There's wide agreement that the bottleneck in California health care -- too many patients and too few doctors -- could get much worse with the implementation of federal changes.
But expect some Capitol clashes this spring on one idea to ease that congestion: allow more patient care to be done by health professionals who aren't physicians.
"How is it that we're going to be requiring somebody to purchase health insurance, but yet they won't have access to a doctor?" asks Sen. Ed Hernandez, D-West Covina.
Hernandez is introducing a trio of bills to bridge what he calls the "medical provider gap," and to do so by allowing pharmacists and optometrists to help diagnose chronic illnesses and manage care. The proposal, which is expected to be formally introduced in the next few days, also would allow nurse practitioners to set up their own practices -- rather than work in facilities under the direct supervision of a doctor.
"We have to look at the current workforce that we have right now, that is available," said Hernandez, a licensed optometrist himself, at a Sacramento news conference on Wednesday.
Estimates are the implementation of the federal Affordable Care Act could mean as many as 5 million Californians -- all currently without insurance -- could come into the system, even as many rural and low-income communities in the the state are already short of primary care physicians.
"Without some change, many Californians who have coverage in the future will not have access to care," said Debra Bakerjian, a family nurse practitioner.
The debate focuses on what is known as "scope of practice," the laws that govern the services different health care professionals are allowed to provide, and under what conditions. Supporters of revising those laws argue that the main ways to get more doctors on the job will take longer to get up to speed than the state has before millions of new patients begin to fill waiting rooms.
But the state's powerful physician advocacy group says there are, in fact, ways to speed up the deployment of doctors... and those should be the focus, not allowing less trained providers into the system.
"A supervising physician could be 20 miles away," says Dr. Ruth Haskins, a Folsom OB/GYN who chairs the legislative council of the California Medical Association (CMA).
"A supervising physician could be somebody who's not trained to handle that emergency. Or a supervising physician could be, if it isn't put in the bill the right way, somebody who doesn't have credentials at the nearby hospital to be able to hand the emergency."
The CMA is all but certain to oppose the Hernandez bills, arguing it's the wrong prescription both in terms of patient safety and dollars and cents. The organization believes less well-trained medical staff are likely to order more tests, which costs money.
Dr. Haskins says what the CMA will advocate for is a "rearrangement" of the relationship between doctors and support personnel like nurse practitioners and physician assistants, so that physicians can spend more time with patients, and less on administrative duties.
And both sides agree on the need for actually getting more doctors on the job -- with proposals ranging from full funding of UC Riverside's medical school to more funding for residency positions, doctors who could then be used to help fill the shortages in dozens of California communities.
Meantime, Senator Hernandez concedes he's got a steep legislative hill to climb. The coalition supporting his proposals has mobilized with its own website and advocacy effort as legislative hearings on the proposal begin next month.