Surgeons Help ACS Drive State Advocacy Efforts on Scope of Practice, Other Issues

State policymakers play a key role in shaping policies and regulations directly affecting surgeons and their practice, and ACS members and their chapters continue to help the College spearhead efforts to advance these goals. Overall, in 2024, 45 states introduced more than 158,000 state bills, and 25,400 were enacted.

With a considerable number of healthcare issues under consideration, the ACS diligently works to advance policies elevating surgical practice while advocating against proposals that undermine it. In 2024, the ACS State Affairs team reviewed more than 3,700 bills, monitoring and tracking close to 1,100.

This article provides a brief overview of the legislation.

Scope of Practice

Nonphysician healthcare practitioners continued to seek expanded scope-of-practice legislation at the state level in 2024. The College activated a grassroots initiative and sent 23 letters of opposition to scope expansion.

The ACS and state chapters supported other physician specialties in opposing scope-of-practice expansion state bills, including physician supervision of certified registered nurse anesthetists (CRNAs) and advanced practice registered nurses (APRNs). The College tracked the following scope-of-practice bills:

Certified Registered Nurse Anesthetists

The College tracked 28 scope expansion bills concerning the practice of CRNAs, allowing for independent or semi-independent practice. While CRNAs provide valuable and timely services, allowing a CRNA to practice independently places the responsibility on the operating surgeon should the patient experience any anesthesia-related complications. The College sent letters opposing state bills attempting to allow for CRNA independent practice in Missouri, New York, and Virginia. To date, no legislation has been enacted.

In a related action, Washington State enacted SB 5184, which establishes licensure for anesthesiology assistants (AA) as a new health profession in the state. An AA works under the direct supervision of an anesthesiologist and within the AA’s education, training, and experience.

Optometrists

Optometrists were especially active this year in pushing their surgical agenda. The ACS State Affairs team is tracking 11 bills that seek to allow optometrists to perform laser and scalpel surgeries around the eye, as well as provide injections. Working with the American Academy of Ophthalmology, the College sent letters opposing this gross expansion of scope and, as a result, all but one bill failed.

Newly enacted South Dakota HB 1099 allows optometrists to:

• Provide diagnostic and therapeutic agents
• Use intense pulsed light for the treatment of dry eye disease
• Provide an intradermal injection of a paralytic agent
• Provide the intralesional injection of a steroid to treat a chalazion
• Use local anesthetic to remove a skin tag
• Select laser to treat trabeculoplasty and posterior

Governor Kristi Noem signed the bill into law March 5.

Physician Assistants

Most state medical licensure boards regulate the practice of physician assistants (PAs), reflecting the supervisory nature of the relationship between a physician and PAs. Allowing nonphysicians to diagnose and treat patients without any physician oversight is a step in the wrong direction. The College is monitoring 21 PA scope expansion bills.

Introduced by Washington Representative Marcus Riccelli, HB 2041 allows a PA who has completed 4,000 hours of postgraduate clinical practice to practice without a collaborative agreement with a physician. The bill also contains provisions for 2,000 additional hours under collaboration with a physician if the PA chooses to change specialties. Governor Jay Inslee signed the bill into law March 13.

Oregon is the first state to officially adopt the title name change from “physician assistant” to “physician associate.” Introduced by the House Behavioral Health Care Committee, HB 4010 changes “physician assistant” to “physician associate.” Governor Tina Kotek signed the bill into law April 4.

Advanced Practice Registered Nurses

Multiple studies show nurse practitioners, regardless of the scope laws they are working under, tend to practice in the same areas of the state as physicians do and order more diagnostic tests. The College is monitoring 22 bills seeking to expand the scope of practice for APRNs. To date, only Virginia has enacted legislation

Introduced by delegate Kathy Tran, Virginia HB 971 reduces the number of required clinical practice hours an APRN needs prior to working independently from 5 years to 3 years. Governor Glenn Youngkin signed the bill into law April 4.

