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Creating policy changes to enhance employment opportunities for immigrants and refugees : a multi-state study

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Creating policy changes to enhance employment opportunities for immigrants and refugees : a multi-state study
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Newman, Kayleigh
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Denver, Colo.
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University of Colorado Denver
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This client-based project was completed on behalf of the City and County of Denver’s Office of Immigrant and Refugee Affairs and supervised by PUAD 5361 Capstone course instructor Dr. Wendy Bolyard and second faculty reader Dr. Denise Scheberle. This project does not necessarily reflect the views of the School of Public Affairs or the faculty readers. Raw data were not included in this document, rather relevant materials were provided directly to the client. Permissions to include this project in the Auraria Library Digital Repository are found in the final Appendix. Questions about this capstone project should be directed to the student author.

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Running Head: CREATING POLICY CHANGES TO ENHANCE EMPLOYMENT
Creating Policy Changes to Enhance Employment Opportunities for Immigrants and Refugees: A Multi-State Study Kayleigh Newman
University of Colorado Denver School of Public Affairs
This client-based project is submitted in partial fulfillment of the requirements for the degree of Master of Public Administration in the School of Public Affairs at the University of Colorado Denver Denver, Colorado
Summer
2017


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Capstone Project Disclosures
This client-based project was completed on behalf of the City and County of Denvers Office of Immigrant and Refugee Affairs and supervised by PUAD 5361 Capstone course instructor Dr. Wendy Bolyard and second faculty reader Dr. Denise Scheberle. This project does not necessarily reflect the views of the School of Public Affairs or the faculty readers. Raw data were not included in this document, rather relevant materials were provided directly to the client. Permissions to include this project in the Auraria Library Digital Repository are found in the final Appendix. Questions about this capstone project should be directed to the student author.


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Table of Contents
Literature Review.............................................................................7
The Client.................................................................................7
Challenges Facing Immigrants and Refugees Re-entering the Workforce........................8
A Multiple Streams Lens...................................................................11
Methodology..................................................................................15
Measurement and Data Collection...........................................................15
Sampling Plan.............................................................................16
Validity and Reliability..................................................................16
Results......................................................................................17
Policy Stream.............................................................................18
Problem Stream............................................................................20
Political Stream..........................................................................22
Policy Entrepreneurs......................................................................23
Policy Window.............................................................................25
Challenges.................................................................................25
Facilitators...............................................................................26
Discussion and Recommendations...............................................................26
Recommendations............................................................................28
Limitations................................................................................30
Conclusion...................................................................................31
References...................................................................................32
Appendices...................................................................................35
Appendix A: Interview Guide...............................................................35
Appendix B: Coding Structure..............................................................37
Appendix C: Interviewees..................................................................40
Appendix D: Timeline and Key Players......................................................41
Appendix E: Summary of Results by State...................................................43
Appendix F: Advice from Each State........................................................46
Appendix G: Massachusetts Related Documents...............................................48
Appendix H: Michigan Bills................................................................51
Appendix I: Minnesota Bills...............................................................55
Appendix J: Missouri Bill.................................................................66
Appendix K: Washington Bill...............................................................77


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Executive Summary
Although immigrants and refugees resettling in the United States often have years of educational and work experience, the issues of unemployment and underemployment are predominant for both communities. To help foreign trained professionals reenter their previous fields of employment in Colorado, Denvers Office of Immigrant and Refugee Affairs has requested an analysis of immigrant and refugee employment related policies in five states. This capstone project investigates the policy creation and implementation process in Massachusetts, Michigan, Minnesota, Missouri, and Washington. Data were collected through qualitative interviews with key informants and framed using the Multiple Streams Theory. Although the findings indicate that the factors impacting each states efforts around policy development and implementation vary, a few key themes emerged: Demonstrating a specific need and framing foreign trained professionals as a solution to this need was critical to successfully passing legislation; champions come from a variety of sectors but play a significant role in initiating and passing the legislation; and, strategically developing partner buy-in is important, especially with groups that may have opposition to the policy. Using the findings of this study, the client will be better able to understand what policies may be the most appropriate for Colorado and best practices for creating and implementing said policies.


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In recent years, immigration has become an increasingly dominant topic in American politics, as citizens and public administrators alike debate if and how to reform immigration policies, while simultaneously attempting to integrate the vast number of immigrants already living in the United States into their communities. According to the American Community Survey in 2015, immigrants made up 13% of the U.S. population, totaling 43.3 million individuals (Zong & Batalova, 2017). This number will continue to grow as different groups of immigrants, such as refugees and asylum seekers, seek to rebuild their lives in the United States. In fact, the U.S. accepted 84,994 refugees for resettlement during FY 2016 alone (Zong & Batalova, 2017). Yet, despite the considerable size of the immigrant population in the United States, it is estimated that around 2 million immigrants and refugees are not working in high-skilled jobs which they are qualified for through both college education and experience (McHugh & Morawski, 2017). Nationally, nearly a quarter of all highly skilled immigrants experience brain waste, or being unemployed or underemployed. This brain waste accumulates to nearly $39 billion in lost wages annually, costing the U.S. nearly $10 billion in untapped tax revenue (Batalova, Fix, & Bachmeier, 2016).
For immigrants migrating to the United States, an Immigrant Assimilation Model has been discovered, characterized by occupational downgrading initially after arrival (Akresh, 2008). In fact, a 2006 study found that 50% of immigrants who entered the United States experienced this occupational downgrading (Akresh, 2006). However, occupational downgrading and unemployment or underemployment do not impact all immigrant groups equally. Refugees, who often have fewer years of education and less time or training in the United States, are particularly disadvantaged. Generally, refugees have lower occupational status and wages than other immigrant groups (Conor, 2010).


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Securing employment, especially appropriate level employment, has historically been one of the primary barriers facing immigrants and refugees. Although many immigrants struggle to find employment due to limited English proficiency, work experience, or education, even highly educated and qualified immigrants must overcome larger systematic barriers in order to obtain employment. These systematic barriers include licensing requirements, transferring international credentials into U.S. standards, unclear or restrictive policies, and discrimination (McHugh & Morawski, 2017). The potential solutions to many of these barriers lie at the state and local levels, as licensing responsibilities, the definitions of required competencies, and admittance into certain fields are typically defined at the state level (Creticos et al., 2006). Thus, as the immigrant population continues to grow, several states across the U.S., including Colorado, are searching for ways to reduce employment barriers and successfully integrate immigrants and refugees into their local economy.
The purpose of this project is to create recommendations for Colorado based on the policy and programmatic efforts surrounding immigrant and refugee employment currently occurring in the following states: Washington, Minnesota, Massachusetts, Pennsylvania, and Missouri. The data collected during this study are used to provide practical recommendations for those agencies and individuals working within Colorado to promote immigrant and refugee employment. These recommendations are based on the actual experiences of those working on similar efforts in other states as detailed in qualitative interviews.
First, this paper provides a review of the literature surrounding immigrant and refugee employment barriers and discusses the Multiple Streams Theory as a potential framework for considering immigrant and refugee related policy processes. Following the review of literature, the paper shifts to providing background on the methodology used. Finally, the results of the


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study are presented, followed by a discussion and recommendations to inform future policy efforts in the state of Colorado.
Literature Review
To provide appropriate context for this paper, first the client for which it is being written is described. Then, the major themes surrounding skilled immigrant and refugee employment barriers are outlined, namely language and social barriers, licensing barriers, and credential recognition. Finally, the five different aspects of Multiple Streams Theory, the theoretical framework which this study utilized, is described. These aspects include the policy stream, problem stream, politics stream, policy entrepreneurs, and policy windows.
The Client
This capstone project hopes to inform efforts surrounding improving immigrant and refugee employment in Colorado, and is being written based on the recommendations of the City and County of Denvers Office of Immigrant and Refugee Affairs. This office, under the broader department of Human Rights and Community Partnerships, focuses on promoting awareness and integration of immigrants and refugees into Denver communities. The Office of Immigrant and Refugee Affairs partners with nonprofits, community based organizations, residents and government agencies to develop and implement policies, practices and programs that influence the various paths of immigrant integration (Office, 2017). As part of this mission, the office is currently participating in a workgroup with local immigrant and refugee serving nonprofits and government agencies focused specifically on reducing barriers and supporting immigrant and refugee inclusion in the Colorado workforce.


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Challenges Facing Immigrants and Refugees Re-entering the Workforce
Language and social barriers. Research has found that the lack of English proficiency is the most significant risk factor for unemployment or underemployment among immigrant and refugee populations. In fact, immigrants who reported speaking English not well or not well at all were five times more likely to be in low-skilled jobs, regardless of other factors (Batalova et al., 2016). Even among college educated immigrants, 54% scored below proficient in English literacy (Batalova & Fix, 2015). However, refugees are particularly impacted by lack of English proficiency as they tend to have less English ability and formal educational experience (Conor, 2010).
Although English language classes are a critical service provided by immigrant and refugee serving agencies, the classes offered are typically English as a Second Language classes, which provide basic English training, but not training in career-specific or professional terminology (McHugh & Morawski, 2017). The provision of more extensive language services is often beyond the capacity of nonprofits or government agencies working with immigrant populations. For example, consider that the refugee population in the U.S. alone consists of individuals from 64 countries who speak 162 languages (Capps et al., 2015). Clearly, the funding and capacity needed to provide proficient training in each of these languages, or in each specific career field, would be far beyond what the current system in the United States could handle. Although the reauthorization of the federal Workforce Innovation and Opportunity Act of 2014 may have opened new possibilities of expanding language training to immigrant professionals through state and local providers, the possibilities of funding cuts under the current political administration may put such programs and initiatives for English education at risk of dissolution (Batalova et al., 2016).


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In addition to language barriers, there are certain cultural barriers that impact the ability of immigrants and refugees to re-enter the workforce after arrival in the United States. The two primary barriers in this context are employer bias and racial discrimination. Even when immigrants meet requirements for a high-skill position, they typically have to seek entry level positions because employers are biased towards candidates with U.S. work experience (McHugh, & Morawski, 2017). Additionally, in a 2015 study involving 4,000 high-skilled immigrants,
20% of interviewees reported facing discrimination based on their race, gender, or ethnicity when searching for jobs in the United States (Bergson-Shilcock & Witte, 2015).
Licensing barriers. Within the United States, the licensing process is extremely complex, not only differing between professional fields, but being controlled by separate entities. In general, the procedures and requirements for receiving licensure vary by different agencies at the federal, state, local, union, or professional association level. Oftentimes, these procedures and requirements overlap; however, there are occasions where requirements are in direct conflict with one another (Rabben, 2013). This wide dispersion of licensing requirements and regulatory bodies present a significant structural barrier for immigrants and refugees seeking re-licensure in the U.S. (Rietig & Squires, 2015).
A prime example of licensing requirements placing undue burden on immigrant populations can be found in the medical field. In this field, immigrant medical professionals must pass all U.S. medical licensing exams and complete a three to eight-year residency, regardless of how many years they practiced medicine in their home country (Rabben, 2013). This becomes even more burdensome and unrealistic when one considers the small number of residencies that are offered on an annual basis, let alone employer (or educational provider) bias towards lack of U.S. experience and education described earlier.


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Nevertheless, some states or occupations have found creative solutions to this barrier through creating or changing licensing policies. For instance, immigrant engineers cannot receive a license in the state of Tennessee without acquiring transcripts from their home institution (an often difficult or sometimes impossible task), whereas Ohio will allow immigrants to become licensed simply with the passing of an exam. Tennessee and Ohio have created a reciprocal licensing agreement, allowing for immigrants to receive licensure in Ohio and practice as a licensed engineer in Tennessee. These types of agreements, known as mutual recognition agreements (MRAs), are becoming increasingly common between governments and professional associations which make the rules for licensing professionals who are from other countries (Sumption et al., 2013).
Certain states, rather than creating mutual recognition agreements, have chosen to focus on changing their own specific policies. For example, the state of Wyoming altered its licensing laws for lawyers to allow immigrants to take the bar exam, even if they are not U.S. citizens (Jauregui et al., 2017). Similarly, West Virginia relaxed licensing procedures for teachers by allowing foreign trained teachers to teach in public schools provided they met minimum teaching requirements of the state (Jauregui et al., 2017).
Credential recognition. As if licensing procedures were not difficult enough, a primary aspect of receiving licensure and thus employment is the ability for immigrants to demonstrate their education and work experience through credentials. Immigrants, and refugees in particular, face the challenging task of trying to receive documentation of their academic and professional qualifications from abroad, often from conflict-torn areas of the world. In many cases, they are unable to receive such documentation and thus they cannot verify their qualifications for U.S. employers.


