California doctors’ long-held opposition to nurse practitioners expanding their scope of practice into areas now reserved exclusively for doctors has become even more intense with the growing evidence that medical technology enhanced by artificial intelligence can play a much bigger role in health care. Nurse practitioners with such powerful tools could conceivably supplant doctors in many areas of medicine.

But state lawmakers — concerned about California’s increasingly severe physician shortage — seem ready for big changes. Last month, the Assembly Business and Professions Committee voted 16-0 for Assembly Bill 890, by Assemblyman Jim Wood, D-Healdsburg. It would allow properly certified nurse practitioners to order and interpret diagnostic procedures and to prescribe some drugs, among other duties, without supervision by a medical doctor.

In 2013 and 2015, bills expanding nurse practitioners’ scope of duties passed the Senate before dying in the Assembly. That makes the unanimous Assembly committee vote look even more significant.

The committee first heard testimony about the findings of the California Future Health Workforce Commission, which warns the state faces a shortage of 4,100 doctors in coming years. In February, the commission — chaired by University of California President Janet Napolitano — urged California to join the 22 states which already allow nurse practitioners to work without a doctor’s supervision in some areas of health care.

CMA: Change would lead to lower quality of care

That prompted criticism from the California Medical Association: “We continue to oppose efforts to lower standards of care to expand access. Nurse practitioners, while hugely important to the health care delivery system and an integral part of medicine, do not have the same level of training and expertise, and we should be wary of creating a system that only allows those patients who can pay top dollar access to a fully trained and licensed physician.”

But a March report by the Brookings Institution pointed to a future in which such physicians are much less important. It noted research that showed an artificial intelligence system “was equal or better than radiologists” at evaluating mammograms; that computers are as competent as ophthalmologists in examining some retinal images; and that robots which performed intestinal surgery on a pig did much better than humans with the sutures used to close up surgical incisions.

Bay Area physician Rahul Parikh, writing in October in the MIT Technology Review, thinks specialists may be in trouble — but not family doctors, who can use artificial intelligence to improve their care. And he argues that any transition to a health care system reliant on AI will face profound questions.

“Are patients willing to share more of their personal data with us? If the AI shows your care is better one way, but you or your doctor feel differently, will an insurance company accept it?” he wrote. “What if the algorithm misses something or is applied incorrectly? Who is liable, the doctor or the machine’s maker?”

Assembly Bill 890 will be heard next by the Assembly Appropriations Committee. No hearing date has been scheduled yet.

But this track record of advancement doesn’t impress prominent California politicians. The 11 candidates to succeed Newsom in Tuesday’s primary are arguably as obscure as any collection of candidates for an open statewide office in the 21st century.

Three candidates have each won support of key elements in the Democratic coalition, and one Republican hopeful has also stood out. But since the state’s major independent pollsters have skipped the race, it’s difficult to know what to expect Tuesday. Based on money raised as of campaign spending reports published May 13, here’s a look at the major candidates in order of those who had the most resources.

Sacramento Democrat Eleni Kounalakis, 52, had raised $4.5 million, at least $2.5 million of it her own money; a Sunday Sacramento Bee story reported the updated sum is actually $4.2 million. She is a developer who served as U.S. ambassador to Hungary under the Obama administration, having been sworn in by Secretary of State Hillary Clinton in 2010. Kounalakis, pictured, who would be the first woman lieutenant governor, has emphasized her housing background as giving her insights into addressing California’s housing crisis, and also focuses on reducing income inequality.

Kounalakis is counting on Clinton’s 2016 network of fundraisers and supporters to help her make the final two in November. This network includes her father, wealthy Sacramento developer Angelo Tsakopoulos, a prolific Clinton fundraiser who has given nearly $5 million to a nominally independent expenditure committee formed by the California Medical Association that has touted her candidacy. U.S. Sen. Kamala Harris, D-San Francisco, another Clinton backer, is all aboard.

State Sen. Ed Hernandez, 60, an Azusa Democrat and optometrist backed by labor, has raised $2.8 million. One of the reasons the CMA supports Kounalakis is its distaste for Hernandez’s efforts to allow medical professionals, including optometrists, to offer care that can now only be provided by those with traditional medical degrees. But it is unclear how Hernandez would have more means to advance such legislation as a lieutenant governor than in the Legislature.

Hernandez says if elected, he would push a broader health agenda, emphasizing the need to give access to care to 3 million state residents who now are shut out. Of the private polling that had been done by mid-May, Hernandez reportedly had the lead going into the final weeks of the primary campaign.

