2019 though still
below that of 1990 at 1.28 Latinx matriculants/100,000, a decrease of 14 percent. In short, the rapid increase in
Latinx population numbers did not lead to a corresponding increase in the number of Latinx medical students,
leaving the current ratio of Latinx matriculants to Latinx residents in California below that of 1990.

Black/African American Matriculants

From 1990 to 2019, the population of Black/African American Californians increased by 3 percent from 2,110,700
to 2,171,989 (Figure 8). Relative to the entire population of California, the proportion of Black/African American
Californians decreased from 7 percent in 1990 to 5 percent in 2019.

The proportion of Black/African American matriculants (6 percent in 1990 and 8 percent in 2019) has kept pace
with trends in the Black/African American population of California and, at times, outpaced it. In 1990, there were
2.98 Black/African American matriculants per 100,000 Black/African American Californians (Figure 8). The ratio of
Black/African American matriculants/100,000 fell following the enactment of Proposition 209, reaching a low of 2.3
in 2005. In 2019, there were 5.57 Black/African American matriculants/100,000, representing an 87 percent

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 12

increase since 1990. In 2013, the number of Black/African American matriculants/100,000 surpassed the number
of White matriculants/100,000.

Asian Matriculants

Similar to the rapid growth in the Latinx population, the Asian population increased by 111 percent from 2,747,780
in 1990 to 5,786,711 in 2019. While the absolute number of Asian matriculants also increased, the magnitude of
that increase has not matched the rise in population numbers. In 1990, there were 10.6 Asian
matriculants/100,000 Asian Californians; in 2019, that number was 9.9 (Figure 8). Overall, there was about a 7
percent decrease in the number of Asian matriculants/100,000 during this period. Despite this decrease, the
number of Asian matriculants/100,000 remains substantially higher than the corresponding ratios for Latinx,
Black/African American and White Californians.

White Matriculants

The White population in California decreased by 16 percent from 17,093,961 in 1990 to 14,356,081 in 2019. In
1990, there were 2.93 White matriculants to California medical schools per 100,000 White Californians (Figure 8).
Following the enactment of Proposition 209, the ratio increased to 3.21 in 2000. The ratio reached a low of 2.92 in
2014 and then increased to 3.58 in 2019. Overall, the change in the ratio of White matriculants/100,000 White
Californians from 1990 to 2019 was an increase of 22 percent.

Discussion

In these analyses examining race-ethnic diversity in California's MD-granting medical schools over the last 30
years, we found that California has recovered the level of diversity that existed prior to the implementation of
Proposition 209, but has made little further progress. The increase in diversity has come largely from the public
(i.e., UC) medical schools, despite the increase in the number of medical students matriculating at the state's
private schools. Furthermore, we found that while the proportion of medical students from Latinx and
Black/African American backgrounds is now slightly larger than that of the early 1990s, changes in state
demographics, and particularly the growth of the Latinx population, has left California further behind in creating
physicians who represent the state's diverse population.

Our findings regarding the years immediately after the enactment of Proposition 209 are consistent with those of
previous studies that looked at early impacts of the UC Regents' decision and Proposition 209. Grumbach, Mertz
and Coffman found that in comparison to peak years in the early 1990s, by 1998 there had been a 32 percent
reduction in URM matriculants.* An issue brief released by AAMC in 2008" and a journal article that analyzed
AANC data through 2011 reached similar conclusions regarding the negative impact of Proposition 209 on the
matriculation of URMs at California medical schools.*®

Our analyses of more recent data indicate that the numbers of Black/African American and Latinx matriculants at
public medical schools have increased substantially since then and that the percentages of matriculants who are
Black/African American or Latinx have also increased somewhat. These findings suggest that public medical
schools' concerted efforts to address issues of diversity through PRIME, holistic review, and other initiatives have
helped to curb the negative impact of Proposition 209 on physician diversity.