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Yet, even with the correct documentation, it has been well documented within the literature that employers do not value overseas training or experience as highly as that from the United States (Rabben, 2013). Furthermore, regulatory agencies such as state licensing bodies or professional associations sometimes will not count education or work experience abroad towards their certification requirements (Rabben, 2013).
Currently, there is no system in place within the United States to translate educational and work experience for immigrant professionals if the foreign institute from which they received their degree does not have a mutual recognition agreement with an institution or government in the U.S. (Creticos et al., 2006). Also, for some highly-skilled immigrants with years of work experience in a field, but no formal credentials, there is no system in place to translate this experience to American employers or educational institutions (Creticos et al.,
2006).
Although facing a difficult task, some states have recognized the need for re-credentialing immigrant professionals and developed programs or policies in order to do so. For example, Maryland created a specific credentialing office for highly-skilled immigrants and Washington requested that higher education institutions create tailored educational programs specifically for the purpose of re-credentialing (Rabben, 2013). However, these efforts are seemingly few and far between at this point, and the complexity of recertification procedures, coupled with the need for tailored occupation-specific assistance, makes these efforts resource intensive and difficult for states to support (Rabben, 2013, p. 2).
A Multiple Streams Lens
When analyzing the policy process and what influences whether a policy is passed successfully, one of the most widely accepted theories is John Kingdons Multiple Streams


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Theory. To summarize, Kingdon theorized that there are five major factors that influence the creation and passing of a policy: the policy stream, problem stream, politics stream, policy entrepreneurs, and policy windows (Petridou, 2014). Multiple Streams Theory states that policy change will take place when a policy entrepreneur combines the three streams during a short and specific period of time, or policy window (Petridou, 2014). These terms and their relation to immigrant related policy are detailed below. This study uses Multiple Streams Theory to understand how policies were developed and passed, but takes this information a step further to look at the actual implementation of said policies.
Policy stream. The idea behind a policy stream is that as attention for different policies and issues constantly ebb and flow, policies typically develop very slowly over time (Cairney, 2013). Thus, an individual or group will present an idea for a policy, which is later adapted by a larger group. By creating solutions that are accepted by a wide audience, policies can be more quickly implemented when the time or context is appropriate. When considering policies regarding immigrant or refugee employment, it is important to have a basis of immigrant or employment related policies already in place which may be amendable to changes which would reduce barriers. Therefore, an agency or individual interested in influencing immigrant employment policies would want to plant the initial seed with other groups or policymakers so that when the time is appropriate, the policy can be quickly altered and promoted.
Problem stream. A problem may be defined as any policy-related issue that requires attention and a solution (Cairney, 2013). As mentioned previously, attention for these problems and policies can develop or wane very quickly, which is often determined by how a problem is framed. For example, a major event or crisis typically generates attention which sets the stage for a policy to be created or implemented. Since there are so many problems and policies that


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policymakers are asked to focus on, it is important that when attention is given to a problem, supporters of a policy are ready to act on the opportunity.
This is particularly important in issues such as those facing immigrant and refugee populations. Under the current administration, immigration reform and refugees have been a hot button issue and are receiving more media attention than in previous years. Those wishing to influence policies which may benefit these populations should use this public attention to shine a light on the issues they are concerned with and potential policy solutions.
Politics stream. The politics stream refers to whether policymakers are interested in making a policy change, or are provided the opportunity to do so (Caimey, 2013). For example, supportive immigrant and refugee policies were a major focus of the Obama administration, even leading to the development of the White House Task Force on New Americans in 2014 (Batalova et al., 2016). This group was specifically charged with helping immigrants to integrate into American society, with an emphasis on employment for foreign trained professionals. In contrast, under the Trump administration, there has been a focus on cracking down on illegal immigration, reducing the funding available for programs serving immigrants and refugees, and policies placing a ban on immigration from specific countries. This example highlights how political context significantly impacts if a policy issue will be focused on, and further, whether a policy will ever come to fruition based on the leanings of political actors currently in place.
Policy entrepreneurs. Kingdon described a policy entrepreneur as an individual who uses their knowledge, skills, and connections to frame policy issues, create policy solutions, and be ready to present their policies at the right time politically (Cairney, 2013). Knaggard (2015) describes the policy entrepreneur as someone who works to present a ready package of problems and solutions to policy makers at the right moment (p. 450). In short, this individual


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knows how to frame policy problems and read the political climate to understand when to push for a policy change. Policy entrepreneurs are typically considered to be spokespeople for their cause, and use their energy and passion to push their policy agendas. In the context of immigrant and refugee employment policies, it would be important to understand if are any policy entrepreneurs already working around reducing employment barriers for immigrant populations, or if not, what person or agency may be able to take this pseudo-leadership role in pushing for policy change.
Policy windows. A policy window is a small, specific window of opportunity for a policy to be focused on or pushed forward (Caimey, 2013). Policy windows are created when all three policy streams (policy, problem, and politics) converge, creating the right political climate and energy for a policy to be advanced. Therefore, when considering immigrant employment policies, one would want to consider if there is a substantial enough problem to capture the attention of policymakers or the public; whether policies already exist in relation to this topic and whether they need to be amended or replaced; if the current political climate is supportive of such a policy, or should policies be prepared and held off until a more appropriate time; and if there is someone who can act as a policy entrepreneur to support and push for the policy actively.
In summary, the issues surrounding professional immigrant and refugee integration into the U.S. workforce are diverse and complex, including language and social barriers, licensing barriers, and credential recognition. Yet, by using a Multiple Streams lens to analyze policies which have been passed in other states, partners in Colorado can gain a better understanding of the policy stream, problem stream, politics stream, policy entrepreneurs, and policy windows that may improve their chances of successfully passing legislation to address these issues.


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Methodology
This project looks at the creation and passing of immigrant and refugee employment related policy through a Multiple Streams lens, and evaluates whether there were specific factors that led to the successful development or implementation of these policies in the five states included in the study. The specific research questions this project focuses on include:
1. What was the policy stream that led to the creation or evolution of the policy?
a. Was there pre-existing policy in this area, or what led to the evolution of this policy in this state?
b. Proposition: States that had pre-existing policies related to immigrants and refugees are more likely to successfully implement a policy impacting immigrant employment.
2. What was the problem stream that led to the development of this policy?
a. Was there a specific need that the state had which led to the development of the policy?
b. Proposition: States that have a large immigrant or refugee population will be more likely to implement a policy related to immigrant employment.
3. What was the political stream of the state like at the time of development and implementation of the policy?
a. Were there contextual reasons within the state that led to support of the policy?
b. Proposition: States where the legislature recognized an employment gap that could be met via foreign trained professionals were more likely to pass legislation.
4. Who were the policy entrepreneurs that were integral to the development and implementation of this policy?
a. Who were the key players and what roles did they play?
b. Proposition: States that have a clear policy entrepreneur are more likely to pass a policy related to immigrant employment.
5. What was the policy window like at the time of development and implementation of the policy?
a. Why did the policy makers push the policy when they did?
b. Proposition: States that recognized a specific window of opportunity are more likely to pass a policy related to immigrant employment.
Measurement and Data Collection
This study relies exclusively on qualitative data collected through key informant interviews. Interviews were conducted in a semi-structured manner, with specific questions


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being asked to all interviewees and additional probing questions being included as needed. The interview protocol is found in Appendix A.
Sampling Plan
Key informants selected for interviews were based specifically on their involvement in the policy-making process in their individual states. This study used a non-probability sample, since interviewees were selected because of their participation in the policy-making process.
The five states selected for analysis were provided by the client, and were selected because they have successfully created or passed policies related to reducing employment barriers for immigrant and refugee populations. Although other states have successfully passed similar legislation, the client was particularly interested in learning about efforts in these specific states. Two key informant interviews were conducted with each state. Interviewees were selected based upon their level of participation in the policy process regarding the policy in question.
Validity and Reliability
Although the small sample size of interviewees may decrease the studys validity, the overarching goal of the project is to provide rich context and guidance for similar future policy efforts in Colorado. In this instance, the focus is on the practicality of implementing a policy, and what experiences in other states may mean for Colorado. To increase the studys reliability, multiple researchers provided feedback. Lastly, as the researcher, personal bias and the lens through which this project and the related interviews are viewed is recognized. In the past, the researcher has worked with refugee serving agencies and has a passion for supporting immigrant and refugee rights. However, since this study focuses strictly on the policy-making process rather than immigrants and refugees themselves, it is believed that this bias does not impact the validity of the results.


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The results of this study are not necessarily generalizable, but instead are meant to provide situational context for the individual client, so that they may consider what policy interventions may or may not work for their specific efforts in Colorado.
Data Analysis
All interviews were recorded with permission, but not transcribed. The qualitative data collected were coded broadly by the categories of the five Multiple Streams, challenges encountered, and facilitators that led to the creation of the policy in question. Sub-codes were developed based on emergent theme coding. The frequency of key themes and sub-codes within each aspect of Multiple Streams was used to show comparative data and draw conclusions about which factors were the most or least important to the policy process in the individual states considered, thus supporting or denying the previously stated propositions.
Results
The interviews provided a great deal of context surrounding why particular policies were pushed at a specific time in each of the five states involved in this study. In each state, at least one policy was focused on throughout the interview; however, four out of five states mentioned multiple pieces of legislation as part of the background to why the specific policy in question had come to fruition. To provide context and background information on the different efforts occurring in each state, the table on the following page provides a breakdown of the specific policies studied, including the bill number and main purpose. A summary of the results by state can be in found in Appendix D.


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Table 1. Summary of States and Bills Studied
State Bill Main Purpose of Policy
MA HB 3248 (2017) Developed a commission to study reducing barriers for foreign trained medical professionals.
MI Executive Order Executive Order by the Governor which created the Michigan Office for New Americans.
HB 5396 (2014) Reduced credentialing barriers for people in the barber industry.
MN Minnesota State Session Laws, Chapter 228, Article 5, Section 12 (2014) Created a Foreign Trained Physician Task Force.
SB 1049 (2015) and Statute 144.1911 (2016) Senate Bill 1049, originally proposed by the Task Force, which eventually became passed (in part) via state Statute 144.1911. The statute developed the International Medical Graduates Assistance Program.
MO HB 1842 (2014) Established a licensing pathway for foreign trained medical professionals to become assistant physicians.
WA HB 1445 (2017) Called for the development and expansion of dual language programs in schools.
Overall, the most important themes that appeared throughout the interviews were the importance of demonstrating a need that the state had in order to develop legislative buy-in for the policy, the use of a policy entrepreneur or Champion to kickstart the policy process, and developing partner buy-in, particularly with groups or individuals that may be opposed to the legislation. Although identifying a specific policy window was helpful to some states, it was not required to successfully create or pass the legislation.
Policy Stream
What was the policy stream that led to the creation or evolution of the policy?
a. Was there pre-existing policy in this area, or what led to the evolution of this policy in this state?
b. Proposition: States that had pre-existing policies related to immigrants and refugees are more likely to successfully implement a policy impacting immigrant employment.


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As previously stated, four out of five states mentioned having at least one piece of prior legislation in relation to immigrant and refugee employment which may have influenced their ability to create new legislation. Thus, the findings of this study support the proposition that states which had pre-existing policies related to immigrants and refugees were more likely to successfully create or pass policies impacting immigrant employment. Generally, these pieces of legislation were focused on areas such as the creation of a Task Force to study the issue of immigrant and refugee under-employment or credentialing barriers (Massachusetts and Minnesota), the development of a state level office of Immigrant and Refugee Affairs (Michigan), or the creation of Alternative Routes programs (Washington).
In short, these pieces of legislation set the stage for future policies by supporting the development of research and legislative recommendations through Task Forces, designating a state office to focus on issues impacting immigrants and refugees, and creating funding streams for the development of programs to assist immigrant and refugee populations. Missouri, the one exception to having previously existing legislation, instead passed its first bill because of an extreme need that the state had regarding health care professionals in rural areas.
Catalyst. When discussing how the policy process behind the bills in question first began, the states reported a variety of sources. Efforts in Massachusetts began with an individual advocate who approached a Senator; Michigan pointed to the support of a specific politician (the Governor) and the work of nonprofit partners in the state; Missouri stated that it was based solely on the idea of a state agency (the State Medical Association) that the bill originated; Minnesota reported a mixture of individual and nonprofit advocates that first proposed the need for legislation; and, Washington cited other programs, such as dual language pilot programs and the states Alternative Routes program, as the origin of their work. However, despite the variety


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reported between states, each source (politician, nonprofit, state agency, advocates and other) was coded an equal number of times.
Timeline. Although each state had a unique timeline for the policy process behind their bills, one thing that most states shared was a long history, usually several years, of developing programs and/or policies as well as relationships around immigrant and refugee employment.
The origins of Massachusettss policy were traced back to 2014; Michigans efforts went back to 2013; Minnesota goes as far back as 2003; Missouri began its work in 2014; and, Washingtons policies and relationships have slowly developed since around 2000. In the states with longer histories, Minnesota and Washington, interviewees reported advocacy work and the strategic development of partnerships between state agencies and nonprofit partners as key to their eventual legislation being developed. Whereas in states with shorter histories, namely Massachusetts, Michigan and Missouri, it appears that a specific event or need played more of a significant role in the creation of related legislation. Massachusetts kickstarted efforts with research at the state level and the push from an individual advocate from the career field in question. In Michigan, the election of Governor Schneider, a strong supporter of immigrant and refugee integration into the Michigan economy, was a turning point that allowed for the creation of legislation over a rather short period of time. In the case of Missouri, the dramatic shortage of health care providers throughout the state allowed the legislature to see HB 1842 as a potentially easy solution, despite having few partners involved and no real history of similar legislation.
Problem Stream
What was the problem stream that led to the development of this policy?
a. Was there a specific need that the state had which led to the development of the policy?
b. Proposition: States that have a large immigrant or refugee population will be more likely to implement a policy related to immigrant employment.


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When looking at the problem stream that drew attention to the issue of immigrant and refugee unemployment or under-employment in each state, this study focused on three key aspects: Was a specific need identified within the state; how was the issue framed to gain legislative support; and, what evidence was used to either demonstrate a need or frame the problem more clearly? The findings outlined below demonstrate that although demographics (e.g., having a high immigrant or refugee population) is one of the key determining factors in whether a state pushes for legislation around immigrant and refugee employment, there are other factors that may have played an equal or perhaps more significant role.
Need. The state recognizing a specific need for legislation which reduces barriers for foreign trained professionals played the largest role in determining whether legislation was ever developed or passed in terms of having the highest code frequency. In comparison to the other areas of the problem stream focused on in this study, demonstrating a Need was the most frequently mentioned reason behind legislation.
Within the category of Need, the most frequent sub-codes were shortage within the specific career field the legislation focused on (e.g., medical professionals or education) and the states demographics. This finding supports the proposition that states which have a higher immigrant or refugee population are more likely to pass legislation around immigrant employment. Examples of demographic needs that interviewees discussed included the growth of immigrant and refugee populations in their states and health or education disparities that disproportionately impact these populations. The combination of both shortage and demographics were reported by four out of five states (the outlier being Missouri) as part of the need behind the legislation being discussed.


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Framing. All interviewees but one referenced how partners framed the legislation or issue within their state. The most frequently used sub-codes were solution, meaning that the proposed bill was framed as a possible solution to the problem or need that the state had, and other. The next in frequency was diversity, focusing on improving diversity among the professionals in their state; followed by economic, framing the policy as having an economic benefit to the state; and success, meaning those framing the problem outlined similar legislation or programs which were successful.
Using evidence. Although the type of evidence used to promote the legislation varied by state, interviewees from all states but Missouri reported using evidence as part of how the problem was recognized and their legislation gained support. Minnesota, the state with the highest number of codes in this area, used various forms of evidence, including: return of investment data, statistics on healthcare disparities, information on how diverse doctors improve population health, and referencing models in other countries that have proven to be successful. Similarly, Washington used statistics that highlighted their changing student demographics as well as specific studies on immigrant and refugee brainwaste in their state. However, Michigan used an economic lens, focusing on the growth of immigrant population in the state regarding the potential tax income and career field shortages that may be filled. One respondent from Michigan recommended to back your policies with jobs, stating that it is difficult for anyone to oppose legislation if you can prove economic benefits.
Political Stream
What was the political stream of the state like at the time of development/implementation of the policy?
a. Were there contextual reasons within the state that led to support of the policy?


