Capitol Rx
Prescriptions for progress and the legislative pills hardest to swallow from this year’s session
Jon R. Roth, MS,
EDITORIAL
EDITOR,
Lauren S. Williams
DESIGNED BY
Morganne Stewart
COMMUNICATIONS COMMITTEE
Michelle Caraballo, MD, Chair
Ravindra Mohan Bharadwaj, MD
Jawahar Jagarapu, MD
Ravina R. Linenfelser, DO
Sina Najafi, DO
Celine Nguyen, Student
Shyam Ramachandran, Student
Erin Roe, MD, MBA
BOARD OF DIRECTORS
Shaina Drummond, MD, President
Gates Colbert, MD, President-elect
Vijay Giridhar, MD, Secretary/Treasurer
Deborah Fuller, MD, Immediate Past President
Emma Dishner, MD, Board of Censors Chair
Neerja Bhardwaj, MD
Justin Bishop, MD
Sheila Chhutani, MD
Philip Huang, MD, MPH
Nazish Islahi, MD
Allison Liddell, MD
Riva Rahl, MD
Anil Tibrewal, MD
The 2025 Legislative Session Wins, Setbacks, and What Comes Next
Shaina Drummond, MD
NOW THAT THE 2025 TEXAS LEGISLATIVE SESSION
has concluded, it is a fitting time to reflect on what became one of the most active and challenging sessions for our profession in recent memory. Physicians across the state rose to the occasion, showing up in force to advocate for the future of medicine. The Texas Medical Association reported a high level of engagement from its members, with many testifying before lawmakers on high-stakes issues. From scope of practice and liability reform to public health, maternal care, insurance regulation, and the state budget, physicians played a vital role in shaping the conversation.
As with every session, the outcomes were shaped not only by the legislation itself, but by the people debating it, and this year brought considerable political change. The Texas House welcomed 32 new members, alongside three new senators and a newly appointed Speaker of the House. These shifts led to new committee leadership and a realignment of legislative priorities. Navigating this evolving landscape required focus, persistence, and a strong, unified voice from our profession—and physicians across Texas delivered.
Key Legislative Victories
Protecting physician-led care remained a top priority for TMA. Efforts to expand scope of practice for non-physician providers were met with strong opposition, and ultimately, every proposal aimed at granting independent authority to advanced practice registered nurses and pharmacists was defeated. These included attempts to allow unsupervised prescriptive rights and expanded
diagnostic authority without physician oversight.
These victories preserved the physician-led care model and reinforced the importance of rigorous training, clinical judgment, and evidence-based practice in delivering safe, high-quality care. When physicians advocate together, we protect not only our profession but also the health and safety of the communities we serve.
A major legislative victory was achieved with the veto of Senate Bill 268. Although the bill passed both chambers with support from health plans and private equity groups, Governor Abbott ultimately rejected it. The bill would have weakened the Texas Medical Board’s ability to stop the unauthorized practice of medicine. The veto was a direct result of persistent physician advocacy that emphasized patient protection.
Another milestone was the passage of Senate Bill 31, the Life of the Mother Act. This bipartisan legislation provides clarity on Texas’s abortion laws, affirming that physicians can act on their clinical judgment when a pregnancy threatens a woman’s life or could cause serious harm to her health. The law also ensures consistency across state statutes, safeguards physicians who seek consultation, and requires the state to prove wrongdoing in legal actions. This will help reduce delays in emergency care and restore physician confidence in navigating complex clinical situations. Tort reform remained a high-stakes issue. TMA helped defeat Senate Bills 30 and 39, which would have altered the way juries award damages in medical liability cases.
Preserving the protections enacted in 2003 remains essential to maintaining a stable legal environment that allows physicians to focus on patient care.
This session also brought welcome progress in addressing noncompete agreements. New legislation now limits the enforceability of these clauses by requiring reasonable geographic and time restrictions. Physicians must also be given the option to buy out their non-compete agreements and retain access to medical records to support continuity of care. These reforms support both physician autonomy and patient access, reinforcing that employment contracts should never compromise clinical care.
The TMA also achieved several other significant victories. Senate Bill 922 provides physicians with a three-day window to review and discuss serious test results, such as those involving cancer or genetic findings, before they are released electronically to patients. This change ensures that patients receive potentially life-changing information with appropriate context and support from their physician. The origin of this legislation dates back nearly three years, when DCMS member Dr. David Gerber, an oncologist at UT Southwestern, raised concerns about the risks of patients accessing sensitive results without medical guidance. Recognizing the harm that could come from patients viewing sensitive results without proper explanation, Dr. Gerber brought the issue to DCMS. The society then brought the recommendation to the Texas Medical Association and urged that it be made a legislative priority. As a result of that coordinated advocacy, a
How to Stay Involved
There are many ways you can continue to make an impact throughout the year:
CONNECT WITH YOUR LEGISLATORS
Reach out to your representatives and senators. Let them know you are a physician and a member of DCMS and TMA. Offer to serve as a resource on health-related matters. Share how policy decisions affect your patients and your practice. Invite them to your clinic. Attend their community events. These relationships make a difference.
SUPPORT TEXPAC
Join TMA’s bipartisan Political Action Committee, which helps elect candidates who support physician leadership and patient care. Your support helps ensure medicine is well represented at every level of government.
STAY INFORMED
Sign up for updates and alerts from DCMS and TMA. These resources keep you informed about interim hearings, proposed regulations, and opportunities to take action.
BE A PUBLIC VOICE
Your perspective matters beyond the exam room. Write an op-ed, testify at a hearing, serve on a board, or speak at a community event. Your experience can significantly impact the broader conversation on healthcare.
THANK YOU TO OUR DCMS ADVOCATES
To every Dallas County physician who took time away from your practice and your family to advocate for our profession, thank you. Whether you traveled to Austin for First Tuesdays, testified at a hearing, sent an email, made a phone call, or met directly with lawmakers, your voice made a lasting impact. You helped shape the policies that affect how we care for our patients and how we practice every day.
Now is the time to maintain that momentum. Your involvement is not only appreciated, but it is essential. Let us continue to show up, speak out, and lead the way in protecting the future of medicine in Texas.
concern raised by one local physician is now a statewide policy that strengthens patient care throughout Texas.
