Surgeons Lead State Efforts to Protect Patients, Profession

In a political climate that is more challenging than ever, one thing remains consistent—lawmakers are receptive to the voice of their constituents.

When legislators want to understand the effects of policies and issues, they depend on constituents to explain the problem and offer solutions. Therefore, it is imperative that surgeons use their voices when it comes to matters related to the medical profession and the care of their patients.

Although some might find the thought of becoming an advocate intimidating, surgeons only need a desire to make an impact, according to Amy Liepert, MD, FACS. “Advocacy is teaching,” she said. “It’s using your training, expertise, and influence as a respected member of society.”

ACS members often hear about advocacy initiatives at the federal level; the College is also very active at the state level.

In 2025, the ACS tracked approximately 1,500 state bills. The following is a summary of activities.

State Advocacy Days

In 2025, ACS chapters planned and participated in state advocacy days in California, Delaware, District of Columbia, Florida, Indiana, New York, Tennessee, Virginia, and Wisconsin. Surgeons met with legislators at state capitol buildings about issues affecting their practices, patients, and businesses.

“Advocacy is a natural extension of our professional responsibility as surgeons. Just as we strive to achieve the best outcomes for our patients in the operating room, we must also stand up for our patients and profession at State houses across the country to ensure safe, timely, and equitable surgical care through policymaking and sustained advocacy,” said Kevin Koo, MD, MPH, FACS.

Prior Authorization

137 bills tracked
38 enacted

Improving health insurance prior authorization requirements to ensure timely access to care for patients remains a priority for the ACS. Prior authorization requirements interrupt care, divert resources from patients, and complicate medical decision-making.

The Texas “Gold Card” law made headlines when it was enacted in 2021 and again this past spring when the Texas Department of Insurance released a report showing only 3% of healthcare professionals received the prior authorization gold card.¹ To achieve gold card status, health insurers must approve at least 90% of prior authorization requests. Texas enacted a law this year to extend the evaluation period for prior authorization exemption eligibility from 6 months to 1 year, and it requires health insurers to release an annual report detailing how many exemptions they have granted or denied.

At least nine other states enacted gold card laws.² However, making the process more transparent and efficient on the insurer side would allow physicians to see their progress in trying to achieve gold card status.

Most prior authorization bills introduced in states share the following provisions:

• Prohibit or limit the use of artificial intelligence in denying prior authorization
• Establish shorter timeframes for insurers to respond (24 hours for urgent care, 48 hours for nonurgent care)
• Require the reviewing physician be licensed in the same state and have relevant experience with the specific medical condition
• Prohibit retroactive denials if care was pre-authorized and services were provided
• Make prior authorization valid for at least 1 year or the length of treatment for a chronic condition
• Require public release of prior authorization data to a state agency or on the insurer’s website (i.e., total number of monthly prior authorization requests, the number of prior authorization requests approved/denied per month)
• Require electronic submission or an online portal for prior authorization requests

Several states passed multiple prior authorization bills this year. For example, Montana enacted four pieces of legislation that:

• Prohibit a health insurer from rescinding prior authorization once the medical service is provided
• Require health insurers to use a state-licensed physician with a specialty relevant to the condition under review to make adverse determinations and grievance reviews
• Ensure approvals for chronic conditions last for the duration of the condition
• Require health insurers to honor prior authorizations for at least 90 days when enrollees switch plans

This piecemeal legislative approach suggests legislators are willing to take incremental steps to change their prior authorization laws.

Medical Liability Reform

110 bills tracked
14 enacted

Trial attorneys put surgeons on defense again this year with legislation seeking to remove caps on noneconomic damages and allowing more plaintiffs to join in a malpractice action. Many bills were defeated, and a few states were able to enact tort reforms this year.

The ACS Florida Chapter strongly opposed a bill removing a prohibition on recovery of noneconomic damages in medical negligence cases by the decedent’s children 25 years of age and older, as well as parents of a deceased child who was 25 years of age or older at the time of death. Chapter leaders successfully lobbied Governor Ron DeSantis (R) to veto the bill on June 2.