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b. Proposition: States where the legislature recognized a specific need that could be could be met via immigrant or refugee employment were more likely to pass legislation.
When coding for the political stream, this study focused on the aspects of Political Willpower/Legislative Support in each state. The most frequent sub-codes were Supportive Legislature and Politician. Supportive Legislature referred to any time a legislature had recognized the problem within the state and was generally willing to work towards finding a solution. The fact that Supportive Legislature was the most frequently used code supports the proposition that states which had a legislature that recognized a specific need that could be filled using foreign trained professionals were more likely to create or pass legislation. Other subcodes included: Bi-Partisan, Lack of Opposition, and Lobbying. The findings suggest that having a supportive legislature is crucial to the development and passing of related policies, and that developing legislative support is directly tied to demonstrating a specific state need.
Policy Entrepreneurs
Who were the policy entrepreneurs that were integral to the development/implementation of this policy?
a. Who were the key players and what role did they play?
b. Proposition: States that have a clear champion or policy entrepreneur are more likely to pass a policy related to immigrant employment.
To evaluate what policy entrepreneurs were involved in the policy making process in each state, interviewees were asked to identify what partners were involved with developing or passing the legislation, as well as if there were any specific champions or policy entrepreneurs.
Champions. All five states reported having at least one individual or agency that championed the efforts for creating and passing the legislation being discussed. However, there was a variety between states regarding what arena their Champion or policy entrepreneur came from. The most frequently used sub-code was Politician, followed by State Agency, Advocate,


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Nonprofit, and Individual(s) in career field. Michigan relied heavily on the support of a specific politician (the Governor) to pass legislation, whereas Washington relied exclusively on nonprofit partners to champion the policy. Massachusetts, Missouri and Minnesota each reported a mixture of champions from various backgrounds; albeit, Missouri leaned towards politicians and state agencies while Minnesota primarily utilized individual advocates.
Interviewees spoke frequently about the importance of their Champions in their success with the legislature. In support of the proposition earlier stated, the high number of codes for Champions suggests that having a policy entrepreneur is directly connected to the passing of immigrant and refugee employment related policies, however the arena that this Champion comes from can vary.
Partners. The significance of inter-organizational partnerships cannot be overstated in the development and passing of immigrant and refugee employment related policies.
Interviewees reported a total of 103 partners, varying from only 2 partners in Missouri to 23 in Michigan. Yet, perhaps of more significance than the total number of partnerships within each state are the different sectors that these partners came from.
This study found that partnerships with State Agencies, Nonprofits and Ethnic Groups appear to be the most commonly utilized when attempting to pass legislation relating to immigrant and refugee employment. Interviewees who discussed working with State Agencies referenced their ability to build connections and impact legislation on a state-level, as well as their access to resources such as funding. These partnerships were typically different than partnerships with Nonprofits and Ethnic Groups, which instead were key for advocating for the policy and developing support within the legislature.


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Policy Window
What was the policy window like at the time of development/implementation of the policy?
a. Why did the policy makers push the policy when they did?
b. Proposition: States that recognized a specific window of opportunity are more likely to pass a policy related to immigrant employment.
Although only one state (Missouri) specifically mentioned recognizing a policy window (a specific point in time in which a policy has a higher likelihood of being passed), all five of the states mentioned some aspect of timing, legislative buy-in or a specific need that influenced their decision to attempt to pass their policy at a specific time. Therefore, although there is some indication that recognizing a specific policy window is advantageous when attempting to pass legislation regarding immigrant and refugee employment, it is not necessarily required to do so. Thus, this proposition was not supported.
Challenges
Interviewees spoke frequently about challenges they faced while trying to pass or implement the legislation in their state. The most frequently cited Challenge by far was receiving Pushback, either from the legislature or partners, surrounding the policy. All states reported some form of Pushback, although who the Pushback was coming from varied by the state and policy. Interviewees reported particularly intense Pushback regarding policies around foreign trained medical professionals from the medical community at large and different licensing agencies.
The transferring of Education/Experience was one of the second most frequently cited Challenge, along with Lack of Financial Support. Education/Experience transfer was used to code statements regarding reluctance to allow for greater flexibility for foreign trained professionals to become credentialed based on their previous education or work experience. The


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code Lack of Financial Support was used when a respondent spoke about how the lack of financial backing behind a policy made it difficult to push or implement. For example, in the state of Washington, educational funding is not seen as the constitutional duty of the state, meaning that asking for funding to support a dual language learning program proved to be a difficult barrier for partners to overcome.
Facilitators
Despite facing some daunting challenges, each of the states interviewed has either successfully passed or is attempting to pass legislation to reduce barriers for foreign trained professionals. Two of the most prominent Facilitators mentioned, Partner Buy-In and Feedback from Partners, further highlight the importance of strategic partnerships in the passing of legislation. Partner Buy-In was cited as being important for helping to advocate for the policy among legislatures. Further, a respondent from Minnesota discussed how important it was for their group to receive Feedback from Partners, particularly partners who were originally opposed to parts of the bill. By receiving feedback from members with opposition, the group was able to address these concerns before trying to pass the legislation and develop more trust among partners and buy-in for the policy.
Discussion and Recommendations
Despite the complexities and sometimes seemingly overwhelming obstacles involved with successfully navigating the policy process, this study has highlighted several factors that may increase the chances of passing legislation relating to immigrant and refugee employment. A few of the key points that were illustrated through these findings include:


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The push for legislation can start from a variety of places, although it typically begins within the nonprofit or programmatic realm, and then seeks support from specific politicians and legislatures. Politicians may not have the time to push a piece of legislation on their own, but with the support of nonprofits and other advocates to collect data and build support, they can be a critical partner in the legislature itself.
Demonstrating a Need within the state and highlighting how a specific policy could be a Solution to the need are two highly effective ways of gaining the attention and support of the legislature.
o Issues can be framed in a variety of ways, but several states had success by framing their policy as a Solution that had economic benefits and/or provided benefits to the population of the state (e.g., improved health outcomes).
Evidence and/or data are powerful tools when developing support among the legislature.
Several states used specific data on their own immigrant/refugee population (demographics, employment areas, etc.), the potential economic benefits that could come from the policy, and potential economic losses that could come from brainwaste. Multiple states also referred to successes in other states or countries that implemented similar programs as a way to combat pushback.
The political makeup of the legislature between Democrat and Republican does not necessarily impact whether or not a policy will get passed. Two states reported their work being bi-partisan, and one respondent referenced how political parties did not matter so much with their bill since both sides could agree that the Need was significant; however, the parties did have to negotiate on a final bill.
Although formal lobbying is helpful for building support among legislators, only one state referred to a formal lobbyist as being influential to their ability to pass legislation.


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In general, all of the states relied much more on individual and nonprofit advocates to gather support. Gaining the support of powerful bodies within the legislature (e.g., State Medical Boards) proved to be more important than having a specific lobbyist.
Diverse partners are necessary to create and pass relevant legislation. The interviewees in this study reported how important Partner Buy-In and Feedback were to their success. Developing partnerships with organizations that may be opposed to the bill was of upmost importance.
Recommendations
The results of this research highlight several recommendations that may be beneficial for the Office of Immigrant and Refugee Affairs to consider:
1) Policy Stream: Propose easier legislation first.
a. Rather than proposing a bill that asks for a large amount of funding to start a program, instead take what Massachusetts described as a baby step by establishing a committee to further explore barriers impacting immigrants and refugee employment in Colorado.
i. This provides a platform to bring partners together, will place the issue on the radar of the legislature, and will lead to some form of recommendations that can act as a stepping stone to further work.
2) Problem Stream: Collect specific data to demonstrate the Need.
a. Collecting Colorado-specific data around immigrant and refugee populations, such as their education level, employment background, and potential level of brainwaste.
ii. Other states collaborated with universities, national-level nonprofits, and other organizations who may already be working around collecting similar data.
b. Since Colorado has similar health care disparities compared to Massachusetts, Minnesota and Missouri, this may be an easier sell to the legislature.


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3) Politics Stream: Spend time developing a Supportive Legislature.
a. Use data to demonstrate the problem, frame the proposed policy as a potential solution to this problem, and utilize constituents (especially foreign trained professionals in that field) as a means of developing understanding and support among key legislators.
i. For example, Massachusetts presented its bill one legislative session in order to build awareness for the next years session.
c. Gaining buy-in from leaders of the House and/or Senate was key for several states. This was done by highlighting a political pathway for the policy by demonstrating that key stakeholders (e.g. Medical Associations) were supportive.
4) Policy Entrepreneur: Identify a Champion based on the employment area with the greatest Need and work on developing relationships with State Agencies and Ethnic Groups.
a. Once a specific career field or policy is chosen to focus on, find the appropriate champions both inside and outside of the legislature.
i. Having someone in the legislature who is either passionate about the issue, or somehow related to the issue is extremely beneficial, but outside individual advocates were a powerful player in several of the states involved in this study.
ii. Examples: In Missouri, having two physicians in the legislature who could push their policy with other members of the House and Senate was crucial. In Minnesota, having a well-respected immigrant physician promote the bill carried a lot of weight within their legislature.
d. Both State Agencies and Ethnic Groups were important in both defining the need and garnishing support in other states. Reaching out to begin building relationships with relevant State Boards (depending on the career field) as well as Ethnic Chambers and Coalitions will be important to Colorados efforts.
i. Ethnic Councils can help to define the needs of their constituents and provide powerful advocacy.


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5) Policy Window: Identify if there is a potential policy window for the career field being impacted. If there is not, work towards creating one over time by advocating with legislators and collecting evidence.
a. Multiple states mentioned pushing their legislation when legislation in a similar arena were being passed.
b. For example, in the year that Minnesota chose to push its legislation around foreign trained medical professionals, the legislature had been focusing on addressing the medical shortage in the state and had already passed multiple pieces of legislation on this topic that session.
Limitations
Although the findings of this study accurately represent the policy making and implementation process of each state, the study does have some limitations. The main limitation to this study was the limited number of interviews that were possible in the projects timeframe. In the future, it would be beneficial to conduct further research by interviewing more individuals from each state, especially from different partners that were involved, as well as to include more states in the study. Although this study was designed to provide practical recommendations for the Office of Immigrant and Refugee Affairs based on the experiences of these specific states, there were several other states which could be studied in the future to provide even further context for Colorado.
Another limitation to this study was the lack of intercoder reliability. Although the researcher tried to remove all personal bias while coding the interviews, but as with any qualitative study, there is always the chance that how this researcher chose to code the material is different than what another researcher might have chosen. This issue could be avoided in the future by having multiple researchers design and implement the project.


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Finally, the findings of this study highlighted two primary needs for future research. First, for Colorado specifically, the findings indicated the importance of conducting research on the specific needs of immigrant and refugee professionals in the state. Information about how many immigrant professionals live in the state, their fields of expertise, or other evidence that can be used to demonstrate a specific need for legislation (e.g., health disparities, population demographics, etc.) will play an important role in passing future legislation. Second, this study originally intended to look at the impact of policies that had been passed but interviewees reported having difficulties with measuring impact. Colorado should consider how impact may be measured for the policies it chooses to pursue and build that process into the policy or program from the beginning of implementation.
Conclusion
The issue of brainwaste is significant in Colorado, with 23% of foreign-born college-educated people being either unemployed or underemployed (Colorado State Immigration Data Profile, 2015). Fortunately, the Office of Immigrant and Refugee Affairs can learn from the endeavors of other states which have passed legislation to try to combat brainwaste with the hope of improving the chances of successfully navigating the policy process in Colorado. Although removing barriers for foreign trained professionals through legislation will be a difficult task, with strategic partnerships, data, and the right champions, Colorado can improve the economic opportunities for its immigrant and refugee populations while simultaneously solving issues that negatively impact Colorado residents.


Running Head: CREATING POLICY CHANGES TO ENHANCE EMPLOYMENT
References
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Akresh, I. (2006). Occupational mobility among legal immigrants to the United States. The International Migration Review, 40(4):854-884.
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Caimey, P. (2015). What is a policy entrepreneur? Retrieved from:
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Appendix A: Interview Guide
Appendices
Thank you so much for taking the time to talk to me today. Just as a reminder, I am currently a Masters student at the University of Colorado Denver. I am conducting research on behalf of the City of Denvers Office of Immigrant and Refugee Affairs by conducting interviews with individuals who were involved with successfully passing legislation around reducing barriers for immigrant and refugee professionals re-entering their field of employment here in the United
States. We wanted to talk to you about your involvement in efforts in________. Specifically, we
are hoping to gain insight into how these policies were first developed and the process behind getting the policy passed through the legislature. I anticipate that our discussion will last about 45 minutes.
Consent: Before we get started, I want to assure you that your responses to these questions will be held in strict confidence, except as required by law. Summary information from these interviews, together with material taken from public documents, may be presented in a capstone paper; however, NO specific names of individuals will be used. However, organizational names may be used to provide important context within the capstone paper. I will record this conversation for the purpose of creating accurate summary notes, but will destroy all recordings once the study is concluded. Your participation is completely voluntary, if you are uncomfortable with any question we can skip it. Do you have any questions about confidentiality before we begin?
Policy Stream
1) How did you begin the process of implementing policy change related to immigrant and refugee employment in state ?
2) What was the timeline for the process? Were the same people involved throughout, or did the participating groups change over time?
Problem Stream
3) What originally brought this problem to attention?
4) What were the drivers for pushing this policy? (Why this policy, employment area,
etc.)
Politics Stream
5) How long has the process been going on?
6) Why when they did? Legislative buy-in? Political support?
Policy Entrepreneurs


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7) Who did you need to contact or partner with to achieve policy or program changes? (In other words, were there certain people, organizations, or community partners that you worked with to push for these changes?)
8) Who was involvedwhat role did they fill? (Government, nonprofits, private sector)
9) Was there a champion? If there was a champion, where did they come from?
Policy Windows
10) Is there anything about the specific context of_that may have influenced your
ability to implement these policy or program changes? (e.g. political will power, demographics, need, etc.)
Challenges/Impact
11) What challenges did you encounter while trying to impact policy and programs in
_______?
a. If challenges, how did you overcome these?
12) Were there specific career fields, policies, or programs that were particularly difficult to impact?
a. Why?
13) Were there any career fields, policies, or programs which took less effort or time to impact?
a. Why?
14) How is your state measuring the impact of this policy? What has happened since passing the policy or implementing the program?
a. If programmatic:
i. How will you capture impact? Is it built into the program or model to report back?
ii. Can they share this data, or point us to the right person?
1. Number of people served, success rates, placement rates, etc. Funding? Who funds it? Is it possible to get the pre and post salary for those that were placed?
15) Once a policy is enacted, does it lead to more?
Closing Questions
16) If there is a legislative bill, could we get a copy of the language?
17) Is there anyone else that you believe we should speak with to have a fuller
understanding of these policy or program changes in_______?
a. If so, could you provide me with contact information, or connect us?
18) Is there anything else that you would like to add about the process of impacting
policy and programs related to immigrant and refugee employment in_______?


