BILL ANALYSIS Ó
AB 154
Page 1
Date of Hearing: April 9, 2013
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Richard S. Gordon, Chair
AB 154 (Atkins) - As Amended: March 19, 2013
SUBJECT : Abortion.
SUMMARY : Authorizes a nurse practitioner (NP), certified nurse
midwife (CNM), and physician assistant (PA) to perform an
abortion by aspiration techniques, in addition to medication, in
the first trimester of pregnancy upon completion of specified
training and validation of clinical competency, as specified.
Specifically, this bill :
1)Declares that it is unprofessional conduct for any NP, CNM, or
PA to perform an abortion by medication or aspiration
techniques in the first trimester of pregnancy without
completing training and validation of clinical competency.
2)Deletes superfluous reference to "performing, assisting,
procuring or aiding, abetting, attempting, agreeing, or
offering to procure an illegal abortion" in regards to what
constitutes unprofessional conduct for failure to comply with
the Reproductive Privacy Act.
3)Deletes obsolete references to "surgical" and "nonsurgical"
abortions and replaces the terms as necessary with abortion by
"medication" or "aspiration techniques."
4)Deletes unnecessary references to "assisting" in performing an
unauthorized abortion in regards to what constitutes a public
offense.
5)States that a person is not guilty of the public offense of
practicing medicine without the appropriate legal
authorization if he or she performs an abortion by aspiration
techniques in the first trimester of pregnancy while having a
valid, unrevoked, and unsuspended license or certificate
authorizing him or her to perform an abortion by aspiration
technique, as specified.
6)Requires a NP or CNM to complete training recognized by the
Board of Registered Nursing (BRN) in order to perform an
AB 154
Page 2
abortion by aspiration techniques. Further requires the
competency-based training protocols established by Health
Workforce Pilot Project No. 171 (HWPP 171) through the Office
of Statewide Health Planning and Development (OSHPD) to be
used from January 1, 2014 until January 1, 2016.
7)Authorizes NPs or CNMs who have completed the HWPP 171
training and achieved clinical competency to perform abortions
by aspiration techniques.
8)Requires a PA to complete training either through training
programs approved by the Physician Assistant Board (PAB) or by
training to perform medical services which augment his or her
current areas of competency, as specified, in order to receive
authority from his or her supervising physician and surgeon to
perform an abortion by aspiration techniques. Requires the
training and clinical competency protocols established by HWPP
171 through OSHPD to be used as training and clinical
competency guidelines to meet this requirement from January 1,
2014 through January 1, 2016.
9)Deems the training protocols established by HWPP 171 to meet
the PAB standards.
10)Authorizes a PA who has completed the HWPP 171 training and
achieved clinical competency to perform abortions by
aspiration techniques.
11)Makes other clarifying and technical changes.
12)States that no reimbursement is required by this act pursuant
to Section 6 of Article XIIIB of the California Constitution
because the only costs that may be incurred by a local agency
or school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction, or
changes the penalty for a crime or infraction within the
meaning of Government Code Section 17556, or changes the
definition of a crime within the meaning of Section 6 of
Article XIIB of the California Constitution.
EXISTING LAW :
1)Establishes the Reproductive Privacy Act (Act) which does the
following:
AB 154
Page 3
a) Makes legislative findings that every individual
possesses a fundamental right of privacy with respect to
personal reproductive decisions. Accordingly, the Act
specifies that it is the public policy of the State of
California (State) that:
i) Every individual has the fundamental right to choose
or refuse birth control;
ii) Every woman has the fundamental right to choose to
bear a child or to choose and to obtain an abortion,
except as specifically limited by this Act; and,
iii) The State shall not deny or interfere with a woman's
fundamental right to choose to bear a child or to choose
to obtain an abortion, except as specifically permitted
by this Act. (Health and Safety Code (HSC) Section
123462)
b) Provides that the State may not deny or interfere with a
woman's right to choose or obtain an abortion prior to
viability of the fetus, or when the abortion is necessary
to protect the life or health of the woman. (HSC 123466)
c) Specifies that the performance of an abortion is
unauthorized if either of the following is true:
i) The person performing or assisting in performing the
abortion is not a health care provider authorized to
perform or assist in performing an abortion pursuant to
Business and Professions Code (BPC) Section 2253.
