California Advocacy Produces Six Lessons for Surgeons across America

Surgeon-led healthcare advocacy in California has a long and accomplished history and has paved the way for new trends across the nation.

Efforts in the late 1960s were driven by the ACS Committee on Trauma’s vision to establish a unified and coordinated approach to trauma care in California, and into the early 2000s, served as the foundation of ongoing advocacy by ACS California leaders, including David B. Hoyt, MD, FACS, Immediate Past ACS Executive Director.

Today, with the advent of surgical acute care programs, payment reforms, regulations (e.g., surprise medical billing), and the consolidation of surgical practices, surgical advocacy is more important than ever. In recent decades, there have been increasing recognition and efforts from the ACS Division of Advocacy and Health Policy (DAHP) at the federal level.

However, sustained state-level advocacy efforts remain a challenge. This article summarizes the advocacy-related successes and challenges of the ACS California chapters since 2011 that have helped define expectations for future statewide goals and objectives that may inspire and help other state chapters.

Three ACS California Chapters

California is the most populous state in the US, spanning a geographically large and diverse region with large academic institutions and private healthcare provider systems that operate large and small healthcare facilities in all chapters. California is one of six states in America with multiple chapters (see Figure 1).

California has three chapters: Northern California (3,044 members), Southern California (3,864 members), and San Diego-Imperial (821 members), accounting for approximately 10% of ACS members in the US.

The state capital of Sacramento is within the Northern Chapter jurisdiction, with the University of California, Davis being the closest academic institution. The Southern Chapter includes the surrounding urban environments of Los Angeles, while the San Diego-Imperial Chapter is the farthest from Sacramento and represents the third largest city in California.

Uniting Chapter Efforts through ACS Grant Funding

In a large state with three chapters, building a strong and coordinated advocacy effort at the state level requires improved communication, an understanding of differing priorities, and respect for each chapter’s independent operations.

After the inception of the ACS Chapter State Advocacy Grant Program in 2011, the California chapters were awarded 12 consecutive advocacy grants.

For the first 3 years, the Northern California Chapter applied alone; in 2014, the Southern California Chapter joined for the first time.

Cross-communication was strengthened by the creation of the Joint Advocacy Committee (now called the Joint Advocacy Committee of the ACS California Chapters) with representation from each chapter in Washington, DC, at the 2016 Leadership & Advocacy Summit. Later that year, the three chapters united for the first time to apply for a joint statewide legislative grant.

Another key step forward to unify surgical health policy advocacy was the invitation of Southern California Chapter President Craig J. Collins, MD, FACS, to speak at the 2019 Northern California Chapter meeting to reach consensus on future advocacy priorities.

As reported in previous ACS Bulletin articles, advocacy efforts regarding surgical health policy in California achieved significant successes through coordinated action. The topics covered included several ACS state-level priorities:^1-6

• Limiting the scope of practice expansion by optometrists and nonphysician health practitioners
• Improving emergency and trauma care access
• Supporting the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA)
• Promoting firearm safety
• Preserving medical liability protections
• Strengthening insurance in-network coverage and access to care
• Enhancing colorectal cancer screening

The Joint Advocacy Committee continued to work virtually when in-person meetings with legislators and fellow surgeons were canceled or replaced by video conferencing, and many political issues were pushed aside in the maelstrom of pandemic-related priorities.

While the annual state advocacy day in Sacramento was canceled in 2020 and 2021, a virtual day allowed surgeons to meet, collaborate, and develop relationships with legislators.⁷ In 2022, the three chapters emerged from social distancing restrictions to continue advocacy efforts that led to major statewide success with ACS STOP THE BLEED^®.

Six Lessons Learned through Advocacy

1. Wins in passing sponsored legislation are harder than defeating bills that you oppose. Playing defense is easier than introducing and supporting new bills.

It took a decade to repeat our initial success with passing a sponsored bill. In 2012, the Northern California Chapter championed a prostate cancer screening bill with Assemblymember Linda Halderman, MD, FACS (R), who was the first and only general surgeon elected to the California State Legislature in its 173-year history.²

Ten years later, the chapters jointly sponsored the STOP THE BLEED Assembly Bill (AB) 2260 with Assemblymember Freddie Rodriguez (D). The legislation, Emergency Response: Trauma Kits, was the first statewide law of its kind to make bleeding control kits widely accessible.

Throughout the next decade, the chapters had many advocacy-related successes, principally by defeating the undesirable bills sponsored by others. We also opposed unfavorable bills that still passed, such as surprise medical billing, and championed acts like UEVHPA that research revealed could be implemented without new legislation.

Resist becoming discouraged by setbacks when trying to pass your own legislation, and instead gain experience and visibility by defeating or supporting the legislation of others. This way, you may become a powerful advocacy presence and, by cultivating relationships with elected officials and their staff, you may create opportunities to speak at state capitol hearings, press conferences and debates, and with the media.

