Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Between the impacts of the One Big Beautiful Bill Act and legislation at the state level, it's been a big year for health policy. We wanted to invite back our friends of the pod, Dr. Sirani Hare Kwan and Dr. Alice Martinagara to talk about what this all means for nurses.

Absolutely. Great to be here. Great to be back.

Yes, we're so excited to have you all back. And it's honestly been a really big year for legislation. So let's just dive right into it. And I want to start with California legislation because there were a lot of bills that were signed or vetoed at the state levels this year in California. And so, Sirani, I believe there were about 15 different bills that the ACNL Health Policy Committee monitored, plus more that are still moving through the legislative process. And so I'm curious if you could give a rundown of some of the work that the ACNL Health Policy Committee has done, and then if you can share just some more about what those bills were, especially for nursing practice.

Absolutely. And more than 15. I think the committee actually has their fingers on probably 30 or 40 at any given time because legislation is multi-umfactorial in California. And things are either one-year or two-year bills. And so we are constantly monitoring the legislation that is rolling through. So first on the list, I want to talk about AB489, which has to do with healthcare professions and the use of deceptive terms or letters specific to artificial intelligence. Now, this is a huge win. It was approved by the governor. Everything in California that's signed by the governor in a legislative year becomes law the next January 1st. So this will be active January 1st of 2026. This makes it illegal for AI systems to call themselves out as licensed healthcare providers, like a nurse or a doctor or a nurse practitioner or a PA. So this is a really big deal. And I will tell you that the at the federal level, there is a lot of interest in our management of AI in California, and they don't like it. So I just heard a brief comment about the AI giants really looking at ways that they can try to limit California's ability to pass laws on AI specifics. I just want to let everyone know that this is a big win and a big deal. So no AI tool in California will be allowed to be used and call itself a nurse or a nurse practitioner, et cetera. So that's a big deal. Next is AD82, another really big deal. So ADM82 is um it's just generically called health care protections, but this is really about privacy of your patients' data, your data, and specific to gender affirming and reproductive care. So why does this matter? It matters because of what's going on at the federal level in the United States. So we know that everywhere we um uh look in the United States, we are seeing a lot of um impacts on gender-affirming care, uh, whether it's limiting the ability for kids under the age of 18 to have gender-affirming care or eliminating the use of um terms uh in the workplace uh regarding uh people's preferred pronouns, et cetera. And also since the overturn of Roe v. Wade, uh reproductive freedom. So in California, the goal of AB 882 is really to protect um patients and people uh with these particular um um uh issues. And so this means that there are confidentiality um terms now around people that are providing care for gender-affirming uh care specifically for patients in the United States or California, sorry. And also, we uh this is a big deal for those of um your listeners that are prescribers, like nurse practitioners, midwives, and PAs. Um, we are no longer in California going to be reporting prescriptions for testosterone or mifopristone to the Cures database. So this is kind of a big deal because I go to Cures and I check every time I'm filling narcotics, and testosterone is a controlled substance, and those will no longer be reported up to Cures at the federal level for protection reasons. So California will have to sort out a different way to keep track of testosterone for our patients in a confidential manner. And it also creates penalties for posting any personal information about people that are seeking gender affirming care or providing gender affirming care that with the intent to incite violence or harassment. So this is a really big deal for any trolls that are out there on social media or Facebook, et cetera, looking to get in front of the care of patients like that. So I really um I think this is a really big deal for California, and we'll see how many other states kind of keep up with this um this great work that we've done. Um next, I want to talk about uh AB583, which is about death certificate signing by nurse practitioners. It's kind of a big deal because interestingly, in California, we have never been able to sign death certificates as a nurse practitioner, which is ridiculous. Uh, so this bill finally um was um able to make that happen for nurse practitioners. Unfortunately, it won't be active until July 1st of 2026. And the reason for that is because there is a lot of places that they have to build in nurse practitioners as an option to sign death certificates online. Um, this bill lived in um AB 583, which is an omnibus bill. So, those of you not uh familiar with that term, it's kind of like a it's like a cleanup bill. So it has a lot of different um codes and regulations that it addresses, and they're very specific. So the nurse practitioners were able to get death certificates added to nurse practitioner practice in this omnibus bill. Unfortunately, in this exact same bill was the language that the physicians in the Medical Practice Act added DOs to be able to use the term doctor, the abbreviation DR. And that created a lot of confusion about the fact that they're limiting or restricting the use of the term doctor for anybody else in nursing. That's a completely different uh topic. We are not going to get in that today, but I just another podcast episode. I want to acknowledge, yeah, that that that AB 583 did get approved, allowing nurse practitioners to sign death certificates. Big deal. And then the other really um, I think remarkable uh um win this year was for our nurse anesthetist colleagues in Assembly Bill 876. So this specifically um addressed the confusion around nurse anesthetist scope of practice. Um, many years ago, the governor Schwarzenegger at the time signed a um memorandum allowing uh nurse anesthetists to practice without standardized procedures, essentially independently in hospitals. And that caused a lot of confusion because people were like, well, wait a minute, how long does that last? What does this actually mean for nurse anesthetist practice? So the nurse anesthetists said, you know what, we're gonna go put this into law. So it's very clear that nurse anesthetists are allowed to provide anesthesia services in the state of California, and that is done. So that was a lovely win for our nurse anesthetist colleagues. So we're really delighted about that. So I'm gonna turn it over to Alice to talk about the next couple.