Piedmont Democrat Jeff Bleich, 56, an attorney who served in the Obama White House as a special counsel; as U.S. ambassador to Australia; and as chair of the California State University Board of Trustees; had raised $2 million. Bleich has emphasized policy goals of reforming higher education and improving environmental protections.

Like his two Democratic rivals, Bleich has support from key party factions, including environmental groups such as the Sierra Club and various LGBT organizations. The former president of the California State Bar also has state trial lawyers in his corner, as well as Rep. Adam Schiff, the Burbank Democrat who has become a national figure because of his high-profile opposition to President Donald Trump.

The most viable Republican on the ballot, Pasadena international import-export businessman Cole Harris, had $1.9 million in campaign funds at last report, nearly all from his own checkbook. Harris has the state GOP’s endorsement and was the first lieutenant governor candidate to run TV ads in the important Los Angeles metro market. But he has done relatively little retail campaigning, and his bare-bones campaign website offers few policy specifics beyond support for the Trump administration and border security and opposition to socialized health care.

Harris’ endorsement from the state GOP might be enough to carry him to the November runoff. But it is unclear if he is ready to self-fund a statewide general election race, and most California Republican insiders expect GOP donors to care more about preserving seven endangered U.S. House seats in the Golden State than any other California campaigns.

One of the most liberal states in the nation has said no thanks to a key Obamacare provision and instead is enacting its own version of the law.

California has decided to skirt the “Buy 1, Get 3 Free!” loophole in the Affordable Care Act, a modest piece of the sprawling health care regulation with huge implications. The provision holds the insured blameless for failing to make monthly premium payments, while requiring doctors and insurers to continue to offer health care. During a three-month grace period before cancellation, subsidized policy holders can see doctors, have operations and rack up medical bills without paying for anything.

Doctors and insurers will be left holding the bag.

“California is usually leaning to the left, but Obamacare has gone so far that even the left coast is coming back a little to the center,” said Rep. Louie Gohmert, R-Texas, who is among a core group of congressional members who have tried to unwind Obamacare.

He has a counterpart in California: state Sen. Ted Gaines, R-Rocklin, who is vice chairman of the state’s insurance committee.

“When even California has stricter rules (than Obamacare) for a giveaway, that should tell you something,” Gaines said. “This three-for-one freebie is so bad that even the No. 1 Obama cheerleader state had to break ranks. I’m not shocked anymore by any ridiculous Obamacare example. I’m surprised it’s not four-for-one or six-for-one.”

CA version

To that end, the California Department of Managed Health Care is drafting its own version of section 156.270 of the Affordable Care Act that says policy holders will be suspended and unable to use their Obamacare plan after one month of non-payment, which is consistent with California law for all other plans purchased outside of the state’s exchange.

“From our perspective this makes it much clearer to the enrollee who ultimately is responsible to pay these bills,” said Marta Green, spokesperson for DMHC. “If I walk into an insurance provider in month two or three and if I get $10,000 worth of services, at the end of the month I am responsible for $10,000 worth of bills. We are not going to have people caught unaware.”

California is drafting language to the law and then it must go through a 45-day public comment period before it can be enacted.

“We have to analyze those comments and if everyone is on board we will finalize the regulation,” Green said. “It is our priority to get this resolved.”

March is the first month that doctors could conceivably be stuck with fronting free health care.

Freebie loophole

The freebie loophole first caught the attention of the vocal California Medical Association several years ago. CMA officials immediately began peppering the U.S. Department of Health and Human Services with notices of concern seeking clarification. Initial drafts of Obamacare left insurance companies on the hook for all three months of the grace period.

“Nobody really had any idea that the feds were going to go in this direction — that doctors are left holding the bag for months two and three,” said CMA Association Director C. Brett Johnson. “They came out of nowhere with this and didn’t give us a public comment period.”

When the federal government’s final ruling came down on March 27, 2012, the CMA found that it violated several California laws. But it was also missing something that would give the CMA some leverage: language stating that the Affordable Care Act was preemptive, meaning that the federal version would prevail over conflicting state laws.

So, armed with this bit of ammunition, the CMA set its sights on state health regulators and found a willing ally.

Besides the three-month grace period, Obamacare also violates these California laws:

• “Prompt pay,” which states that health plans must promptly reimburse health care providers; and
• “Recision,” which means California has a host of conditions that must be in place before retroactively terminating a policy. None of these is addressed in Obamacare.

