SB 5
Department of Legislative Services
Maryland General Assembly
2021 Session
FISCAL AND POLICY NOTE
Third Reader - Revised
Senate Bill 5 (Senator Griffith, et al.)
Finance and Budget and Taxation Health and Government Operations
Public Health - Implicit Bias Training and the Office of Minority Health and
Health Disparities
This bill requires applicants for the renewal of a license or certificate issued by a health
occupations board to attest to completion of an approved implicit bias training program the
first time they renew their license or certificate after April 1, 2022. Beginning in
fiscal 2023, the Governor must include in the annual budget bill an appropriation for the
Office of Minority Health and Health Disparities (OMHHD) that is the greater of either
$1,788,314 or 0.012% of the total funds appropriated to the Maryland Department of
Health (MDH) in that fiscal year. OMHHD must publish on its website (and update at least
every six months) health data that includes race and ethnicity information it collects.
Fiscal Summary
State Effect: MDH general and special fund expenditures increase by an indeterminate
amount in FY 2022 only to implement the bill’s implicit bias training requirements, as
discussed below. General fund expenditures increase by $290,500 in FY 2023 to meet the
mandated appropriation. Future years reflect growth in the MDH appropriation. Revenues
are not affected. This bill establishes a mandated appropriation beginning in FY 2023.
(in dollars) FY 2022 FY 2023 FY 2024 FY 2025 FY 2026
Revenues $0 $0 $0 $0 $0
GF Expenditure - 290,500 375,800 464,500 556,800
SF Expenditure - 0 0 0 0
Net Effect $0 ($290,500) ($375,800) ($464,500) ($556,800)
Note:() = decrease; GF = general funds; FF = federal funds; SF = special funds; - = indeterminate increase; (-) = indeterminate decrease
Local Effect: None.
Small Business Effect: Minimal.
 Analysis
Bill Summary: The Cultural and Linguistic Health Care Professional Competency
Program, in coordination with OMHHD, must identify and approve implicit bias training
programs that must be recognized by a health occupations board or accredited by the
Accreditation Council for Continuing Medical Education (ACCME).
The bill specifies the intent of the General Assembly that OMHHD supplement funds from
the mandated appropriation with funding from federal and special fund sources. By
October 1 each year, OMHHD must report on its efforts to obtain federal and special
funding and the amount of any such funding received.
The bill requires that the Health Care Disparities Policy Report Card published by
OMHHD include the racial and ethnic disparities in morbidity and mortality rates for
dementia.
Current Law:
Implicit Bias Training for Health Care Professionals Involved in Perinatal Care
Chapter 337 of 2020 requires the Cultural and Linguistic Health Care Professional
Competency Program to establish and provide an evidence-based implicit bias training
program for health care professionals involved in perinatal care of patients. By
January 1, 2021, the program must establish the implicit-bias training program, and by
January 1, 2022, and at least once every two years thereafter, health care professionals
involved in the care of patients at a perinatal care facility must complete the training.
Cultural and Linguistic Health Care Provider Competency Program
Chapter 414 of 2009 established a voluntary Cultural and Linguistic Health Care Provider
Competency Program to offer classes to health care providers on cultural and linguistic
competency. The program must work collaboratively with universities and colleges of
medicine, nursing, pharmacy, and dentistry and other health care professional training
programs to develop courses with cultural competency, sensitivity, and health literacy that
are designed to address the problems of racial and ethnic disparities in health care access,
utilization, treatment decisions, quality, and outcomes.
Health Care Disparities Policy Report Card
OMHHD must, in collaboration with the Maryland Health Care Commission (MHCC),
publish annually on the MDH website and provide in writing on request a Health Care
Disparities Policy Report Card that includes (1) an analysis of racial and ethnic variations
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in insurance coverage for low-income, nonelderly individuals; (2) the racial and ethnic
composition of the physician population compared to the racial and ethnic composition of
the State’s population; and (3) the racial and ethnic disparities in morbidity and mortality
rates for cardiovascular disease, cancer, diabetes, HIV/AIDS, infant mortality, asthma, and
other diseases identified by MHCC.
For more general information about OMHHD and health disparities in Maryland, see the
Appendix – Health Disparities.
State Expenditures:
Impact on Health Occupations Boards
The bill requires each applicant for renewal of a health occupations license or certificate to
attest in the renewal application that the applicant has completed an approved implicit bias
training program. This attestation must happen on a one-time basis at the first renewal
occurring after April 1, 2022. In total, the 20 health occupations boards renewed
116,045 licenses in fiscal 2019 and 98,997 licenses in fiscal 2020, plus an additional
unknown number of certificates. As most renewals are processed electronically, the boards
must alter online renewal systems to include the required attestation or implement
alternative processes for collecting attestations for all renewals occurring after
April 1, 2022. While 18 boards are special funded, two are general funded. Thus, general
and special fund expenditures for the health occupations boards increase by an
indeterminate but potentially significant amount in fiscal 2022 to prepare for collection of
attestations.