Thanks, Arani. The next topic is um related to um SB 596, which is the health facilities administrative penalties. So the goal of this bill is um aims to making to make violating staffing rules much more expensive and difficult to justify with stricter rules for claiming exemptions. This is talking about staffing um out of ratio and our variances. The fines are set at $15,000 for the first offense and $30,000 for subsequent months, treating each day of a non-compliance as a separate violation and tightening the rules for on-called nurse exemptions to boost accountability for staffing. Um, so the key provisions on this is really the increased penalty. The first violation is $15,000, and second and subsequent consequences will be up to $30,000 per day for the facility. The daily violations, each day a facility is under staff, counts as a new violation, escalating costs to the facility. Stricter on-call exemptions, hospital must exhaust a specific qualified on-call list to find nurses within the specific unit skills that is for that particular department before claiming an exemption, reducing loopholes. Therefore, the focus of the enforcement on this bill is the bill empowers the California Department of Public Health to more rigorously enforce staffing compliance. The impact of the facilities, higher cost but non-compliance. Hospitals are facing substantial daily fines for failing to meet the mandated nurse staffing ratios. Another impact would be renewed emphasis on staffing, which means staffing compliance and better safe patient safety documentation. And another one is the defined on-call list, meeting stricter criteria for using on-call nurses to avoid penalties. So the status of this bill is it was signed into law by Governor Newsom in October of 2025, which significantly increased the administrative penalties for health facilities such as hospitals, nursing homes, violating nurse to patient staffing ratios.

Well, these are some major bills that are have come into, you know, that are have been coming into the picture in 2025. And uh a lot of it does sound like it impacts practice for not only registered nurses, but also for advanced practice registered nurses. So a lot of just different changes to consider here. And I want to turn over to the topic of nursing education too, because I know that there have been some bills in that in that arena as well. So, Alice, I wanted to turn it over to you to talk uh a little bit more about Assembly Bill 1082.

Yeah, Assembly Bill 1082, this is about nursing students who are in out of state programs. Um the this bill, the goal of this bill was to allow California residents who are nursing students enroll in out-of-state pre-licensure distant education nursing programs to complete their required clinical placements and clinical hours in California facilities supervised by the facility license RM. The nursing bill aims to alleviate workforce needs by creating pathways for distance learners. While the key aspect to this bill is actually to address the California nursing shortage by providing more flexible education options. Well, what's the impact? The impact is really requires program accreditation. Uh nursing programs who are not accredited and approved by the California Board of Registered Nursing in the state of California, it does not have a physical location and is able to directly supervised nursing students in the state of California. Well, that's the impact to the facility because now it's requiring the facility to provide the RN supervision and ensures that the clinical placements is not displacing in-state students who are currently in California approved nursing programs with a fee for out of state programs. So the status of this bill right now is on May 23rd, 2025, the assembly bill, the assembly actually held the submission. So this is not the end of this. This is the second bill that's come around this year. Um so we probably may see this bill again in the future in a different form or format. Um that's that's the nature of this bill. And I'll I'll hand it over to Sarani uh to talk about the AB 1400, which is the community college backlurate degree nursing pilot program.