In contrast to the growth in Black/African American and Latinx students at public medical schools, the rates at
which Black/African American and Latinx students are matriculating at private medical schools have remained
relatively stagnant. This finding is particularly troubling because the majority of growth in medical school
enrollment over the past 30 years has occurred among private medical schools. Increasing the numbers of

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 13

Black/African American and Latinx physicians in California will require private medical schools to join public
medical schools in implementing effective strategies for increasing diversity.

Although the numbers of Black/African American and Latinx medical students have rebounded from the losses
that occurred in the immediate aftermath of Proposition 209, these gains need to be considered within the context
of California's rapidly changing population. While Blacks/African Americans and Latinx are both underrepresented
in the physician workforce relative to the population," underrepresentation is even more pronounced for Latinx
Californians, in part due to the tremendous population growth in the past 30 years. Multiple studies have found
that Latinx and Black/African American physicians are more likely to care for underserved patients,'*-29 are more
likely to elicit trust,2' and achieve higher patient satisfaction2?24 and often better health outcomes in their patients
of color.2°.26 In addition, research has shown that Spanish-speaking patients are more likely to have better health
outcomes when Spanish-speaking physicians help manage complex diseases like diabetes.?'

Overall, our analyses indicate that over the last 30 years, there has been little progress in achieving the required
level of diversity within California's medical schools to meet the needs of California's population. While the
absolute numbers of Latinx and Black/African American students are greater than those of 30 years ago, there
has been only modest increases in the proportions of these students. The number of Latinx medical students has
fallen further behind the growth of the state's Latinx population, a dispiriting conclusion for public medical schools
that have focused on increasing diversity.

Since California voters did not approve Proposition 16, which would have repealed Proposition 209, increasing
racial/ethnic diversity among California's medical students will require substantial investment in programs aimed
at increasing the number of Black/African American and Latinx Californians who can compete successfully for
admission to medical school. In 2019, the California Future Health Workforce Commission, comprised of a
diverse cadre of key stakeholders from healthcare, higher education and philanthropy, issued key
recommendations to address current and future health workforce needs in the areas of primary care, behavioral
health and care of an aging population. We highlight several of the report's recommendations as promising
strategies to increase the number of Black/African American and Latinx medical students.

To increase the number of competitive Black/African American and Latinx applicants, the Commission
recommended that the state budget should include funds to support Health Careers Opportunity Program (HCOP)
programs on 20 undergraduate campuses. These programs would be modeled after the federal HCOP program,
which provides grants to undergraduate campuses to support comprehensive academic enrichment, advising,
career development, mentorship and peer support to undergraduates from disadvantaged backgrounds who wish
to become health professionals. The federal HCOP program has demonstrated success in recruiting and
supporting underrepresented students of color.28 Evaluations from California-based HCOP programs have shown
success supporting URM enrollment into health profession graduate programs.® The Commission recommended
investing $159 million over 10 years to fund 20 HCOP pilot programs at private, UC, California State University
(CSU) and community college campuses. This investment would yield an estimated 25,500 new health care
workers (including physicians), a majority of whom would be from underrepresented racial/ethnic groups.®

The Commission also recommended that the state should provide funds to expand postbaccalaureate programs
for medical school reapplicants from disadvantaged backgrounds. These programs aim to strengthen the ability of
applicants from disadvantaged backgrounds to secure medical school admission by helping them improve their
test taking skills, scientific knowledge, and written and verbal communications skills. A study of the UC
Postbaccalaureate Consortium, which encompasses postbaccalaureate programs for reapplicants on five UC
campuses, found that reapplicants from disadvantaged backgrounds who participated in these programs were
three to six times more likely to be admitted to medical school than similar applicants who did not participate.29
The Commission recommended that the state invest $26 million over 10 years to expand postbaccalaureate

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 14

reapplicant programs. Investing this amount would yield 1,000 additional postbaccalaureate positions and provide
scholarships to cover 100 percent of tuition charged by these programs. If participants were admitted to and
graduate from medical school at the same rate as alumni of the UC Postbaccalaureate Consortium, 82 percent
would be admitted to medical school.®