Impact on the Office of Minority Health and Health Disparities and the Cultural and
Linguistic Health Care Professional Competency Program
While the Cultural and Linguistic Health Care Professional Competency Program is
already required to establish and provide an evidence-based implicit bias training program
for health care professionals involved in perinatal care, the bill requires the program, in
coordination with OMHHD, to identify and approve implicit bias training programs that
are recognized by a health occupations board or accredited by ACCME that are available
for all 20 health occupations boards with a diverse range of licensees and certificate
holders. Identification and approval of training programs must also take place soon after
the effective date of the bill in order for individuals renewing their licenses and certificates
to take the course prior to their first renewal after April 1, 2022 (six months after the bill’s
effective date). Thus, MDH general fund expenditures may increase by an indeterminate
amount in fiscal 2022 only for contractual assistance to identify and approve implicit bias
training programs for all 20 health occupations boards.
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OMHHD is currently required, among other duties, to collect and analyze relevant data;
serve as a clearinghouse for information about health disparities data; and, in collaboration
with MHCC, publish an annual report card. (However, the Department of Legislative
Services notes that a report card was last produced in 2010.) OMHHD staff includes a
part-time (75%) epidemiologist. Thus, this analysis assumes that OMHHD can publish on
its website health data that includes race and ethnicity information collected by the office
and update such data at least once every six months, expand any future report card to
include information on the racial and ethnic disparities in morbidity and mortality rates for
dementia, and report on efforts to obtain federal and special funding using existing
budgeted resources, particularly if, as MDH advises may be necessary, a vacant but funded
research statistician position is filled. To the extent additional assistance is required, MDH
general fund expenditures increase to provide contractual assistance.
Mandated Appropriation
MDH general fund expenditures increase by $290,525 in fiscal 2023, increasing to
$556,849 in fiscal 2026, to meet the mandated appropriation. The fiscal 2021 allowance
includes $1,788,314 for OMHHD ($1.62 million in general funds and $169,676 in federal
funds), which equates to 0.012% of the total fiscal 2021 allowance for MDH
($15.1 billion). The Governor’s proposed fiscal 2022 budget includes $1,655,379 in
general funds for OMHHD, which equates to 0.01% of the total fiscal 2022 allowance for
MDH ($16.9 billion). This estimate is based on the following information and assumptions:
 On average, the MDH allowance increased by 4.1% annually between fiscal 2017
and 2021.
 Assuming this rate of growth continues, the total MDH allowance will be
$17.6 billion in fiscal 2023, increasing to $19.8 billion by fiscal 2026.
 The mandated appropriation under the bill must be the greater of $1,788,314 or
0.012% of the total MDH appropriation.
 In fiscal 2023, 0.012% of the projected MDH allowance will be $2,078,839,
increasing to $2,345,163 by fiscal 2026.
 The annual impact on general fund expenditures reflects the difference between the
projected 0.012% of the MDH allowance and $1,788,314.
 Despite lower funding in fiscal 2022 for OMHHD, funding for fiscal 2023 is
assumed to otherwise be equivalent to funding provided in fiscal 2021.
 General funds must be used to meet the mandate since the bill specifies legislative
intent that federal and special funds supplement the mandated appropriation.
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 Additional Information
Prior Introductions: None.
Designated Cross File: HB 28 (Delegates Pena-Melnyk and R. Lewis) - Health and
Government Operations.
Information Source(s): Department of Budget and Management, Maryland Department
of Health, Department of Legislative Services
Fiscal Note History: First Reader - January 22, 2021
rh/ljm Third Reader - March 11, 2021
Revised - Amendment(s) - March 11, 2021
Analysis by: Jennifer B. Chasse Direct Inquiries to:
(410) 946-5510
(301) 970-5510
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 Appendix – Health Disparities
Racial and ethnic minorities are more likely to experience poor health outcomes as a
consequence of their social determinants of health, including access to health care,
education, employment, economic stability, housing, public safety, and neighborhood and
environmental factors. A broad body of research has quantified the existence of health
disparities between Black, Hispanic, and Native American individuals and their White
counterparts, including a greater risk of heart disease, stroke, infant mortality, maternal
mortality, lower birth weight, obesity, hypertension, type 2 diabetes, cancers, respiratory
diseases, and autoimmune diseases.
Health Disparities in Maryland
Data consistently shows ongoing and in some cases growing health disparities in Maryland,
including the impact of COVID-19, maternal and infant mortality, incidence of HIV, and
emergency room (ER) visits for substance use, asthma, diabetes, and hypertension. For
example:
 While Black individuals comprise 29.8% of the Maryland population, they represent
36% of COVID-19 deaths as of January 18, 2021.