Um this bill is uh a two-year bill that is finally done. Um I'm sure it'll come back though. So, as Alice said, uh, some of these uh bills that we've been tracking uh are gonna uh re-emerge looking slightly different. So they'll change their clothes and come back for another round in California. I think this will be one of those. So this specific bill um allowed for a pilot to occur in community college um awarding baccalaureate degrees for nursing. And while some of the community colleges were very excited about this because it does offer an opportunity to expand um offerings in their communities for nursing specifically, uh, it also made some of our existing university, um, you know, traditional university programs a little concerned that it would uh pull potential students away from them, like the Cal States and the UCs. So there is, I would say, probably not um overwhelming agreement for this particular concept. It was vetoed by the governor ultimately in October, and I think the uh disagreement was a big part of that. So the concept is a good one, right? We we need more nurses in California. And we know that there is um a required pathway into leadership and education and research for nurses, and that is your baccalaureate degree in nursing. So, wouldn't it be great if we could find a way to increase the number of programs that offer baccalaureate degrees in nursing? Absolutely. But this concept was not something that the parties could agree on. So on um ultimately vetoed. Uh, but as Alice said, I'm sure we'll see this come back in some form or the other in the next couple of years. So we'll we'll keep an eye on that for the group and we'll come back next year with an update.

Yeah, that sounds great. And you know, there there has been a lot of action in the state when it comes to legislation. And I'm wondering how can nurse leaders watch out for some of these updates in 2026, or is there any ways that or any resources that the health policy committee um offers so that nurses can stay in touch with some of these updates?

Well, I'll just say um we would love to have you apply for the committee, but I know not everyone can do the committee. It's like uh the health policy committee is a passion. I love it. I've been involved um since I joined ACNL. And um we we have created an amazing uh health advocacy certificate program called the C. Duane Donner Health Policy Certificate Program for Nurse Leaders. So we have several of our modules published, and they're very doable with the very limited time that nurse leaders have. I think it's worth your time to check it out. And this is a great way to kind of um become engaged with health policy, learn a little bit more about how you can learn more about health policy and also uh how to look for ways that you as a health leader can uh make changes um in the state of California through your advocacy. So, yeah, learn more about uh checking out our um health certificate program. I think it would be well worth your while to do that.

That sounds great. Thank you so much for that. And I do want to shift gears, moving you know, from state legislation and now talking about federal policy. And so, so Alice, in particular, when we talk about the impacts of the One Big Beautiful Bill Act or the OBBBA that was signed into law on July 4th, 2025, how are the changes in that bill reshaping financial realities for hospitals, especially when it comes to safety net hospitals or systems with high utilization of Medicaid?

Yeah, thanks, uh Charlene. Uh, you know, this this one big beautiful bill was signed uh last July 4th, um, 2025. And the impact to it is significant cuts to the Medicaid, the Affordable Care Act, and the financial strain for hospitals and health systems, especially those serving low-income and high Medicaid populations, as well as a decrease in access to care for vulnerable populations or vulnerable patients. You know, this is also um creating some staffing workforce challenges with disruptive um resource planning, requiring nurse leaders to focus on operational resiliency as well as advocacy. Um, in addition, recently, um, you know, and it's made through, you know, its name and um exposure through social media is is the controversial reclassification of nursing as a non-professional degree. This is, as Sarani says earlier and mentioned in the other previous bills of advanced education for nurses. This is limiting student loan access, uh creating an additional financial strain, not just for the facility to have advanced practice nurses within their areas of specialties to provide more access to care, but also a major US law that's impacting healthcare leaders who must now adapt to reduced funding, potential payment cuts, and increasing patient burdens while advocating for a future nursing pipeline stability amidst uh these policy shifts. So more to come. Uh, we just don't know what the future looks like because this is still ongoing and is um looking like there will be a greater impact to healthcare and how we do business to provide care.

Yes, thank you for that overview. And it really sounds like the one big beautiful bill act will have some significant changes when it comes to uh the financial operations and hospitals and also the what it means for staffing and workforce development and how that can impact uh the implementation of care delivery with some of these changes. And I'm curious, you know, what what would you say that nurse leaders should really know about this bill, or what what can they kind of anticipate when it comes to to this bill, or is there any way that they could kind of you know prepare for some of these changes, or do we really just not know yet? What is your take on it for both either of you can share?

Well, I think uh I'll start and just say that being aware of it is the first big step because you're really um, as the nurse leader in your organization, I don't care what your title is, uh, all nurses are leaders, whether you're in an acute or ambulatory setting, you should be aware of the impacts, future impacts that these changes are going to have on the workforce, the nursing workforce specifically, but also any other um ancillary staff that are supporting nursing in your organizations. And then you need to go talk to your legislators. And that doesn't need to be a big visit to Washington, D.C. That can actually be a local visit in your local hometown or uh adjacent town where your federal legislators uh will show up and meet with um their constituents. It's really important when they have a nurse show up and talk about how these things impact them. So please just do that. If you can't even do that, an email is an awesome way to let people know in the federal and the state level how this is impacting you and your work um workplace. Just sending an email is so important. I can't even emphasize how big of a deal that is. You don't need to pick up the phone and call, you don't need to fax anything, you can just shoot an email to your legislator, both at the state and the federal level, to let them know how this is impacting you. Those stories are critical and they get shared at the state and the federal level. So that is how you can be very active because your stories are important to share. Because I think that, you know, in the halls of DC and the Capitol in Sacramento, there aren't a lot of healthcare providers showing up and talking about how work actually happens on the ground. How do we actually take care of patients? And how do the things that are happening in California have ripple effects into our hospitals, our ambulatory facilities, our schools, and um and all of the things that impact the way we train our future generation and our current um employees. So if you can be the voice, just an email, it's completely okay, but a visit is incredibly impactful. That's what I would say that you can do right now to make sure your story is heard and shared.