The Commission also recommended increasing enrollment in the UC PRIME programs and providing stable state
funding for them. These programs are successful in enrolling students from diverse backgrounds. While data
gathering is ongoing, PRIME programs appear successful in producing racially/ethnically diverse physicians who
care for underserved patients. The Commission recommended investing $93.5 million over 10 years to fully fund
all 354 existing seats in PRIME programs and is expected to increase the number of first-year students by 10 per
year (100 additional first-year students over 10 years).5

State resources should be complemented by use of holistic review in admissions for all California medical
schools, both public and private. The AAMC provides admissions committees with multiple tools for implementing
holistic review. California medical schools can also learn from one another's experience with the AAMC's tools
and tools that they have developed to inform holistic review on their campuses, such as the UC Davis School of
Medicine's tool that adjusts for applicants' socio-economic disadvantages.*°

Increasing medical student and hence physician diversity will require concerted action at the UC undergraduate
campuses (a major source of students matriculating at California's medical schools) as well as within both public
and private medical schools. A substantial investment by the California legislature will also be required. These
initiatives should be a key component of California's efforts to achieve greater health equity for all Californians.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 15

References

1. University of California Board of Regents. (2001). Regents Policy 4401: Policy on future admissions, employment, and
contracting (Resolution rescinding SP-1 and SP-2).
https://regents.universityofcalifornia.edu/governance/policies/4401 .html

2. California Legislative Analyst's Office. (1996). Proposition 209 prohibition against discrimination or preferential treatment by
State and other public entities. https://lao.ca.gov/ballot/1996/prop209 11 _1996.html

 

3. Grumbach, K., Mertz, E., & Coffman, J. (1999). Underrepresented minorities and medical education in California. Center
for California Health Workforce Studies: University of California, San Francisco.
https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/10.%201999-

03 Underrepresented Minorities and Medical Education in California Recent Trends in Declining Admissions.pdf

 

4. University of California Office of the President. (n.d.) Programs in Medical Education (PRIME). https:/Mwww.ucop.edu/uc-
health/initiatives/prime.html

5. California Future Health Workforce Commission. (2019). Meeting the demand for health: Final report of the California
Future Health Workforce Commission. https://futurehealthworkforce.org/wp-
content/uploads/2019/03/MeetingDemandForHealthFinalReportCFHWC.pdf

 

6. Addams, A. N., Bletzinger, R. B., Sondheimer, H. M., White, S. E., & Johnson, L. M. (2010). Roadmap to diversity:
Integrating holistic review practices into medical school admission processes. Association of American Medical Colleges.
https://store.aamc.org/downloadable/download/sample/sample_id/195/

7. Association of American Medical Colleges. (2013). Roadmap to excellence: Key concepts for evaluating the impact of
medical school holistic admissions. https://store.aamc.org/downloadable/download/sample/sample_id/198/

8. Coleman, A. L., Lipper, K. E., Taylor, T. E., & Palmer, S. R. (2014). Roadmap to diversity and educational excellence: Key
legal and educational policy foundations for medical schools. Association of American Medical Colleges.
https://store.aamc.org/downloadable/download/sample/sample_id/192/

9. Grabowski, C. J. (2018). Impact of holistic review on student interview pool diversity. Advances in Health Sciences
Education: Theory and Practice, 23(3), 487-498. https://doi.org/10.1007/s10459-017-9807-9

10. Witzburg, R. A., & Sondheimer, H. M. (2013). Holistic review--Shaping the medical profession one applicant at a time. The
New England Journal of Medicine, 368(17), 1565-1567. https://doi.org/10.1056/NEJMp130041 1