In addition, the TMA helped defeat legislation that would have imposed excessive reporting and financial burdens on small practices. It also stood firm against harmful public health proposals, including bills that sought to expand vaccine exemptions. Although one bill related to school immunization policy did pass, many others were successfully stopped. TMA also secured increased funding for residency training programs, women’s health services, and public health initiatives—further demonstrating the power and effectiveness of physician-led advocacy.
Areas of Concern
Despite meaningful wins, not every outcome was favorable. Progress in insurance reform stalled, particularly after the departure of Representative Tom Oliverson, MD, as chair of the House Insurance Committee. His successor introduced multiple bills opposed by TMA, highlighting the continued need for physician leaders in policymaking roles.
Vaccine policy also took a step backward. A new law makes it easier for parents to claim nonmedical exemptions for school immunization requirements. This is especially troubling in light of the recent measles outbreaks in Texas, which illustrate the real-world consequences of weakened public health policy. The medical community must continue to speak out for evidence-based practices that protect vulnerable populations.
The Work Ahead
The challenges we face are not confined to Texas. Physicians across the country are facing similar challenges, including administrative burdens, scope of practice disputes, and increasing threats to public health infrastructure. While this session yielded essential gains, it also highlighted the fragility of progress without continued engagement. Even though the next legislative session may seem far off, the work of advocacy begins now. Lawmakers are back in their home districts, meeting with constituents and considering their legislative priorities. This is the time to build relationships, share our expertise, and make sure physician voices remain central in health policy conversations.
Advocacy Doesn’t End with Adjournment
The end of the legislative session does not mark the end of our work. In many ways, it signals the beginning of the next phase. Meaningful advocacy happens year-round, well before bills are filed or votes are cast. Staying engaged between sessions allows us to shape early legislative conversations, promote patient-centered care, and advocate for evidence-based reforms. It also allows us to push back on proposals that may threaten physician autonomy or compromise patient safety. Most importantly, it ensures that physicians remain central to public health discussions and decisions that impact the future of medicine. DMJ
Texas Legislation A Case Study in Physician Advocacy Impact
Jon R. Roth, MS, CAE
TEXAS PHYSICIANS ACHIEVED REMARKABLE
legislative victories in recent sessions, demonstrating how organized medical advocacy directly shapes healthcare policy.
Four specific bills—Senate Bill 268, House Bill 31, Senate Bill 922, and House Bill 139—illustrate both the power of physician engagement and the consequences of having medical voices absent from policy decisions.
Recent legislative victories showcase advocacy effectiveness
House Bill 31 emerged as the most dramatic success story.
Known as the “Life of the Mother Act,” this 2025 legislation clarified medical emergency exceptions to Texas’ abortion restrictions after documented maternal deaths exposed dangerous legal ambiguities. The bill passed with overwhelm-
ing bipartisan support—31-0 in the Senate and 134-4 in the House—following intensive advocacy by the Texas Medical Association (TMA) and Texas Hospital Association (THA).
The medical community’s unified response proved decisive. THA designated HB 31 as their highest-priority bill for the 2025 session, while TMA provided expert testimony through dozens of their members. This collaboration between hospital and physician organizations created unstoppable momentum, with Lt. Governor Dan Patrick listing the bill among his top priorities.
Senate Bill 268 was a scope expansion bill in disguise. The bill was promoted as addressing administrative burdens that affect healthcare practitioners across various licensing entities. However, the legislation would have stripped the Texas Medical Board of the power to issue cease-and-desist letters
to those non-physician practitioners who were charged with illegally practicing medicine. Despite receiving less public attention due to its last-minute introduction, the bill passed with 120-14 support in the House. As the bill headed to Governor Abbott’s desk, hundreds of DCMS and TMA members weighed in on the dangerous precedent this legislation represented, arguing that it would strip the Medical Board of its powers to regulate the practice of medicine and compromise patient care. Fortunately, the Governor agreed and vetoed SB 268 citing similar concerns.
Electronic health records legislation demonstrates nuanced advocacy needs.
Senate Bill 922, originally conceived by DCMS member Dr. David Gerber, tackled the delicate balance between patient access and clinical judgment in electronic health records. Authored by Senator Kelly Hancock—himself a kidney transplant recipient—the bill requires physician review before electronic release of sensitive test results to a patient. This seemingly technical legislation received bipartisan support (112-34 in the House) despite opposition from fiscal conservatives who viewed it as unnecessary bureaucracy.
The bill’s success illustrates how personal legislative experience with healthcare can drive policy change. Dr. Gerber’s knowledge as an oncologist testified about experiences where patients received sensitive test results before their physician. Hancock’s medical background informed his understanding that immediate electronic access to concerning test results without a physician’s context could harm patients rather than help them.
House Bill 139 represents a cautionary example of legislation where limited physician engagement proved costly to patient care. This 2025 bill would have allowed employers to offer “Employer Choice of Benefits Plans” that exclude state-mandated health benefits while meeting only federal minimum standards. Although the legislation passed the committee and was placed on the General State Calendar, organized medicine and the Texas Hospital Association opposed the measure in the House Insurance Committee, recognizing how reduced coverage standards could compromise patient access to comprehensive care. The bill would have created a two-tiered system where employees might unknowingly enroll in plans lacking critical state protections, such as coverage for specific specialties, extended mental health benefits, or mandated preventive services. While proponents argued the legislation would reduce employer costs and increase coverage options, healthcare organizations understood that apparent affordability often translates into coverage gaps that ultimately burden both patients and providers when medical needs arise. HB 139 advanced through the committee despite opposition from healthcare stakeholders, but ultimately the bill was killed due to sustained testimony from physicians and hospitals. It is an important reminder that illustrates how legislative success requires sustained physician advocacy throughout the entire process, not just initial testimony.
Dallas County Medical Society’s advocacy delivers results
The Dallas County Medical Society’s sophisticated advocacy approach extends far beyond these individual bills. Representing over
9,000 physicians in the nation’s second-largest medical society, DCMS operates through structured programs including TMA’s monthly “First Tuesday” visits during legislative sessions and a dedicated DCMS Legislative Affairs and Political Action Committee.
Relationship building forms the foundation of effective medical advocacy. As one DCMS leader noted, “legislators are open to meeting with doctors and ask us if legislation is good or bad.” This credibility enables physicians to influence decisions and prevent harmful expansions of scope of practice and other anti-patient bills.