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Appendix B: Coding Structure
Main Code Definition (Based upon Paul Cairneys Policy Concepts in 1000 Words: Multiple Streams Analysis) Sub-Codes Additional Codes
Policy Stream An idea is proposed by one actor, then modified by many participants. Developing widely-accepted solutions in anticipation of future problems, then find the right time to exploit or encourage attention to a relevant problem Anything relating to the beginning of the policy process or relating to the timeline of development. Catalyst: Information about how the idea originated or initial action that began push for the policy. Timeline: Any information regarding a progression towards the policy. Catalyst: Politician Nonprofit Advocates State agency Other programs
Problem Stream How the problem gained attention. Specific drivers of legislation (e.g. Why this population? Why this employment area?) Need: A need that was identified which led to the development of the policy/program. Framing: How the issue/message was framed to gain support. Using evidence: Using data, statistics, etc. to gain support. Need: Shortage Demographics Career field specific barrier Other Framing: Economic Success Solution Diversity Other
Politics Stream Policymakers have the motive and opportunity to turn a solution into a policy. Information relating to why a specific policy was pushed at a particular time. Political willpower/Legislati ve support Politician Supportive Legislature Lack of opposition Bi-Partisan Lobbying
Policy Entrepreneurs A championsomeone who uses their knowledge, skills, and connections to push policies at the appropriate time. Champion Partner Champion: Politician State agency


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Individual in career field Advocate Nonprofit Partners: State Agency Ethnic Group Nonprofit University Private Sector Association/Union Network Board Other
Policy Window A specific window of opportunity for a policy to be focused on or pushed forward. Anything relating to specific context of the state that may have allowed for success. Timing Legislative buy-in Need
Challenges Any barriers or challenges that made the policy difficult to create or pass. Pushback Drain on resources Lack of Financial Support Engaging private sector Negative perceptions Limited Data Finding a focus Education Credit Transfer Implementation Lack of State Office of Immigrant and Refugee Affairs Competing Priorities
Facilitators Anything that was mentioned which specifically led to a success (e.g. improving relationships, generating buy-in) Partner Buy-in Feedback from partners Working as a team Proximity between partners Funding Exposure Career Field


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Previous Wins
Impact Any form of measurement used to gauge the effect of the policy (e.g. number of foreign trained professionals employed after policy, number of policies successfully passed, economic growth, etc.) Report Logic Models Website views


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Appendix C: Interviewees
State Bill Interviewees
MA HB 3248 (2017) Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA) Senators Office
MI Executive Order and HB 5396 (2014) Michigan Department of Licensing and Regulatory Affairs Michigan Office for New Americans
MN Minnesota State Session Laws, Chapter 228, Article 5, Section 12 (2014), SB 1049 (2015) and Statute 144.1911 (2016) Foreign Trained Physician Task Force Member and Nonprofit Director (New Americans for Alliance and Development) Minnesota Department of Health
MO HB 1842 (2014) Representative from House Legislature Missouri State Medical Association
WA HB 1445 (2017) Professional Educator Standards Board OneAmerica


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Appendix D: Timeline and Key Players
Focus Area Main Bills Discussed Timeline Key Players
MA Medical House Bill 3248 which developed a commission to study reducing barriers for foreign trained medical professionals.
MI General/ Barbers Executive Order by the Governor which created the Michigan Office for New Americans House Bill 5396 (2014) which reduced credentialing barriers for people in the barber industry. 2013: Partnership between Upwardly Global and Office of Licensing and Regulatory Affairs to develop licensing guidelines. 2014: Governor passed Executive Order to create the MI Office for New Americans; Ethnic Cabinets were developed; Upwardly Global ran a state funded program to help immigrants who are un- or under-employed; HB 5396 is passed. 2015: Office for New Americans moved under the Office of Licensing and Regulatory Affairs; State took over Upwardly Global program (Michigan International Talent Solutions); City of Detroit opens Office of Immigrant and Refugee Affairs. Catalyst: Governor Champions: Governor, Office of New Americans, Office of Licensing and Regulatory Affairs.
MN Medical Minnesota State Session Laws, Chapter 228, Article 5, Section 12 (2014) which created a Foreign Trained Physician Task Force Senate Bill 1049 (2015), originally proposed by the Task Force, which eventually became passed (in part) via state Statute 144.1911 (2016). The statute developed the International Medical Graduates Assistance Program. 2003: Advocacy from immigrant physician community; passing of two bills to create job preparation programs (funded to through Department of Employment and Economic Development). 2004: The African and American Friendship Association for Cooperation and Development is opened, this group pushed this legislation. 2011-2012: University of Michigan started the Preparation for Residency Program. 2014: The Foreign Physician Task Force was created by state statute. 2015-2016: International Medical Graduates Assistance Program Bill is developed and passed in part. Catalyst: Advocate & Individuals in career field Champions: Advocate, Individuals in career field, Department of Health, Politician
MO Medical House Bill 1842 (2014), established a licensing pathway for foreign trained medical professionals to become assistant physicians. 2014: State Medical Association partnered with Representative Frederick to draft the bill; bill was passed. 2014-2017: Rule making process through the State Board of Healing Arts. 2017: Began issuing assistant physician licenses; 3 other states passed similar legislation. Catalyst: State Medical Association. Champions: Politician, State Medical Association,


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Individual in career field.
WA Education House Bill 1445 (2017), called for the development and expansion of dual language programs in schools. 2000: Professional Educator Standards Board is created; Alternative Routes first gains funding (would later be used as the vehicle to push Grow Your Own); development of relationships between nonprofit and state agencies. 2015: A budget proviso was passed that created a small pilot program to be administered by the Office of Superintendent of Public Instruction; English Language Learner Bill was proposed but did not pass. 2016: OneAmerica developed framework for a Grow Your Own bill. 2017: House Bill 1445 was proposed; the inclusion of 7 bill this session with a Grow Your Own aspect (HB 1445, HB 1645, HB 1646, HB 1644, HB 1827, SB 5712); the creation of a Paraeducator Board (HB 1115). Catalyst: Other programs (Alternative Routes) Champions: Nonprofits.


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Appendix E: Summary of Results by State
State Bill Summary of Findings
MA HB 3248 (2017) Policy: Started by a foreign trained professional in the impacted career field (medical) acting as an advocate and approaching the Senators office. In 2014, the state was conducting research on the issue of brainwaste and an immigrant physician approached the Senators office. The bill was presented twice as an amendment to the Senate budget.
Problem: Issue was framed as a solution to a health care shortage/brainwaste which would have economic benefits. Use of evidence was key; Specific statistics about foreign trained professionals, health care shortages, state demographics, etc. were used.
Politics: Political willpower or legislative support were not mentioned.
Policy Entrepreneur: A foreign trained physician was a key advocate which started efforts within a Senators office. The main partners involved were the Senators office and MIRA (Massachusetts Immigrant and Refugee Advocacy Coalition).
Policy Window: National level politics (Trump Administration) meant that people are paying more attention to immigrant/refugee issues and looking for ways to help.
Challenges: Pushback (from legislators, public, licensing agencies) was most significant challenge.
Facilitators: Partner buy-in and feedback from partners were more important.
MI Executive Order and HB 5396 (2014) Policy: Executive Order was done by the Governor. HB 5396 began with Ethnic Council worked with the state Office of Licensing and Regulatory Affairs to pass barber bill.
Problem: The state had a need because of its growing immigrant and refugee population and labor shortages in certain fields. The message was framed to highlight foreign trained professionals as a means of economic development for the state. Evidence, especially regarding the tax benefit of employing foreign trained professionals, was mentioned.
Politics: Supportive Governor was critical. Conservative legislature at the time.
Policy Entrepreneur: Governor Schneider was a Champion created Office for New Americans and generally very supportive of immigrant and refugee employment.
Policy Window: Governor was supportive and made it part of his agenda, immigrant/refugees in MI had employment needs, MI economy was changing and needed to fill jobs.


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Challenges: Pushback from legislators (conservatives) and licensing boards. Educational credit transfer/documents.
Facilitators: Funding for program development and partner buy-in were important (especially with Ethnic Groups).
MN Minnesota State Session Laws, Chapter 228, Article 5, Section 12 (2014), SB 1049(2015) and Statute 144.1911 (2016) Policy: Nonprofit and foreign trained professional advocates began process. Interviewees described a process of building momentum for their policies over 10 years.
Problem: MN recognized a shortage of healthcare providers in rural parts of the state, framed policies and foreign trained physicians as a solution. Framed the solution as benefiting the state economically, socially (health outcomes), and increasing diversity of workforce/medical providers. Relied on evidence to build support, including a return of investment study, outlining models used in other states, statistics about healthcare disparities, and data about foreign trained physicians in the state.
Politics: The legislature recognized a healthcare need, the governor made it part of his agenda, efforts were bi-partisan, and they received free lobbying services.
Policy Entrepreneur: Foreign trained physicians and individual advocates were important to starting the efforts. State agencies, ethnic groups, nonprofits, universities, and private sector (hospitals with residency programs) were important partners.
Policy Window: Legislature recognized need in healthcare field, had some knowledge of the issue and worked together to compromise, had the support of important players like the Minnesota Medical Association.
Challenges: Pushback (especially from the medical community), negative perceptions towards foreign trained professionals, and limited data were some of the challenges encountered.
Facilitators: Partner buy-in and feedback from partners were most significant. Feedback from people/groups who opposed the bill helped to create relationships and buy-in.
MO HB 1842 (2014) Policy: State Medical Association came up with idea, passed it quickly towards the end of the legislative session.
Problem: Shortage of health care providers in rural parts of the state, the policy was presented as a solution. Career field specific barrier (too few residencies) and brainwaste. Used success of similar programs for Nurse Practitioners to build support.
Politics: Not much opposition at the time of passing, legislature recognized the need for a solution.


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Policy Entrepreneur: Champions were the State Medical Association and an individual politician (who was a physician); they were the main partners.
Policy Window: Severe shortage of healthcare providers. Waited until the last week of the legislature so that most people who could have opposed did not have time to prepare or become vocal.
Challenges: Pushback from medical community. Implementation has been difficult because even though some foreign trained professionals becoming licensed as assistant physicians, nobody is hiring them (questions about Medicare reimbursements).
Facilitators: None mentioned.
WA HB 1445 (2017) Policy: Policies originated because of other programs that existed (Alternative Routes) which created a vehicle to develop and fund Grow Your Own. Policy process began in early 2000s.
Problem: Lack of diverse educators in the state, not meeting the needs of their diverse population. Framed the policy as a solution to their teacher shortage by using people who already lived in WA that could become paraeducators/bilingual educators. Evidence about brainwaste and state demographics helped support their case.
Politics:
Policy Entrepreneur: Non-profits were the champions of this legislation. A large number of partners from a variety of sectors.
Policy Window: Legislature had knowledge around need, a lot of partners to testify on behalf of bill or advocate.
Challenges: Pushback from a variety of groups, and challenges with education credit transfer were the most important barriers.
Facilitators: Partner buy-in and funding (through Alternative Routes) made passing the legislation and implementing programs easier.


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Appendix F: Advice from Each State
Massachusetts
o Try to pass legislation that is an easier lift for politicians first
... [creating a commission to explore barriers facing foreign trained medical professionals] is almost like a baby step, and then they can recommend something further. Its an easier lift in a way, than saying OK, were going to change licensing requirements and create conditional licensing in MA.
Didnt have the knowledge base to propose legislation amending licensing procedures, so chose to propose bill for commission instead. Using this to move the conversation forward.
o Engage immigrants and refugees in the career field you are focusing on throughout the process.
You want to find a way to convene and engage the medical professionals themselves.
If you are at legislature talking to people, absolutely bring constituents with you that live in their district. Youll probably find them again, by tapping into the immigrant and refugee structures that are already in major hospitals.
o Utilize local partners who may be able to help you.
If we have immigrant/refugee programs in hospitals, talk to the individuals who run it to find the foreign trained professionals and potential allies.
Talk to universities or other institutes that may be working around the economic contribution of immigrants, etc.
o Realize it might take several years to pass, but use time to build understanding around the issue among the legislature and constituents.
MA has 2 year legislative cycle. Often takes several years to get things through, try again each year.
Get House and Senate leadership on board. If you have strong sponsors for the bill, they can advocate for this.
Using this commission bill to introduce the idea/topic to legislature and develop more willpower to pass future legislation.
o Passed the legislation by adding it as an amendment to the state budget.
o With bills that have widespread public impact and the public is knowledgeable, easier to pass. Bills that are more narrow require you to develop that support.
o Was important that key decision makers (House/Senate Leadership) knew that there was a political path already created via the support of MIRA and State Medical Board.