 Maryland’s maternal mortality rate for Black women is 3.7 times that of
White women, and the racial disparity has widened in recent years.
 Maryland’s infant mortality rate for all races/ethnicities has remained level but
remains highest (10.2 per 1,000 in 2018) among the Black non-Hispanic population,
nearly 2.5 times higher than the rate for the White non-Hispanic population.
 The incidence of HIV for all races/ethnicities has generally declined in Maryland;
although the incidence among the Black non-Hispanic population
(49.0 per 100,000) remains 2.4 times that of the total population.
 In 2017, ER visits for the Black non-Hispanic population compared with all
races/ethnicities were 50% higher for substance use disorder; nearly 200% higher
for asthma-related ER visits; 86% higher for diabetes-related ER visits; and
89% higher for hypertension-related ER visits.
Maryland Office of Minority Health and Health Disparities
A central effort to address health disparities in Maryland was the establishment of the
Office of Minority Health and Health Disparities (OMHHD) in the Maryland Department
of Health (MDH) in 2004. The purpose of the office is to address social determinants of
health and eliminate health disparities by leveraging resources, providing health equity
consultation, impacting external communications, guiding policy decisions, and
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influencing strategic direction on behalf of the Secretary of Health. The office provides
grants and technical assistance to community-based organizations, collects data on race
and ethnicity, and targets programs and initiatives to three health conditions that
disproportionately impact minorities in Maryland: infant mortality, asthma, and
diabetes/prediabetes. The office’s Minority Outreach and Technical Assistance Program
provides grant funding for activities such as coordination and navigation of health care
services, access to community-based health education, linkage to health insurance
enrollment and social services, and self-management support through home visiting. In
2006 and 2010, the office prepared a Maryland Plan to Eliminate Minority Health
Disparities.
Other Major Efforts to Address Health Disparities Since 2004
In January 2010, the Maryland Health Care Commission (MHCC) and OMHHD produced
a Health Care Disparities Policy Report Card. The report card examined racial and ethnic
distribution of Maryland physicians compared to the Maryland population and found that
Black/African American, Hispanic/Latino, and American Indians/Native Americans were
underrepresented in the physician workforce and in graduating classes from Maryland
medical schools.
Other legislative efforts to address health disparities have focused on workforce
development for health care providers, including convening a Workgroup on Cultural
Competency and Workforce Development for Mental Health Professionals; establishing a
Cultural and Linguistic Health Care Provider Competency Program; facilitating the
workforce development, training, and certification of community health workers; requiring
health occupations boards to report on efforts to educate regulated individuals regarding
reducing and eliminating racial and ethnic disparities, improving health literacy, improving
cultural and linguistic competency, and achieving racial and ethnic health equity; and
requiring evidence-based implicit bias training for perinatal health care professionals.
In recent years, legislative initiatives regarding health disparities have focused on maternal
and child health, including requiring a study on the mortality rates of African American
infants and infants in rural areas, requiring MDH to establish a Maternal Mortality
Stakeholder Group to examine issues resulting in disparities in maternal deaths, and
requiring the Maternal Mortality Review Program to make recommendations to reduce
disparities in the maternal mortality rate (including recommendations related to social
determinants of health) and to include information on racial disparities in its annual report.
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Senate President’s Advisory Workgroup on Equity and Inclusion
In August 2020, the President of the Senate appointed a Senate workgroup to address
environmental justice, health care disparities, and wealth and economic opportunity for
minority Marylanders. The workgroup issued a report in January 2021, which includes
recommendations relating to health disparities, including:
 requiring the director of OMHHD to meet with MHCC and MDH at least
once annually to examine the collection of health data that includes race and
ethnicity information and identify any changes for improving such data;
 requiring OMHHD to prepare an updated plan to eliminate minority health
disparities and requiring MHCC to prepare a revised health care disparities policy
report card;
 extending Medicaid coverage for pregnant women until 12 months postpartum and
providing care coordination and health literacy education for individuals as they
transition from Medicaid coverage;
 establishing a standing Maternal and Child Health Committee in MDH to develop
a Blueprint for Maternal and Child Health;
 ensuring that all pregnant women receive comprehensive prenatal care by increasing
awareness of and access to resources for all women, including establishing an
emergency program that covers prenatal care for undocumented immigrants;
 assessing certified nurse midwife privileges in Maryland hospitals and developing
recommendations with major stakeholders;
 establishing a Medicaid Doula Pilot Program in two counties;
 taking actions to increase the number of minority health care providers;
 requiring the Cultural and Linguistic Health Care Professional Competency
Program to identify and approve implicit bias training programs for all individuals
licensed and certi