The multi-tiered approach combining grassroots physician engagement, professional lobbying, and coalition building has proven most effective. TMA Past President, Dr. Ray Callas, credited the “generosity of the AMA Scope of Practice Partnership” as “key to our success” in defeating scope expansion attempts.
Conclusion: Legislative engagement as professional responsibility
These bills demonstrate that organized physician advocacy is effective when deployed effectively. HB 31’s life-saving clarifications, SB 268’s veto, SB 922’s protection of clinical judgment, and HB 139’s defeat all resulted from the engagement of the medical community. The 2025 session presented both opportunities in workforce development and mental health funding, as well as threats through continued scope creep pressure.
The choice between engagement and spectatorship will determine whether medical expertise continues to guide healthcare policy in Texas. Dallas County physicians have established an effective advocacy infrastructure through partnerships with DCMS and TMA, but success requires ongoing participation. The stakes—patient safety, access to care, and professional integrity—justify legislative engagement as a core professional responsibility, not an optional political activity.
Physician voices have shaped policies that protect patient lives, streamline healthcare regulation, and preserve clinical judgment in patient care. The question for Dallas physicians is whether they will continue this tradition of advocacy leadership or allow others to make healthcare decisions without their expertise. DMJ
Jon R. Roth, MS, CAE DCMS EVP/CEO
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Christie Davis Keith Dugger Avi Kerendian
James (Mac) Stewart Chandani Patel
Miles Moody
Brandon Kulwicki
Texas Abortion Restrictions Under Senate Bill 31
by Brandon Kulwicki and Chandani Patel, Attorneys with Hall, Render, Killian, Heath & Lyman, P.C. & Whitney Jordan, Summer Associate at Hall Render
UNDER EMTALA, A HOSPITAL MUST PROVIDE TREATMENT to stabilize a patient’s emergency medical condition or transfer the patient to a hospital where necessary medical care may be provided.1 However, the following rules and regulations exist at the state level, further complicating compliance with federal mandates.
Texas Health & Safety Code § 241.027(c) mandates that a hospital may not transfer a patient whose emergency medical condition has not been stabilized.2 However, there are three exceptions: (1) when the patient or another individual acting on the patient’s behalf with the requisite authority makes an informed written request to transfer the patient; (2) when a written certification containing “a summary of the risks and benefits, that, based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer” and a licensed physician has signed the certification; and (3) a licensed physician has consulted with the patient and made a determination in accordance with the previous exception, and while such physician is not present in the emergency room at the time of the patient’s transfer, a qualified medical individual has signed a written certification as set out in the previous exception.3 Additionally, under Texas Administrative Code § 505.44(c), a hospital’s policy on patient transfer must not permit the transfer of a patient with a critical medical condition for any non-medical purpose, except under specified exceptions.4
While these state requirements appear to align with the federal EMTALA, it is the enforcement of state-specific exceptions that can conflict with federal guidance, causing confusion among healthcare providers. For example, in Texas v. Becerra, the Fifth Circuit held that HHS was restricted from enforcing guidance requiring abortions to stabilize the emergency medical condition of a pregnant patient under EMTALA.5 This holding leaves space for creative maneuvering by the State in restricting emergency abortions to certain narrowly defined situations, even in the face of EMTALA’s broader protections. Additionally, on June 20, 2025, Senate Bill 31 was signed into law by Governor Abbott.6 The law clarifies the State’s
abortion exceptions by, for example, aligning them with In re State 7 (holding that there is no requirement that a medical emergency be irreversible and imminent for the abortion exception to apply) and State v. Zurawski8 (declaring that the State holds the burden of proving that “no reasonable physician would have concluded that the mother had a life-threatening physical condition that placed her at risk of death or of substantial impairment of a major bodily function unless the abortion was performed”).9
In the face of changing state and federal enforcement priorities, it is critical that medical professionals continuously monitor and comply with state and federal requirements when providing abortion care in Texas. DMJ
This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 6152025; Chandani Patel at (214) 615-2037; or your primary Hall Render contact. Brandon Kulwicki and Chandani Patel are attorneys with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law.
REFERENCES
1 Hall Render, HHS and CMS Rescind Guidance on Emergency Reproductive Health Care Under EMTALA (June 9, 2025), https://hallrender.com/2025/06/09/hhs-and-cms-rescind-guidanceon-emergency-reproductive-health-care-under-emtala/.
2 Tex. Health & Safety Code § 241.027(c), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.241. htm.
3 Tex. Health & Safety Code § 241.027(c)(1)-(3), https://statutes.capitol.texas.gov/Docs/HS/htm/ HS.241.htm.
4 26 Tex. Admin. Code § 505.44(c), https://regulations.justia.com/states/texas/title-26/part-1/ chapter-505/subchapter-c/section-505-44/.
5 Texas v. Becerra, 89 F.4th 529, *533 (5th Cir. Jan. 2, 2024); American Health Law Association, Fifth Circuit Blocks Enforcement in Texas of EMTALA Guidance on Abortion Care (January 12, 2024), https://www.americanhealthlaw.org/content-library/health-law-weekly/ article/2ec0accb-d6b0-41f2-b35c-c28b58c3a211/fifth-circuit-blocks-enforcement-of-emtala-guidanc#:~:text=The%20appeals%20court%20also%20found,2%2C%202024.
6 The Texas Tribune, Texas Legislature clarifies when doctors can perform life-saving abortions (updated May 22, 2025), https://www.texastribune.org/2025/05/21/texas-abortion-exceptionsave-mothers/.
7 In re State, 682 S.W.3d 890, *894 (Tex. 2023).
8 State v. Zurawski, 690 S.W.3d 644, *663 (Tex. 2024).
9 Texas Legislature Online, Bill: SB 31, https://capitol.texas.gov/BillLookup/History. aspx?LegSess=89R&Bill=SB31.
VOICES FROM THE CAPITOL: TMA AND DCMS PHYSICIAN LEADERS REFLECT ON THE 2025 LEGISLATIVE SESSION
A Q&A with the Texas Medical Association’s Council on Legislation and Chief Lobbyist
The Dallas County Medical Society recently sat down with key Texas Medical Association leaders to discuss the outcomes of the 2025 Texas legislative session. The panel included Dr. Zeke Silva, Chair of the TMA Council on Legislation, and DCMS members serving on the TMA Council on Legislation, Drs. Deborah Fuller, Mark Casanova, and Roger Khetan; and Clayton Stewart, TMA Vice President of Public Affairs and Chief Lobbyist. Jon Roth, CEO of the Dallas County Medical Society, and Ruby Blum, Vice President of Policy and Legislative Affairs for DCMS, moderated the conversation. Dr. Joe Saad, a DCMS member on the TMA Council on Legislation, was unable to participate.