2. Beware of forces beyond your control.

Focus on the policy issues that endure, rather than individuals who may not. Advocacy-related victories are not always the result of one’s own actions because opponents sometimes make unforced errors.

In 2014, the chapters’ focus was on Senate Bill (SB) 47, which sought to eliminate the bullet-button modification of semiautomatic weapons to convert them into assault weapons.⁴ As the bill neared the governor’s desk, the legislative author was forced to leave office, and all efforts in support of the bill were abandoned. Events beyond your control can derail a promising legislative agenda.

In 2014, the defeats of Proposition 45 and Proposition 46 at the ballot box by overwhelming voter majorities proved to be significant victories for surgeons.^5,6 These twin propositions had been sponsored by the trial attorneys to raise medical liability caps, require mandatory drug testing of physicians, and allow intervenors to file court challenges to health insurance rates.

One of the keys to victory was an “off the cuff” comment by one of the proponents that drug testing of physicians had been added as the “ultimate sweetener” to secure passage of the proposition, as drug testing had polled favorably with voters. His comment proved to be an unforced error that backfired, as some voters rebelled against the perception that they could be manipulated.

3. Be persistent.

While the intent of your advocacy-related efforts may not succeed in the first year, they may be fulfilled in the future. Don’t underestimate the power of the ballot box.

In 2013, the Northern California Chapter endorsed SB 374, which sought to limit high-capacity magazines for semiautomatic weapons, but was vetoed by Governor Jerry Brown (D).⁴

The next year, SB 47 failed when the Senate author was forced out of office. In 2016, the three chapters were asked to support a comprehensive package of firearm legislation (Proposition 63) championed by then Lieutenant Governor Gavin Newsom (D). A lack of consensus among ACS members on firearm safety resulted in none of the California chapters endorsing Proposition 63, which passed by an overwhelming margin at the ballot box.

The silver lining is that the entire slate of unsuccessful firearm safety bills supported by the Northern California Chapter in earlier years (e.g., SB 374, SB 47) were part of the package in Proposition 63 and, eventually, all became California laws in a single action by the voters. In 2018, the Northern California Chapter also endorsed SB 1100, which raised the firearms purchase age to 21 and was signed into law by Governor Newsom.

In 2017, the three California chapters first championed bleeding control kit legislation to require public trauma kits in public buildings and schools. With the help of Jay J. Doucet, MD, FACS, FRCSC, a STOP THE BLEED training session with state legislators and staff was arranged for the same day as testimony at an Assembly committee hearing where the bill advanced.

Unfortunately, the bill did not pass the Appropriations Committee as it was assigned a high fiscal price tag. Repeat efforts over the next several years were unsuccessful, mainly due to the inability to pass the Appropriations Committee.

A revamping of the bill better aligned with STOP THE BLEED, and introduction in the Senate drove this effort forward with a new strategy. Finally, in 2022, the revised STOP THE BLEED AB 2260 passed with broad support and was signed into law.⁸

Be aware of cost estimates by legislative analysts, which proved to be the pitfall for both the colorectal cancer screening and initial versions of the STOP THE BLEED bill. If your bill is scored with a high fiscal price tag, try every measure to reduce the cost estimate by using volunteers, through charitable contributions, and by strategically addressing materials and scope, which led to passage of AB 2260 and other bills.

4. Partner with your state medical association, the ACS team in Washington, DC, and the SurgeonsVoice advocacy network.

Over the years, the primary ACS advocacy meeting in Sacramento was held concurrently with the California Medical Association (CMA) Legislative Advocacy Day, and partnering with the CMA and the ACS state affairs team have been keys to success.

In 2018, in the aftermath of AB 72 (surprise medical billing), another major threat to the practice of medicine was introduced—AB 3087, which sought to create a commission that would cap rates for healthcare services in all California clinics, hospitals, and physician practices.

The CMA focused the entire Legislative Advocacy Day in opposition to AB 3087. A letter from Dr. Hoyt was distributed to every elected official in the Capitol on that day. AB 3087 died shortly afterward in the Assembly Appropriations Committee.

In recent years, STOP THE BLEED training sessions were held at the CMA Legislative Advocacy Day, and the ACS delegation met in the CMA offices to prepare for the day.

Using the SurgeonsVoice advocacy network to email legislative updates and activate the grassroots network of ACS members was helpful to defeat Proposition 46 in 2014 and secure passage of the STOP THE BLEED bill in 2022.⁶

5. Partner with a strong coalition and master media training, while also being willing to participate in statewide television commercials on important topics.

In 2018, the three chapters united to oppose Proposition 8 that would have required dialysis centers to have a physician onsite and likely would have forced many dialysis centers to close. The chapters joined a broad statewide coalition to defeat the ballot initiative.

The ballot measure reappeared in 2020, and a new ACS logo designed for the three chapters was featured in the statewide television commercials to defeat the measure a second time. The initiative returned for a third time in 2022 (Proposition 29), and the California chapters united to defeat it once again.