Georgia enacted a bill addressing how and when noneconomic damages can be introduced in court, limiting the recovery of special damages to the actual cost of medical expenses paid and allowing bifurcation of the trial. Bifurcation in medical malpractice trial means that first the jury decides if the defendant’s negligence caused the injury, then it decides how much compensation the injured party should receive. Governor Brian Kemp (R) signed the bill into law on April 21.

For the third year in a row, the Grieving Families Act failed to pass in New York. This legislation would expand the type of damages recoverable in a wrongful death action. The ACS New York Chapter and the College worked together using SurgeonsVoice to encourage surgeons to send emails to their state legislators opposing the bills. Governor Kathy Hochul (D) vetoed the bill again, but it is expected to be reintroduced.

Utah legislators enacted a law requiring plaintiffs to submit an affidavit of merit in professional liability cases. Many states require an affidavit of merit be filed early in a medical malpractice lawsuit to ensure there is a legitimate basis for the claim before it proceeds. This bill also capped the total amount of damages a claimant can receive to $1 million, except in cases involving death. Governor Spencer Cox (R) signed the bill into law on March 27.

Noncompete/Restrictive Covenants

34 bills tracked
4 enacted

Restrictive covenants are used to protect an employer’s interests by restricting when and where the employee can relocate for work, limiting a physician’s ability to practice medicine within a specified time period and geographic area.

Legislators in Arkansas, Indiana, and Wyoming enacted laws voiding restrictive covenant agreements in physician contracts entirely. In Texas, the law limits restrictive covenants to 1-year post employment, within a 5-mile radius from the former employer’s primary practice location, and includes a buyout option.

International Medical Graduates/Foreign-Trained Physicians

32 bills tracked
12 enacted

State legislators are researching ways to provide licensure pathways for internationally trained physicians (ITPs) and international medical graduates (IMGs). According to the Federation of State Medical Boards (FSMB), 18 states enacted legislation allowing qualifying ITPs to receive full licensure without accredited postgraduate training (PGT), and three states have licensure pathways for limited licensure without any additional graduate medical education.³

Several states enacted laws allowing ITPs to be licensed without completing PGT, and most states offer a limited license with the potential to convert to a full, unrestricted license.

The Advisory Commission on Additional Licensing Models—co-chaired by the FSMB, Accreditation Council for Graduate Medical Education, and Intealth—was established in December 2023 to guide and advise state policymakers.⁴ ACS staff continue to monitor state and federal requirements for IMGs and ITPs.

Violence Against Healthcare Professionals

30 bills tracked
4 enacted

Violence against healthcare workers is escalating, and states across the country are increasingly attempting to address the growing problem.

Ohio enacted a bill requiring each hospital system to establish a security plan for preventing workplace violence and managing aggressive behaviors. The plan must involve a team that includes healthcare employees who provide direct patient care. Governor Mike DeWine (R) signed the bill into law on January 8.

Virginia enacted a bill classifying verbal threats against a healthcare provider as a Class 1 misdemeanor. The commonwealth also enacted legislation making a verbal threat to discharge a firearm in a healthcare setting a Class 1 misdemeanor. Governor Glenn Youngkin (R) signed both bills into law on March 24.

Scope of Practice

170 bills tracked
4 enacted

Scope of practice is primarily determined by state law, and the number of scope bills the ACS tracked in 2025 increased by 60% over last year. The College sent position letters and provided action alerts to several states opposing scope expansion efforts. The ACS and state chapters continued to support other physician specialties in opposing scope of practice expansion state bills, including physician supervision of certified registered nurse anesthetists (CRNAs), optometrists, physician assistants (PAs), and advanced practice nurse practitioners (APRNs).

CRNAs

26 bills tracked
2 enacted

CRNA scope of practice varies by state, with some states allowing CRNAs to work without supervision. In 2025, the ACS sent letters opposing state bills attempting to allow for CRNA independent practice in Maine, Mississippi, and West Virginia. 

New Mexico enacted Senate Bill 78 allowing CRNAs to operate independently without supervision to provide anesthesia care and related services. They also are allowed to prescribe and administer therapeutic measures, including controlled substances. In addition, the law provides for a 30-day expedited licensure process for CRNAs licensed in other states who want to be licensed and practice in New Mexico.

