Heavy lobbying from well-funded medical groups hastened the dramatic defeat this month of a bipartisan bill that would have eased regulations on physician assistants in Colorado, proponents of the legislation say.
House Bill 1095 would have let physician assistants practice with less oversight from doctors, which the bill’s sponsors said would help increase access to health care for people living in rural and underserved communities.
The measure appeared on its way to final House approval when it was defeated in a 35-28 vote.
Opponents, including the two House members who work in medicine, argued the bill would leave patients with a poorer quality of care and could create departments entirely staffed by physician assistants.
“That is scary. That is unacceptable. It’s inappropriate,” said state Rep. Kyle Mullica, a Federal Heights Democrat and emergency room nurse. “I cannot stress how passionate I am about this because ... we are talking about safety. We are talking about our patients here.”
The bill is among the 30 most-lobbied measures at the General Assembly this year, with more than 60 lobbyists and lobbying firms representing nearly 40 clients in trying to influence lawmakers on the measure.
Of the 10 groups opposing the bill, three are medical industry groups that donated nearly $150,000 to 43 of the state’s 65 House members from 2019 through the end of 2021. Three-quarters of that spending went to 28 of the 35 representatives who voted against House Bill 1095, a Colorado Sun analysis found.
Of the 11 House members who received the largest contributions from the medical groups – the Colorado Medical Society, medical liability insurance group COPIC, and the Colorado chapter of the American College of Emergency Physicians – 10 voted against House Bill 1095.
UnitedHealth Group’s PAC was the only campaign donor identified by The Sun of the eight groups supporting the bill. Several are nonprofits that aren’t involved in supporting political candidates. UnitedHealth’s PAC donated $6,000 to 18 House candidates in 2019 and 2020. Only five of those who received donations voted for the bill. Individuals and traditional PACs may donate up to $400 during an election cycle to state legislative candidates, while small donor committees may donate up to $5,350.
State Reps. Perry Will, R-New Castle, and Susan Lontine, D-Denver, the prime sponsors of House Bill 1095, blame their bill’s failure on intense lobbying from medical groups. They also said opposition from medical groups was based more on a fear of industry competition than patient safety.
“It is a turf war,” Lontine said.
Lawmakers who voted against the legislation said their positions were not influenced by financial contributions. The groups that opposed the legislation said the bill was defeated because it is bad policy that could leave patients or physician assistants in unsafe environments.
Dr. Mark Johnson, president of the Colorado Medical Society, said he was proud the group’s lobbyists were able to convey “exactly what this bill is going to do and how it damages or could potentially damage patient safety.”
“I think we were able to defeat this bill on the merits of the case,” he said, “not on the fact that we sometimes do donate money to political campaigns.”
Physician assistants help doctors see more patients by handling routine cases, freeing the physician up to handle more complicated problems, he said. The lengthy education doctors receive better equips them to handle complex or unexpected complications, he said.
Under House Bill 1095, physician assistants with 5,000 or more practice hours would consult a health care team when they need help. Those with less experience would maintain a “collaborative plan” with a doctor.
That’s a departure from the current state requirement that all physician assistants work under a doctor’s supervision, providing care that fits within that doctor’s skill set.
About 20 states – including West Virginia, Wisconsin and New Mexico – have allowed physician assistants to have more of a collaborative relationship with doctors. Utah, North Dakota and Wyoming have passed legislation similar to House Bill 1095, which critics say goes further by allowing experienced physician assistants to practice without onsite supervision.
The first physician assistant program was started by a doctor in the 1960s, meant to help war medics enter the medical profession, said Alyn Whelchel, president of the Colorado Academy of Physician Assistants.
At the time, physicians typically owned their own practices; a physician assistant would be employed by the practice, and work under the physician’s supervision.
Now, though, most physicians and physician assistants are employed by large health systems. And physician assistants are struggling to find jobs in parts of Colorado because they can’t find a physician to supervise them, Whelchel said.
If a doctor leaves, their physician assistant is out of work if they can’t find a new supervisor. If a new doctor comes in with a more limited skill set, the physician assistant can only practice within that physician’s area of expertise, she said.
Physician assistant Susanna Storeng, for example, has for nearly two decades provided preventive HIV treatment and long-acting reversible contraceptives, like IUDs, which are placed in the uterus to prevent pregnancies. She practices at a safety net clinic in southeast Colorado, a rural part of the state where turnover among health care providers is high and there are few providers to begin with, she said.