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Michigan
o Reach out to other State Offices for New Americans for advice, o Look for champions, they are not always exactly who you think they are going to be... cast a broad net.
o Work with the New American Economy.
o Do not use terms like Welcoming Communities or Sanctuary City in the legislation.
o Avoid social narratives and stick with raw data.
Back up the policy with jobs.
Minnesota
o See their 2017 report to the legislature for specific language they used in recommendations to the legislature.
http://www.health.state.mn.us/divs/orhpc/img/documents/2017imgc.pdf o Get rural legislators and advocates on board.
o Get medical community powerhouses (Board of Medical Practice, Medical Schools, etc.) on board.
o Do not use the word immigrant in the title.
Missouri
o Approach a physician that works in the House or Senate as a possible Champion, o Contact him (Representative Frederick) if we choose to pass legislation around foreign trained physicians.
He said he is willing to come to Colorado to talk to committees, nonprofits, or legislators in order to help efforts here.
Washington
o N/A


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Appendix G: Massachusetts Related Documents
House Bill 3248.
HOUSE
HOUSE DOCKET, NO. 3234 FILED ON: 1/20/2017
....................................No. 3248
Gflf)t Commontoealtf) of Jllasfsfacimsfetts;
PRESENTED BY:
Jack Lewis
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill: An Act to increase access to healthcare in underserved areas of Massachusetts.
PETITION OF:
Name: District/Address :
Jack Lewis 7 th Middlesex
Ruth B. Balser 12th Middlesex
Marjorie C. Decker 25th Middlesex
Diana DiZoglio 14th Essex
James B. Eldridge Middlesex and Worcester
Tricia Farley-Bouvier 3rd Berkshire
Dylan Fernandes Barnstable, Dukes and Nantucket
Sean Garballey 23rd Middlesex
Jonathan Hecht 29th Middlesex
Natalie Higgins 4th Worcester
Jay R. Kaufman 15 th Middlesex
Kay Khan 11th Middlesex
Peter V. Kocot 1st Hampshire
Jason M. Lewis Fifth Middlesex
Adrian Madaro 1st Suffolk
Denise Provost 27 th Middlesex
David M. Rogers 24th Middlesex


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Daniel./. Ryan 2nd Suffolk
Jose F. Tosado 9th Hampden
Chris Walsh 6th Middlesex
Timothy R. Whelan 1st Barnstable
Bud Williams 11th Hampden
HOUSE DOCKET, NO. 3234 FILED ON: 1/20/2017
HOUSE.............................................................No. 3248
By Mr. Lewis of Framingham, a petition (accompanied by bill, House, No. 3248) of Jack Lewis and others for an investigation by a special commission (including members of the General Court) to study the licensing of foreign-trained medical professionals with the goal of expanding and improving medical services in rural and underserved areas. Public Health._________
Wtyt Commontoealtf) of Jllas;s;acfmsietts;
In the One Hundred and Ninetieth General Court (2017-2018)
An Act to increase access to healthcare in underserved areas of Massachusetts.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
SECTION 1. (a) There shall be a special commission to study and make recommendations regarding the licensing of foreign-trained medical professionals with the goal of expanding and improving medical services in rural and underserved areas.
(b) The commission shall consist of the following 17 members: 1 member appointed by the governor from the governors advisory council for refugees and immigrants; the secretary of the executive office of health and human services, or a designee, who shall serve as chair; the commissioner of public health, or a designee; 1 member appointed by the senate president; 1 member appointed by the speaker of the house; 1 member appointed by the minority leader of the senate; 1 member appointed by the minority leader of the house; the house and senate chairs of the joint committee on public health; 1 member of the board of registration of medicine; 1


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member of the board of dentistry; 1 member of the board of registration in pharmacy; 1 member of the board of nursing; 1 member of the division of health professional licensure; 1 member of the board of registration of psychology; 1 member of the board of allied health professionals and 1 representative of the Massachusetts Immigrant and Refugee Advocacy Coalition.
(c) The commission shall examine, report and make recommendation on topics including but not limited to: (1) implement strategies to integrate foreign-trained medical professionals into rural and underserved areas that are in need of medical services, (2) identify state and national licensing regulations that may pose unnecessary barriers to practice for foreign-trained medical professionals, (3) develop recommendations for corresponding changes to state licensing requirements (4) identify opportunities to advocate for corresponding changes to national licensing requirements, and (5) other matters pertaining to licensing foreign- trained medical professionals. The commission may hold hearings and invite testimony from experts and the public to gather information. The commission shall review and identify best practices learned from similar efforts in other states. The report may include guidelines for full licensure and conditional licensing of foreign-trained medical professionals.
(d) The commission shall file a report containing its recommendations, including legislation and regulations necessary to carry out its recommendations to the joint committee on public health and with the clerks of the house and senate within one year of the enactment of this law.


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Appendix H: Michigan Bills
Executive Order Creating the State Office for New Americans.
EXECUTIVE ORDER No. 2014-2
CREATION OF THE MICHIGAN OFFICE FOR NEW AMERICANS EXECUTIVE OFFICE OF THE GOVERNOR RICK SNYDER, GOVERNOR BRIAN CALLEY, LT. GOVERNOR
WHEREAS, Section 1 of Article V of the Michigan Constitution of 1963 vests the executive power of the state of Michigan in the Governor; and
WHEREAS, Section 2 of Article V of the Michigan Constitution of 1963 empowers the Governor to make changes in the organization of the executive branch or in the assignment of functions among its units that the Governor considers necessary for efficient administration; and
WHEREAS, in the last decennial U.S. Census, Michigan was the only state in the country to suffer a population loss; and
WHEREAS, talented immigrant entrepreneurs, scientists, students, and workers are currently living and working to fuel Michigan's comeback and are a vital component of Michigan's economic engine, tax base, and social and cultural fabric; and
WHEREAS, immigrants are critical to the success of businesses and entrepreneurial activity across the state and are key to Michigan's agricultural and tourism industry; and
WHEREAS, immigration policy is set at the federal level, but the benefits and challenges of immigration are felt at the state and local levels; and
WHEREAS, a proactive policy for attracting and retaining new Americans at the state level will maximize the benefits immigrants bring to the state and its municipalities, while helping immigrants overcome the challenges they face becoming fully integrated; and
WHEREAS, the state of Michigan and its partners in the community foundation, non-profit, and private sectors jointly play a vital role in building upon the strengths of immigrants and enabling their speedy transition to self-sufficiency; and WHEREAS, it is crucial to Michigan's reinvention, population growth, economic vitality, cultural diversity, and well-being that Michigan is known as a state that embraces, welcomes, and sustains a diverse population and the economic growth resulting from that diversity;
NOW, THEREFORE, I, Richard D. Snyder, Governor of the state of Michigan, by virtue of the power and authority vested in the Governor by the Michigan Constitution of 1963 and Michigan law, order the following:


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I. CREATION OF THE MICHIGAN OFFICE FOR NEW AMERICANS
A. The Michigan Office for New Americans ("Office") is created within the Executive Office of the Governor.
B. The Governor shall appoint a Director to lead the Office. The Director shall serve at the pleasure of the Governor.
C. The Director of the Office shall be the chief advisor to the Governor and state departments on all matters regarding the formulation and implementation of immigration policies, programs, and procedures.
II. FUNCTIONS OF THE MICHIGAN OFFICE FOR NEW AMERICANS The Office shall perform the following functions:
i. Serve as the coordinating office for all executive branch agencies that are responsible for programs related to services for immigrants, including but not limited to the Global Michigan Initiative, and all programs concerning immigrant entrepreneurship, licensing, workforce training, education, housing, healthcare, and quality of life.
ii. Analyze and make recommendations to the Governor on proposals and policies relating to immigrants, and on the elimination of duplication in existing state programs in these areas.
iii. Lead the Global Michigan Initiative a collaborative statewide effort to retain and attract international, advanced degree, and entrepreneurial talent to our state and develop sustainable partnerships with existing community foundation, non-profit, and private sector service providers already serving immigrant communities statewide.
iv. Provide information and assistance related to immigration issues to all departments and agencies of the executive branch of government, both directly and by functioning as a clearinghouse for information received from such agencies, other branches of government, other states, and the federal government.
v. Engage in state and federal advocacy and provide substantive recommendations concerning immigration law and policy to advance state economic and population growth.
III. MISCELLANEOUS
All departments, committees, commissioners, or officers of the state shall give the Michigan Office for New Americans or any member or representative of the Office, any necessary assistance required by the Office so far as that assistance is compatible with its duties.
This Executive Order shall become effective upon filing,


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House Bill 5396.
Act No. 137 Public Acts of 2014
Approved by the Governor May 27, 2014 Filed with the Secretary of State May 27, 2014 EFFECTIVE DATE: May 27, 2014
STATE OF MICHIGAN 97TH LEGISLATURE REGULAR SESSION OF 2014
Introduced by Rep. LaFontaine
ENROLLED HOUSE BILL No. 5396
AN ACT to amend 1980 PA 299, entitled An act to revise, consolidate, and classify the laws of this state regarding the regulation of certain occupations and to regulate certain persons and activities relative to those occupations; to create a board for each of those occupations; to establish the powers and duties of certain departments and agencies and the boards of each occupation; to provide for the promulgation of rules; to provide for certain fees; to provide for penalties and civil fines; to establish rights, relationships, and remedies of certain persons under certain circumstances; to provide immunity from certain civil liability for certain entities and certain related occupations under certain circumstances; to repeal certain parts of this act on a specific date; and to repeal certain acts and parts of acts, by amending section 1110 (MCL 339.1110), as amended by 1988 PA 463.
The People of the State of Michigan enact:
Sec. 1110.
(1) The department shall license a barber college that meets all of the following requirements:
(a) Through its owners or managers, has applied to the department for a license.
(b) Provides an educational program requiring completion of 225 hours of classroom study, demonstrations, and recitations and 1,575 hours of practical barber training.
(c) Meets the sanitation standards required of barbershops as set forth in rules promulgated by the board and determined by inspection by the department.
(d) Files and maintains a corporate surety or cash bond of $10,000.00 conditioned on the faithful performance and satisfaction of the contractual rights of students enrolled in the barber college.
(e) Employs or contracts with not fewer than 2 full-time, licensed instructors and ensures that both of the following are met:
(i) At any time classroom study or theory training is given to any number of students, at least 1 instructor is present.
(ii) If practical training occurs, there is at least 1 instructor present for every 30 students at all times.
(f) Is completely partitioned from any other place of business or dwelling. A person shall not conduct any other business from a barber college than the rendering of barber services and the teaching of barbering, although a barber college may sell at retail to patrons those preparations used on patrons who are receiving barbering services from students.


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(g) Provides reasonable classroom facilities and other equipment for the proper instruction of students described in this subdivision and rules promulgated by the board, including 1 stationary wash basin with hot and cold running water and a connected drain for every 2 barber chairs. A barber college shall arrange its enrollment and course scheduling so that students are not required to share the use of a training station during any practical training period.
(2) Except as provided in this subsection, a student instructor may not instruct without a supervising instructor present in the room. In case of emergency, a student instructor may instruct up to 30 students, but the barber college shall provide notice of the emergency to the department in writing and ensure that an instructor is on the premises at all times. Use of a student instructor as a substitute instructor under this subsection shall not continue for more than 7 consecutive days without written approval of the department certifying the emergency circumstances.
(3) The license of a barber college is automatically revoked if there is a transfer of ownership or change of location of a barber college. The department shall not grant a new license to new owners or for a new location unless the requirements of subsection (1) are met.
(4) The classroom courses of a barber college shall include at least all of the following: scientific fundamentals for barbering; hygiene; bacteriology; histology of hair, skin, and nails; structure of the head, face, and neck, including muscles and nerves; elementary chemistry relating to sterilization and antiseptics; diseases of the skin, hair, glands, and nails; massaging and manipulating the head, face, and neck; haircutting and shaving; cosmetic therapy; arranging, styling, dressing, coloring, bleaching, curling, permanent waving, and tinting of the hair; elements of business training; and barber laws and rules of the state.
(5) The department by rule shall prescribe the number of hours of instruction a barber college is required to provide for each subject set forth in subsection (4). Each barber college shall provide a written copy of the rules to each student at the beginning of his or her instruction.
(6) A barber college shall display the license of the barber college and all instructors, student instructors, and students in a prominent place visible to the public at all times. An individuals license may be displayed at the individuals work station.
Enacting section 1. This amendatory act does not take effect unless Senate Bill No. 612 of the 97th Legislature is enacted into law.
This act is ordered to take immediate effect.


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Appendix I: Minnesota Bills
Session Law Calling for Creation of Task Force.
2014 Minnesota State Session Laws, Chapter 228, Article 5, Section 12 Sec. 12. FOREIGN TRAINED PHYSICIAN TASK FORCE.
(a) The commissioner of health shall appoint members to an advisory task force by July 1, 2014, to develop strategies to integrate refugee and asylee physicians into the Minnesota health care delivery system. The task force shall:
(1) analyze demographic information of current medical providers compared to the population of the state;
(2) identify, to the extent possible, foreign-trained physicians living in Minnesota who are refugees or asylees and interested in meeting the requirements to enter medical practice or other health careers;
(3) identify costs and barriers associated with integrating foreign-trained physicians into the state workforce;
(4) explore alternative roles and professions for foreign trained physicians who are unable to practice as physicians in the Minnesota health care system; and
(5) identify possible funding sources to integrate foreign-trained physicians into the state workforce as physicians or other health professionals.
(b) The commissioner shall provide assistance to the task force, within available resources.
(c) By January 15, 2015, the task force must submit recommendations to the commissioner of health. The commissioner shall report findings and recommendations to the legislative committees with jurisdiction over health care by January 15, 2015.


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Senate Bill 1049 (Not Passed).
A bill for an act relating to health; addressing barriers to integrating international medical graduates into the Minnesota health care delivery system; appropriating money; proposing coding for new law in Minnesota Statutes, chapter 144.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
Section 1. [144.1911] INTERNATIONAL MEDICAL GRADUATES ASSISTANCE PROGRAM.
Subdivision 1. Establishment. The international medical graduates assistance program is established to address barriers to practice and facilitate pathways to assist immigrant international medical graduates to integrate into the Minnesota health care delivery system, with the goal of increasing access to primary care in rural and under served areas of the state.
Subd. 2. Definitions.
(a) For the purposes of this section, the following terms have the meanings given.
(b) "Commissioner" means the commissioner of health.
(c) "Immigrant international medical graduate" means an international medical graduate who was born outside the United States, now resides permanently in the United States, and who did not enter the United States on a J1 or similar nonimmigrant visa following acceptance into a United States medical residency or fellowship program.
(d) "International medical graduate" means a physician who received a basic medical degree or qualification from a medical school located outside the United States and Canada.
(e) "Minnesota immigrant international medical graduate" means an immigrant international medical graduate who has lived in Minnesota for at least two years.
(f) "Rural community" means a city or township that is: (1) outside the seven-county metropolitan area as defined in section 473.121, subdivision 2; and (2) has a population under 15,000.
(g) "Underserved community" means a Minnesota area or population included in
the list of designated primary medical care health professional shortage areas, medically underserved areas, or medically underserved populations (MUPs) maintained and updated by the United States Department of Health and Human Services.
Subd. 3. Program administration.
(a) In administering the international medical graduates assistance program, the commissioner shall:
(1) provide overall coordination for the planning, development, and implementation of a comprehensive system for integrating qualified immigrant international medical graduates into the Minnesota health care delivery system, particularly those willing to


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serve in rural or underserved communities of the state;
(2) develop and maintain, in partnership with community organizations working with international medical graduates, a voluntary roster of immigrant international medical
graduates interested in entering the Minnesota health workforce, to assist in planning and program administration, including making available summary reports that show the aggregate number and distribution, by geography and specialty, of immigrant international
medical graduates in Minnesota;
(3) award grants to eligible nonprofit organizations to provide career guidance
and support services to immigrant international medical graduates seeking to enter the Minnesota health workforce. No grant shall exceed $500,000. Eligible activities under this program include the following:
(i) educational and career navigation, including information on training and licensing
requirements for physician and nonphysician health care professions, and guidance in
determining which pathway is best suited for an individual international medical graduate
based on the graduate's skills, experience, resources, and interests;
(ii) support in becoming proficient in medical English;
(iii) support in becoming proficient in the use of information technology, including
computer skills and use of electronic health record technology;
(iv) support for increasing knowledge of and familiarity with the United States health care system;
(v) support for other foundational skills identified by the commissioner;
(vi) support for immigrant international medical graduates in becoming certified by the Educational Commission on Foreign Medical Graduates, including help with
preparation for required licensing examinations and financial assistance for fees; and
(vii) assistance to international medical graduates in registering with the program's
Minnesota international medical graduate roster;
(4) award the initial round of grants under this program by December 2015;
(5) work with graduate clinical medical training programs to address barriers
faced by immigrant international medical graduates in securing residency positions in Minnesota, including the requirement that applicants for residency positions be recent graduates of medical school. The annual report required in subdivision 6 shall include any progress in addressing these barriers;
(6) develop a standardized assessment of the clinical readiness of eligible immigrant international medical graduates to serve in a residency program. The commissioner may


