BILL ANALYSIS Ó AB 864 Page 1 Date of Hearing: April 23, 2013 ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER PROTECTION Richard S. Gordon, Chair AB 864 (Skinner) - As Amended: April 1, 2013 SUBJECT : Athletic trainers. SUMMARY : Establishes the Athletic Training Practice Act (Act) to license and regulate athletic trainers (ATs) through the creation of an Athletic Trainer Licensing Committee (Committee) under the Physical Therapy Board of California (Board), to commence on July 1, 2014 and expire on January 1, 2019. Specifically, this bill : 1)Declares that the provisions enacted by this bill may be known and cited as the Athletic Training Practice Act. 2)Prohibits any individual from engaging in the practice of athletic training unless duly licensed under the Act. 3)Prohibits a person from using the title "athletic trainer," "licensed athletic trainer," "certified athletic trainer," "athletic trainer certified," "a.t.," "a.t.l.," "c.a.t.," "a.t.c.," or any other variation of these terms, or any other similar terms indicating that the person is an AT, unless that person is duly licensed under the Act. 4)Permits an individual who has practiced athletic training in California for a period of 15 consecutive years prior to July 1, 2014, and is not eligible for an athletic training license, to use the title "athletic trainer" without being licensed by the Committee, upon registration with the Board; provided that no person may use the title "athletic trainer" on or after January 1, 2017 without being duly licensed under the Act. 5)Establishes the Committee within the Board, which shall consist of seven members, organized in the following manner: a) Four licensed athletic trainers, as specified; b) One public member; c) One physician and surgeon licensed by the Medical Board AB 864 Page 2 of California or one osteopathic physician and surgeon licensed by the Osteopathic Medical Board of California; and, d) One physical therapist licensed by the Board. 6)Provides that the Committee shall sunset on January 1, 2019, unless it is deleted or extended beyond that date, and further subjects the Committee to the authority of the Joint Sunset Review Committee after its sunset date. 7)Provides that, subject to confirmation by the Senate, the Governor shall appoint two of the licensed ATs, the public member, and the physician and surgeon or osteopathic physician and surgeon; the Senate Committee on Rules and the Speaker of the Assembly shall each appoint a licensed athletic trainer; and the Board shall appoint the licensed physical therapist. 8)Provides that all appointments shall be for a term of four years and shall expire on June 30 of the year in which the term expires, with vacancies to be filled for any unexpired term. 9)Provides that, for initial appointments made on or after January 1, 2014, the public member appointed by the Governor shall serve a term of one year. The athletic trainers appointed by the Senate Committee on Rules and the Speaker of the Assembly shall serve terms of three years, and the remaining members shall serve terms of four years. 10)Provides that each member of the committee shall receive per diem and expenses, as specified. 11)Authorizes the Committee to adopt, repeal, and amend regulations as may be necessary to enable it to carry into effect the provisions of the Act. 12)Authorizes the Committee, in promulgating regulations, to consult the professional standards issued by the National Athletic Trainers' Association (NATA), the Board of Certification, Inc. (BOC), the Commission on Accreditation of Athletic Training Education (CAATE), or any other nationally recognized professional organization. 13)Requires the Committee to approve programs for the education AB 864 Page 3 and training of ATs. 14)Requires the Committee to investigate each applicant before a license is issued in order to determine whether the applicant meets the qualifications required by the Act. 15)Requires that protection of the public be the highest priority for the Committee in exercising its licensing, regulatory, and disciplinary functions, and that whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount. 16)Requires the Committee, except as otherwise provided, to issue an athletic training license to an applicant who meets all of the following requirements: a) Has submitted an application demonstrating that the applicant has graduated from an accredited and approved professional degree program in athletic training at an accredited and approved post-secondary institution or institutions, as specified; b) Has passed an athletic training certification examination offered by BOC, its predecessors or successors, or another nationally accredited athletic trainer certification agency approved and recognized by the Committee; c) Possesses an emergency cardiac care certification from a certification body approved by the Committee that adheres to the most current international guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care; and, d) Has paid the application fee established by the Committee. 17)Requires the Committee to issue an athletic training license to an applicant who did not graduate from an accredited athletic training education program as described above, but who received athletic training via an internship, if the applicant meets all of the following requirements: a) Furnishes satisfactory evidence of completion of a AB 864 Page 4 degree at an accredited post-secondary institution that included instruction in basic sciences related to, and on the practice of, athletic training; b) Has passed an athletic training certification examination offered by the BOC, its predecessors or successors, or another nationally accredited AT certification agency approved and recognized by the Committee; c) Completed at least 1500 hours of clinical experience under an AT certified by the BOC; d) Possesses an emergency cardiac care certification from a certification body, approved by the committee, that adheres to the most current international guidelines for CPR and emergency cardiac care; and e) Has paid the application fee established by the Committee. 