And in addition, I would also encourage you all to share your knowledge. Once you know about the legislative initiative or bills, please share with your colleagues because I know we're busy day to day, but having this knowledge is powerful. And taking a step, another step of sending an email, a simple email, and speaking to your local legislator who may be your neighbor, you don't know, right? And so just sharing your story and having a nurse speak to their um and how impactful this will be to their practice is very crucial.

Yes, thank you both so much for sharing those insights. And it really sounds like when it comes to the One Big Beautiful Bill Act, what's really important for nurses to know is to have the awareness, to educate themselves on what this means for their practice, for their organizations, and then to take some action, whether it is sharing their story, sharing their voice, visiting legislators, writing an email, or taking these simple actions, because just as you were both saying, it's really these smaller actions that create big ripples when we all come together and we all um use our expertise and use our stories to really impact what's happening in our country. So very um great advice to keep in mind. And and I want to talk about 2026 for a little a little bit too, because you know, as we're closing this year in 2025, um I want to see what should we expect for 2026? So across all of the legislation that's being monitored and our position statements with ACNL, what would you say are the major themes that are emerging emerging right now for California nursing for this new year?

I think that we're gonna continue to see more efforts to um get our arms around AI in uh healthcare. I think that will be a theme that we'll continue to observe in California specifically. And I know based on what I'm seeing out in the kind of national uh media, there are concerns about that from the the big AI companies that they don't like that. So be be prepared for a lot of conflicting information in the media that you that you consume. The other thing that will be very big is the need to address our workforce um shortages, right? There, that is not going away, that's only worsening year after year. So I think in the state of California, we're trying to figure out what that looks like. How do we generate more nurses? Um, but not only nurses, medical assistants, nurse, you know, nurse aides, uh, NPs, nurse midwives, I mean, all of them, because the landscape is um pretty frightening right now to look at what's out there. Um and another big gap is the training part of getting new healthcare providers out there, whether they're uh nurses or nurse practitioners or midwives, we don't have enough people training. So precepting is hard work. I've pre said it precepted all my career, both for nursing and nurse practitioners. And I think that there aren't enough um people to do that. And I think that the state is gonna have to figure out what that looks like in the future going forward, as well as um healthcare organizations. I think the burden is falling on healthcare organizations, and I don't know that that they can afford it. So I think we've got a little bit of an opportunity there in California. So those are the two big things that I see coming. And and along with all of the regular scope topics, uh, you know, this is you know, my thing. You can't come do that thing. I think we'll continue to have those discussions um amongst different healthcare providers um in the coming year. Alice, anything else to add? I guess.

No, you sum it up really well. Thank you, Sarani.

And and I'll ask just a final question to you too, Alice. What single call to action would you offer to nurse leaders so that they can stay informed and influence policy direction in 2026?

Oh, I would say empower yourself with knowledge. Knowledge is key. Join our health policy committee. Uh, you know, this is how we all learn. Uh, we're novice once upon a time, but with lots of good support through ACNL, uh, you know, we've evolved and we continue to evolve into letter writing, position statements, and whatnot. And, you know, it's it's just part of your benefit being an ACNL member. So that's what my call to action. And talk to someone, tell them, you know, share your stories.

That's wonderful. Well, I want to say thank you both so much for sharing your expertise for all the work that you do within our ACNL Health Policy Committee and for being with us for multiple episodes too to share that work. And we're so uh excited for what the 2026 year will have and how we can help support legislation for next year. But just want to say thank you both, and we can't look we look forward to the next episodes with you with you all for the next year, too. Thank you. Appreciate it. Thank you. Our guests today were Dr. Sarani Hare Kwan and Dr. Alice Martinagara, members of the ACNL Health Policy Committee. We'd love to hear your feedback. Email us at socialmedia at acnl.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is presented by the Association of California Nurse Leaders with new episodes on the first Friday of every month. To learn more about the show or ACNL in general, visit us at acnl.org. Thank you for listening.