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initially develop assessments for clinical readiness to practice one or more primary care specialties, adding additional assessments as resources are available. The commissioner may contract with an independent entity or another state agency to conduct the assessment.
In order to be assessed for clinical readiness, eligible international medical graduates must have obtained certification from the Educational Commission on Foreign Medical Graduates;
(7) issue a Minnesota certificate of clinical readiness for residency to those who pass the assessment;
(8) develop a plan for the assessment and certification system by December 31, 2015, including proposed legislation, a proposed budget, and an implementation schedule that allows for assessment and certification of international medical graduates by July 1,
2017;
(9) award grants to support clinical preparation for Minnesota international medical graduates needing additional clinical preparation or experience to qualify for residency. A grant shall not exceed $750,000. The grant program shall include:
(i) proposed training curricula;
(ii) associated policies and procedures for clinical training sites, which must be part
of existing clinical medical education programs in Minnesota; and
(iii) monthly stipends for international medical graduate participants. Priority shall
be given to primary care sites in rural or underserved areas of the state, and international
medical graduate participants must commit to serving at least five years in a rural or
underserved community of the state;
(10) develop policies and procedures for the clinical preparation program by December 2015, including an implementation schedule that allows for grants to clinical preparation programs beginning in June 2016;
(11) award grants to support primary care residency positions designated for Minnesota immigrant physicians who are willing to serve in rural or underserved areas of the state. A grant shall not exceed $150,000 per residency position per year. The program shall include:
(i) a prerequisite that participating international medical graduates have lived in Minnesota for at least two years and are certified by the Educational Commission on
Foreign Medical Graduates and hold a Minnesota certificate of clinical readiness for
residency once such certificates become available;
(ii) a requirement that participants commit to providing primary care for at least five
years in a rural or underserved area of Minnesota;


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(iii) a requirement that participants commit to pay back a portion of program costs,
with those costs being determined by the commissioner; and
(iv) the option that the program include sponsored primary care residency positions,
if private funding is made available;
(12) explore and facilitate more streamlined pathways for immigrant international medical graduates to serve in nonphysician professions in the Minnesota workforce; and
(13) study, in consultation with the Board of Medical Practice and other stakeholders, changes necessary in health professional licensure and regulation to ensure full utilization of immigrant international medical graduates in the Minnesota health care delivery system. The commissioner shall include recommendations in the annual report required under subdivision 6 due January 1, 2017.
Subd. 4. Consultation with stakeholders. The commissioner shall administer the international medical graduates assistance program, in consultation with the following sectors:
(1) state agencies:
(i) Board of Medical Practice;
(ii) Office of Higher Education; and
(iii) Department of Employment and Economic Development;
(2) health care industry:
(i) a health care employer in a rural or underserved area of Minnesota;
(ii) a health insurer;
(iii) the Minnesota Medical Association;
(iv) licensed physicians experienced in working with international medical graduates; and
(v) the Minnesota Academy of Physician Assistants;
(3) community-based organizations:
(i) organizations serving immigrant and refugee communities of Minnesota; and
(ii) organizations serving the international medical graduate community, such as the
New Americans Alliance for Development and Women's Initiative for Self Empowerment;
(4) higher education:
(i) University of Minnesota;
(ii) Mayo Clinic School of Health Professions;
(iii) graduate medical education programs not located at the University of Minnesota
or Mayo Clinic School of Health Professions; and
(iv) Minnesota physician assistant education program; and
(5) two international medical graduates.


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Subd. 5. Board of Medical Practice. Nothing in this section alters the authority of the Board of Medical Practice to regulate the practice of medicine.
Subd. 6. Report. The commissioner shall submit an annual report to the chairs and ranking minority members of the legislative committees with jurisdiction over health care and higher education on the progress of the integration of international medical graduates into the Minnesota health care delivery system. The report shall be submitted by January 15 each year, beginning January 15, 2016.
Subd. 7. Voluntary hospital programs. A hospital may establish residency programs for foreign-trained physicians to become candidates for licensure to practice medicine in the state of Minnesota. A hospital may partner with organizations, such as the New Americans Alliance for Development to screen for and identify foreign-trained physicians eligible for a hospital's particular residency program.
Sec. 2. APPROPRIATION.
$....is appropriated in fiscal year 2016 and $.is appropriated in fiscal year
2017 from the general fund to the commissioner of health for the grant programs and operations described in Minnesota Statutes, section 144.1911. The commissioner shall develop recommendations for any additional funding required for initiatives needed to achieve the objectives of Minnesota Statutes, section 144.1911. The commissioner shall report the funding recommendations to the legislature by January 15, 2016.


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2016 State Statute (Passed).
144.1911 INTERNATIONAL MEDICAL GRADUATES ASSISTANCE PROGRAM.
Subdivision 1.Establishment.
The international medical graduates assistance program is established to address barriers to practice and facilitate pathways to assist immigrant international medical graduates to integrate into the Minnesota health care delivery system, with the goal of increasing access to primary care in rural and underserved areas of the state.
Subd. 2.Definitions.
(a) For the purposes of this section, the following terms have the meanings given.
(b) "Commissioner" means the commissioner of health.
(c) "Immigrant international medical graduate" means an international medical graduate who was bom outside the United States, now resides permanently in the United States, and who did not enter the United States on a J1 or similar nonimmigrant visa following acceptance into a United States medical residency or fellowship program.
(d) "International medical graduate" means a physician who received a basic medical degree or qualification from a medical school located outside the United States and Canada.
(e) "Minnesota immigrant international medical graduate" means an immigrant international medical graduate who has lived in Minnesota for at least two years.
(f) "Rural community" means a statutory and home rule charter city or township that is outside the seven-county metropolitan area as defined in section 473,121. subdivision 2. excluding the cities of Duluth, Mankato, Moorhead, Rochester, and St. Cloud.
(g) "Underserved community" means a Minnesota area or population included in the list of designated primary medical care health professional shortage areas, medically underserved areas, or medically underserved populations (MUPs) maintained and updated by the United States Department of Health and Human Services.
Subd. 3.Program administration.
In administering the international medical graduates assistance program, the commissioner shall:
(1) provide overall coordination for the planning, development, and implementation of a comprehensive system for integrating qualified immigrant international medical graduates into the Minnesota health care delivery system, particularly those willing to serve in rural or underserved communities of the state;
(2) develop and maintain, in partnership with community organizations working with international medical graduates, a voluntary roster of immigrant international medical graduates interested in entering the Minnesota health workforce to assist in planning and program administration, including making available summary reports that show the aggregate number and


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distribution, by geography and specialty, of immigrant international medical graduates in Minnesota;
(3) work with graduate clinical medical training programs to address barriers faced by immigrant international medical graduates in securing residency positions in Minnesota, including the requirement that applicants for residency positions be recent graduates of medical school. The annual report required in subdivision 10 shall include any progress in addressing these barriers;
(4) develop a system to assess and certify the clinical readiness of eligible immigrant international medical graduates to serve in a residency program. The system shall include assessment methods, an operating plan, and a budget. Initially, the commissioner may develop assessments for clinical readiness for practice of one or more primary care specialties, and shall add additional assessments as resources are available. The commissioner may contract with an independent entity or another state agency to conduct the assessments. In order to be assessed for clinical readiness for residency, an eligible international medical graduate must have obtained a certification from the Educational Commission of Foreign Medical Graduates. The commissioner shall issue a Minnesota certificate of clinical readiness for residency to those who pass the assessment;
(5) explore and facilitate more streamlined pathways for immigrant international medical graduates to serve in nonphysician professions in the Minnesota workforce; and
(6) study, in consultation with the Board of Medical Practice and other stakeholders, changes necessary in health professional licensure and regulation to ensure full utilization of immigrant international medical graduates in the Minnesota health care delivery system. The commissioner shall include recommendations in the annual report required under subdivision 10, due January 15, 2017.
Subd. 4.Career guidance and support services.
(a) The commissioner shall award grants to eligible nonprofit organizations to provide career guidance and support services to immigrant international medical graduates seeking to enter the Minnesota health workforce. Eligible grant activities include the following:
(1) educational and career navigation, including information on training and licensing requirements for physician and nonphysician health care professions, and guidance in determining which pathway is best suited for an individual international medical graduate based on the graduate's skills, experience, resources, and interests;
(2) support in becoming proficient in medical English;
(3) support in becoming proficient in the use of information technology, including computer skills and use of electronic health record technology;
(4) support for increasing knowledge of and familiarity with the United States health care system;
(5) support for other foundational skills identified by the commissioner;


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(6) support for immigrant international medical graduates in becoming certified by the Educational Commission on Foreign Medical Graduates, including help with preparation for required licensing examinations and financial assistance for fees; and
(7) assistance to international medical graduates in registering with the program's Minnesota international medical graduate roster.
(b) The commissioner shall award the initial grants under this subdivision by December 31,
2015.
Subd. 5.Clinical preparation.
(a) The commissioner shall award grants to support clinical preparation for Minnesota international medical graduates needing additional clinical preparation or experience to qualify for residency. The grant program shall include:
(1) proposed training curricula;
(2) associated policies and procedures for clinical training sites, which must be part of existing clinical medical education programs in Minnesota; and
(3) monthly stipends for international medical graduate participants. Priority shall be given to primary care sites in rural or underserved areas of the state, and international medical graduate participants must commit to serving at least five years in a rural or underserved community of the state.
(b) The policies and procedures for the clinical preparation grants must be developed by December 31, 2015, including an implementation schedule that begins awarding grants to clinical preparation programs beginning in June of 2016.
Subd. 6.International medical graduate primary care residency grant program and revolving account.
(a) The commissioner shall award grants to support primary care residency positions designated for Minnesota immigrant physicians who are willing to serve in rural or underserved areas of the state. No grant shall exceed $150,000 per residency position per year. Eligible primary care residency grant recipients include accredited family medicine, internal medicine, obstetrics and gynecology, psychiatry, and pediatric residency programs. Eligible primary care residency programs shall apply to the commissioner. Applications must include the number of anticipated residents to be funded using grant funds and a budget. Notwithstanding any law to the contrary, funds awarded to grantees in a grant agreement do not lapse until the grant agreement expires. Before any funds are distributed, a grant recipient shall provide the commissioner with the following:
(1) a copy of the signed contract between the primary care residency program and the participating international medical graduate;
(2) certification that the participating international medical graduate has lived in Minnesota for at least two years and is certified by the Educational Commission on Foreign Medical Graduates.


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Residency programs may also require that participating international medical graduates hold a Minnesota certificate of clinical readiness for residency, once the certificates become available; and
(3) verification that the participating international medical graduate has executed a participant agreement pursuant to paragraph (b).
(b) Upon acceptance by a participating residency program, international medical graduates shall enter into an agreement with the commissioner to provide primary care for at least five years in a rural or underserved area of Minnesota after graduating from the residency program and make payments to the revolving international medical graduate residency account for five years beginning in their second year of postresidency employment. Participants shall pay $15,000 or ten percent of their annual compensation each year, whichever is less.
(c) A revolving international medical graduate residency account is established as an account in the special revenue fund in the state treasury. The commissioner of management and budget shall credit to the account appropriations, payments, and transfers to the account. Earnings, such as interest, dividends, and any other earnings arising from fund assets, must be credited to the account. Funds in the account are appropriated annually to the commissioner to award grants and administer the grant program established in paragraph (a). Notwithstanding any law to the contrary, any funds deposited in the account do not expire. The commissioner may accept contributions to the account from private sector entities subject to the following provisions:
(1) the contributing entity may not specify the recipient or recipients of any grant issued under this subdivision;
(2) the commissioner shall make public the identity of any private contributor to the account, as well as the amount of the contribution provided; and
(3) a contributing entity may not specify that the recipient or recipients of any funds use specific products or services, nor may the contributing entity imply that a contribution is an endorsement of any specific product or service.
Subd. 7. Voluntary hospital programs.
A hospital may establish residency programs for foreign-trained physicians to become candidates for licensure to practice medicine in the state of Minnesota. A hospital may partner with organizations, such as the New Americans Alliance for Development, to screen for and identify foreign-trained physicians eligible for a hospital's particular residency program.
Subd. 8.Board of Medical Practice.
Nothing in this section alters the authority of the Board of Medical Practice to regulate the practice of medicine.
Subd. 9.Consultation with stakeholders.


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The commissioner shall administer the international medical graduates assistance program, including the grant programs described under subdivisions 4, 5, and 6, in consultation with representatives of the following sectors:
(1) state agencies:
(1) Board of Medical Practice;
(ii) Office of Higher Education; and
(iii) Department of Employment and Economic Development;
(2) health care industry:
(i) a health care employer in a rural or underserved area of Minnesota;
(ii) a health plan company;
(iii) the Minnesota Medical Association;
(iv) licensed physicians experienced in working with international medical graduates; and
(v) the Minnesota Academy of Physician Assistants;
(3) community-based organizations:
(i) organizations serving immigrant and refugee communities of Minnesota;
(ii) organizations serving the international medical graduate community, such as the New Americans Alliance for Development and Women's Initiative for Self Empowerment; and
(iii) the Minnesota Association of Community Health Centers;
(4) higher education:
(i) University of Minnesota;
(ii) Mayo Clinic School of Health Professions;
(iii) graduate medical education programs not located at the University of Minnesota or Mayo Clinic School of Health Professions; and
(iv) Minnesota physician assistant education programs; and
(5) two international medical graduates.
Subd. 10.Report.
The commissioner shall submit an annual report to the chairs and ranking minority members of the legislative committees with jurisdiction over health care and higher education on the progress of the integration of international medical graduates into the Minnesota health care delivery system. The report shall include recommendations on actions needed for continued progress integrating international medical graduates. The report shall be submitted by January 15 each year, beginning January 15, 2016.