18)Declares that a license issued by the Committee to be valid for two years and thereafter shall be subject to renewal requirements. 19)Authorizes the Committee to establish license application and renewal fees in an amount sufficient to cover the reasonable regulatory costs of carrying out the Act. 20)Authorizes the Committee to renew a license if an applicant meets all of the following requirements: a) Pays the renewal fee as established by the Committee; and, b) Submits proof of all of the following: i) Satisfactory completion of continuing education; ii) Current athletic training certification from a certification body approved by the committee, including, but not limited to, the BOC, or its predecessors or successors; and, iii) Current emergency cardiac care certification from a AB 864 Page 5 certification body approved by the Committee that adheres to the most current international guidelines for CPR and emergency cardiac care. 21)Authorizes the Committee to deny a license or the renewal of a license for an applicant or licensee who is described by any of the following: a) Does not meet the requirements of the Act; b) Has had an athletic training license, certification, or registration revoked or suspended by an accredited organization, state, or territory; c) Has been convicted of a felony or any other crime that substantially relates to the functions or duties of an AT; or, d) Has committed unprofessional conduct, as specified. 22)Authorizes the Committee to order any of the following actions relative to an athletic training license after a hearing for unprofessional conduct, which includes, but is not limited to, a violation of the Act, any regulation adopted by the Committee pursuant to the Act, and revocation or suspension of an athletic training license, certification, or registration by an accredited organization, state, or territory: a) Issue a training license subject to terms and conditions; b) Suspend or revoke the athletic training license; and, c) Impose probationary conditions upon the athletic training license. 23)Declares that the practice of athletic training includes all of the following: a) Risk management and injury or illness prevention; b) The clinical evaluation and assessment of an injury or an illness sustained or exacerbated while participating in physical activity, or both; AB 864 Page 6 c) The immediate care and treatment of an injury or an illness sustained or exacerbated while participating in physical activity, or both; and, d) The rehabilitation and reconditioning from an injury or an illness sustained or exacerbated while participating in physical activity, or both. 24)Declares that the practice of athletic training does not include the practice of physical therapy, the practice of medicine, the practice of osteopathic medicine, the practice of chiropractic medicine, the practice of nursing, or medical diagnosis or treatment. 25)Requires an AT to refer a patient to an appropriate licensed health care provider when the treatment or management of the injury, illness, or condition does not fall within the practice of athletic training. 26)Prohibits an AT from providing, offering to provide, or representing that he or she is qualified to provide any treatment that he or she is not qualified to perform by his or her education, training, or experience, or that he or she is otherwise prohibited by law from performing. 27)Defines "injury" or "illness" means an injury or illness sustained as a result of, or exacerbated by, participation in athletics or physical activity for which the AT has had formal training during his or her professional education program, including nationally recognized educational competencies and clinical proficiencies for the entry-level AT or advanced post-professional study, and falls within the practice of athletic training. 28)Requires an AT to render treatment within his or her scope of practice under the direction of a physician and surgeon licensed by the Medical Board of California or an osteopathic physician and surgeon licensed by the Osteopathic Medical Board of California, with such direction provided by: a) Verbal order when the directing physician and surgeon or osteopathic physician and surgeon is present; and, b) Written order or by athletic training treatment plans or AB 864 Page 7 protocols, to be established by the physician and surgeon or osteopathic physician and surgeon, when the directing physician and surgeon or osteopathic physician and surgeon is not present. 29)Authorizes the Committee, notwithstanding any other law and consistent with the Act, to establish other alternative mechanisms for the adequate direction of an AT. 30)Exempts from the requirements of the Act the following individuals: a) An AT licensed, certified, or registered in another state or country who is in California temporarily, traveling with a team or organization, to engage in the practice of athletic training for, among other things, an athletic or sporting event; b) An AT licensed, certified, or registered in another state who is invited by a sponsoring organization, such as the United States Olympic Committee, to temporarily provide athletic training services under his or her state's scope of practice for athletic training; c) A student enrolled in an athletic training education program, while participating in educational activities during the course of his or her educational rotations under the supervision and guidance of an athletic trainer licensed under the Act chapter or other licensed health care provider; or, d) A member or employee of the United States Armed Forces, licensed, certified, or registered in another state, as part of his or her temporary federal deployment or employment in California for a limited time. 31)Declares that the Act does not limit, impair, or otherwise apply to the practice of any person licensed and regulated as a healing arts professional. 