In addition, Obamacare creates a federal dichotomy because the law states that insurance companies cannot charge different rates inside the exchange. In reality, rates would have to be higher inside the exchanges to compensate for the grace-period freebies.

So the DMHC contacted the Center for Medicare and Medicaid Services and told them what they intended to do.

“We got approval,” Green said. “What California is proposing is that, if you (the insured) get in the black and pay your premium retroactively, you are all good. If you had services, you will be reimbursed.”

On Tuesday, the American Medical Association passed a resolution stopping short of backing California’s version of Obamacare. It asked for doctors to be notified if patients were in the grace period and stated an opposition to any federal law that would preempt state law.

“States have been floating around saying, ‘This really sucks but it’s out there and we don’t know what we can do,’” Johnson said. “We have a solution.”

Editor’s note: This is cross-posted from Watchdog.org.

Contact Tori Richards at tori@watchdog.org or on twitter @newswriter2.

Assemblywoman Toni Atkins, D-San Diego, is pushing AB 154 to allow nurses, midwives and physician assistants to perform abortions.

Assemblywoman Toni Atkins

The CMA supports the bill.

But SB 491 by Sen. Ed Hernandez, to allow nurse practitioners to practice without the supervision of a physician, is opposed by the CMA.

Meanwhile, Assemblyman Dr. Richard Pan, D-Sacramento, has another bill, AB 980, which would remove the current requirements that abortions are to be done in a medically surgical and sterile setting, with a post-abortion recovery area adequate for recovering patients, and a counseling area that is maintained and provides privacy for patients requesting it.

Thus far, the CMA has been silent on Pan’s bill.

Old arguments about abortion now ignored

Abortion bill redux: the San Diego connection

Atkins’ bill is a redux of bills authored in previous years by Sen. Christine Kehoe, D-San Diego. Kehoe authored SB 1501 last year, a bill originally written about boating and waterways. But Kehoe gutted it and replaced the language with the abortion bill.

Prior to SB 1501, there was SB 1338, also by Kehoe, which would have allowed nurse practitioners, nurse midwives and physician assistants to provide first-trimester abortions. Kehoe scaled her bill down to include only 41 providers involved in a UC San Francisco pilot program throughout the state. But a Senate committee deadlocked on the vote, and the bill failed to pass.

That bill was also sponsored by Planned Parenthoood, NARAL, the California Nurses Association and the SEIU. Most of the bill’s analysis was provided by these organizations.

However, Kehoe took the language from the failed bill, then placed it in budget bill SB 623. Kehoe received much criticism for trying to cram a failed bill into a budget trailer bill without the usual  committee hearings, public notification or debate.

ex-Sen. Christine Kehoe

I wrote about Kehoe’s bills last year.

From gerontology to abortion

Atkins’ bill stems from a California “pilot project” which started as a program to increase access to gerontology care in 1973 and morphed into being used to train midwives and nurses to perform surgical abortion procedures.

The abortion program was quietly concealed in the pilot gerontology program behind a phrase in the code “expanding early pregnancy care.” But since 2006, this project has been used in some cities to train nurses and medical assistants to do abortions.

And state regulations were suspended in order to allow “Nurse Midwives, Nurse Practitioners and Physician Assistants” to do these procedures, according to former Assemblywoman Linda Halderman and former Sen. Sam Aanestad. Both lawmakers looked into the pilot program while still in office, and tried to get it stopped.

Planned Parenthood claims Atkins’ bill is necessary to “integrate abortion care into current practice settings.”

Voters don’t approve

A recent poll of California voters sharply rejected the idea of allowing nurse practitioners and physician assistants to conduct abortions. By an even greater margin, 76 percent to 18 percent, voters reject the notion of also giving nurse midwives the ability to provide abortions.

The poll, which surveyed 600 registered voters in April 2013, was conducted by Smith-Johnson Research of Sacramento with a sampling error of plus or minus 4 percent.  (See survey ).

The bills are scheduled for hearing in the Senate Appropriations Committee on Monday, Aug. 12.

By John Hrabe

When he isn’t in Sacramento, state Sen. Ed Hernandez is busy treating patients at his five-star rated optometry practice, Hernandez Optometry, in La Puente. The nearby picture is of him on the front page of his Web site.

For most people, it might be a challenge to balance two full-time jobs. Hernandez, though, has found a novel way to solve the problem: he’s merged his obligations as a state legislator with his profitable optometry practice.