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Appendix J: Missouri Bill
House Bill 1842.
97TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE FREDERICK.
AN ACT
To repeal sections 334.035, 334.104, and 334.735, RSMo, and to enact in lieu thereof four new sections relating to assistant physicians.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.035, 334.104, and 334.735, RSMo, are repealed and four new sections enacted in lieu thereof, to be known as sections 334.035, 334.036, 334.104, and 334.735, to read as follows:
334.035. Except as otherwise provided in section 334.036, every applicant for a permanent license as a physician and surgeon shall provide the board with satisfactory evidence of having successfully completed such postgraduate training in hospitals or medical or osteopathic colleges as the board may prescribe by rule.
334.036. 1. For purposes of this section, the following terms shall mean:
(1) "Assistant physician", any medical school graduate who:
(a) Is a resident and citizen of the United States or is a legal resident alien;
(b) Has successfully completed Step 1 and Step 2 of the United States Medical Licensing Examination or the equivalent of such steps of any other board-approved medical licensing examination within the eighteen-month period immediately preceding application for licensure as an assistant physician; and
(c) Has not entered into postgraduate residency training prescribed by rule of the board under section 334.035;
(d) Has proficiency in the English language;
EXPLANATION Matter enclosed in bold-faced brackets [thusjin the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language.
(2) "Assistant physician collaborative practice arrangement", an agreement between a physician and an assistant physician which meets the requirements of this section and section 334.104;
(3) "Medical school graduate", any person who has graduated from a medical college or osteopathic medical college described in section 334.031.2.


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2. (1) An assistant physician collaborative practice arrangement shall limit the assistant physician to providing only primary care services and only in medically underserved rural or urban areas of this state.
(2) For a physician-assistant physician team working in a rural health clinic under the federal Rural Health Clinic Services Act, P.L. 95-210, as amended:
(a) An assistant physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS); and
(b) No supervision requirements in addition to the minimum federal law shall be required.
3. (1) For purposes of this section, the licensure of assistant physicians shall take place within processes established by rules of the state board of registration for the healing arts. The board of healing arts is authorized to establish rules under chapter 536 establishing licensure and renewal procedures, supervision, collaborative practice arrangements, fees, and addressing such other matters as are necessary to protect the public and discipline the profession. An application for licensure may be denied or the licensure of an assistant physician may be suspended or revoked by the board in the same manner and for violation of the standards as se t forth by section
334.100, or such other standards of conduct set by the board by rule.
(2) Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority de legated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2014, shall be invalid and void.
4. An assistant physician shall clearly identify himself or herself as an assistant physician and shall be permitted to use the terms "doctor", "Dr." or "doc". No assistant physician shall practice or attempt to practice without an assistant physician collaborative practice arrangement, except as otherwise provided in this section and in an emergency situation.
5. The collaborating physician is responsible at all times for the oversight of the activities of, and accepts responsibility for, primary care services rendered by the assistant physician.
6. The provisions of section 334.104 shall apply to all assistant physician collaborative practice arrangements. To be eligible to practice as an assistant physician, a licensed assistant physician shall enter into an assistant physician collaborative practice arrangement within six months of his or her initial licensure and shall not have more than a six-month time period between collaborative practice arrangements during his or her licensure period. Any renewal of licensure under this section shall include verification of actual practice under a collaborative practice arrangement in accordance with this subsection during the immediately preceding licensure period.


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334.104. 1. A physician may enter into collaborative practice arrangements with physicians, physician assistants, or registered professional nurses. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, may delegate to [a] an assistant physician, physician assistant, or registered professional nurse the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the assistant physician, physician assistant, or registered professional nurse and is consistent with that assistant physician's, physician assistant's or nurse's skill, training and competence and the skill and training of the collaborating physician.
2. Collaborative practice arrangements, which shall be in writing, may delegate to:
(1) An assistant physician or physician assistant the authority to dispense or prescribe drugs and provide treatment to the extent permitted within the assistant physician's or physician assistant's scope of practice and licensure;
(2) A registered professional nurse the authority to administer, dispense or prescribe drugs and provide treatment if the registered professional nurse is an advanced practice registered nurse as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016, the authority to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of section 195.017; except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in Schedules III, IV, and V of section 195.017 for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty-hour supply without refill.
Such collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols or standing orders for the delivery of health care services.
3. The written collaborative practice arrangement shall contain at least the following provisions:
(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the assistant physician, physician assistant, or advanced practice registered nurse to prescribe;
(3) A requirement that there shall be posted at every office where the assistant physician, physician assistant, or advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an assistant physician, physician assistant, or advanced practice registered nurse and have the right to see the collaborating physician;


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(4) All specialty or board certifications of the collaborating physician and all certifications of the assistant physician, physician assistant, or advanced practice registered nurse;
(5) The manner of collaboration between the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse, including how the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse will:
(a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;
(b) Maintain geographic proximity, except the collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty-eight days per calendar year for rural health clinics as defined by P.L. 95-210, as long as the collaborative practice arrangement includes alternative plans as required in paragraph (c) of this subdivision. This exception to geographic proximity shall apply only to independent rural health clinics, provider-based rural health clinics where the provider is a critical access hospital as provided in 42 U.S.C. 1395i-4, and provider-based rural health clinics where the main location of the hospital sponsor is greater than fifty miles from the clinic. The collaborating physician is required to maintain documentation related to this requirement and to present it to the state board of registration for the healing arts when requested; and
(c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;
(6) A description of the assistant physician's, physician assistant's, or advanced practice registered nurse's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the assistant physician, physician assistant, or nurse to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence;
(7) A list of all other written practice agreements of the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(8) The duration of the written practice agreement between the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(9) A description of the time and manner of the collaborating physician's review of the assistant physician's, physician assistant's, or advanced practice registered nurse's delivery of health care services. The description shall include provisions that the assistant physician, physician assistant, or advanced practice registered nurse shall submit a minimum of ten percent of the charts documenting the assistant physician's, physician assistant's, or advanced practice registered nurse's delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every fourteen days; and


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(10) The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every fourteen days a minimum of twenty percent of the charts in which the assistant physician, physician assistant, or advanced practice registered nurse prescribes controlled substances. The charts reviewed under this subdivision may be counted in the number of charts required to be reviewed under subdivision (9) of this subsection.
4. The state board of registration for the healing arts pursuant to section 334.125 [and] in consultation with the board of nursing [pursuant to section 335.036 may jointly] shall promulgate rules regulating the use of collaborative practice arrangements for assistant physicians, physician assistants, and nurses. Such rules shall [be limited to specifying] specify geographic areas to be covered, the methods of treatment that may be covered by collaborative practice arrangements, the development and implementation of proficiency benchmarks and periodic skills assessment, and the requirements for review of services provided pursuant to collaborative practice arrangements, including delegating authority to prescribe controlled substances. Any rules relating to dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy.
Any rules relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the department of health and senior services and the state board of pharmacy. [In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of nursing may separately promulgate rules relating to collaborative practice arrangements. Such jointly promulgated rules shall be consistent with guidelines for federally funded clinics] The state board of registration for the healing arts shall promulgate one set of rules applicable to all three licensure categories, and shall not promulgate separate rules applicable to only one licensure category. Such promulgated rules shall be consistent with guidelines for federally funded clinics.
The rulemaking authority granted in this subsection shall not extend to collaborative practice arrangements of hospital employees providing inpatient care within hospitals as defined pursuant to chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
5. The state board of registration for the healing arts shall not deny, revoke, suspend or otherwise take disciplinary action against a physician for health care services delegated to [a] an assistant physician, physician assistant, or registered professional nurse provided the provisions of this section and the rules promulgated thereunder are satisfied. Upon the written request of a physician subject to a disciplinary action imposed as a result of an agreement between a physician and [a] an assistant physician, physician assistant, or registered professional nurse [or registered physician assistant], whether written or not, prior to August 28, 1993, all records of such disciplinary licensure action and all records pertaining to the filing, investigation or review of an alleged violation of this chapter incurred as a result of such an agreement shall be removed from the records of the state board of registration for the healing arts and the division of professional registration and shall not be disclosed to any public or private entity seeking such information from the board or the division. The state board of registration for the healing arts


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shall take action to correct reports of alleged violations and disciplinary actions as described in this section which have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his or her medical practice, physician completing forms or documents shall not be required to report any actions of the state board of registration for the healing arts for which the records are subject to removal under this section.
6. Within thirty days of any change and on each renewal, the state board of registration for the healing arts shall require every physician to identify whether the physician is engaged in any collaborative practice agreement, including collaborative practice agreements delegating the authority to prescribe controlled substances, [or physician assistant agreement] and also report to the board the name of each licensed professional with whom the physician has entered into such agreement. The board may make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such agreements to ensure that agreements are carried out for compliance under this chapter.
7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services without a collaborative practice arrangement provided that he or she is under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed. Nothing in this subsection shall be construed to prohibit or prevent a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into a collaborative practice arrangement under this section, except that the collaborative practice arrangement [may] shall not delegate the authority to prescribe any controlled substances listed in Schedules III, IV, and V of section 195.017.
8. A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent assistant physicians, physician assistants, or advanced practice registered nurses. Such limitation may include any three full-time equivalent combination of assistant physician, physician assistant, and advanced practice registered nurse, but shall not exceed a total of three full-time equivalents for all three categories combined. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
9. It is the responsibility of the collaborating physician to determine and document the completion of at least a one-month period of time during which the assistant physician, physician assistant, or advanced practice registered nurse shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. This limitation shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100 as of April 30,
2008.
10. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital as defined in section 197.020 if such


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protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.
11. No contract or other agreement shall require a physician to act as a collaborating physician for an assistant physician, physician assistant, or advanced practice registered nurse against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular assistant physician, physician assistant, or advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any assistant physician, physician assistant, or advanced practice registered nurse, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by hospital's medical staff.
12. No contract or other agreement shall require any assistant physician, physician assistant, or advanced practice registered nurse to serve as a collaborating advanced practice registered nurse for any collaborating physician against the assistant physician's, physician assistant's, or advanced practice registered nurse's will. An assistant physician, physician assistant, or advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician.
13. All assistant physicians, physician assistants, and advanced practice registered nurses in collaborative practice arrangements shall wear identification badges while acting within the scope of their collaborative practice agreement. The identification badges shall prominently display the licensure status of such assistant physicians, physician assistants,and advanced practice registered nurses.
334.735. 1. As used in sections 334.735 to 334.749, the following terms mean:
(1) "Applicant", any individual who seeks to become licensed as a physician assistant;
(2) "Certification" or "registration", a process by a certifying entity that grants recognition to applicants meeting predetermined qualifications specified by such certifying entity;
(3) "Certifying entity", the nongovernmental agency or association which certifies or registers individuals who have completed academic and training requirements;
(4) "Department", the department of insurance, financial institutions and professional registration or a designated agency thereof;
(5) "License", a document issued to an applicant by the board acknowledging that the applicant is entitled to practice as a physician assistant;
(6) "Physician assistant", a person who has graduated from a physician assistant program accredited by the American Medical Association's Committee on Allied Health Education and Accreditation or by its successor agency, who has passed the certifying examination administered by the National Commission on Certification of Physician Assistants and has active certification by the National Commission on Certification of Physician Assistants who provides health care services delegated by a licensed physician.


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A person who has been employed as a physician assistant for three years prior to August 28, 1989, who has passed the National Commission on Certification of Physician Assistants examination, and has active certification of the National Commission on Certification of Physician Assistants;
(7) "Physician assistant collaborative practice arrangement", an agreement between a physician and a physician assistant which meets the requirements of this section and section 334.104;
(8) "Recognition", the formal process of becoming a certifying entity as required by the provisions of sections 334.735 to 334.749[;(8) "Supervision", control exercised over a physician assistant working with a supervising physician and oversight of the activities of and accepting responsibility for the physician assistant's delivery of care. The physician assistant shall only practice at a location where the physician routinely provides patient care, except existing patients of the supervising physician in the patient's home and correctional facilities. The supervising physician must be immediately available in person or via telecommunication during the time the physician assistant is providing patient care. Prior to commencing practice, the supervising physician and physician assistant shall attest on a form provided by the board that the physician shall provide supervision appropriate to the physician assistant's training and that the physician assistant shall not practice beyond the physician assistant's training and experience. Appropriate supervision shall require the supervising physician to be working within the same facility as the physician assistant for at least four hours within one calendar day for every fourteen days on which the physician assistant provides patient care as described in subsection 3 of this section. Only days in which the physician assistant provides patient care as described in subsection 3 of this section shall be counted toward the fourteen-day period. The requirement of appropriate supervision shall be applied so that no more than thirteen calendar days in which a physician assistant provides patient care shall pass between the physician's four hours working within the same facility. The board shall promulgate rules pursuant to chapter 536 for documentation of joint review of the physician assistant activity by the supervising physician and the physician assistant],
2. (1) A supervision agreement shall limit the physician assistant to practice only [at locations described in subdivision (8) of subsection 1 of this section, where the supervising physician is no further than fifty miles by road using the most direct route available and where the location is not so situated as to create an impediment to effective intervention and supervision of patient care or adequate review of services] in accordance with this section and section 334.104.
(2) For a physician-physician assistant team working in a rural health clinic under the federal Rural Health Clinic Services Act, P.L. 95-210, as amended, no supervision requirements in addition to the minimum federal law shall be required.
3. The scope of practice of a physician assistant shall consist only of the following services and procedures:
(1) Taking patient histories;
(2) Performing physical examinations of a patient;


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(3) Performing or assisting in the performance of routine office laboratory and patient screening procedures;
(4) Performing routine therapeutic procedures;
(5) Recording diagnostic impressions and evaluating situations calling for attention of a physician to institute treatment procedures;
(6) Instructing and counseling patients regarding mental and physical health using procedures reviewed and approved by a licensed physician;
(7) Assisting the [supervising] collaborating physician in institutional settings, including reviewing of treatment plans, ordering of tests and diagnostic laboratory and radiological services, and ordering of therapies, using procedures reviewed and approved by a licensed physician;
(8) Assisting in surgery; and
(9) Performing such other tasks not prohibited by law under the supervision of a licensed physician as the physician's assistant has been trained and is proficient to perform
[; and(10)] Physician assistants shall not perform or prescribe abortions.
4. Physician assistants shall not prescribe nor dispense any drug, medicine, device or therapy unless pursuant to a physician [supervision agreement] collaborative practice arrangement in accordance with the law, nor prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the measurement of visual power or visual efficiency of the human eye, nor administer or monitor general or regional block anesthesia during diagnostic tests, surgery or obstetric procedures. Prescribing and dispensing of drugs, medications, devices or therapies by a physician assistant shall be pursuant to a physician assistant [supervision agreement] collaborative practice arrangement which is specific to the clinical conditions treated by the [supervising] collaborating physician and the physician assistant shall be subject to the following:
(1) A physician assistant shall only prescribe controlled substances in accordance with section 334.747;
(2) The types of drugs, medications, devices or therapies prescribed or dispensed by a physician assistant shall be consistent with the scopes of practice of the physician assistant and the [supervising] collaborating physician;
(3) All prescriptions shall conform with state and federal laws and regulations and shall include the name, address and telephone number of the physician assistant and the [supervising] collaborating physician;
(4) A physician assistant, or advanced practice registered nurse as defined in section 335.016 may request, receive and sign for noncontrolled professional samples and may distribute professional samples to patients;
(5) A physician assistant shall not prescribe any drugs, medicines, devices or therapies the supervising physician is not qualified or authorized to prescribe; and
(6) A physician assistant may only dispense starter doses of medication to cover a periodof time for seventy-two hours or less.
5. A physician assistant shall clearly identify himself or herself as a physician assistant and shall not use or permit to be used in the physician assistant's behalf the terms "doctor", "Dr." or "doc"