11.Grbic, D., Morrison, E., Sondheimer, H. M., Conrad, S. S., & Milem, J. F. (2019). The association between a holistic review
in admissions workshop and the diversity of accepted applicants and students matriculating to medical school. Academic
Medicine: Journal of the Association of American Medical Colleges, 94(3), 396-403.
https://doi.org/10.1097/ACM.0000000000002446

12.Bleemer, Z. (2020). The impact of Proposition 209 and access-oriented UC admissions policies on underrepresented UC
applications, enrollment, and long-run student outcomes. University of California Office of the President.
https:/Awww.ucop.edu/institutional-research-academic-planning/_files/uc-affirmative-action.pdf

13. Johnson, H., McGhee, E., & Cuellar Mejia, M. (2020). California's population. Public Policy Institute of California.
https:/Avww.ppic.org/publication/californias-population/

14. Association of American Medical Colleges. (2020). Mairiculants to U.S. Medical Schools by Sex, Academic Years 1980-
1981 through 2020-2021. [Data Set]. Association of American Medical Colleges.
https:/Avww.aamc.org/media/37706/download

15. Association of American Medical Colleges. (2008). After affirmative action: Diversity at California medical schools.
https:/Awww.aamc.org/data-reports/analysis-brief/report/after-affirmative-action-diversity-california-medical-schools

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 16

16. Garces, L. M., & Mickey-Pabello, D. (2015). Racial diversity in the medical profession: The impact of affirmative action
bans on underrepresented student of color matriculation in medical schools. The Journal of Higher Education, 86(2), 264-
294. https://doi.org/10.1353/jhe.2015.0009

17.Coffman, J., Fix, M., & Ko, M. (2018). California physician supply and distribution: Headed for a drought? California Health
Care Foundation. https:/Avww.chcf.org/wp-content/uploads/2018/06/CAPhysicianSupply2018. pdf

18. Marrast, L. M., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians' role in the care of
underserved patients: Diversifying the physician workforce may be key in addressing health disparities. JAMA Internal
Medicine, 174(2), 289-291. https://doi.org/10.1001

19.Komaromy, M., Grumbach, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A. B. (1996). The role of Black
and Hispanic physicians in providing health care for underserved populations. The New England Journal of Medicine,
334(20), 1305-1310. https://doi.org/10.1056

20.Moy, E., & Bartman, B. A. (1995). Physician race and care of minority and medically indigent patients. JAMA, 273(19),
1515-1520.

21.Doescher, M. P., Saver, B. G., Franks, P., & Fiscella, K. (2000). Racial and ethnic disparities in perceptions of physician
style and trust. Archives of Family Medicine, 9(10), 1156-1163. https://doi.org/10.1001/archfami.9.10.1156

22.Cooper, L. A., Roter, D. L., Johnson, R. L., Ford, D. E., Steinwachs, D. M., & Powe, N. R. (2003). Patient-centered
communication, ratings of care, and concordance of patient and physician race. Annals of Internal Medicine, 139(11), 907-
915. https://doi.org/10.7326/0003-48 19-139-1 1-200312020-00009

23. Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Vu, H. T., Powe, N. R., Nelson, C., & Ford, D. E. (1999). Race, gender, and
partnership in the patient-physician relationship. JAMA, 282(6), 583-589. https://doi.org/10.1001/jama.282.6.583

24.Laveist, T. A., & Nuru-Jeter, A. (2002). Is doctor-patient race concordance associated with greater satisfaction with care?
Journal of Health and Social Behavior, 43(3), 296-306.