32)Declares that the Act does not require new or additional third party reimbursement for services rendered by an individual licensed under the Act. 33)Creates the Athletic Trainers' Account in the existing AB 864 Page 8 Physical Therapy Fund. 34)Defines the terms "athletic trainer," "Board," and "Commission". 35)Provides that the provisions of this bill related to title protection, the structure of the Committee, the scope of practice, and physician and surgeon direction of the AT shall become operative on July 1, 2014, as specified. 36)Makes findings and declarations relative to the need to regulate the profession of athletic training. EXISTING LAW provides for the regulation of various professions and vocations, including those of an athlete agent. FISCAL EFFECT : Unknown COMMENTS : 1)Purpose of this bill . This bill would create the Athletic Training Practice Act to license and regulate ATs through a Committee created under the Physical Therapy Board. The Committee would have powers similar to other licensing boards under the Department of Consumer Affairs to promulgate regulations, approve training and educational programs, investigate applicants and issue licenses, and order disciplinary measures up to and including license suspension. The Act would become operational on July 1, 2014 and sunset on January 1, 2019 unless dissolved or extended before that date. Opponents question the need for full licensure rather than simple title protection, and also contend that the scope of practice is overly broad and that the Committee should not be located under the Board. This bill is sponsored by the California Athletic Trainers' Association (CATA). 2)Author's statement . According to the author: "Athletic trainers and other individuals are currently practicing athletic training - a health care profession - in an unregulated manner. Athletic training is recognized by the American Medical Association as an allied health care profession that is in the same category as physical therapy and occupational therapy. Currently 48 other states regulate athletic training due to the inherent risk AB 864 Page 9 of individuals practicing healthcare without oversight. Individuals have come to California from other jurisdictions after losing their license or certification and practice in the state. In some cases, individuals who have no training, instruction, or experience in athletic training (or any other health or medical profession) are practicing as athletic trainers. They are employed by schools, businesses and healthcare facilities. In some cases, individuals such as janitors, coaches, shipping and receiving clerks and others have been given the title Athletic Trainer and the responsibility for doing things such as evaluating and managing concussions, spinal cord injuries, shoulder dislocations, and knee injuries. This lack of oversight has caused harm to the public in California and in other states. "Furthermore, the lack of oversight of athletic trainers is a consumer protection problem. The athletes with whom these unqualified individuals work, and the employers who hire them, have no way of knowing that these individuals are not qualified to be athletic trainers. The public has no way to determine if someone practicing athletic training is qualified. The public has no way to file a complaint, or ask for a practitioner to be investigated and/or sanctioned for incompetence, unethical practice, etc. This creates a huge regulatory gap in the healthcare system?. "Additionally, athletic trainers are typically the most available, and also the most qualified, health care providers to evaluate symptoms of a head injury suffered at a school practice or competition to determine if the athlete has a concussion. However, current law bars athletic trainers from managing concussions simply because they are not licensed." 3)The practice of athletic training . ATs are physical medicine and rehabilitation specialists who generally work in institutional settings under the direction of a physician. In practice, they are often the first healthcare providers on the scene when injuries occur (particularly at sporting events), and must be able to recognize, evaluate and assess injuries and provide immediate care when needed. ATs operate with substantial independence and professional decision-making authority, as a physician need not be onsite with the AT, or even to individually know or work with the AT's clientele. AB 864 Page 10 The Act generally describes the practice of athletic training as including the professional treatment of a patient for risk management and injury or illness prevention, as well as the clinical evaluation and assessment, immediate care and treatment, organizational health and well-being, and rehabilitation and reconditioning of a patient from an injury or illness sustained or exacerbated while participating in physical activity. ATs are considered "health care professionals" by the American Medical