West Virginia enacted a bill to allow CRNAs to administer anesthesia in cooperation with physicians and other healthcare providers. The bill included an interesting provision absolving physicians from liability for “any act or omission” of a CRNA who orders or administers anesthetics.⁴

Ten states introduced anesthesiologist assistant (AA) bills. Most bills defined how an AA works under the direct supervision of an anesthesiologist, and five states introduced bills to provide a pathway to licensure in their state. Tennessee enacted legislation providing a pathway for AAs to be licensed in the state.

Optometrists

18 bills tracked
2 enacted

A growing number of states considered permitting optometrists to perform certain surgical procedures, particularly laser surgeries, and the ACS is tracking 18 bills seeking to allow optometrists to perform laser and scalpel surgeries around the eye, as well as provide injections. Currently, 10 states allow optometrists to perform laser surgeries: Alaska, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, Oklahoma, South Dakota, and Wyoming.

Working with the American Academy of Ophthalmology, the ACS sent letters opposing this gross expansion of scope. In 2025, Montana enacted laser and in-office surgical procedures for optometrists. The law specifically excludes penetrating intraocular surgery, intravitreal injections, and refractive surgery. Optometrists may only perform laser surgical procedures if certified by the state board of optometry, which requires completion of additional didactic and clinical training from an accredited optometry school or college.

Virginia enacted legislation to allow optometrists with pharmaceutical agent certification to prescribe and administer Schedule II hydrocodone with acetaminophen, and Schedules II-V controlled substances.

Committee on Trauma

Stop the Bleed

36 bills tracked
8 enacted

The ACS campaign for Stop the Bleed continues to gain support across the country. In 2025, bills in Connecticut, Maine, Missouri, and Virginia were enacted. Four states adopted resolutions recognizing May 22 as Stop the Bleed Day.

The Connecticut law requires bleeding control training and kits in state-owned buildings and integrates bleeding control training into existing requirements for first responders, school staff, and local employees. Governor Ned Lamont (D) signed the bill into law on June 6.

Maine enacted a bill that was signed by Governor Janet Mills (D), requiring state-owned buildings with 50 or more employees to have at least one bleeding control kit. The legislation also allocated funds to purchase and install the kits.

Missouri enacted legislation requiring schools to develop a bleeding control protocol and place Stop the Bleed kits in schools. Schools must designate a staff member to receive annual training in Stop the Bleed techniques. The bill provides Good Samaritan protections for school staff who use the kit in good faith. Governor Mike Kehoe (R) signed the bill on July 9.

Virginia legislation mandates bleeding control programs and kits in all public elementary and secondary schools and provided funding for the purchase of these kits. The original version of the bill required school board employees to receive training in Stop the Bleed techniques and Good Samaritan protections, but the Senate removed those provisions prior to passage. The ACS Virginia Chapter is currently working with state legislators and reviewing their options on how to amend the new law with training language. Governor Glenn Youngkin (R) signed the bill into law on July 1.

Commission on Cancer

294 bills tracked
68 enacted

The ACS Commission on Cancer (CoC) supports efforts to advance legislation on cancer priorities, which include: expanding health insurance coverage for breast, prostate, lung, and colorectal cancer screenings; seeking no-cost sharing (no out-of-pocket costs to the patient) cancer screenings; biomarker coverage; step therapy and proton beam therapy bills.

Breast Cancer

88 bills tracked
13 enacted

Breast cancer is the second most common cancer and the second-leading cause of cancer death in women. Many bills provide for no cost-sharing screening and imaging services, including improving standards for breast density classification, supplemental testing, and examinations. Seven states passed legislation eliminating cost-sharing for diagnostic and supplemental breast examinations.

Prostate Cancer

22 bills tracked
7 enacted

The ACS is tracking 22 bills related to prostate cancer, as well as working as part of a coalition led by ZERO Prostate Cancer. To date, the District of Columbia and Virginia enacted no cost-sharing screening bills, which prohibit health insurers from imposing deductibles, coinsurance, co-payments, or other cost-sharing requirements for prostate cancer screenings.

