Battling the Behemoth

When it comes to health policy in California, we are beholden to one very indisputable political influence: The California Medical Association (CMA). For proof, we need look no further than the recent legislative collapse of SB323 and the impending demise of AB1306. The bills are similar in that they promise workable solutions to the limited health care options in California and are well regarded by a large majority of Assembly members and Senators. AB1306 would remove the outdated supervisory regulations which prevent nurse-midwives from tending to under served communities. SB323, similarly, would have allowed nurse practitioners to practice with the full authority of their education and training. Neither bill went so far as to request independence from physicians, only to request a structure for collaboration that allows for safe and less expensive treatment options to all Californians. CMA has successfully squashed both attempts while keeping their subservient Senate and Assembly members cleanly out of the line of fire. How are they doing this and how can they be stopped?


What do you see when, in the interests of physicians and their allies, a huge conglomeration of wealth promotes laws that make you less safe, less free, and less able to afford your own health choices?

The Nature of the Beast

The top priorities of CMA represent fine goals to protect the proprietary rights of California’s 40,000 physicians. These priorities are not malicious ones when guided by progressive thinking that is inclusive of changing demographic factors, nationwide impacts of the Health Care Act, and the shared proprietary rights of other Advanced Practice practitioners. Priorities , on the other hand, that keep Californians on the losing end of a turf war between practitioners and that serve to benefit only physicians have placed California health care drastically out of step with the rest of the nation. One of CMA’s current objectives that continues to provoke statewide controversy and harm is its stance on mid-level practitioners.

Excerpted from CMA website
CMA’s Top Issues
"Mid-level practitioners and other allied health professionals play a significant role in health care, but patients must not substitute them for physicians. A patient's care should begin with a primary care physician, who can most ably advise a patient on what care he or she needs. Simply expanding the scope of practice of practitioners, without expanded training or education, can mean lowering the standard of care for patients. It is imperative that the drive for "access" does not translate into a second tier of health care, one that offers convenience and lower cost in exchange for poorer quality and reduced patient safety. All Californians deserve a health care system that protects their safety and standard of care."

The CMA has allies, not only with other physician interest groups, but with interest groups in the pharmaceutical industry, hospital associations, and in high tech healthcare related fields. These allies rely on CMA’s  guidance during these complex times of change in order to contract effectively with physicians - the distributors of their goods and services. It is thus a catastrophic failure of leadership when they must follow advocacy guidelines riddled with goals of obstructionism and subordination. Legislators are faced with high financed lobbyists from multiple fields synchronized solely upon ruthless methods of maintaining power for physicians that, at this point, run of their own accord.

Campaign Finance Data Records for the election cycles taking place between 2004 to 2012 show CMA  contributing a total of $1,422,237 to the Assembly as a whole.  Some Assembly women – like Beth Gaines, Toni Atkins, and Susan Bonilla – belonged to an uncomfortable club of Assembly members that CMA has selected as their top 10 recipients of campaign funding over the past two years. One might hazard a guess that CMA has appraised the situation correctly. An increase in campaign funding to these representatives was necessary to offset their natural alliance with California women who would benefit directly from expanded health care services from nurses and midwives.

With our government forced to support such outmoded protectionism, California remains one of the last six states that still requires physician supervision of nurse-midwives. As a result, 33% of all births in California are by cesarean, and 9 out of 58 counties have no access to a nurse-midwife at all.

Last Year's Politics 


In 2015, strategists for AB1306 (Removing Supervision for Certified Nurse Midwives) and SB323 (Full Practice Authority for Nurse Practitioners)  attempted contradictory methods to wage legislative influence for their bills.

1. The failed strategy of Outright Defiance

Rankled by previous years defeats, Senator Ed Hernandez continued his authorship for the Nurse Practitioner bill SB323 in a tone of outright defiance of CMA’s opposition.  Mr. Hernandez, even as a longtime recipient of CMA’s campaign donations, refused their recommendations for amendments to his bill. Though difficult to penetrate the thinking of our multi pocketed Senators, perhaps his experience allowed him to see through CMA’s disingenuous offers of compromise. Hernandez seemed to know what he was doing. Even with CMA’s declaration of opposition, SB323 passed the Senate floor with ease.

The pockets of California’s representatives in the Assembly, however, are not as deep as those in the Senate. Thus the formidable contributions from CMA can play a much larger part in paying for their election campaigns.  The big question for any health care reform that is perceived as encroaching upon physicians is thus how to get it passed in the Assembly.

2. The failing strategy of Coalition Building

In a spirit of emboldened cooperation with CMA, strategists for the Nurse Midwife bill chose an author with a very short history in Sacramento, Autumn Burke. As a new member to the Assembly, Ms. Burke has comparatively little campaign revenue attributable to CMA. She is friendly toward physician associations but her tenure is not yet completely bought and paid for by their contributions. Ms. Burke could thus be friendly to CMA and earn her place as a future recipient of CMA’s funding while still maintaining the negotiating power of a free agent (if such a status could ever truly exist in a political world).

A similar pro midwifery bill for Licensed Midwives (SB1308)  had just been passed with unanimous approval in the Assembly in 2014. In a surprisingly progressive move, SB1308’s passage was heralded with silent neutrality of CMA. This afforded Assembly women Gaines, Atkins, and Bonilla a chance to speak their minds freely and openly about women’s health and health reform in general with no threat of financial blow back from CMA. It was a very good year for women’s health and for women in politics.

