State Senator Ed Hernandez, D-West Covina, has reintroduced legislation that would allow nurse practitioners to treat patients and obtain diagnostic tests without the sign-off from a physician. He serves as chair of the Senate Health Committee.

“This is not a new fight here in California, but with 2.5 million previously uninsured Californians receiving health coverage under the Affordable Care Act, we need to pass this law to ensure that more trained health care professionals are available,” said Hernandez, according to the Sacramento Business Journal.

He added, “It is well documented that California is facing a shortage of primary care physicians and giving trained nurse practitioners full practice authority would go a long way to help remedy this situation.”

2013: Revival of SB493

Last legislative session, Hernandez authored Senate Bill 493, which passed the Senate on a 22-12 vote. Among the expanded responsibilities included in that earlier bill were “ordering durable medical equipment, prescribing drugs, establishing diagnoses, referring patients, performing procedures that are consistent with their training, and delegating tasks to medical assistants, among others.”

The 2013 measure eventually stalled in the State Assembly, due in large part to the concerns from the California Medical Association. The CMA, which represents 40,000 members of the state’s medical community, argued Hernandez’s proposal would compromise patient safety.

“Nurse practitioners are an important part of the health care team and, when practicing under physician supervision, can significantly increase access to quality medical care in a community,” the CMA wrote in opposition to SB493, according to a legislative analysis. “Allowing nurse practitioner practice without standardized protocols and physician supervision reduces patient safety and quality of care.”

Hernandez has yet to offer specific language for this session’s bill, Senate Bill 323. In order to meet the February 27 bill introduction deadline, he introduced placeholder language, also known as a “spot” bill.

Health care system stressed by Affordable Care Act

Fewer than 5 percent of the state’s 408,413 nurses have the advanced training and years of experience to be designated a nurse practitioner. As of Sept. 2013, 18,541 active nurse practitioners were registered and licensed by the Board of Registered Nursing.

Hernandez contends these nurse practitioners can help address the increased demands on the country’s health care system, which is under stress from the wave of new patients that signed up for insurance rather than pay a fine under the Affordable Care Act, also called Obamacare. In 2014, 6.7 million people obtained private health insurance, according to the Associated Press, “flooding a primary care system that is struggling to keep up with demand.”

Here in California, an estimated 1.2 million people have enrolled in new private health plans since the launch of the ACA, according to the San Jose Mercury News. That doesn’t include another 2.7 million new enrollees in Medi-Cal, the state’s taxpayer-funded health program. More than 12 million people, roughly a third of the state’s population, are enrolled in Medi-Cal.

Millions of new patients, without a corresponding increase in medical care providers, have led to longer wait times and people complaining of difficulty finding doctors accepting new patients — a problem that, Hernandez says, can be addressed through expanded scope-of-practice.

“If we truly want to increase access to quality care, especially in areas of our state where the provider shortage is at its worst, then we must allow trained medical professionals like Nurse Practitioners the ability to practice to the full extent of their training,” Hernandez said in a statement last year. “It’s unacceptable to mandate people purchase health coverage without taking steps to ensure those same people are able to use their coverage to see a qualified health care provider.”

A 2014 report by the Bay Area Council Economic Institute argued that expanding the scope-of-practice for nurse practitioners is “one of the most effective steps that states can take to increase the supply of primary care providers while maintaining high quality and driving down costs.”

In its placeholder language, SB323 promises it “will assist in addressing the primary care provider shortage by removing delays in the provision of care that are created when dated regulations require a physician’s signature or protocol before a patient can initiate treatment or obtain diagnostic tests that are ordered by a nurse practitioner.”

Shorter wait times with lower professional standards

It’s not yet clear how many nurse practitioners would be covered by Hernandez’s proposal. In 2013, Hernandez began with a requirement that nurse practitioners receive 6,240 hours under the supervision of a physician. The bill was later amended to reduce the time by a third to just 4,160 hours.