Naturopaths

In recent years, the Washington Association of Naturopathic Physicians (WANP) has become increasingly aggressive in its efforts to expand its scope of practice to include treatments, procedures, and independent authority inconsistent with its education and training. This approach jeopardizes the safety and quality of healthcare delivered to patients. For example, the WANP sought to expand its scope of practice to include abortions and vasectomies through a licensure board opinion, rather than through regulation or legislation where the obvious flaws could be exposed.

The WANP also seeks to expand its scope of practice to include performing “minor” office procedures. However, there is no clear definition of what constitutes a minor office procedure, nor is there a listing of procedures they are trained to provide. This reality leaves the door open for naturopaths to perform procedures beyond their levels of training and expertise. The ACS will continue to monitor the situation.

International Medical Graduates/Foreign-Trained Physicians

State legislatures and medical boards have examined ways to ease licensure requirements for foreign-trained physicians and international medical graduates (IMGs), including if and how to count graduate medical education (GME) completed outside of the US or Canada.

Currently, four states (Maine, Oklahoma, Tennessee, and Washington) allow physicians who have completed GME outside of the US and Canada to be licensed without the need to complete any additional GME in the US. Two jurisdictions (Minnesota and New Hampshire) have a process for granting a license by eminence for physicians who have completed GME outside the US and Canada and have an exceptional skill set.

Approximately 22 jurisdictions grant at least some credit to applicants who completed GME outside the US and Canada. This credit is generally granted in instances where the applicant completed at least 1 year of GME in the US and Canada, or is already specialty board certified, licensed in another state, or both.

Prior Authorization

Improving insurance prior authorization requirements to ensure timely access to care for patients remains a priority for the College. These requirements can interrupt care, divert resources from patients, and complicate medical decision-making. In a 2024 American Medical Association survey, 78% of physicians reported that patients often or sometimes abandon treatment due to prior authorization issues.

In 2024, the ACS monitored more than 70 prior authorization bills that aimed to:

• Establish quick response times (24 hours for urgent, 48 hours for nonurgent care)
• Mandate any physician reviewing care be licensed in the same state and trained in the same specialty as the physician managing the patient
• Prohibit retroactive denials if care was pre-authorized
• Make prior authorization valid for at least 1 year, regardless of dosage changes or for the length of treatment for a chronic condition
• Require public release of prior authorization data on the number of requests and number approved/denied per month
• Require an online portal for submission of prior authorization requests

Signed by Governor J. B. Pritzker on July 10, Illinois HB 5395 requires health insurers to provide access to a standardized, electronic prior authorization request transaction process, and publish all services requiring this authorization on their website. The law also bans step-therapy requirements, requires formularies to be posted online and include any information on cost-sharing requirements, and provides coverage for both generic and brand-name medications.

Colorado recently enacted a bill requiring healthcare insurers and pharmacy benefit managers to adopt a prior authorization application programming interface by January 1, 2027, to automate the process and facilitate secure electronic transmission of requests and determinations.

The legislation specifically stipulates prior authorization for surgical procedures cannot be denied for related procedures identified during the surgery if they meet the following criteria: The surgeon determines delaying the provision of additional care to the patient is not medically advisable, the additional service is a covered benefit under the patient’s plan, and the additional procedure is not experimental or investigational.

The legislation also stipulates that after completing the procedure, the surgeon must notify the insurer that they provided the additional services. Under this law, the surgeon must file a timely claim for the services, and the insurance carrier is prohibited from denying the approved initial surgical procedure.

The Ensuring Transparency in Prior Authorization Act—signed by New Jersey Governor Phil Murphy on January 6—mandates online publication of detailed prior authorization statistics. The law also requires that physicians who make adverse determinations be of the same specialty as the physician who is managing the patient. Under this law, prior authorization is valid for 1 year, and it requires a response to all prior authorizations within 1 business day.