As AB1306 was brought to vote on the Assembly floor that year, it was stated in hearing that Burke and CMA were in good faith negotiations, allowing Assembly women (and men) to continue their outspoken adoration of nurse-midwives. It seemed SB1308 and AB1306 would be remembered as a turn in the road for women's health care. Had CMA really softened its outdated stance on mid level practitioners?

Not so fast.  CMA’s neutral stance came only with one crucial caveat!

Assembly members insisted that Ms. Burke include a non regulatory, purely administrative, amendment suggested by CMA. This amendment (the very same amendment refused by Hernandez on the Senate side) would implement limitations regarding employment of nurse-midwives similar to those imposed upon physicians. In highly complex language, it purports to protect the public from the undue influence of corporations on health professionals. Ms. Burke accepted the amendment and the bill passed the Assembly floor with overwhelming approval.

The administrative amendment, however, served well it’s design as a “poison pill”. Within the month, as the Nurse Practitioner and Nurse Midwife bills traversed to the other houses of the legislative body, they were stymied by the impossibility of

1) applying the amendment via the Senate in the case of AB1306 and

2) not applying the very same amendment via the Assembly in the case of SB323.

Double Bind
n. 1. A psychological impasse created when a person perceives that someone in a position of power is making contradictory demands, so that no response is appropriate.

Thus, in a skillfully structured Catch 22 arrangement, Assembly woman Autumn Burke could not carry her bill through the Senate and Senator Ed Hernandez could not carry his bill through the Assembly. Like children of divorced parents who are not on speaking terms, both houses refused to offer common ground. The Senate and Assembly appeared honestly perplexed by the dysfunctional double bind they were placing on both authors.  (full videos below) As it dawns on them that CMA has worked both houses to take oppositional stances on two Advanced Practice bills that they both overwhelmingly favor, there is much hand wringing and bemoaning. A casual observer of both hearings however, will note one glaring consistency:

They refuse to  openly name CMA as the culprit

At 20 min mark: CMA rep Juan Thomas announces that poison pill has been accepted...followed by removal of opposition from Medical Board, Ass. of California Health Care Districts, etc

At 23:30 rep from California Hospital Association announces that CMA's amendment to the bill (CPH ban) creates threat to hiring in rural settings. Watch as Senators first seriously doubt the legitimacy of her argument, then strangely with no additional facts presented, begin to fall in line.

At 31:00 Senator Jackson announces that she sees the poison pill for what it is.

At 1:00:00 Meet Senator Hernandez as he votes against the bill because of the amendment. His NPbill in the Assembly, meanwhile, has just been voted down for not having the amendment. 

At 1:18:00: Senator Ed Hernandez begins his effort to provide Nurse Practitioners the same full practice authority that he chose to oppose for Nurse-Midwives in the Senate. He prefers his bill because it refuses the CPM Ban proposed by CMA.

At1:44:00: Meet CMA rep Juan Thomas again, this time showing his teeth by opposing the NP bill - based mostly for refusing to include the CPM ban. Is that smile on his face reflecting that he knows such a ban would result in the bill's failure at the Senate? AT 2:05:00 Assembly Chair Bonilla initially shows regret that she is backing off her original support for the bill (2 years ago) due to a novel new concern: the CPM ban! She goes on to use the fact that the Nurse-Midwives accepted it (at her insistence) so "for consistency sake", the Nurse Practitioners should as well. At 2:58:40 Bonilla attempts to summarize by showing her willingness to disagree with CMA on several of their suggestions which leaves her very uncomfortable trying to justify why she caves to their demand for a CPM ban - that is unnecessary and will get the bill killed in the Senate.


In examining how AB1306 and SB323 were tabled last year, we see that CMA has learned to work the dysfunction of a two house legislative body so as to leave both sides justified as the more reasonable. They also leave constituents for health care reform divided and feeling betrayed by one another.

  • Senator Hernandez left that year ready to blame the Nurse-Midwife bill for including CMA's poison in their draft, and deflating his unified call to arms at the Assembly.

  • Assembly woman Burke left that year shocked that Nurse Practitioners and Hospital Associations failed to support Nurse-Midwives for no reason but politics at the Senate.

Appealing to the mercy of a bully is a fool's errand. 
After you've done all you can to play by their rules, 
the time comes to appeal to a larger force.

Where we stand today

For those wishing to see Assemblywoman Autumn Burke in action, here she is on 6/27/2016 gaining unanimous support in a sub committee of the Senate for AB1306 . Watch as she prepares for CMA’s arguments to come as she carries the fight on to the Senate floor and then back to the Assembly in a few short weeks.


It's now clear Ms. Burke will not win this fight without broad grassroots support from the women whom this bill was created to support.

United under a single movement to Improve Women's Health in California, its time for all women in California to focus on the disparity of healthcare options for women.

Start at minute 25:00 to hear our advocates by name as Senate Pro Tem Kevin de León rededicates the Rose Ann Vuich Hearing Room, and unveils portraits in honor of the 42 trailblazing women Senators who have served in the California State Senate.


Who stands to benefit most directly from having access to Nurse-Midwives?  Women

Whose employment will be most impacted by the granting of full practice authority to Nurses? Women

Who gave birth to each of the physicians represented by CMA and comprise 100% of their sisters, aunts, and daughters? Women

Who can cut through the divisive sleight of hand in the Senate and join with Assembly women to return both houses to order ? Women







Jonathan BartlettComment