Lung Cancer

19 bills tracked
9 enacted

Lung cancer remains the leading cause of death in the US for both men and women diagnosed with cancer. Arkansas and Nevada enacted laws to require health insurers to provide no-cost-sharing lung cancer screenings and follow-up healthcare services. Both legislatures recognize the critical need for lung cancer screenings in the state and emphasize the need for early detection through low-dose computed tomography, especially in rural areas of their state.

Colorectal Cancer

27 bills tracked
5 enacted

Alabama passed a law requiring Medicaid to cover noninvasive colorectal cancer screening tests and mandates coverage for a colonoscopy if a positive result is obtained. The act will be sunset in 2 years. Governor Kay Ivey (R) signed the bill into law on May 21.

Kentucky enacted House Bill 421, which requires health insurers to provide no-cost-sharing colorectal cancer screenings for individuals aged 45 and older, or those under 45 at high risk, and includes US Food and Drug Administration (FDA)-approved bowel preparation without prior authorization or cost-sharing for services from participating providers. Governor Andy Beshear (D) signed the bill into law on April 2.

Ovarian Cancer

4 bills tracked

Routine ovarian cancer screening is not typically recommended or covered by insurance for women at average risk. In high-risk and symptomatic women, ovarian cancer screening tests would be considered diagnostic and are typically covered by insurance. Genetic counseling and testing for BRCA mutations, which increase the risk of ovarian cancer, are often covered under the Affordable Care Act for eligible women.

Step Therapy

26 bills tracked
10 enacted

Claiming to control drug costs, step therapy is a specific type of prior authorization requiring patients to try less expensive medication before the health insurer will consider covering the cost of more expensive medication. Step therapy is typically used for chronic conditions where there might be multiple medication options.

Alaska enacted legislation prohibiting the use of step therapy for patients with Stage 4 advanced metastatic cancer. The bill became law without Governor Mike Dunleavy’s (R) signature on July 30.

Maine and Tennessee enacted legislation prohibiting health insurers from requiring an enrollee to fail step therapy protocols before covering a drug approved by the FDA for the treatment of metastatic cancer. Governor Janet Mills (D) signed the bill into law on July 1. A similar bill in Montana was vetoed by Governor Greg Gianforte (R), and the veto override attempt failed on July 14.

New Jersey, North Dakota, and Oklahoma enacted laws to provide exceptions to step therapy protocols when a required drug is contraindicated, likely to cause adverse reactions, or expected to be ineffective based on a patient’s clinical characteristics. The issue is trending and expected to draw greater attention in the 2026 legislative session.

Biomarker Testing

29 bills tracked
2 enacted

Both Maine and New Jersey enacted legislation this spring requiring health insurers to provide coverage for biomarker testing for diagnosis, treatment, management, or disease monitoring. Biomarker testing will certainly be back on the docket for state legislatures in the future.

The ACS State Affairs team is available to answer questions and provide background information regarding state issues and policy programs. State advocacy resources, including the weekly legislative update, are available at facs.org/advocacy/state-legislation. 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.

References

1. Huff C. State-mandated ‘gold card’ programs to ease prior authorization burdens offer little relief, experts say. Medscape Medical News. July 7, 2025. Available at: https://www.medscape.com/viewarticle/state-mandated-gold-card-programs-ease-prior-authorization-2025a1000hw9. Accessed October 13, 2025.
2. Federation of State Medical Boards.  States with enacted and proposed additional licensure pathways. Available at: https://www.fsmb.org/siteassets/advocacy/policies/states-with-enacted-and-proposed-additional-img-licensure-pathways-key-issue-chart.pdf. Accessed October 13, 2025.
3. Federation of State Medical Boards. Advisory Commission on Additional Licensing Models releases second set of draft preliminary recommendations for public comment. Available at: https://www.fsmb.org/advisory-commission-comment-period/. Accessed October 13, 2025.
4. West Virginia SB 810, (d) A physician, a dentist, a podiatrist, an advanced practice registered nurse, and/or a physician assistant is not liable for any act or omission of a certified registered nurse anesthetist who orders or administers anesthetics under this section.