Chapter members appeared in television interviews, spoke at press conferences and in radio debates, were featured in the newsprint media, and on statewide mailers to oppose Proposition 46. It is essential, however, to understand the importance of media training, and clear and concise communication. A Proposition 46 supporter mistakenly spoke to a Los Angeles Times reporter in what he thought was an off-the-record conversation and inadvertently disclosed information that defeated his own effort.

A 2014 Bulletin article highlighting the importance of protecting medical liability caps in California helped educate ACS members and was available for them to share with their patients.⁶ The ACS team in Washington, DC, also sent materials to every California ACS member, requesting their engagement in defeating Propositions 45 and 46.

Success in our advocacy over the decade also came from multiple letters to the editor published in the Sacramento Bee and other state newspapers, live debates on radio and television programs, and speaking at press conferences and rallies.

6. Recognize the power of and need for the surgeon perspective in the legislature.

Be certain to work with the minority party. Our major victories in sponsoring new legislation came through partnerships with Republicans Dr. Halderman and then-Assemblymember Marc Steinorth.²

Defeating the most powerful California labor union over a surgical technologist bill revealed an intriguing insight. A Sacramento lobbyist reviewed the California chapters’ opposition to a bill claiming that using surgical technologists would reduce wound infections. The lobbyist also noted that California surgeons were standing alone in opposition to a labor union that outnumbered the ACS in membership by nearly 500 to 1.

Our concerns as surgeons about the flawed science behind the bill were heard, and the bill was vetoed by the governor, citing the specific concerns we raised. The lesson is to stand up for what you believe in, have the data to be convincing, and be persistent. You can have a great impact outside of the operating room.

Building a statewide joint coordinating advocacy committee is critical to success in large states with several chapters. The three California chapters have not always agreed on topics like tobacco control and firearm safety, resulting in a chapter sometimes having to act alone on a bill. After the passage of AB 2260, it became clear that advocacy committee bylaws would help guide the future coordinated decision-making and statewide priorities for the Joint Advocacy Committee.

This decision led to the creation of a memorandum of understanding (MOU) outlining leadership succession, membership structure, and voting procedures, in addition to the mission and goals of the committee.

The MOU represents the inaugural establishment of a joint advocacy committee between different ACS chapters within a state and may serve as a blueprint for other states to use. The new details in the MOU were designed to help unite a much larger constituency and enhance the ability to find coalition partners.

Finally, carefully note key legislative deadlines and calendars for bills to move through committees and the house of origin. Success in advocacy requires planning and anticipation, just like the operating room. The California State Legislature begins in January, recesses for the month of July, and returns for a short session in August before adjourning for the rest of the year, with few exceptions.

The time for action on potential bills is focused on the first half of the calendar year. In California, new bills must be submitted by February, well before theannual state Lobby Day. One strategy is to introduce several “spot bills” as placeholders early in the year or to “gut and amend” an existing bill if deadlines are missed. Your advocacy priorities may evolve, so try to be nimble in anticipating change and be willing to pivot rapidly to harness new legislative opportunities.

As the legislative session winds down in September each year, preparation of new advocacy topics for the following January is essential to meet the tight deadline of drafting a new bill and finding sponsors. Use the time when the legislature is not in session to meet with your elected member in the district.

As a surgeon-advocate and credible member of your community, you can complement the work of registered lobbyists and share your expertise to craft new solutions in health policy. 

Dr. John Maa is the immediate past-chief of general and acute care surgery at Marin Health Medical Center in Greenbrae, CA, and was the 2013 President of the ACS Northern California Chapter.

References

1. Maa J, Hedstrom K. College advocates for ensuring quality eye care for America’s  veterans. Bull Am Coll Surg. 2010:95(9):8-10.
2. Garry J, Maa J. Northern California Chapter builds influence in state capitol. Bull Am Coll Surg. 2011;96(7):48-51.
3. Kaups K, Maa J, Garry JE, Upadhyaya P, et al. Northern California Chapter engages in ongoing legislative activities. Bull Am Coll Surg. 2014;99(3):51-53.
4. American College of Surgeons. Healthcare leaders focus on emergency and trauma care at Northern California IQ forum. Bull Am Coll Surg. 2014 99(3):49-50.
5. Maa J, Sutton JH. Preserving MICRA and patient access to surgical care in California. Bull Am Coll Surg. 2014;99(10):60-61.
6. Maa J, Sutton JH. The defeat of Proposition 46 in California: A case study of successful surgeon advocacy. Bull Am Coll Surg. 2016;101(1):61-63.
7. Liepert A, Doucet J, Johnson C. How the San Diego-Imperial Chapter maintained surgical health policy advocacy in the era of COVID-19. Bull Am Coll Surg. 2021;108(2):44-47.
8. American College of Surgeons. American College of Surgeons applauds passage of STOP THE BLEED^® bill in California. September 28, 2022. Available at: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/press-releases/2022/california-passes-stop-the-bleed-bill. Accessed April 5, 2023.