The TMA Council on Legislation plays a crucial role throughout the legislative session. They assess legislation and provide direction to the TMA lobby team. Their decisions are guided by the TMA Policy, set by the House of Delegates, which informs their positions on legislation.
JON ROTH: Dr. Silva, as chair of the Council on Legislation for TMA, when you think about the session overall, how would you characterize this session as it relates to healthcare in general, and then physician issues specifically?
DR. ZEKE SILVA: It definitely felt busy. It felt faster-paced than I remember from prior sessions. However, it is worth noting that our portfolio is extremely broad during this session. We go all the way from insurance to public health to vaccines to AI to GME. The challenges were significant, but we faced them head-on.
When you consider a portfolio that broad and the depth of those issues, the one thing that always grounds me and keeps me fo-
cused is who we are and what we represent. We represent 59,000 physicians. So, we are unquestionably the voice of physicians. When we come to the table, they know that we are speaking on behalf of the doctors.
I felt like it was a greater responsibility this session to represent physicians on some very complex issues than it had in prior sessions.
JON ROTH: Clayton, building on that, we came into this session with a lot of firstyear legislators who had been elected in the prior year’s election. How did that interplay happen politically, where you’ve got new first-year members who may have minimal healthcare experience juxtaposed with some complex issues?
CLAYTON STEWART: That is a great question, and I will tell you, it was a challenge. The simple answer to that is just being present. We were in the Capitol more than I have ever been previously. We had a rule of thumb that when in doubt, testify. Find a physician, get someone there, testify on that bill.
We did it because we felt like, especially on the House Public Health Committee, you had a lot of first-year members. They knew enough about healthcare to be dangerous, which was actually a very good thing. Regardless of whether they were conservative or liberal, they were willing to ask questions. And what we realized was that if they’re willing to ask questions, we need to be there to provide answers.
We had 136 physicians provide 183 testimonies. That’s a record for us. I don’t think we’ve ever had this many physicians testify. In fact, there was one week early in the session where we had over 20 testimonies in one week, which is absolutely unheard of.
JON ROTH: Is part of that education with the lawmakers letting them know that they need to reach out to TMA, that you are there, and you are going to have an opinion?
CLAYTON STEWART: Yes, absolutely. When you’re in sight, you’re on the mind. Our First Tuesday advocacy day numbers were very impressive. We had 718 physicians participate
RUBY BLUM: Dr. Casanova, what was the experience like this year from your perspective?
DR. MARK CASANOVA: The sense that I had during this session, and likewise in speaking to other colleagues, was that given the seemingly endless assaults on medicine and infringement on the physician-patient relationships, many physicians have simply had enough. I also believe that the TMA physician leadership and advocacy team has done a great job of relaying the clear message that, in order to effect change, individual physicians need to get off the sidelines. We saw that unfold this session, as physicians adjusted their schedules to travel to Austin and advocate for the Health of All Texans.
“We (the Council on Legislation) have the equal responsibility to listen to our physicians and understand their challenges because we’re not
on the ground with them every single day.”
DR. ZEKE SILVA, CHAIR OF THE TMA COUNCIL ON LEGISLATION
throughout the legislative session, 253 of whom were new, which I think is a record. We are different than any other association in that we have four advocacy days during the session. Having that consistency reminds legislators that the physicians are here; I know who I can call. We saw more physician member engagement than I’ve ever seen.
RUBY BLUM: Dr. Fuller, I know you’re one of the physicians that made a lot of those trips down for First Tuesdays and to testify on important bills. Tell us a little bit about those pull-out-the-stops moments where you dropped everything from your practice and your personal life and went down to testify.
DR. DEBORAH FULLER: This was my first legislative session to testify, but not my first legislative session to be involved. I have been part of TMA First Tuesday advocacy days since the onset.
This legislative session saw several highprofile bills within my specialty, and with my involvement in the Campaign for Mothers on House Bill 44 and Senate Bill 31, I felt it was time to take action. It was time to put my expertise to use and testify. So, I stepped out of my comfort zone from “I’m here for First Tuesdays to follow the bills,” to being an active participant in the legislative process.
Scope
of Practice: The Ongoing Battle
JON ROTH: Dr. Silva, when you think about all the scope of practice bills that we face every session, would you say that the potential consequences of this year’s bills were more contentious or dire than in previous sessions?
DR. ZEKE SILVA: We know we will face scope battles going into legislative sessions. We have, within recent memory, a proverbial battle we are going to have to fight. Our TMA, our House of Delegates, and our leadership have told the Council on Legislation that we do not want to see this advance. Physician-led care is going to be our focus, and that is not a compromise we’re willing to make.
Every bit of progress that the other side makes stands to make it harder for the next session. Seeing a Senate bill in committee is a big deal for them. Regardless of what ultimately happens with that bill, the fact that it made it that far late in the session is relevant. However, it’s not enough for TMA to simply say “no” to these proposals. You cannot just go into the session and make it about protecting turf. The lawmakers are convinced that we have a physician distribution problem, and if you’re not going to produce enough physicians, we need to find a solution elsewhere. We must come to the table with alternative solutions to address this access
problem, particularly in rural settings.
DR. ROGER KHETAN: It is not uncommon for other providers to want to creep into the physician realm, and looking at the states that have done it, several things become apparent. Cost increases, not decreases – more consulting, higher amounts of prescribing new medications, and increased utilization of imaging. Lastly, “you don’t know what you don’t know” –the training and education provided are not comparable to those of other providers, as they are not equivalent to the education required to be a physician; it’s just a fact. One does not know what they lack in terms of training and experience, and it becomes evident in the care from those providers.
Rural Healthcare Access: Finding Solutions
JON ROTH: Dr. Silva, if it’s not expanding the scope by letting APRNs or NPs practice independently in rural Texas, what is the answer? Can you talk about how TMA influenced policy regarding the expansion of rural health access?