25. Traylor, A. H., Schmittdiel, J. A., Uratsu, C. S., Mangione, C. M., & Subramanian, U. (2010). Adherence to cardiovascular
disease medications: Does patient-provider race/ethnicity and language concordance matter? Journal of General Internal
Medicine, 25(11), 1172-1177. https://doi.org/10.1007/s11606-010-1424-8

26.Alsan, M., Garrick, O., & Graziani, G. C. (2018). Does diversity matter for healthy? The experimental evidence from
Oakland. National Bureau of Economic Research. https://Awww.nber.org/papers/w24787

27.Parker, M. M., Fernandez, A., Moffet, H. H., Grant, R. W., Torreblanca, A., & Karter, A. J. (2017). Association of patient-
physician language concordance and glycemic control for limited-English proficiency Latinos with type 2 diabetes. JAMA
Internal Medicine, 177(3), 380-387. https://doi.org/10.1001/jamainternmed.2016.8648

28.Health Resources and Services Agency. (n.d.) Health careers pipeline and diversity programs academic year 2018 - 2019.
https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/program-highlights/2019-2020/health-careers-
pipeline-diversity-programs-2019.pdf

29.Grumbach, K., & Chen, E. (2006). Effectiveness of University of California postbaccalaureate premedical programs in
increasing medical school matriculation for minority and disadvantaged students. JAMA, 296(9), 1079-1085.
https://doi.org/10.1001 /jama.296.9.1079

30.Fenton, J. J., Fiscella, K., Jerant, A. F., Sousa, F., Henderson, M., Fancher, T., & Franks, P. (2016). Reducing medical
school admissions disparities in an era of legal restrictions: Adjusting for applicant socioeconomic disadvantage. Journal of
Health Care for the Poor and Underserved, 27(1), 22-34. https://doi.org/10.1353/hpu.2016.0013

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 17

Appendix A. Timeline of Key Contextual Milestone Events

 

 

 

 

 

Event Description Date
UC Regents' decision that prohibited consideration of

SP-1 race, religion, sex, color, ethnicity or national origin July 1995
as criteria for admission to any program of study.

Sp-2 Similar to SP-1 above but extended the resolution to November 1996
UC's employment and contracting policies.
California voters approved prohibiting state

Proposition 209 | institutions from considering race and other attributes November 1996
listed above for employment at state institutions.
August 2004 (UCI)
Launch of PRIME An innovative program focused on developing more August 2007 (UC Davis, UCSD,

future physicians committed serving to the UCSF)

Programs

underserved populations of California.

August 2008 (UCLA, UCR, Charles
Drew University)

 

AAMC Road Map

The beginning of intentional integration of holistic

 

 

 

 

 

 

to Diversity review processes to medical school admissions. Spring 2010
Inaugural Class | The first class at University of California, Riverside August 2013
at UCR began instruction.
Inaugural Class_ | The first class at California Northstate University August 2015
at CNUCOM College of Medicine began instruction.
Inaugural Class_ | The first class at California University of Science and Summer 2018
at CUSM Medicine began instruction.

 

© 2020 Healthforce Center at UCSF

 
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools

Appendix B. California's Allopathic and Osteopathic Medical Schools

 

California Allopathic (MD-degree granting) Medical Schools

 

Public

 

. University of California, Davis

 

. University of California, Irvine

 

. University of California, Los Angelest

 

. University of California, Riverside*

 

. University of California, San Diego

 

oO} On) |) w)N] =

. University of California, San Francisco

 

Private

 

. California Northstate University College of Medicine*

 

. California University of Science and Medicine*

 

. Kaiser Permanente Bernard J. Tyson School of Medicine'#

 

. Loma Linda University

 

ol] ] G] dO} =

. Stanford University

 

6. University of Southern California

 

California Osteopathic (DO-degree granting) Medical Schools*

 

1. California Health Sciences University*

 

2. Touro University California*

 

3. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

 

+In addition to its medical school, UCLA has partnered with Charles R. Drew University since 1981 to
operate the Charles R. Drew/UCLA Medical Education Program, a four-year community-based medical
education program that prepares medical students who have a demonstrated commitment to care for
underserved populations.

#Medical school opened in the last 30 years (1990 - 2020).

"Excluded from analyses as they did not admit their first class until fall of 2020.

*Excluded because brief only analyzed data from MD-degree granting programs.

 

 

 

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 19

Appendix C.

