BILL ANALYSIS Ó
AB 154
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 154 (Atkins)
As Amended June 24, 2013
Majority vote
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|ASSEMBLY: |50-25|(May 28, 2013) |SENATE: |25-11|(August 26, |
| | | | | |2013) |
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Original Committee Reference: B., P. & C.P.
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 obsolete references 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 obsolete 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
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of Registered Nursing (BRN) in order to perform an 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,
achieved clinical competency, and adhere to specified standardized
procedures, to perform abortions by aspiration techniques.
8)Requires a NP and CNM to adhere to standardized procedures in
order to perform an abortion by aspiration techniques that must
specify all of the following:
a) The extent of supervision by a physician and surgeon with
relevant training and expertise;
b) Procedures for transferring patients to the care of the
physician and surgeon or a hospital;
c) Procedures for obtaining assistance and consultation from a
physician and surgeon;
d) Procedures for providing emergency care until physician
assistance and consultation is available; and,
e) The method of periodic review of the provisions of the
standardized procedures.
9)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; further 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.
10)Deems the training protocols established by HWPP 171 to meet the
PAB standards.
11)Authorizes a PA who has completed the HWPP 171 training, achieved
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clinical competency, received authority from his or her
supervising physician and surgeon, and acts according to specified
protocols, to perform abortions by aspiration techniques.
12)Requires a PA, in order to receive authority from his or her
supervising physician and surgeon to perform an abortion by
aspiration techniques, to comply with protocols that specify:
a) The extent of supervision by a physician and surgeon with
relevant training and expertise;
b) Procedures for transferring patients to the care of the
physician and surgeon or a hospital;
c) Procedures for obtaining assistance and consultation from a
physician and surgeon;
d) Procedures for providing emergency care until physician
assistance and consultation is available; and,
e) The method of periodic review of the protocols.
13)Makes other clarifying and technical changes.
14)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.
The Senate amendments state that that certain provisions of this
bill regarding the ability for an NP to perform an abortion by
aspiration techniques will be in effect notwithstanding any other
law in the Nurse Practice Act.
FISCAL EFFECT : According to the Senate Appropriations Committee:
1) One-time costs up to $150,000 for the adoption or revision of
regulations by the Board of Registered Nursing (Board of
Registered Nursing Fund);
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2) One-time costs up to $150,000 for the adoption or revision of
regulations by the Medical Board of California (Contingent Fund
of the Medical Board of California); and,
3) Indeterminate impact on state health care programs, such as
Medi-Cal and CalPERS (various funds). While the impact on state
programs is not known, the bill is not likely to increase
overall state spending on those programs.
By authorizing more health care providers to provide first
trimester aspiration abortions, it is possible that the bill
will increase the overall number of abortions performed in the
state. However, this impact is uncertain. It is not known
whether limitations in the number of providers for first
trimester abortions actually limits the number of abortions that
are performed in the state. Currently, women who desire a first
trimester abortion and face a shortage of providers may travel
to an area where services are available or delay their abortion
until later in the pregnancy. In such cases, this bill would not
increase the overall number of abortions. Given that the cost to
provide a first trimester aspiration abortion is less than the
cost to provide a second trimester surgical abortion, greater
access to first trimester aspiration abortions may reduce state
health care costs.
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)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 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,
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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.
"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.
3)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.
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.
4)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
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abortions. This pilot project, known as HWPP 171, was approved in
2007. The project is ongoing through 2014, but results were
published in the peer-reviewed American Journal of Public Health
(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."
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301
FN: 0001762