DR. ZEKE SILVA: I think it’s important to note that the TMA acknowledged the circumstances occurring in rural Texas. We came forth and said, “We agree there’s an access to care problem in many of our rural counties. There are not enough primary care physicians, hospitals, or specialists.”
We were purposeful about helping educate people about the number of physicians in those rural areas. We even provided some granular data, showing exactly what it might require in terms of population to support a physician. That data proved a critical backdrop for the policy debate about scope and access to care.
We also brought in experts from other states like Rebecca Bernard, who authored the book “Impostor Doctors.” She spoke to the data about their experience with independent practice. Not only did independent non-physicians, such as APRNs and PAs, not practice in rural settings, but they were also drawing rural physicians from neighboring states, creating problems for those states. Additionally, a sizable percentage — over 50 percent — were actually practicing in med spas and boutiques, rather than in primary care or rural settings.
CLAYTON STEWART: As an example of TMA acknowledging the issue, we got called into a very small meeting with the nurses and the Lieutenant Governor. I have to give the TMA President at the time, Dr. Ray Callas, a lot of credit. That was easily the tensest meeting I have ever been to in my life. Dr. Callas stepped up, went out on a limb, and said, “We’ll get rid of the delegation fee” in contracts between physicians and APRNs and PAs, which was their main argument for why nurses could not afford to work in rural settings.
This resulted in Senate Bill 2695, which was our attempt to acknowledge the issue and propose a solution. Senator Kolkhorst was great in the hearing about asking the nurses why this bill wouldn’t work. When she laid out her bill, she said, “The silence of the nurses is deafening.”
I was recently on a call with my colleague in Mississippi and Missouri, and they said, “Y’all changed the narrative on this.” Dr. Callas called their bluff. We figured out a solution.
JON ROTH: Dr. Fuller, last question on this subject. As an Ob-Gyn, can you speak from a clinical standpoint about the potential consequences of less-trained individuals out in rural Texas trying to care for a high-risk pregnancy patient?
DR. DEBORAH FULLER: Currently, many ObGyns are not practicing in these rural areas, so we have obstetrical deserts. In Texas, nearly half of our counties are obstetrical deserts. Most
“Our
grassroots effort and TexPAC
well as surrounding resources. That will lead to bad outcomes for patients.
Public Health and Vaccines
RUBY BLUM: Let’s talk about public health. We have a lot of strong public health advocates as part of our DCMS membership, and there were a lot of concerns about vaccine access, vaccine promotion, and mandates related to vaccines. Clayton, what happened with vaccines during the session, especially in light of the measles outbreak in Texas?
CLAYTON STEWART: There is an excellent chart that my team produced of what happened with the 44 different vaccine bills that were filed. Most of them did not pass, which was beneficial for us; however, there were numerous bills that we had to weigh in on.
The measles outbreak was helpful in that conversation. We started hearing, specifically in the House Public Health Committee, when the conversation came up about the measles outbreak, that they began parsing out the COVID-19 vaccine from everything else. That, to me, was a huge victory. We did have this powerful anti-vax mindset coming out of COVID. However, when they saw measles resurface in something that had been declared eradicated in 2000, there was a genuine and thoughtful conversation among all members.
The fact that we only had two vaccine bills pass—one requiring an additional consent form for COVID-19 and another one mak-
are everything. Our physicians’ personal relationships with elected officials and their political giving are absolutely critical to what we do.”
CLAYTON
STEWART, TMA VICE PRESIDENT OF PUBLIC AFFAIRS
Ob-Gyns are not willing to raise their hand and say, “Hey, put me out here in a rural county,” because they are not going to have a hospital in which to deliver the high-risk pregnancy or other resources to care for the patient. Imagine a lesser-trained APRN in that situation and the potential harm that could occur? If we want to provide nurse practitioners in these areas, we need the physician to be available for complex cases, as well as the other resources in those desert communities. You can’t just stick an APRN out in rural Texas all alone without the proper training and oversight, as
AND CHIEF LOBBYIST
ing the school exemption form printable at home—is remarkable. These two were not particularly significant, considering everything else that was out there, including the increasing liability for physicians.
DR. MARK CASANOVA: The vaccine issue is a particularly difficult one when it comes to effectively testifying for evidence-based science in the face of some pretty outrageous statements by others. My personal experience with testifying in Austin involves the end-of-life (EOL) space, which is a complex issue involving
faith, cultural perspectives, and competing social values. With vaccines, it’s fundamentally an issue of “facts” and data that for decades have validated the effectiveness and collective safety of vaccines. To bear witness to this assault on “the facts” and health benefits of vaccines, particularly for children in the state, is difficult. Sadly, the Texas measles outbreak this year worked in our favor. That’s a sad testament to the fact that children who bore the brunt of a dangerous illness were likely the ones who also contributed to the degree of success (avoidance of harm) that unfolded in the vaccine space this last session.
Insurance and Prior Authorization Reform
RUBY BLUM: Let’s move to insurance issues. Prior authorization is one of the easiest issues to talk about with legislators because their staff have had family members or themselves impacted. Health policy and legislation can be complex, but physicians and patients alike are in step on the harms of prior authorizations. Due to the great work of TMA, we were one of the first states to get a “gold carding” prior authorization bill passed into law in 2021. Clayton, can you tell us about the progress on prior authorizations over the last couple of sessions?
CLAYTON STEWART: What we’ve done on prior authorization in Texas has really set the stage around the country. That has really changed the narrative nationwide. We see every other state trying to pass legislation reforming prior authorization. However, being the first to implement the gold card legislation, we knew there would be problems because we did not know how the insurance companies would react.
So, we did initiate a gold card cleanup bill. The data collection requirement alone, and understanding just how many of these gold cards are being issued, is significant because the numbers differed between what the health plans reported and what the Texas Department of Insurance reported.
The six-month enrollment period was changed to a year, which is significant because we got a lot of feedback from doctors that it was too short a timeframe. Some definitional changes were beneficial in defining what a prior authorization is or a utilization review in general.
“You can’t just stick an APRN out in rural Texas all alone without the proper training and oversight, as well as surrounding resources. That will lead to bad outcomes for patients.”
DR. DEBORAH FULLER, MEMBER OF THE TMA COUNCIL ON LEGISLATION
RUBY BLUM: Dr. Silva, what do you want to share with your fellow physicians about the work they put in and what they saw come out of the session on this issue?