ii) The abortion is performed on a viable fetus, and
both of the following are established:
(1) In the good faith medical judgment of the
physician, the fetus was viable; and,
(2) In the good faith medical judgment of the
physician, continuation of the pregnancy posed no risk
to life or health of the pregnant woman. (HSC 123468)
2)Provides that failure to comply with the Act in performing,
assisting, procuring or aiding, abetting, attempting,
agreeing, or offering to procure an illegal abortion
AB 154
Page 4
constitutes unprofessional conduct. (BPC 2253 (a))
3)Makes it a public offense, punishable by a fine not exceeding
$10,000 or imprisonment, or both, for a person to perform or
assist in performing a surgical abortion, and at the time of
so doing, does not have a valid, unrevoked, and unsuspended
license to practice as a physician and surgeon, or to assist
in performing a surgical abortion without a valid, unrevoked,
and unsuspended license or certificate obtained in accordance
with some other provision of law that authorizes him or her to
perform the functions necessary to assist in performing a
surgical abortion. (BPC 2253 (b)(1))
4)Makes it a public offense, punishable by a fine not exceeding
$10,000 or imprisonment, or both, for a person to perform or
assist in performing a nonsurgical abortion if the person does
not have a valid, unrevoked, and unsuspended license to
practice as a physician and surgeon, or does not have a valid,
unrevoked, and unsuspended license or certificate obtained in
accordance with some other provision of law that authorizes
him or her to perform or assist in performing the functions
necessary for a nonsurgical abortion. (BPC 2253 (b)(2))
5)Provides that a "nonsurgical abortion" includes the
termination of pregnancy through the use of pharmacological
agents. (BPC 2253 (c))
6)Establishes the Nursing Practice Act which provides for the
certification and regulation of registered nurses, NPs and
advanced practice nurses, including CNMs, by BRN within the
Department of Consumer Affairs. (BPC 2700 et seq.)
7)Provides that the practice of nursing includes direct and
indirect patient services, including but not limited to, the
administration of medications and therapeutic agents necessary
to implement a treatment, disease prevention, or
rehabilitative regimen ordered by and within the scope of
licensure of a physician, dentist, podiatrist, or clinical
psychologist. (BPC 2735 (b)(2))
8)Provides that the practice of nursing may be performed under
"standardized procedures," as defined, for specified
functions, treatments and procedures. (BPC 2725)
9)Provides that a CNM may furnish or order drugs or devices,
AB 154
Page 5
including controlled substances, if furnished or ordered
incidentally to the provision of family planning services,
routine health care or perinatal care, or care rendered
consistent with the CNM's practice, occurs under physician and
surgeon supervision, and is in accordance with standardized
procedures or protocols as specified. (BPC 2746.51)
10)Provides that a NP may furnish or order drugs or devices,
including controlled substances, if it is consistent with a
NP's educational preparation or for which clinical competency
has been established and maintained, occurs under physician
and surgeon supervision, and is in accordance with
standardized procedures or protocols as specified. (BPC
2836.1)
11)Defines the furnishing or ordering of drugs or devices by NPs
to mean the act of making a pharmaceutical agent or agents
available to the patient in strict accordance with a
standardized procedure. (BPC 2836.2)
12)Establishes the Physician Assistant Practice Act which
provides for the licensure of PAs by the Physician Assistant
Board within the Department of Consumer Affairs. (BPC 3500 et
seq.)
