By Howard Fischer
Capitol Media Services
PHOENIX -- Arizona Gov. Katie Hobbs is siding with doctors and against other medical providers in the latest round of an ongoing dispute over the process the latter group has to through to provide more services to the public.
The governor on Friday vetoed SB 1248 which would have eliminated the "sunrise process,'' one of the procedural hoops now required by health care professions seeking to expand their scope of practice. That involves additional hearings above and beyond actually getting legislators to change the law.
And that process, more often than not, has ended up with medical doctors and osteopathic physicians and their lobbyists arguing successfully that they are the only ones who should be entitled to provide certain services to the public.
In rejecting the change, Hobbs acknowledged there is an "imbalance of power'' between what she called the "high level'' providers like doctors and everyone else. And the governor agreed there are not only problems with the sunrise process, but that additional regulatory burdens can be a barrier to expanding care in underserved communities.
"However, repealing the sunrise applications for scope of practice expansion altogether without replacing it with a better mechanism will not address the underlying issues, and poses a threat to the health and safety of Arizonans,'' she wrote.
Sen. T.J. Shope, R-Coolidge, who sponsored the measure, called the veto "absurd,'' saying it was designed to upend the "tremendous imbalance'' that often occurs when lawmakers are faced with requests from medical groups.
"Too often, medical doctors will control the process to keep the medical providers that most of see on a routine basis down in arbitrary ways,'' he said. "This bill would have leveled the playing field.''
The veto is a setback for groups like optometrists, pharmacists and nurse practitioners who over the years have come to the Legislature with arguments that they have the training to do more than they are currently allowed under the law -- and that they can do it cheaper than medical doctors and provide needed services in areas with few, if any, doctors.
Under the current law, any group that wants to expand what its practitioners are allowed to do has to make its case to a special "committee of reference'' months before the regular legislative session begins.
That sunrise process requires the group to explain several factors, including why increasing its scope is beneficial, whether practitioners have special education, and whether it may result in a savings in cost to the state and the public. That committee then submits a report to legislative leadership.
Regardless of what's in that report, nothing precludes a lawmaker from sponsoring legislation to give the group what it wants. And Jessie Armendt, who represents both dental hygienists and nurse anesthetists, said all the paperwork and the sunrise hearing just become unnecessary hurdles -- one that doesn't exist for other legislative changes.
She told lawmakers earlier this year, for example, that they get to decide and change laws on complex issues, ranging from tax policy to water law, all without the need for a pre-session review. It is only when it comes to medical issues, Armendt said, there is this extra step.
And she pointed out to lawmakers that, with or without the sunrise process, any change in the scope of a group's medical practice still needs to get a majority of the House and Senate as well as the signature of the governor, the same as any other law.
What the sunrise process also does, according to Don Isaacson, lobbyist for the Arizona Optometric Association, is provide an early advantage to the doctor groups "so that the medical profession can prepare to oppose it.''
And Isaacson said the sunrise process creates "a presumption that anything other than the medical profession MD or DO is second class and that has to bring a petition before the Legislature even begins in order to subsequently file legislation.''
But Amanda Rusing, who lobbies for the Arizona Medical Association -- the group that represents MDs and medical students -- said the extra step is appropriate.
"When it comes to professional regulation, especially in the health care field, the stakes are high,'' she told members of the Senate Health Committee at a January hearing.
"The decisions should be made by all of you with plenty of time and plenty of data to take a look at the situation and consider the positives and negatives,'' Rusing said. "These are heavy decisions with potentially serious patient consequences.''
Lawmakers heard similar arguments from Jeremy Browning who lobbies for the osteopathic physicians.
"We need, the public deserves, the legislature deserves all the data necessary to ensure that these individuals can practice safely in the state of Arizona,'' he said.
That argument apparently resonated with Hobbs, saying there needs to be a "critical eye'' to preserving health and safety considerations for constituents.
"Some expansions provide authority to prescribe dangerous and/or addictive substances, to perform medical procedures, or to practice medicine with less supervision,'' she write, "Some are much more mundane, but that does not mean that they should not be held to some level of scientific and public health scrutiny.''
And Hobbs, who as a legislator from 2011 through 2018 participated in the sunrise process, said she sees a danger in eliminating the extra step.
"Without the sunrise application process, provider groups could fast-track their priorities through the legislative process without adequate attention to why the change is necessary, or if it will impact communities with the greatest needs,'' she wrote in her veto.
But Amanda Hagerman of the Goldwater Institute, testifying in support of the measure, said the process has instead proven to be a barrier to certain medical groups being able to provide care that she believes is within their training.
She said that is borne out by the fact that in the last 10 years only 14 of 41 applications to expand scope of practice have made it through. And Hagerman said there's a good reason for that.
"The sunrise process is more about limiting competition between health professions instead of putting the needs of Arizona patients first,'' she said. "If people have appropriate training, we want them practicing in our state.''
Hobbs vetoed the change even though it had the support of a number of Democratic lawmakers.
Sen. Eva Burch of Mesa said they key is expanding access to care.
"Patients who have access to some care are doing better than patients who have access to no care at all,'' she said.
The turf war has been going on for decades.
In the 1980s, House Speaker Frank Kelly held up the legislative process until colleagues agreed to support a measure he wanted to let optometrists use eye drops to dilate pupils, something that has become a common practice. Optometrists and ophthalmologists, who are medical doctors, have been sparring ever since.
More recently pharmacists fought with doctors over whether they are qualified to decide when people need vaccinations.
And just last year dentists won a fight with doctors and got the ability to administer Botox and certain fillers to help puff up lips, fill out cheeks and smooth wrinkled brows.
Friday's veto is her 15th of the session, following her rejection of 13 budget-related bills and a bid by GOP lawmakers to block cities from taxing residential rentals. She did, however, sign her first two bills, one of which eliminates the need for certain hearings on development plans and the other which conforms Arizona's tax code with changes in federal law.