That change reflects the trade-off for proponents of scope-of-practice expansion: in order to add a meaningful number of new health care providers, the change requires a reduction in professional standards. Two-thirds of the state’s nurse practitioners already “have furnishing numbers … which allows them to order or furnish drugs and devices to patients using approved standardized procedures,” according to the legislative analysis for Hernandez’s 2013 bill. In other words, the majority of nurse practitioners already have one of the expanded powers sought with the proposal.

As CalWatchdog.com has reported, Hernandez unsuccessfully introduced a trio of scope-of-practice bills during the 2013-14 legislative session. The most controversial of the three measures, Senate Bill 492, would have expanded the scope-of-practice for optometrists.

Hernandez and his wife, Diane, operate an optometry practice in La Puente. As of June 2013, Hernandez had accepted more than $140,000 in campaign contributions from optometrists.

Three bills by Sen. Ed Hernandez, D-West Covina, who is also an optometrist, would expand the definition of the scope of practice and medical duties for optometrists, nurse practitioners and pharmacists, will be heard today at a hearing in the Assembly Business, Professions and Consumer Protection Committee.

Hernandez, who chairs the Senate Health Committee, introduced the three “scope and practice” bills earlier in the year to address the anticipated doctor shortage as Obamacare implementation takes place in California. But during committee hearings earlier in the spring, it became evident there will be a battle with physicians over this “scope of care,” and what the role of professionals versus para-professionals will be in the future.

And some are concerned with Hernandez authoring a bill from which he would personally benefit.

Ophthalmologists, optometrists and opticians all provide eye-care services, but optometrists and opticians are not physicians.

According to the Harvard Journal of Ophthalmology, an ophthalmologist is a physician (doctor of medicine, M.D., or doctor of osteopathy, D.O.) who specializes in the medical and surgical care of the eyes and visual system and in the prevention of eye disease and injury. An ophthalmologist has completed four or more years of college premedical education, four or more years of medical school, one year of internship and three or more years of specialized medical and surgical and refractive training and experience in eye care.

An optometrist is a health-service provider who is involved exclusively with vision problems. Optometrists are specifically educated and trained by an accredited optometry college in a four-year course but do not attend medical school.

Hernandez’s bills would allow optometrists to do many procedures currently only performed  by ophthalmologists.

Expanded coverage, but not enough care providers

“Here in the state of California, we have a capacity issue. We have a work-force shortage,” Hernandez said at a joint Senate Health Committee and Business and the Professions and Economic Development Committee hearing I attended in March. Hernandez warned the problem is already at a breaking point in California’s inner cities and rural areas. Up to 7 million uninsured Californians will be required to be insured as of next year.

“How is it that we’re going to be requiring somebody to purchase health insurance, but yet they won’t have access to a doctor?” Hernandez asked. “This is what we need to address.”

“We are working hard at the state level to ensure every Californian has access to affordable, quality health coverage, but what good is a health insurance card if you can’t get into see a health care provider when you need one?” said Hernandez. “We need to make better use of the trained health care workforce we already have if we are ever going to meet demand.”

But Senate Bill 492, which is opposed by the California Medical Association and other physician groups, would give minimally trained eye doctors the authority “to perform vaccinations and surgical and non-surgical primary care procedures,” according to Hernandez.

Donations raise conflict of interest question

“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,” my colleague John Hrabe wrote in June (“Sen. Hernandez authors bills to benefit his optometry practice”).

“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.”

Hernandez’s bills are Senate Bills 491, 492 and 493. Sen. Fran Pavley, D-Agoura Hills, authored Senate Bill 352, which would expand the “scope of practice” for physician’s assistants.

Assemblyman Dr. Richard Pan, D-Sacramento, authored 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.

Taking up efforts defeated last year, Assemblywoman Toni Atkins, D-San Diego, is pushing AB 154 to allow nurses, midwives and physician assistants to perform abortions.

Last year, Sen. Christine Kehoe, D-San Diego, authored SB 1501, 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 that are 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.