13)Provides that a PA may perform those medical services as set
forth by the regulations of the Medical Board of California
when the services are rendered under the supervision of a
licensed physician and surgeon, and provides that the PA and
the supervising physician and surgeon shall establish written
guidelines or protocols, as specified, for some or all of the
tasks performed by the PA. (BPC 3502)
14)Provides that a PA while under the supervision of a physician
and surgeon may administer or provide medication to a patient,
or transmit orally or in writing a drug order under specified
conditions and protocols adopted by the supervising physician
and surgeon. (BPC 3502.1)
15)Authorizes the Office of Statewide Health Planning and
Development (OSHPD) to, among other functions, collect data
and disseminate information about California's health care
infrastructure, promote equitable distribution of health care
outcomes, and publish information about health care outcomes.
(HSC 127000 et seq.)
AB 154
Page 6
FISCAL EFFECT : Unknown
COMMENTS :
1)Purpose of this bill . This bill authorizes NPs, CNMs and PAs
to perform an abortion by aspiration techniques in the first
trimester of pregnancy upon completion of specified training
and validation of clinical competency, based on protocols
developed under a multi-year University of California, San
Francisco pilot program. This bill is sponsored by the
California Women's Health Alliance, which is comprised of the
following groups: ACCESS Women's Health Justice, American
Civil Liberties Union of California, Black Women for Wellness
California, Latinas for Reproductive Justice, NARAL Pro-Choice
California, and Planned Parenthood Affiliates of California.
2)Author's statement . According to the author, "Evidence
supports safety of early abortion by advanced trained
practitioners. Researchers at the University of California,
San Francisco's Bixby Center for Global Reproductive health
conducted a comprehensive, multi-year study to train and
evaluate NPs, CNMs and PAs in the provision of first trimester
abortion.
"The study, Health Workforce Pilot Project #171, concluded
that trained health professionals can perform early abortions
as safely as physicians. Moreover, patients involved in the
study expressed high rates of satisfaction with the care they
received from all provider types. The study has been
peer-reviewed and published in the American Journal of Public
Health (AJPH).
"Legal ambiguity puts clinicians at risk. Because of the
intense public and political controversy surrounding abortion,
providers are in constant legal jeopardy when statutes
governing abortion are unclear. Unfortunately, this is the
case even in California, a pro-choice state. Clinicians
should be legally protected as they seek to provide safe,
comprehensive and accessible care to their patients within the
scope of their licenses."
3)Current law regarding surgical and nonsurgical abortion .
Current California law states that only a physician and
surgeon may perform a surgical abortion. The law does not
AB 154
Page 7
define a "surgical abortion," but Legislative Counsel has
opined that it includes abortion by aspiration techniques.
Aspiration techniques are also not defined in current law, but
according to Planned Parenthood, an aspiration abortion is a
procedure that ends pregnancy by emptying the uterus with the
gentle suction of a manual syringe or with machine-operated
suction. The most common first-trimester abortion method is
vacuum aspiration. Until 2000, most first-trimester abortions
in the US were surgical abortions performed by vacuum
aspiration or "curettage" (i.e., the scraping of the uterus
with an instrument that is attached to a source of suction
which enables the operator to draw out and collect the
endometrial lining).
"Nonsurgical abortion" is defined in current law to include
the termination of a pregnancy through the use of
pharmacological agents (for example, RU-486). PAs, CNMs, and
NPs are permitted under current law to perform nonsurgical
abortions.
The sponsors of the bill indicate that the terms "surgical"
and "nonsurgical" are no longer current and that abortion
procedures are more appropriately described as "medicinal" and
"aspiration techniques." This bill would permit PAs, CNMs,
and NPs to provide abortions by aspiration techniques after
completing specified training modeled after a recent
peer-reviewed study described below.
4)OSHPD pilot projects . OSHPD was created in 1978 to provide
California with an enhanced understanding of the structure and
function of its healthcare delivery systems. OSHPD considers
itself the leader in collecting data and disseminating
information about California's healthcare infrastructure,
promoting an equitably distributed healthcare workforce, and
publishing valuable information about healthcare outcomes.
