A Unified Voice

Early Leaders Knew From the Start the Importance of Becoming an Influential Part of the Policy Debate

By Celia Johnson
CANP Correspondent

In its founding years, the late 1970s, the California Coalition of Nurse Practitioners (now known as the California Association for Nurse Practitioners, or CANP) recognized the need to become active in state and local government. However, it wasn’t until they’d established a solid foundation for the organization that they began to intensify those efforts.

Among the key contributors to those efforts were four who helped the organization make history as a force for legislative change, so that NPs would have a place and a future in the workforce: Donna Cannady, CCNP president from 1980 to 1982; Lisa Ashley, the organization’s first Government Relations Director, serving from 1984 to 1989; Jeanette Morrow, who served as the State Government Relations Director from 1994 to 1999; and Susanne Phillips, who has served as the Director of Health Policy and Practice from 1999 to 2009.

During Cannady’s time as president, the organization ramped up its efforts to have sway within the government. Without the funds, they weren’t able to bring NPs to Sacramento regularly to have their voices heard, so much of the government outreach at that time involved letter writing. Cannady encouraged members to reach out to their local and state representatives. She worked with the California Nurses Association and the American Nurses Association to identify which of their efforts were relevant to nurse practitioners. The annual CANP conference proved to be an ideal place to share information about current and upcoming legislation. The board would meet beforehand to handpick the issues they needed to discuss.

Much of this work – figuring out game plans, sharing information, and more – was done from members’ homes. They’d call one another late at night, because they had to work during the day. “I told my husband I was busy from 9 to 11pm every night,” Cannady recalled, chuckling. Despite limited resources and time, the organization became even more organized and influential. Members heard from representatives and other key speakers at the conference and local chapter meetings. They also became more politically active, armed with knowledge about the political landscape and urged to take action, writing those letters and making sure that their voices were heard. With the foundation set, they were poised to make big changes in upcoming years.

In 1984, Ashley became the organization’s first Government Relations Director. Ashley had previously been a graduate student at the University of Virginia, and she credits a mentor there, who, as she recalled, “really put into our brains that we needed to be politically active, so that the nurse practitioner practice would continue to grow.” When she relocated to Sacramento in 1983, six months into the move, Ashley was approached by a CANP board member to join and become the Government Relations Director. “I’m not sure why, but I jumped in there with both feet!” she said. Her primary objective when she took on the role was to secure a lobbyist. She reached out to Governmental Advocates, the first female-owned lobbying firm in Sacramento. The firm had been lobbying for nurse anesthetists, focusing on health-related issues, but they still needed to figure out how to best represent NP interests. “They had to learn about who we were and what we did, and they took it on,” Ashley noted.

During those early years, with the help of Governmental Advocates, CANP found its voice in the government. Ashley, who was based in Sacramento, testified on different bills. She had a supportive boss, who’d say, “Go, go!” She worked at a nurse practitioner school. “It was in their best interest to have me step up and testify on behalf of the profession,” she noted. There were certainly challenges, though, along the way. There weren’t many NPs in the state, and so it wasn’t easy to carry the necessary weight to initiate change. And yet, admirably, that didn’t stop CANP members from speaking up. Ashley encouraged members to take every opportunity to publically share their opinions and what they were doing. Regular meetings between members ensured that everyone was up-to-date on critical issues. “We had a phone tree to get people to write or call their legislature. But the phone tree is only as good as the last person you contact, so it wasn’t always the best thing,” Ashley recalled.

Ashley pinpointed a key effort that took place from 1984 to 1987 as an example of the impact CCNP’s legislative work had on the profession. It was a reaction to something that had happened a few years prior. In 1984, the Foundation Health Plan (FHP) decided that Sacramento-based non-physician providers (NPPs) should only be reimbursed 60 percent of the amount that doctors received for their services. “They were also trying to limit access to our practices,” Ashley noted, of the FHP mandate. Those limits included preventing NPPs from referring patients to specialists and requiring a physician to see patients every other visit. FHP cited customer complaints (which they refused to share with NPPs) as the reason for the change. They claimed that patients were upset about being forced to see NPPs.

Ashley and Patricia Kelly, a PA and faculty member at UC Davis, co-wrote a paper about the mandate for The Nurse Practitioner (November 1987, Volume 11, Issue 12). In it, they outlined how NPPs came together against the mandate. In 1985, 50 local NPPs met to discuss next steps. “The initial concerns of NPPs were the following: the potential resultant financial impact upon private offices (most of which had 20 to 40 percent FHP patients), a possible loss of employment, and a resultant decrease in job activity,” Ashley and Kelly wrote.