Association, which states that "athletic training encompasses the prevention, diagnosis and intervention of emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities." ATs are distinct from "personal trainers", who are generally thought of as individuals who prescribe, monitor and modify individual exercise programs in a fitness or sports setting. Athletic training and physical therapy are also specific and different professions, although there are some areas of overlap. ATs are usually employed by organizations such as professional sports teams, colleges and universities, high schools, outpatient rehabilitation clinics, hospitals, industry/corporations, performing arts groups, physicians, the military and health clubs. Roughly 44% of certified ATs work with athletes in educational or professional sports setting, with nearly 19% working in health care facilities, and over 10% working in industry, public safety and the military. The sponsor reports that large employers use ATs in part because of their utility in reducing employee injuries and worker's compensation costs. 4)Current state of regulation for athletic trainers . The educational system for athletic training has been standardized and accredited by a national accreditation agency, CAATE. According to the author, all 48 states currently regulating athletic training utilize the BOC certification examination, which is based on CAATE educational principles. BOC is the only entity that currently provides athletic training certification, which means that it would be the sole provider of the certification exam required by this bill. Certification is not mandatory to practice athletic training in California, and non-certified individuals are not subject AB 864 Page 11 to regulatory discipline. Despite its widespread adoption, BOC has a limited ability to investigate complaints against certified ATs because they have no subpoena power and limited staff with no authority in California. Its sole disciplinary power is the suspension or revocation of the national certification which is not recognized in California and thus poses no barrier to an individual's continued practice. According to the author, athletic trainers are already licensed and regulated in the vast majority of states: "?although 48 states in the nation license athletic trainers and 30 of those states have sunset processes for their licensure acts, no athletic training board has ever been discontinued, demonstrating that there is a continuing need for licensing in those states because of the investigative and regulatory oversight they provide." The sponsor notes that there are 47 states that regulate athletic trainers, 39 of which provide licensure. The remaining 8 states have elements of licensure, although different terminology is used. Only Alaska and Hawaii do not regulate athletic trainers in any form, although they have legislation pending. There are 16 accredited athletic training programs in California. In 2010, 182 Californians were became certified ATs. Currently, there are approximately 2,500 certified ATs practicing in California who would qualify for licensure as ATs under the Act. The sponsor of this bill, CATA, represents approximately 2,300 ATs in California. 5)Evidence of substandard practice . One rationale for licensure is that an oversight body like the Committee can remove bad actors from practice by suspending or revoking the license that may be a precondition for employment. Licensure also makes it difficult for unqualified individuals to hold themselves out professionally as ATs. According to the author, "[a] survey of 760 certified athletic trainers for the Sunrise report found more than 60 cases of harm as the result of improper care provided by non-certified AB 864 Page 12 'athletic trainers.' According to the U.S. Department of Labor Division of Practitioner Data Banks, a voluntary reporting repository for sanctions made by state boards, there were 469 reports of sanctions to athletic trainers - both certified and uncertified - from 2000 to 2010. These sanctions were based upon misconduct including incompetent practice/harm, practicing beyond the scope of practice, and sexual misconduct. The BOC reported over 2,700 violations [nationwide] of professional practice standards in five years (2005-10) with nearly 300 violations in California, including three sexual offenses. In a 2011 case, a collegiate athlete died because of negligence of a collegiate athletic trainer, although no lawsuit has been filed to date. Two additional athletic trainers were fired after being arrested on sexual abuse charges." The sponsor reports that it is aware of at least 150 individuals practicing as athletic trainers without certification in California high schools, and seven individuals working in California community colleges who are similarly unqualified. The standardized training required for licensure and the disciplinary oversight provided by the Committee are intended to address these problems. 6)Proposed California licensure requirements . In order to be eligible for licensure, applicants must have a professional degree from an accredited institution, pass the national written certification exam, possess an emergency cardiac care certification, and pay the application fee. Individuals without a professional degree would be required to complete at least 1500 hours of clinical experience instead. Biannual license renewal will be subject to continuing education requirements, as determined by the Committee. The Act requires ATs to refer a patient to the appropriate health care provider when the treatment of an injury, illness or condition falls outside of the AT's scope of practice. The Act also requires ATs to render treatment only under the written or verbal direction of a physician and surgeon. Exemption from licensure will apply to ATs licensed in another state or country operating temporarily in California due to a sporting event, students participating in educational activities under the supervision of a licensed AT, and active AB 864 Page 13 members of the military. 