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nor hold himself or herself out in any way to be a physician or surgeon. No physician assistant shall practice or attempt to practice without physician supervision or in any location where the [supervising] collaborating physician is not immediately available for consultation, assistance and intervention, except as otherwise provided in this section, and in an emergency situation, nor shall any physician assistant bill a patient independently or directly for any services or procedure by the physician assistant.
6. For purposes of this section, the licensing of physician assistants shall take place within processes established by the state board of registration for the healing arts through rule and regulation. The board of healing arts is authorized to establish rules pursuant to chapter 536 establishing licensing and renewal procedures, supervision, [supervision agreements] collaborative practice arrangements, fees, and addressing such other matters as are necessary to protect the public and discipline the profession. An application for licensing may be denied or the license of a physician assistant may be suspended or revoked by the board in the same manner and for violation of the standards as set forth by section 334.100, or such other standards of conduct set by the board by rule or regulation. Persons licensed pursuant to the provisions of chapter 335 shall not be required to be licensed as physician assistants. All applicants for physician assistant licensure who complete a physician assistant training program after January 1, 2008, shall have a master's degree from a physician assistant program.
7. ["Physician assistant supervision agreement" means a written agreement, jointly agreed-upon protocols or standing order between a supervising physician and a physician assistant, which provides for the delegation of health care services from a supervising physician to a physician assistant and the review of such services. The agreement shall contain at least the following provisions:
(1) Complete names, home and business addresses, zip codes, telephone numbers, and 126 state license numbers of the supervising physician and the physician assistant;
(2) A list of all offices or locations where the physician routinely provides patient care, and in which of such offices or locations the supervising physician has authorized the physician assistant to practice;
(3) All specialty or board certifications of the supervising physician;
(4) The manner of supervision between the supervising physician and the physician assistant, including how the supervising physician and the physician assistant shall:
(a) Attest on a form provided by the board that the physician shall provide supervision appropriate to the physician assistant's training and experience and that the physician assistant shall not practice beyond the scope of the physician assistant's training and experience nor the supervising physician's capabilities and training; and
(b) Provide coverage during absence, incapacity, infirmity, or emergency by the supervising physician;
(5) The duration of the supervision agreement between the supervising physician and physician assistant; and


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(6) A description of the time and manner of the supervising physician's review of the physician assistant's delivery of health care services. Such description shall include provisions that the supervising physician, or a designated supervising physician listed in the supervision agreement review a minimum of ten percent of the charts of the physician assistant's delivery of health care services every fourteen days] The provisions of section 334.104 shall apply to all physician assistant collaborative practice arrangements.
8. When a physician assistant supervision agreement is utilized to provide health care services for conditions other than acute self-limited or well-defined problems, the supervising physician or other physician designated in the supervision agreement shall see the patient for evaluation and approve or formulate the plan of treatment for new or significantly changed conditions as soon as practical, but in no case more than two weeks after the patient has been seen by the physician assistant.
9. At all times the physician is responsible for the oversight of the activities of, and accepts responsibility for, health care services rendered by the physician assistant.
10. It is the responsibility of the [supervising] collaborating physician to determine and document the completion of at least a one-month period of time during which the licensed physician assistant shall practice with a [supervising] collaborating physician continuously present before practicing in a setting where a [supervising] collaborating physician is not continuously present.
11. No contract or other agreement shall require a physician to act as a supervising physician for a physician assistant against the physician's will. A physician shall have the right to refuse to act as a supervising physician, without penalty, for a particular physician assistant. No contract or other agreement shall limit the supervising physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any physician assistant, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by the hospital's medical staff.
12. Physician assistants shall file with the board a copy of their supervising physician form.
13. No physician shall be designated to serve as supervising physician for more than three fulltime equivalent licensed physician assistants. This limitation shall not apply to physician assistant agreements of hospital employees providing inpatient care service in hospitals as defined in chapter 197.


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Appendix K: Washington Bill
House Bill 1445.
CERTIFICATION OF ENROLLMENT SUBSTITUTE HOUSE BILL 1445 65th Legislature 2017 Regular Session Passed by the House April 18, 2017 Yeas 68 Nays 28
Passed by the Senate April 12, 2017 Yeas 45 Nays 4
(originally sponsored by Representatives Ortiz-Self, Stambaugh, Santos, Orwall, Harris, Caldier, Springer, Appleton, Lytton, Condotta, Fey, Pollet, Goodman, Slatter, Bergquist, Maori, Doglio, and Kagi)
AN ACT Relating to dual language in early learning and K-12 2 education; adding a new section to chapter 28A.630 RCW; adding a new section to chapter 28A.300 RCW; adding a new section to chapter 28A.180 RCW; adding a new section to chapter 43.215 RCW; creating new sections; and providing expiration dates.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1. (1) The legislature finds that it should review and revise the K-12 educational program taking into consideration the needs of students as they evolve. In Washington state, immigrant students whose first language is not English represent a significant part of evolving and more diverse school demographics. The legislature finds that Washington's educator workforce in school districts has not evolved in a manner consistent with changing student demographics. Thus, more and more schools are without the capacity to meet the needs of English learners and without the capacity to communicate effectively with parents whose 17 first language is not English.
(2) The legislature finds that:
(a) Between 1986 and 2016, the number of students served in the state's transitional bilingual instruction program increased from fifteen thousand twenty-four to one hundred eighteen thousand five hundred twenty-six, an increase of six hundred eighty-nine percent, and that two-thirds of the students were native Spanish speakers; the next ten most common languages were Russian, Vietnamese, Somali, Chinese, Arabic, Ukrainian, Tagalog, Korean, Marshallese, and Punjabi;
(b) In the 2015-16 school year, forty-six percent of instructors in the state's transitional bilingual instruction program were instructional aides, or paraeducators, not certificated teachers; and (c) Eleven percent of students in the transitional bilingual instruction program received instruction in their native language in the 2015-16 school


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year, and research shows that non-English speaking students develop academic proficiency in English more quickly when they are provided instruction in their native language initially.
(3) The legislature showed its commitment to equity in education by passing legislation creating a seal of biliteracy, requiring world language for high school graduation, easing the transitions of English learners, encouraging training for staff in cultural competence, monitoring the racial and ethnic data of teachers, and funding the creation of K-12 dual language programs.
(4) However, the legislature finds it is necessary to better serve non-English speaking students by addressing and closing the significant language and instructional gaps that hinder English learners from meeting the state's rigorous educational standards.
(5) Thus, the legislature intends to establish a comprehensive approach to support English learners by creating grant programs to:
(a) Expand dual language programs for elementary and secondary students; and
(b) recruit bilingual individuals to become educators who are able to provide instruction in, and support for, dual language programs.
NEW SECTION. Sec. 2. A new section is added to chapter 28A.630 RCW to read as follows:
(1) (a) The K-12 dual language grant program is created to grow capacity for high quality dual language learning in the common schools and in state-tribal compact schools.
(b) A dual language program is an instructional model that provides content-based instruction to students in two languages: English and a target language other than English spoken in the local community, for example Spanish, Somali, Vietnamese, Russian, Arabic, native languages, or indigenous languages. The goal of the program is for students to eventually become proficient and literate in both 2 languages, while also meeting high academic standards in all subject 3 areas. Typically, programs begin at kindergarten or first grade and continue through at least elementary school. Two-way dual language programs begin with a balanced number of native and nonnative speakers of the target language so that both groups of students serve in the role of language modeler and language learner at different times. One-way dual language programs serve only nonnative English speakers.
(2) (a) The office of the superintendent of public instruction shall develop and administer the grant program.
(b) Subject to the availability of amounts appropriated for this specific purpose, by October 1, 2017, the office of the superintendent of public instruction must award grants of up to two hundred thousand dollars each through a competitive process to school districts or state-tribal compact schools proposing to:
(i) Establish a two-way dual language program or a one-way dual language program in a school with predominantly English learners; or


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requirements as developed by their local implementation team, which consists of staff from their school district and the partnering two year and four-year college faculty.
(7) In order to avoid loan repayment, students must (a) earn their baccalaureate degree and certification needed to serve as a teacher or professional guidance counselor; and (b) teach or serve as a counselor in their educational service district region for at least 3 five years. Students who do not meet the repayment terms in this subsection are subject to repaying all or part of the financial aid they receive for college unless students are recipients of funding provided through programs such as the state need grant program or the college bound scholarship program.
(8) Grantees must work with the professional educator standards board to draft the report required in section 6 of this act.
(9) The professional educator standards board may adopt rules to implement this section.
NEW SECTION. Sec. 5. A new section is added to chapter 43.215 RCW to read as follows:
(1) The department of early learning must work with community partners to support outreach and education for parents and families around the benefits of native language development and retention, as well as the benefits of dual language learning. Native language means the language normally used by an individual or, in the case of a child or youth, the language normally used by the parents or family of the child or youth. Dual language learning means learning in two languages, generally English and a target language other than English spoken in the local community, for example Spanish, Somali, Vietnamese, Russian, Arabic, native languages, or indigenous languages where the goal is bilingualism.
(2) Within existing resources, the department must create training and professional development resources on dual language learning, such as supporting English learners, working in culturally and linguistically diverse communities, strategies for family engagement, and cultural responsiveness. The department must design the training modules to be culturally responsive.
(3) Within existing resources, the department must support dual language learning communities for teachers and coaches.
(4) The department may adopt rules to implement this section.
NEW SECTION. Sec. 6. (1) By December 1, 2019, subject to the availability of amounts appropriated for this specific purpose and in compliance with RCW 43.01.036, the office of the superintendent of public instruction and the professional educator standards board must submit a combined report to the appropriate committees of the legislature that:
(a) Details the successes, best practices, lessons learned, and outcomes of the grant programs described in this act; and
(b) Describes how the K-12 education system has met the goals of each grant program and expanded their capacities to support dual language models of instruction because of this act, that is, how many more children were educated in dual language classrooms as a result of the grants in this act.


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(2) This section expires July 1, 2020.
NEW SECTION. Sec. 7. If specific funding for the purposes of this act, referencing this act by bill or chapter number, is not provided by June 30, 2017, in the omnibus appropriations act, this act is null and void. END


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(ii) expand a recently established two-way dual language program or a one-way dual language program in a school with predominantly English learners. When awarding a grant to a school district or a state-tribal compact school proposing to establish a dual language program in a target language other than Spanish, the office must provide a bonus of up to twenty thousand dollars.
(c) The office of the superintendent of public instruction must identify criteria for awarding the grants, evaluate applicants, and award grant money. The office must select grantees that represent sufficient geographic, demographic, and enrollment diversity to produce meaningful data for the report required in section 6 of this act. The application must require, among other things, that the applicant describe:
(i) How the program will serve the applicant's English learner population;
(ii) the number of classrooms that the applicant expects to add with the grant money;
(iii) the planned use of the grant money;
(iv) the applicant's plan for student enrollment and outreach to families who speak the target language;
(v) the applicant's plan to recruit and support bilingual paraeducators, classified staff, parents, and high school students to become bilingual teachers in the district or state-tribal compact school;
(vi) the applicant's commitment to, and plan for, sustaining a dual language program beyond the grant period; and
(vii) whether the school district board of directors or the governing body of a state-tribal compact school has expressed support for dual language programs.
(d) The grant money must be used for dual language program start-up and expansion costs, such as staff and teacher training, teacher recruitment, development and implementation of a dual language learning model and curriculum, and other costs identified in the application as key for start-up. The grant money may not be used for ongoing program costs.
(3) The grant period is two years. At the end of the grant period, the grantees must work with the office of the superintendent of public instruction to draft the report required in section 6 of this act.
(4) The office of the superintendent of public instruction must notify school districts and state-tribal compact schools of the grant program established under this section and provide ample time for the application process.
(5) The superintendent of public instruction may adopt rules to implement this section. 19
(6) This section expires July 1, 2020.20 21
NEW SECTION. Sec. 3. A new section is added to chapter 28A.300 RCW to read as follows:


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(1) Within existing resources, the office of the superintendent of public instruction shall facilitate dual language learning cohorts for school districts and state-tribal compact schools establishing or expanding dual language programs. The office must provide technical assistance and support to school districts and state-tribal compact schools implementing dual language programs, including those establishing or expanding dual language programs under section 1 of this act.
(2) The superintendent of public instruction may adopt rules to implement this section.
NEW SECTION. Sec. 4. A new section is added to chapter 28A.180 RCW to read as follows: In 2017, funds must be appropriated for the purposes in this section.
(1) The professional educator standards board, beginning in the 2017-2019 biennium, shall administer the bilingual educator initiative, which is a long-term program to recruit, prepare, and mentor bilingual high school students to become future bilingual teachers and counselors.
(2) Subject to the availability of amounts appropriated for this specific purpose, pilot projects must be implemented in one or two school districts east of the crest of the Cascade mountains and one or two school districts west of the crest of the Cascade mountains, where immigrant students are shown to be rapidly increasing. Districts selected by the professional educator standards board must partner with at least one two-year and one four-year college in planning and implementing the program. The professional educator standards board shall provide oversight.
(3) Participating school districts must implement programs, including:
(a) An outreach plan that exposes the program to middle school students and recruits them to enroll in the program when they begin their ninth grade of high school;
(b) activities in ninth and tenth grades that help build student agency, such as self-confidence and awareness, while helping students to develop academic mind-sets needed for high school and college success; the value and benefits of teaching and counseling as careers; and introduction to leadership, civic engagement, and community service;
(c) credit-bearing curricula in grades eleven and twelve that include mentoring, shadowing, best practices in teaching in a multicultural world, efficacy and practice of dual language instruction, social and emotional learning, enhanced leadership, civic engagement, and community service activities.
(4) There must be a pipeline to college using two-year and four-year college faculty and consisting of continuation services for program participants, such as advising, tutoring, mentoring, financial assistance, and leadership.
(5) High school and college teachers and counselors must be recruited and compensated to serve as mentors and trainers for participating students.
(6) After obtaining a high school diploma, students qualify to receive conditional loans to cover the full cost of college tuition, fees, and books. To qualify for funds, students must meet program



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