The Health Workforce Pilot Program (HWPP) within OSHPD allows
organizations to test, demonstrate, and evaluate new or
expanded roles for healthcare professionals, or new healthcare
delivery alternatives before changes in licensing laws are
made by the Legislature. An OSHPD pilot project is authorized
to waive laws that would otherwise bar clinicians from
learning and performing procedures outside their current scope
of practice.
AB 154
Page 8
OSHPD establishes minimum standards, guidelines, and
instructions for approved pilot projects after one or more
public hearings. Pilot projects must be sponsored by
community hospitals or clinics, nonprofit educational
institutions, or government agencies engaged in health or
education activities. Organizations requesting designation as
approved projects are required to complete and submit an
application that includes:
a) A description of the project, indicating the
category of person to be trained, the tasks to be taught,
and the numbers of trainees and supervisors;
b) The health care agency to be used for training
students;
c) The types of patients likely to be seen or treated;
d) The evaluation process to be used;
e) The baseline data and information to be collected;
f) The nature of program data that will be collected
and the methods for collecting and analyzing the data;
g) Provisions for protecting the safety of patients
seen or treated in the project; and,
h) A statement of previous experience in providing
related health care services.
Upon approval, OSHPD conducts periodic site visits and
continuous evaluations of the pilot project based on specified
criteria. All data collected by OSHPD and by the pilot
projects are public information, with due regard for the
confidentiality of individual patient information. The raw
data on which projects' reports and OSHPD's evaluation are
based is available for public review.
5)HWPP 171 pilot project outcomes . The Advancing New Standards
in Reproductive Health program at the University of
California, San Francisco Bixby Center for Global Reproductive
Health applied for a pilot project in 2005 to evaluate the
safety, effectiveness and acceptability of NPs, CNMs, and PAs
in providing aspiration abortions. This pilot project, known
AB 154
Page 9
as HWPP 171, was approved in 2007. The project is ongoing
through 2014, but results were published in the peer-reviewed
AJPH on January 17, 2013.
The study collected data from 8,000 patients whose first
trimester aspiration abortion was provided by a NP, CNM or PA.
The study concluded that, overall, complications were rare.
Although the rate of complications from CNM, NP, and
PA-performed aspirations was 1.8%, as compared to physicians'
rate of 0.9%, the study noted that the majority of
complications were minor and "complication rates from
aspiration abortions performed by recently trained NPs, CNMs,
and PAs were statistically no worse than those performed by
the more experienced physician group." The study also noted
that the rates of complication amongst CNMs, NPs, and PAs
would likely further decline with greater experience.
The AJPH article further states that "Nationally, 92% of
abortions take place in the first trimester, but black,
uninsured, and low-income women have less access to this care.
In California, only 87% of women using state Medicaid
insurance obtain abortions in the first trimester. Because
the average cost of a second-trimester abortion is
substantially higher than that of a first-trimester procedure,
shifting the population distribution of abortions to earlier
gestations would result in safer, less costly care.
Increasing the types of health care professionals involved in
abortion care is one way to reduce this health care
disparity."
6)Arguments in support . The American Civil Liberties Union of
California writes, "AB 154 is critically important to
improving women's reproductive health access in California.
According to the Guttmacher Institute, 52% of California
counties lack an abortion provider (removing hospitals, which
typically provide a small number of procedures for medical and
fetal indications). This lack of access causes women to delay
the termination of their pregnancies into the second, or even
third, trimesters. It also forces rural women to travel long
distances - in the case of some rural areas, up to five hours;
women have to raise money to cover these travel costs, further
delaying care. Even women in urban areas face long wait-times
to receive first trimester abortion care.