DR. ZEKE SILVA: The one advantage to having had the gold card since 2021 is that we have experience. Many lawmakers were surprised when we stated that only 3 percent of physicians have received the gold card, but we’re not exactly sure who those 3 percent are, which prompted a lot of focus on solutions.
The momentum around the stories remains. The fact that physicians are not only sharing their own administrative burden but also being able to share more and more patient stories. For example, the data from the AMA shows that 75 percent of physicians report their patients abandoning treatment altogether.
I remember in one hearing when an individual from the insurance industry said, “It’s just a math problem. We just got a math problem. We got to solve the math.” I was astonished because at the end of that “math” is a human, is a person, is someone experiencing a shortcoming in care. To hear them minimize it like that, to me as a physician, was just hurtful.
Physician Engagement: A Grassroots Movement
JON ROTH: One of my favorite stories about physician engagement is about one of our members, Dr. David Gerber, an oncologist at UT Southwestern. He approached us in 2022 regarding concerns with the 21st Century Cures Act’s requirement to automatically release test results to patients. We brought that issue to TMA, and you all worked on it. The bill made it through session in 2023, but the governor vetoed it for unrelated issues. You all ran it again this year, it made it through, and now it’s the law.
Dr. Gerber would likely admit himself; he was just a member back in 2022. Now he is one of our biggest champions, spreading the good news about what physician involvement can do. Dr. Silva, talk about getting involved and getting off the sideline.
DR. ZEKE SILVA: I am a big believer in the bidirectional nature of public policy. We do all these important things at the state level, and we have a responsibility to translate that back to our physicians. But we have an equal responsibility to listen to our physicians and understand their challenges because we’re not on the ground with them every single day. When someone presents an example like that, I think it’s an important opportunity and responsibility for us to translate it into policy. A lot of that is organic. It’s a conversation. That organic nature of public policy really matters.
DR. DEBORAH FULLER: I am all about being more than just a membership card member. Get involved. Start by participating in your county medical society, serving on a TMA committee, contributing to TexPAC, engaging early and often, and building relationships with your representatives.
DR. ROGER KHETAN: Over the past few years, the increase in advocacy by physicians in all stages of practice has increased. I am delighted, as our profession needs to stand up for ourselves, our patients, and for science. Each year, we have seen an increase in the number of people attending TMA First Tuesdays and writing to their representatives and senators. The nice thing about DCMS and the TMA is the legislative alerts they send, making it easy for us to send a letter to our politicians. Advocacy is a distinct aspect of practicing medicine that is enjoyable, as it allows you to network with fellow colleagues and learn from one another.
DR. MARK CASANOVA: As I mentioned before, there was clearly a different “energy” at TMA headquarters and in the Capitol this year. I believe that many physicians have reached the point of “external stimulus,” which prompts them to get off the sidelines, drive to Austin, or, at the very least, call their representatives or send an email. As our lobby team, TMA, and TexPAC leadership have shared with us for years, we have to become more involved. We simply need more physicians to join and become engaged. It is
abundantly clear that the health of Texans and our livelihood is on the line.
CLAYTON STEWART: Our grassroots effort and TexPAC are everything. Our physicians’ personal relationships with elected officials and their political giving are absolutely critical to what we do. Political involvement is legislative involvement at the end of the day.
I think people sometimes are worried about approaching the lobby team or the Council on Legislation with an idea, but we’re very approachable individuals. We do listen. I look at this as a client-based industry, and the physicians are our clients.
Texas Medical Board Defense
RUBY BLUM: The TMA’s focus over the last few sessions is that we have a strong medical board working for Texas physicians and the patients they serve. There was a bill- SB 268- related to stripping the medical board’s authority. Can you tell us about that process?
DR. ZEKE SILVA: For whatever reason, there’s a lot of angst among some legislative members regarding the Texas Medical Board. I think part of that is due to the impact of COVID-19, and some concern regarding the Texas Medical Board’s role in vaccine policy.
We made a commitment that we were going to support a strong medical board. We think our state is better when the medical board is strong and there’s proper oversight of medical practice, and physicians are accountable. When we saw the bill to gut the medical board quickly pass out of the House and the Senate, which stated that the medical board could no longer oversee the practice of medicine if a professional is licensed elsewhere, that was unacceptable to us. This bill was clearly just a last-minute end run by the nurses to try to expand their scope of practice.
CLAYTON STEWART: In two weeks, we had 2,200 physicians reach out to the governor’s office asking for that bill to be vetoed, which is outstanding. That shows the full force of the
grassroots behind what we do. That was a bill where the nurses blatantly lied about what the bill did from a legal standpoint. This session, as it relates to scope of practice bills, it became very evident that the nurses are very willing to be disingenuous to get what they want. This fight has gotten a lot more aggressive.
Surprises and Looking Forward
JON ROTH: Let’s wrap up our time together with a couple of rapid-fire questions. First, what was your biggest surprise of the session, either positive or negative?
DR. DEBORAH FULLER: My biggest negative surprise was the speed at which SB 268—the bill that gutted the medical board—moved through the process. I felt like that bill was a Trojan horse because it slipped through more quickly than I had anticipated.
My positive surprise was how the Senate State Affairs Committee listened to us about the Life of the Mother Act—SB 31. That was a very difficult subject, very personal for me, but I was so pleased that a rational policy was passed that will save women’s lives.
CLAYTON STEWART: The biggest ‘a-ha’ for me was recognizing that we must forge relationships with everyone. Even people with whom we might not think we’re aligned came through on some bills. Tied to that is the need for TexPAC to grow in the current political environment.
DR. ZEKE SILVA: For me, the biggest surprise was also SB 31. Clayton and I attended a meeting about the Life of the Mother Act before it was even called that. We’re in the big TMA conference room, and you’ve got the docs, the hospitals, the Catholic bishops, the pro-life advocates. I remember saying to Clayton, “Oh my gosh, are we really going to be able to come up with one bill to satisfy all of these stakeholders?”
It was a very pleasant surprise that we were able to accomplish that. When that bill passed the House on second reading, it was one of only two times that I teared up during the session, because I couldn’t believe we had actually gotten it to pass.
DR. ROGER KHETAN: My most pleasant surprise is the number of physician First Tuesday participants and the number of calls the Council of Legislation held this past year. My
largest surprise was the passage of the Life of the Mother Act.” Amazing and shows us that people with differing views can come together and move the legislative needle.
