On September 30th, 2018 California Governor Jerry Brown vetoed Assembly Bill 3115, the Community Paramedicine or Triage to Alternate Destination Act. The bill sought to formalize the long-running community paramedic pilot program into state law. Community paramedicine is widely viewed as a good and necessary change in how EMS delivers care. However, the language of AB3115 created controversy which culminated in its demise. Instead of empowering local medical director leadership, the Bill sought to change the make-up of the state EMS commission, and also required alternate destinations to be federally qualified health centers, an unnecessary burden to EMS systems. Governor Brown referenced both of these issues in his letter to legislators.

Community Paramedics Shawn Percival (left) and Anne Jensen (right) meet with an at-risk, frequent 911-user to discuss his care and facilitate appropriate services. In his recent decision, Governor Brown recognized the critical services provided by community paramedics across California, but vetoed a recent attempt to formalize the community paramedic pilot program into law because of shortcomings in the proposed bill.

Assembly Bill 3115 was the latest iteration in a now two-years-long battle to put community paramedicine into state code. It was sponsored by the California Professional Firefighters Association, a union with a stated mission of “serving the needs of career firefighters.” It is this mission that potentially led to the AB3115’s troubling language. The union sought to leverage the implementation of community paramedicine for additional seats in the state’s highest oversight body, the EMS Commission. They proposed the removal of two long-standing nonprofit members from the commission to be replaced by fire and nursing union members. Their language also required that public agencies, further defined as fire departments, get first-rights to run any proposed community paramedic programming.

Community paramedicine has been successful in large-part due to the dedication of local stakeholders in each pilot site working under the oversight of state offices such as the EMS Authority, the Office of Statewide Health Planning and Development, and the California Healthcare Foundation. The proposed changes to the state EMS commission ran contrary to this historical success. Despite widespread and public opposition from California medical directors, EMS administrators, and county administrators, the Professional Firefighters held their ground with the hope that the need to pass community paramedicine would outweigh these concerns.

AB3115 also faced challenges regarding its proposal for triage paramedics and alternate destinations. Currently, California prehospital systems must transport all patients to a hospital emergency department. This leads to emergency departments often becoming inundated with patients, some of which do not require the assessment and treatment of these advanced facilities. The ability for paramedics to triage those specific patient populations, such as mental health and alcohol intoxication, to alternate destinations allows for more efficient prehospital and emergency department operations, but it would also allow at-risk populations to receive appropriate care in these new, centralized destinations.

A bill proposed by the California Hospitals’ Association earlier this year sought to implement this alternate destination system, but that bill was defeated by both the California Nursing Association and California chapter of the American College of Emergency Physicians, who viewed the loss of these patients as a hit to their bottom line. The reincarnation of alternate destinations in AB3115 answered the concerns of both groups by requiring these destinations to be Federally Qualified Health Centers, or FQHCs. FQHCs are comprehensive primary care facilities that furnish services typical to an outpatient center and require both nursing and physician staffing. While good in theory, the requirement of alternate destinations to be FQHCs is cost-prohibitive and defeats the premise of that program.

Governor Brown accurately identified these key issues as non-starters for a community paramedicine bill. Brown directed the extension of the current community paramedicine pilot program, allowing critical services to continue while legislators and stakeholders find a solution. While the formal extension of the pilots requires approval and funding from other regulatory bodies and organizations, it is a strong indication of Governor Brown’s support. It is now up to California EMS stakeholders to move community paramedicine forward yet again.