7)Questions for the Committee . This bill currently establishes the Committee as the responsible regulatory entity for ATs, and locates it within the existing Physical Therapy Board. The location of the Committee may prove to be problematic, given the apparent overlap between the professions and the opposition from some quarters of the physical therapy profession. According to the sponsor, the reason for colocation is simply administrative convenience and avoidance of the cost of creating a new board. Nevertheless, the Committee may wish to consider whether or not the licensing body for ATs should be located under the board of a more closely allied profession, such as the Medical Board of California, or if its mission would be better served as an independent board fully supported by licensing fees. One critically important question is how the scope of practice broadly set out in this bill compares with and overlaps other professions. The California Physical Therapy Association (CPTA) argues that this bill effectively permits ATs to engage in diagnosis (physical therapists require a physician's diagnosis) and grants a broader scope of practice than physical therapists enjoy, which may or may not be merited by their differing educational requirements. Given the importance of consistency in setting scope of practice relative to training and education, the Committee may wish to inquire of the author and sponsor as to exactly how the scope and educational requirements for ATs proposed by this bill compare with those of related professions, such as physical therapists, and whether or not the scope indicated by this bill is clear, consistent and fair. This bill also contains a confusing passage declaring that the practice of athletic training does not include the "practice of physical therapy, the practice of medicine, the practice of osteopathic medicine, the practice of chiropractic medicine, the practice of nursing, or medical diagnosis or treatment." (BPC 2697.22(b)) Given the practical overlap that exists between athletic training and physical therapy, for example, this language read literally could be construed to restrict athletic training only to those practices that do not fall within the other cited professions - which presumably would be minimal. This suggests that the language was intended to communicate the semantic point that the same practices may be AB 864 Page 14 described differently by different professions. The Committee may wish to inquire of the author as to the necessity of that language. One alternative to licensure that has been proposed in previous legislation is certification and title protection, where AT's continue with certification without a regulatory board, but use of the title of "athletic trainer" is reserved by law only for qualified individuals. While this approach would be simpler, less expensive, and likely less controversial, the sponsor argues that the overall level of consumer protection would be lower as well because there would be no mechanism for investigating or disciplining unqualified, incompetent or unethical practitioners. The Committee may wish to inquire of the author as to the relative merits of a title act approach versus the practice act approach taken by this bill. Finally, the Committee may wish to consider whether or not a cap on licensing fees should be made explicit in this bill, as it is with many other regulated professions, which provides a legislative check against excessive licensing fees. 8)Technical amendments . There are two technical corrections that the author may wish to consider. Section 2697.8(f) of the bill related to the sunset date of the Committee contains a reference to the now-defunct Joint Sunset Review Committee. Given that the committee no longer operates, and the sunset review process is now handled jointly by the Senate Business, Professions and Economic Development Committee and the Assembly Business, Professions and Consumer Protection Committee, that reference should be deleted. Page 4, lines 8-12: on line 8, strike the word "The"; strike lines 9-12, inclusive. Section 2697.20(b)(2) contains a typographical error. Page 6, line 13: after a "certification body approved by", delete "te" and insert "the" 9)Arguments in support . According to the sponsor, "Athletic training is a profession that is regulated by 48 states, recognized by multiple governmental and healthcare agencies as AB 864 Page 15 a specific healthcare profession and which has a single nationally accredited education and certification process. As there is no defined scope of practice of athletic training in the state, the status quo is an expansive scope of practice and the ability of individuals to practice without any preparation. Further, the public has no ability to register complaints nor can the state investigate and sanction unsafe or unethical providers. AB 864 will for the first time provide a defined scope for this frontline medical profession that is consistent with the extensive education, training and certification of athletic trainers and ensure physician oversight. It will provide assurance of minimum standards of competence of practitioners and will allow those that are practicing illegally, unsafely or unethically to be sanctioned." The