Medical Liability Reform

The Grieving Families Act in New York would expand the types of damages recoverable in a wrongful death action, including “grief and anguish.” The legislation also extends the timeframe to bring an action and expands the number of close family members who could sue for wrongful death. The ACS New York Chapter members and the College worked together to empower surgeons to send Action Alert emails to state legislators in opposition. New York Governor Kathy Hochul has not yet vetoed the bill, but if she does, the bill is expected to be re-introduced in the next session.

Violence against Healthcare Professionals

Introduced by Assemblymember Freddie Rodriguez, AB 977 makes an assault or battery committed against a physician, nurse, or other hospital healthcare worker engaged in providing services in the emergency department punishable by imprisonment in a county jail not exceeding 1 year, by a fine not exceeding $2,000, or by both fine and imprisonment. The ACS California Chapters and the College sent an Action Alert to all California surgeons requesting that they reach out to Governor Gavin Newsom and encourage him to sign the bill.

Stop the Bleed

The ACS Stop the Bleed (STB) program continues to gain support across the country. In 2024, seven STB bills were enacted. While several bills sought to bring STB kits and training into schools and public buildings, four were resolutions recognizing May 23 as STB Day.

Florida enacted legislation to fund the purchase of bleeding control kits in public schools and Washington Governor Jay Inslee signed SB 5790 into law, mandating schools in the state provide and maintain bleeding control kits on school campuses and ensure at least two employees per school have STB training.

More recently, Illinois Governor J. B. Pritzker signed two bills: HB 1561 amends state law to allow each school to maintain a bleeding control kit on campus, and HB 4653 provides Good Samaritan protections to school employees with STB training should they need to use a bleeding control kit during an emergency.

During a legislative session day in May, the New York State Senate adopted a resolution declaring May as STB month and recognized the ACS New York Chapter sitting in the gallery during their advocacy day.

Trauma Funding

Maryland broke new ground in enhancing trauma funding in 2024 through an increase in the motor vehicle registration surcharge, from $17 to $40. SB 1092 allocated the funds in the following manner: $6.50 of the surcharge goes toward trauma physician services fund, $9 of the surcharge goes toward the R Adams Cowley Shock Trauma Center, and the balance of the surcharge goes to the state emergency medical services operations fund.

The bill also outlines disbursements to the state pediatric trauma centers, with amounts up to $900,000 to Johns Hopkins Children’s Center and up to $900,000 to Children’s National Hospital. The new law changes reimbursement for costs incurred by trauma physicians and trauma centers, and beginning fiscal year 2026, includes an annual appropriation of at least $16.5 million as a baseline for trauma funding.

The success in Maryland prompted John H. Armstrong, MD, FACS, Chair of the Committee on Trauma, to create a trauma funding work group to align with ACS chapters looking for new ways to increase their trauma funding.

Cancer

The ACS Commission on Cancer (CoC) has been supporting efforts to advance legislation on several cancer-related priorities, including:

• Expanding health insurance coverage for breast, prostate, lung, and colorectal cancer screenings
• Asking for the cancer screenings to be provided with no cost-sharing for the patient—meaning no out-of-pocket costs

Other cancer-related priorities tracked by the ACS include biomarker coverage bills, step-therapy, and proton beam therapy bills. Overall, of the 237 cancer bills the ACS is tracking, more than 40 have been enacted and 31 cancer resolutions have been adopted.

Louisiana enacted HB 508 which provides treatment decisions following a diagnosis of cancer are to be made solely by the patient in consultation with their physician. The law also clarifies all levels of medical and surgical treatment considered medically necessary and prohibits exclusion from coverage.

Breast Cancer

For women, breast cancer is the second most common diagnosed cancer and the second leading cause of cancer death. In 2024, the ACS tracked numerous bills that provided no cost-sharing screening and imaging services, including standards for breast density classification, and supplemental testing and examinations.