By 1985, together, the CCNP, CNA, and CANA, through public articles and physician testimonies, among other efforts, were able to get the FHP to agree to 80 percent reimbursement, rather than 60 percent. (At this point in time, the CNA worked through the American Nurse Association; they were not yet an independent union.) Then, in 1986, they sought the help of the Federal Trade Commission, which initiated a formal investigation into the mandate. Because the FHP had held back on enforcing that mandate, upon the commencement of that investigation, the FTC ruled in their favor, stating that they were “no longer engaged in anti-competitive practices.” Ashley observed, “Ultimately, [FHP] had to reverse the mandate. It took us a few years, but it was a good opportunity to visit with legislators, fight for our practices, and educate people on what we did.”

Certainly, this groundbreaking work helped pave the way for more legislative success down the line. Morrow picked up the torch a few years after Ashley stepped down. Like Ashley, she’d moved to California from another state, New Mexico. She got involved with CANP because her NP manager, Stephanie Chatoff (later Stephanie Page Nardini), was on the board of directors and would tell her about all of the work they were accomplishing. “I thought it would be challenging to get involved and, as Stephanie approached the presidency, the State Government Relations Director position became more appealing to me,” she noted. On the national scene, the American College of Nurse Practitioners was also getting started, and there was a lot of excitement around the NP field.

CANP had accomplished some great things on the government front before Morrow came on board, but they’d never carried a bill in the legislature. “We always relied on the CNA, because they have deep pockets and are a big organization. But we were a very small part of their operation,” Morrow stated. This was a turning point for the organization. “If we wanted to get things like prescriptive authority, we’d need to step up and become more politically connected and carry our own bill,” she added.

In the mid-90s, CANP obtained that authority and carried not one, but two bills. With the California Medical Association as their main opponent, CANP was certainly like a David facing Goliath. CMA’s campaign donations were second only to the motion picture industry. They were strongly against any expanded scope of practice for NPs. “We needed to pass one bill [AB 1077] to get the right to write for controlled substances and then we had to pass some cleanup legislation that included the PAs. Ultimately, NPs and PAs both ended up getting DEA numbers,” Morrow noted. In 1996, through the passage of this bill, nurse practitioners obtained the authority to furnish Controlled Substances Scheduled III – V. It was an exciting achievement, and it resulted in an impressive uptick of CANP members, from 750 to 1,500.

This work, it seems, is never fast. It took five years of persistence and endurance to finally obtain the prescriptive authority. “We also had a legislator,” Morrow noted, “who had diabetes and had his health care turned around after going to see a nurse practitioner, so he was a real advocate for us. He carried the bill.” The lobbying firm, Governmental Advocates, proved to be instrumental in helping pass CANP’s AB 1077. “They loved us, because NPs are personable and they represented a lot of hardcore, cutthroat people. We were just trying to get the regulations we needed to allow us to do our job,” Morrow recalled.

Morrow was Phillips’s mentor. Phillips joined CANP in 1998. She went on to join the Government Relations Committee, and, in 1999, became the Director of Health Policy and Practice. Phillips was a student when AB 1077 was passed and NPs achieved Schedule III – V (originally, the bill included Schedule II, but for political reasons it was taken out). She was inspired by that success.

In Phillips’s first year, CANP established the Key Contact Program. This involved a more formalized strategy for action than in the past. Most people still didn’t have computers then, so the Key Contact program was critical. If they needed to move on an issue, they’d activate the phone tree, send out postcards to members, bring NPs together, and figure out who should work on which issues within their specific regions.

Phillips said, “The most exciting legislative accomplishment [during her tenure] was getting Schedule II prescriptive authority.” The bill that achieved this goal, Assembly Bill 1196, sponsored by CANP, was passed in 2003. Phillips noted that part of CANPs legislative success at that point was due, in large part, to having a lobbyist and a dedicated Government Relations Director, who was a clinician. They could do the day-to-day work. “Membership supported the finances, but you have to have staff to really do that groundwork,” she observed.

During her time as Director of Health Policy and Practice, CANP sponsored, co-sponsored or affectively lobbied 21 bills in addition to regulatory amendments that positively impacted NP practice in California – and CANP’s first ever bill had only been passed just a few short years before Phillips took on that role.

Looking back, it is truly amazing to see how far CANP leapt in such a short span of time, becoming a formidable force in state and local government, particularly given what they were up against. Certainly, there are still obstacles to overcome and new ones on the horizon, and so the work continues. CANP is as visionary today as it was decades ago, actively proposing new legislation to further the NP practice, in addition to fighting any legislation that may impede it.