American Medical Society for Sports Medicine (AMSSM) writes, "AMSSM has long recognized the value and role of athletic trainers within a Sports Medicine care team? Athletic trainers play an essential role as the front line healthcare professional for a well-functioning, multi-disciplinary Sports Medicine care team. Athletic trainers interact on a daily basis with the athletes for whom they are caring, are well trained in acute injury and illness evaluation and management, facilitate care from other clinicians when needed, and work closely with team physicians to provide comprehensive care for athletes. "[AB 864] will provide state-specific regulation to the practice of athletic training. This protects the public by ensuring that those individuals who call themselves "athletic trainers" have the proper educational credentials and are adhering to accepted professional and ethical practice standards. AMSSM is concerned that a failure by the state of California to license athletic trainers when licensure exists in 48 other states will promote a situation where 'athletic trainers' in California provide substandard care for athletes. For instance, athletic trainers from other states who have lost their certification or license may come to California to practice. "[AB 864] is a cost-neutral bill that will provide a AB 864 Page 16 defined scope of practice to the profession of athletic training in the state of California. It will provide the public with the certainty that athletic trainers who are practicing in their communities have the requisite skills and educational background to function safely, and it would allow the people of California the means to report and investigate athletic trainers who are practicing in an unsafe manner." 10)Arguments in opposition . According to the California Nurses Association, "There are already qualified healing arts practitioners currently licensed by the state who can perform athletic training services, and thus there is no need to create a new licensing category for athletic trainers. These existing practitioners, like nurses, physical therapists, and others already retain the education, and clinical training and experience to provide these services in a way that is safe for athletes. Further, we have very strong concerns with the proposed scope of practice outlined in the bill which is very broad and would endow athletic trainers with the practice authority to treat, clinically evaluate, assess, rehabilitate, and recondition 'patients'." CPTA opposes the bill on multiple grounds, namely: 1) there is insufficient evidence of a problem caused by a lack of regulations, and that title protection alone would be an appropriate middle ground; 2) the scope of practice of athletic trainers as defined in the bill is "overly broad, unsafe and inconsistent with the education and training of athletic trainers", particularly in comparison to physical therapists who have more stringent educational requirements yet a narrower scope of practice; 3) the bill unwisely outsources the certification of ATs to a for-profit company located in another state; 4) the Board is not an appropriate place to house the Committee because the Board would lack disciplinary authority over ATs while taking on unwanted financial responsibilities; and 5) physical therapists should be exempted from the licensure requirements because of the higher level of required education and training. According to CPTA, the Joint Legislative Sunset Review Committee analyzed the issue of licensure for athletic trainers during its 2005 sunset review hearings, and found that "At this time, there appears to be insufficient justification to license athletic trainers. However, some sort of state recognition of AB 864 Page 17 athletic trainers may be appropriate." The California Federation of Teachers opposes the bill unless amended to permit individuals who have been practicing as ATs for more than 15 years to continue to use the title "athletic trainer" indefinitely. 11)Previous legislation . SB 1273 (Lowenthal) of 2012 was very similar to AB 864. SB 1273 failed passage in the Senate Business and Professions Committee. AB 374 (Hayashi) of 2011 in its most recent version would have extended title protection to ATs. AB 374 was amended in the Assembly Appropriations Committee to address an unrelated issue. AB 1647 (Hayashi) of 2010 would have extended title protection to ATs. AB 1647 was vetoed by the Governor. SB 284 (Lowenthal) of 2007 would have provided for registration of ATs. SB 284 was vetoed by the Governor. SB 1397 (Lowenthal) of 2006 would have provided for registration of ATs. SB 1397 was vetoed by the Governor. AB 614 (Lowenthal) of 2003 would have required the Department of Consumer Affairs to review the need for licensing of ATs. AB 614 was held in the Senate Business and Professions Committee. AB 2789 (Lowenthal) of 2002 would have required the Department of Consumer Affairs to review the need for licensing of ATs and undertake an occupational analysis. AB 2789 was held on the Assembly Appropriations Committee Suspense file. REGISTERED SUPPORT / OPPOSITION : Support California Athletic Trainers' Association (sponsor) American Medical Society for Sports Medicine Advocates for Injured Athletes California Community College Athletic Trainers' Association AB 864 Page 18 1378 private individuals Opposition California Federation of Teachers California Nurses Association California Physical Therapy Association Independent Physical Therapists of California Mount St. Mary's College Occupational Therapy Association of California 398 private individuals Analysis Prepared by : Hank Dempsey / B.,P. & C.P. / (916) 319-3301