Final Advice for Members
JON ROTH: If you can give our members a piece of advice for next year, which is an interim year, what is the one thing a member could do starting January 2026 to get engaged?
CLAYTON STEWART: Number one, give to TexPAC because it does make a huge difference. Also, get to know your elected official and come to our TMA conferences because that’s the best place to stay in the loop.
DR. ZEKE SILVA: Join us at our annual meeting, attend our legislative planning sessions, and participate in the TexPAC sessions. Commit to giving your time to the process to build those relationships. We are truly fortunate to be in a profession where we can make a fairly good living. Giving some of that back to TexPAC and directly to lawmakers matters. I wish it didn’t, but it’s a sacrifice we have to make to protect and advance our profession.
DR. MARK CASANOVA: I hope that our proven success and increased engagement continue to translate into increased membership in TexPAC. It’s difficult to message, at times, until you see it unfold for yourself, the work that TexPAC does behind the scenes. It is what lays the groundwork for our success when walking the halls of the Capitol in Austin.
DR. DEBORAH FULLER: Medicine is being redefined by politics. We know that. So don’t assume someone else is going to do it. Advocacy is a team sport. Your license, your patients, and our profession are on the line. If physicians do not show up to advocate, someone else is going to define our profession for us. DMJ
The Dallas County Medical Society encourages all members to get involved in advocacy efforts. For more information about TMA First Tuesday advocacy days, TexPAC or DCMS PAC contributions, or legislative involvement opportunities, visit the DCMS or TMA websites.
In Discussion With
DR. ZEKE SILVA, Chair of the TMA Council on Legislation
DR. DEBORAH FULLER, Member of the TMA Council on Legislation
DR. MARK CASANOVA, Member of the TMA Council on Legislation
DR. ROGER KHETAN, Member of the TMA Council on Legislation
CLAYTON STEWART, TMA Vice President of Public Affairs and Chief Lobbyist
Preserving Patient Access A Review of the 89th Texas Legislature’s Impact on Healthcare Liability Reform
by Brian Jackson, Executive Director, Texas Alliance for Patient Access
AS THE DUST SETTLES FROM THE 89TH TEXAS Legislature’s 140-day session, I’m pleased to report that the Texas Alliance for Patient Access (TAPA) successfully defended every aspect of the critical healthcare liability reforms that have transformed Texas medicine since 2003. This legislative victory represents more than just policy preservation—it safeguards the foundation that has made Texas a national leader in physician recruitment, patient access, and healthcare innovation.
The Stakes Were Never Higher
The 89th Legislature presented unprecedented challenges to Texas’s medical liability framework. With over 9,000 bills filed, lawmakers faced intense pressure from trial attorneys seeking to dismantle the reforms that have made Texas a model for other states. The session tested our resolve and demonstrated why organizations like TAPA remain essential guardians of patient access.
Our success this session was particularly meaningful given the coordinated assault on medical liability protections. Two Republican House members pushed legislation that would have increased liability exposure for our members by 70%. At the same time, numerous other bills sought to create entirely new avenues for litigation against healthcare providers. The stakes were clear: if these measures were allowed to pass, Texas would follow the catastrophic path of states like Florida, where physicians now pay 400% more for malpractice insurance than their Texas counterparts after losing their liability protections.
Historical Context: From Crisis to Solution
To understand the significance of our 2025 legislative victories, it is essential to recall the crisis that triggered Texas’s medical liability reforms. In the early 2000s, Texas faced a healthcare access emergency. Skyrocketing malpractice insurance premiums—some exceeding $200,000 annually for high-risk specialties—forced physicians to abandon their practices, retire early, or leave the state entirely. Emergency departments closed, obstetric units shuttered, and entire regions faced physician shortages that threatened public health.
The situation was particularly dire in rural Texas and urban areas serving low-income populations. Charity clinics struggled to recruit physicians willing to risk devastating liability exposure for minimal compensation. Hospital emergency rooms turned away patients due to a lack of specialist coverage. The state’s medical infrastructure was crumbling under the weight of an out-of-control litigation environment.
This crisis galvanized the medical community, leading to the formation of TAPA and other advocacy organizations. The coalition recognized that meaningful reform required sustained political engagement and broad-based support from every sector of the healthcare community. The 2003 legislative session became a turning point, establishing damage caps and other liability protections that began Texas’s transformation into a physician-friendly state.
TAPA’s Foundation and Mission
The Texas Alliance for Patient Access emerged from this crisis as a unique coalition representing over 250 healthcare interests across the state of Texas. Our membership spans the entire healthcare ecosystem, encompassing physicians in solo practice and large groups, hospitals ranging from major medical centers to rural critical access facilities, nursing homes that serve our most vulnerable populations, physician/hospital liability carriers that manage risk, and charity clinics that provide care regardless of patients’ ability to pay.
Prominent members include the Dallas County Medical Society and the Texas Medical Association, whose leadership and membership understand that protecting medical liability reforms directly translates to better patient care. These organizations, along with hospital associations, specialty medical societies, and healthcare business groups, provide the political strength and credibility necessary to defend our reforms against well-funded opposition.
TAPA’s mission remains focused on a simple principle: improving access to healthcare by supporting meaningful and
sustainable liability reforms. We recognize that physician availability, especially for high-risk specialties and underserved populations, depends fundamentally on a rational legal environment. When physicians face unlimited liability exposure, they respond predictably—by avoiding high-risk procedures, declining to serve high-risk patients, or leaving practice altogether.
Our organization operates exclusively through member dues and donations, ensuring our independence and accountability to the healthcare community we serve. This funding model enables us to respond promptly to threats and maintain consistent advocacy throughout legislative sessions, judicial proceedings, and public opinion campaigns.
The 2025 Legislative Battlefield
The 89th Legislature tested every aspect of our advocacy capabilities. Trial attorneys, frustrated by two decades of unsuccessful attempts to overturn Texas’s reforms, mounted their most sophisticated campaign yet. Their strategy involved multiple vectors: direct attacks on damage caps, the creation of new liability theories, the elimination of procedural protections, and the expansion of potential plaintiffs in medical malpractice cases.