"AB 154 will address this access shortage by allowing [NPs,
AB 154
Page 10
CNMs and PAs] to perform this procedure under the terms of
their licenses. This bill helps to ensure that women are
getting safe and early care. Furthermore, the bill will help
provide comprehensive and better coordinated reproductive
health care in areas such as miscarriage management,
post-abortion follow-up and contraception. Women should be
able to receive care from clinicians they know and trust."
7)Arguments in opposition . The California Catholic Conference
writes, "We oppose the practice of abortion and until it
becomes illegal, we will advocate for restrictions on its
practice. While the author proposes the training of abortion
practitioners - thereby increasing "access" - these mid-level
clinicians will not have undertaken the rigors of a
physician's medical training. We ask for what other serious
medical intervention would doctors even consider changing the
professional scope of practice?"
8)Previous legislation . SB 1338 (Kehoe) of 2012 would have
allowed an NP, CNM, or PA who has completed training in Health
Workforce Pilot Project 171 and received such training on or
before January 1, 2013, to continue to perform abortions by
aspiration techniques. That bill retained language
restricting who could assist in abortion procedures and
defined "nonsurgical" to include aspiration techniques. That
bill was held in the Senate Business, Professions, and
Economic Development Committee.
SB 623 (Kehoe), Chapter 450, Statutes of 2012, required OSHPD
to extend until January 1, 2014 the Health Workforce Pilot
Project No. 171 to evaluate the safety, effectiveness, and
acceptability of NPs, CNMs, and PAs in providing aspiration
abortions.
AB 1306 (Donnelly) of 2011 would have required a person
authorized to perform an abortion to provide information, as
specified, to any woman seeking an abortion in order to obtain
her informed consent and would have required any facility
where an abortion is authorized to be performed to post the
telephone number of a nonprofit organization that provides
services in support of the elimination of human trafficking.
This bill was held in Assembly Health Committee.
9)Double-referral . This bill is double-referred, and if passed
by this Committee, it will be referred to the Assembly Health
AB 154
Page 11
Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
California Women's Health Alliance (sponsor)
American Civil Liberties Union of California (co-sponsor)
ACCESS Women's Health Justice (co-sponsor)
Black Women for Wellness (co-sponsor)
California Latinas for Reproductive Justice (co-sponsor)
NARAL Pro-Choice California (co-sponsor)
Planned Parenthood Affiliates of California (co-sponsor)
ACT for Women and Girls
American Association of University Women
American College of Nurse-Midwives
American Nurses Association
Bay Area Communities for Health Education
California Association for Nurse Practitioners
California Church IMPACT
California Family Health Council
California Latinas for Reproductive Justice
California Nurse-Midwives Association
California Women's Law Center
Cardea Institute
Center on Reproductive Rights and Justice at UC Berkeley School
of Law
Choice USA
Choice USA at California State University Long Beach
Choice USA at California State University Sacramento
Choice USA at Mills College
Choice USA at San Jose State University
Choice USA at Scripps College Beach
Forward Together
Fresno Barrios Unidos
Khmer Girls in Action
Law Students for Reproductive Justice
League of Women Voters of California
National Asian Pacific American Women's Forum
National Center for Lesbian Rights
National Health Law Program
National Latina Institute for Reproductive Health
National Network of Abortion Funds
Nevada County Citizens for Choice
Physicians for Reproductive Health
AB 154
Page 12
Planned Parenthood Mar Monte
Planned Parenthood of Orange and San Bernadino Counties
Planned Parenthood Pasadena & San Gabriel Valley
Planned Parenthood of Santa Barbara, Ventura, and San Luis
Obispo Counties
Planned Parenthood of the Pacific Southwest
Reproductive Justice Coalition of Los Angeles
Six Rivers Planned Parenthood
Students for Reproductive Justice at Stanford University
Women's Community Clinic
Women's Health Specialists of California
53 private individuals
Opposition
California Catholic Conference
California Right to Life Committee
Capitol Resource Institute
1 private individual
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301