Trends in matriculation to California medical schools by race/ethnicity

Figure 9. Number of Asian Matriculants to Public and Private California Medical Schools from 1990 - 2019

700
600 PRIME
o Programs UCR Inaugural
- 900 P cl
5 rop 209 ass
3 400 SP-1
p
sS 300
oO
te 200
100
0
Oo N + io oo Oo N tT wo [oe] oO N tT wo co
oO) oa Oo) oO) oO) oO Oo Oo So oO a a a a a
o) Lo) ) ) SE ) oo oo oe i eo)
a a a a a N N N N N N N N N N
Academic Year
=@-Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Figure 10. Proportion of Asian Matriculants to Public and Private California Medical Schools from 1990 -
2019

50% Prop 209 PRIME UCR Inaugural
45% SP-1 | ¥ Programs Class
40%
35%
30%
25% "NN
20%
15%
10%
5%
0%

% of Matriculants

on t+ © Oo ON tT oD DW ODN tt OD
a a a a a oO So oO oO oO a al a Sal a
An Dn DBD HA DBD SO So 6 6 G6 G66 6 6
a co a a a N N N N N N N N N N
Academic Year
=@- Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 20

Figure 11. Number of White Matriculants to Public and Private California Medical Schools from 1990 -
2019

700 PRIME
UCR Inaugural
Programs
600 Class
Sp. Prop 209
a 7
£ 500
8
3 400
a
S 300
oO
* 200
100
0
oO N t+ O 0 oO N t+ wo 0 oO N + wo 0
oO a a a oa oO °o oO oO oO od al ad a Se
a a a a a oO oO oO oO oO oO oO oO oO
a a a a a N N N N N N N N N N
Academic Year
=@-Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Figure 12. Proportion of White Matriculants to Public and Private California Medical Schools from 1990 -
2019

70% SP-1_ prop 209 PRIME
ograms UCR Inaugural
0,
60% Class
wn
© 50% AAT rs
5 ox Pe \
g 40% Sr ~De
5 "DS
S 30%
6
se 20%
10%
0%
oO N t+ wo co oO N t+ Ww oo oO N t+ wo 0c
a a a a a oO oO oO oO oO a od ad a a
a a a a a oO oO oO oO oO oO oO oO oO oO
a A a a a N N N N N N N N N N
Academic Year
=@-Private -@-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

© 2020 Healthforce Center at UCSF
Recovery without Progress: Impact of California Proposition 209 on Racial/Ethnic Diversity in Medical Schools 21

Appendix D.

Trends in matriculation to California medical schools by race/ethnicity

Figure 13. Number of American Indian/Alaska Native Matriculants to Public and Private California Medical
Schools from 1990 - 2019

25
20 UCR Inaugural
2 PRIME Class
& Programs
3 15 Prop 209
5
S 10 SP-1
e
3
te

uw

 

0
oO N tT Ww eo oO N Tt WO oo oO N + Ww eo
an an a a oO So Oo Oo oO oO a ad od Sal Sea
oa a a a oa Oo oO oO Oo Oo Oo oO oO oO Oo
a a a a co N N N N N N N N N N
Academic Year
=@=- Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

Figure 14, Proportion of American Indian/Alaska Native Matriculants to Public and Private California
Medical Schools from 1990 - 2019

3%

UCR Inaugural

   

3% PRIME Cl
2 Programs ass
Ss 2% Prop 209
S
oO
5 2%
54" SP-1
=
'o 1% aol ~o
x
1% ad
0%
oO N s+ io oo So N st wo 0 oO N + wo co
a a ao oa a o) oO oO oO oO a a a a a
OY oY oa oa a oO oO oO oO oO oO oO oO oO oO
a a A a a N N N N N N N N N N

Academic Year

=@-Private -@=-Public Total CA Schools

Source: Association of American Medical Colleges Applicant Matriculant Data File, authors' tabulation.

© 2020 Healthforce Center at UCSF