This session, the West Covina Democrat has introduced controversial legislation that would greatly expand the scope of practice for several medical professions, including optometrists. Senate Bill 492, which is opposed by the California Medical Association and other physician groups, would give your local eye doctor the power “to perform vaccinations and surgical and non-surgical primary care procedures.”

Such a major expansion in the scope of practice would financially benefit the state’s 9,000 optometrists, including Hernandez and his wife, Diane, who also is an optometrist at Hernandez Optometry. In return, optometrists throughout the state, who under normal circumstances might be his competition, have supported Hernandez with gifts and more than $140,000 in campaign contributions.

As WebMD makes clear, although doctors, optometrists are not physicians; which is how they differ from opthalmologists, physicians who went to medical school. So Hernandez’s bills effectively would allow optometrists like himself to do many procedures currently allowed to be performed only by ophthalmologists.

Hernandez’s profitable optometry business

According to his most recent financial disclosure statement, Hernandez and his wife each received more than $100,000 in gross income from their optometry clinics. The businesses, listed with separate addresses on the Form 700 disclosure statement, are valued between $100,000 and $1 million.

But Hernandez doesn’t believe it’s a conflict of interest to introduce legislation that would benefit these family businesses.

“There is no conflict here, many Senators have careers other than politics and that makes us a stronger and more thoughtful body,” Hernandez said in an email to CalWatchdog.com. “I fully disclose all my income and political contributions because I have nothing to hide.”

There’s no evidence that Hernandez has broken any of the state’s conflict of interest laws, which do not forbid legislators from carrying bills or voting on issues that would benefit themselves. Under state law, measures that are general in nature and affect an entire industry are not considered a conflict of interest. Campaign finance watchdogs say that, even though the practice is legal, it raises ethical concerns.

“California’s conflict of interest laws deems this activity 100 percent legal, but the court of public opinion should find this 100 percent reprehensible,” said Phillip Ung, a policy advocate with California Common Cause. “It is this type of activity that leads voters to lose faith in their Legislature.”

Hernandez has accepted $140k+ in optometrist contributions

Hernandez’s broad support for the entire optometry industry explains why so many of his competitors have donated to his political campaigns. In recent years, Hernandez has accepted more than $140,000 in campaign contributions from optometrists, optometry businesses and the California Optometric Association.  In 2009-10, Hernandez O.D. Democrat for Senate 2010 accepted $81,799 from 78 campaign contributors that are directly associated with the optometry field.

The committee to fund his 2014 reelection has already accepted another $23,797 from 32 optometry-related campaign contributors. As recently as February 8, the California Optometric PAC contributed $35,000 to a campaign committee controlled by Hernandez. The committee was established “to qualify a measure to create a special healthcare district in San Gabriel Valley.”

According to Maplight, a nonprofit research organization that reveals money’s influence on politics, Hernandez’s single largest contributor over the last four years has been the American Optometric Association, which has donated $33,700 to his campaign committees. “Health Professionals,” a broad industry category that includes optometrists, contributed $129,793 to Hernandez’s campaigns, more than any other industry or profession, according to Maplight.

Optometrists’ generosity to Hernandez has also included a pair of gifts. In 2012, Hernandez reported on his financial disclosure statement two dinners, worth $131, from the California Optometric Association.

California Medical Association opposed to SB 492

Hernandez, who serves as the chair of the Senate Committee on Health, introduced SB 492 as a part of a legislative package to address the looming health care provider shortage brought about by the Affordable Care Act, also called Obamacare. The series of bills, Senate Bills 491, 492 and 493, would expand the scope of practice for optometrists, pharmacists and nurse practitioners.

“SB 492 is part of a package of bills that was drafted to ensure the people of California have meaningful access to a qualified health care provider,” Hernandez said in an email. “The bill is designed to help optometrists better serve the needs of their patients; if anybody stands to benefit from the provisions of this bill, it’s consumers.”

The California Medical Association, along with several other prominent health care associations, are opposed to the bills that they say would compromise patient safety.

“[Optometrists] do not have the training and experience necessary to provide comprehensive primary care,” the California Medical Association wrote in their opposition to the bill. “In addition, SB 492 would allow optometrists to practice medicine without being subject to the Medical Practice Act.”

For his part, Hernandez has made no secret of his financial connections to the bill. A March 2013 press release about the legislative package referenced that he is “an optometrist himself.”