Vermont enacted HB 621 to provide no cost-sharing for mammograms or other medically necessary breast-imaging services to detect the presence of breast cancer and other abnormalities of breast tissue. Iowa, Kentucky, Mississippi, Maryland, and New Hampshire signed legislation requiring healthcare insurers to provide coverage for diagnostic and supplemental breast examinations, with some states providing those examinations with no cost-sharing requirements.

Oklahoma and Rhode Island passed legislation defining breast density classifications. Louisiana amended existing law to add contrast-enhanced mammograms and breast magnetic resonance imaging to standard mammography services.

Prostate Cancer

Working with the American Urological Association and ZERO Prostate Cancer, the ACS wrote letters of support for no cost-sharing prostate cancer bills, including Tennessee HB 2954 signed by the governor on May 29, and Delaware HB 302 currently awaiting the governor’s signature.

Prostate cancer is one of the leading causes of cancer death among men in the US. The relative 5-year survival rate for prostate cancer when diagnosed at an early stage is nearly 100%, while the survival rate drops to 31% when diagnosed at an advanced stage. As with any cancer, early detection is key, and removing cost barriers to screenings will allow more men to survive the disease and maintain their quality of life.

Introduced by Tennessee representative G. A. Hardaway, HB 2954 requires healthcare insurers to cover early detection of prostate cancer in men with a family history, men 40 to 49 years of age at high risk, men 50 years of age and older, and men whose physician determines early detection is medically necessary. Governor Bill Lee signed the bill into law on May 29.

Lung Cancer

Lung cancer is the nation’s number one cause of death for both men and women diagnosed with cancer. While there were several state resolutions to designate November as Lung Cancer Awareness Month, New York introduced a bill seeking no cost-sharing for follow-up screenings or diagnostic services when recommended by a healthcare provider.

Colorectal Cancer

Over the past few decades, colorectal cancer in patients 20 to 49 years of age has increased exponentially. Both the American Cancer Society and the US Preventive Services Task Force (USPSTF) released guidelines lowering the age to begin screening from 50 to 45 years of age. Insurers still have the authority to deny patients coverage of routine colorectal cancer screenings if they are younger than 50 years. The CoC Advocacy Committee has been monitoring 15 colorectal bills since January.

Louisiana Governor Jeff Landry signed HB 361 into law on May 23. This legislation mandates health insurance plans to cover colorectal screenings and allows any test or screening recommended by named medical organizations.

Signed by Nebraska Governor Jim Pillen, LB 829 prevents patients from being subjected to additional charges for any medical service associated with a colonoscopy, including anesthesia and polyp removal.

Introduced by Representative Kate McCann, H 741 amends existing law to mandate insurers provide coverage for colorectal cancer screening for average-risk individuals in accordance with the most recently published recommendations established by the USPSTF. Vermont Governor Phil Scott signed the bill on April 25.

In Virginia, Governor Glenn Younkin signed HB 238 into law March 28. Introduced by Representative Delores McQuinn, HB 238 requires health insurers to provide coverage for examinations and laboratory tests related to colorectal cancer screening in accordance with the most recently published recommendations established by the USPSTF. The law also requires coverage to include follow-up colonoscopy after a positive noninvasive stool-based screening test and prohibits such coverage from being subject to any deductible, coinsurance, or any other cost-sharing requirements for services received from participating providers.

Ovarian Cancer

Delaware is the only state to introduce and enact an ovarian cancer law in 2024. Introduced by House Speaker Valerie Longhurst, HB 15 requires healthcare insurers to cover annual ovarian cancer screening tests, includes monitoring tests after ovarian cancer treatment. Governor John Carney signed the bill into law on March 21.

If you would like to get more involved and help the ACS drive issues that affect your practice and patients, the ACS State Affairs team is available to answer questions. State advocacy resources also are available. For more information, contact state_affairs@facs.org.

Catherine Hendricks is the State Affairs Manager in the ACS Division of Advocacy and Health Policy in Washington, DC.