She’s been supervised by three doctors in three years. Her current supervisory doctor’s scope of practice does not include the preventive HIV treatment, hepatitis treatment or birth control, which means she can no longer provide those services. Now, she sends patients she’s had yearslong relationships with elsewhere for treatment. The closest place to treat a hepatitis patient is an hour away – a specialist with a three-month wait, she said.
“We want to be able to treat the patient to the fullest extent of our training, our education,” Storeng said. “Unfortunately, our license says that we can’t do that if our supervising physician does not have those same skill sets.”
Will said the legislation would be a boon for rural Colorado, in particular, where remoteness and lack of medical professionals pose challenges his urban colleagues fail to comprehend.
Someone facing a health crisis in eastern Colorado – like a horse rolling over on them – just wants help, said Will, who grew up in Cheyenne Wells and now represents northwest Colorado.
“You don’t care if you’re seeing a PA or a physician. You just want some kind of medical health care,” Will said.
There are five Colorado counties without a physician and nine without a physician assistant, according to data provided by the state.
Some lawmakers who opposed the bill said it could discourage people from training as doctors if they could perform similar services without going through years of medical school.
Physicians complete four years of medical school and several years of residency. Physician assistants complete at least 2,000 hours of clinical training in a two-year master’s program.
Nurse practitioners and other health care professionals do not need to enter into collaborative or supervisory relationships with other health care providers in Colorado.
State Rep. Yadira Caraveo, a Thornton Democrat and pediatrician, said she’d recently caught four mistakes made by physician assistants she works with.
“They have no idea that they have made those mistakes and so they probably would never have asked me as a collaborating physician for my input,” Caraveo said.
Other lawmakers said there were more effective ways to solve the rural health crisis, particularly by encouraging rural residents to become doctors. Another bill lawmakers are considering aims to increase the number of health care workers in rural areas by offering scholarships to students who commit to practicing for two years in rural settings.
Emergency room doctors see physician assistants as part of a team and want to be a sounding board for them, said Dr. Allison Trop, president of the Colorado chapter of the American College of Emergency Physicians. Some physician assistants she works with have said they would be uncomfortable practicing on their own in rural environments.
“I also practice rural medicine and it can be a scary place,” Trop said. “You’re alone. And you don’t know what you don’t know, so if you haven’t seen it before, you could really be in a bind.”
The emergency physician group – part of a national organization that advocates against scope of practice bills – was also concerned House Bill 1095 would leave physicians legally liable for care they were not fully supervising, and would not provide physician assistants with support they need. (“CO ACEP only made 5 contributions to legislators this past year, not all of whom opposed HB 1095. We do not make contributions in exchange for votes,” Trop wrote in an email.)
Mullica said lawmakers took seriously his concerns and those of Caraveo.
“Any bill gets lobbied but I think this is unique where we have members that work on the frontlines and work in the field, and I think people really do take that to heart,” he said, adding nothing he said was meant to disparage physician assistants.
Efforts to grant nurses, nurse practitioners or physician assistants more independence have provoked fierce pushback across the country from doctors groups with powerful lobbying arms.
The American Medical Academy expressed “strong opposition” to a precursor to House Bill 1095, that failed to get past a committee in Colorado in 2021. The organization defeated similar bills in Indiana, Louisiana, South Dakota and Texas that year, and state medical associations helped modify legislation in Florida and Nevada, according to the AMA website, which cites more than 100 successes stopping such legislation since 2019.
The AMA has also opposed physician assistants’ efforts to rebrand themselves physician associates, saying it was “clearly an attempt to advance their pursuit toward independent practice.”
After sailing through a House committee 10-1, House Bill 1095 was later voted down by the House, with 35 lawmakers voting against it, including 22 Democrats and 13 Republicans. Twenty-eight lawmakers voted for it, including House Speaker Alec Garnett, a Denver Democrat who has received the most contributions from the medical groups.
Lontine said lawmakers who’d pledged to vote for the legislation flipped their votes “out of the blue.”
“I never thought I was going to get an overwhelming vote. I thought I had enough to get it out of the chamber,” Lontine said.
She called the outcome “deeply disappointing.”