Our most significant victory came in defeating House Bill 4036, which would have raised non-economic damage caps by nearly 70% and indexed them to the Consumer Price Index. This seemingly reasonable adjustment would have fundamentally altered the liability calculation for every healthcare provider in the state of Texas. The proposed changes would have reignited the insurance premium spiral that drove physicians from the state in the 1990s and early 2000s.
The bill’s supporters argued that inflation justified the increase, but they ignored the economic reality of medical practice. Healthcare providers operate on increasingly thin margins, facing pressure from insurance reimbursement rates, regulatory compliance costs, and technological demands. Increasing potential liability exposure by 70% would have necessitated im-
mediate premium increases, potentially driving many providers—particularly those serving rural and low-income communities—out of practice.
We also defeated House Bill 2072, a particularly dangerous piece of legislation disguised as advanced directive reform. This bill would have eliminated statute of limitations protections and created first-degree felony liability for any healthcare provider who allegedly caused patient death by withholding or withdrawing life-sustaining treatment in violation of the Texas Advanced Directives Act. The legislation would have criminalized end-of-life care decisions, forcing physicians to provide futile care rather than risk felony prosecution.
Senate Bill 2516 posed another serious threat by eliminating interlocutory appeals based on sovereign immunity for physicians employed by governmental entities. This procedural protection allows healthcare providers to resolve immunity questions before facing the expense and disruption of full litigation. Eliminating this protection would have exposed public hospital physicians, medical school faculty, and other government-employed providers to prolonged legal proceedings, regardless of the case’s merit.
Defending Against Litigation Expansion
Beyond direct attacks on damage caps, we faced numerous bills designed to expand litigation opportunities. House Bill 2446 would have eliminated the requirement to prove that medical bills under $50,000 were reasonable and necessary, essentially guaranteeing that every case would include at least $49,999 in damages, regardless of the actual medical costs. This provision would have inflated settlement values and encouraged frivolous litigation.
Senate Bill 953 represented a particularly troubling development: allowing forced depositions prior to lawsuit filing. This provision would have subjected physicians and nurses to sworn testimony without knowing specific allegations about their care. The fishing expedition approach would have dramatically increased litigation costs while providing no corresponding benefit to legitimate claimants.
House Bill 4327 sought to expand wrongful death beneficiaries to include siblings, thereby increasing the potential number of plaintiffs and potential damage awards in the most expensive cases. Senate Bill 82 would have created automatic liability for hospitals declaring themselves gun-free zones if violence occurred on their premises, forcing healthcare facilities to choose between safety policies and legal protection.
Perhaps most concerning was Senate Bill 95, which would have created civil liability for vaccine administration without specific parental consent procedures. This bill would have exposed pediatricians, family physicians, and public health providers to damage claims regardless of whether vaccines caused any injury, simply for procedural violations.
The Florida & California Warnings
Throughout our legislative advocacy, we consistently referenced Florida’s experience after losing medical liability protections. Florida physicians now pay 400% more for malpractice insurance than their Texas counterparts—a difference that directly translates to reduced physician availability and increased healthcare costs. Florida’s example demonstrates that liability reform isn’t just about protecting physicians; it’s about maintaining access to healthcare for patients.
California provides another cautionary tale. After maintaining a medical malpractice cap of $250,000 for nearly fifty years, California significantly increased its limits in 2023, raising non-economic damage caps to
$350,000 for injury cases and $500,000 for wrongful death cases, with annual increases planned until reaching $750,000 and $1 million, respectively, by 2034. While California’s changes were more gradual than the complete elimination of caps, the substantial increases signal a troubling trend away from the liability protections that have made Texas healthcare more accessible and affordable.
The experiences in Florida and California validate every aspect of our advocacy. When liability exposure increases dramatically, insurance companies respond with proportional premium increases. Physicians facing unsustainable insurance costs often reduce high-risk services, limit their practice scope, or relocate to states with more favorable liability environments. The patients who suffer most are those requiring complex care, emergency services, or treatment in underserved areas.
Looking Forward
Our success in the 89th Legislature reflects the strength of our coalition and the growing recognition among Texas lawmakers that medical liability reform is effective. Since 2003, Texas has attracted thousands of new physicians, expanded medical school capacity, and improved healthcare access across the state. Rural hospitals have maintained emergency services, charity clinics have recruited volunteer physicians, and high-risk specialties, such as obstetrics and neurosurgery, have remained available in communities that might otherwise lose these services.
However, our work continues. Trial attorneys will undoubtedly regroup for future legislative sessions, developing new strategies to undermine Texas’s reforms. We must remain vigilant, maintaining the political coalitions and advocacy capabilities necessary to defend our achievements.
The Dallas County Medical Society, Texas Medical Association, and our other member organizations understand that protecting medical liability reform requires sustained engagement. Physicians, hospitals, and other healthcare providers cannot afford to become complacent. The benefits we enjoy—reasonable insurance premiums, practice autonomy, and legal predictability—depend on continued political support for liability reform.
Conclusion
The 89th Texas Legislature reinforced Texas’s position as a national leader in medical liability reform. By preserving damage caps, defeating the expansion of litigation opportunities, and maintaining procedural protections, we ensured that Texas healthcare providers can continue to focus on patient care rather than lawsuit avoidance.
Our success reflects the commitment of TAPA’s diverse membership and the recognition among Texas lawmakers that liability reform has a direct impact on patient access. As we prepare for future challenges, we remain committed to defending the reforms that have made Texas a model for other states and a destination for healthcare providers seeking a rational legal environment.
The work continues, but the 89th Legislature demonstrated that when the healthcare community speaks with one voice, Texas lawmakers listen. Our patients deserve nothing less than our continued vigilance in protecting the reforms that ensure their access to quality medical care. DMJ
Brian Jackson serves as Executive Director of the Texas Alliance for Patient Access. For more information about TAPA or to inquire about membership, contact bjackson@tapa.info.
Save theDate
DALLAS COUNTY
SATURDAY, DECEMBER 13, 2025 GEORGE W. BUSH HALL OF STATE
Virtual event on Wednesday, September 24
and Clayton Stewart, Vice President of Public Affairs and Chief Lobbyist for the
Texas Medical Association
Featuring Dallas County State Representative Cassandra Garcia Hernandez
Second Time’s a Charm Dallas Doctors Return to Capitol to Advocate for Better Medical Communication
by David E. Gerber, MD & Philip A. Bernard, MD
WHEN GOVERNOR GREG ABBOTT SIGNED TEXAS
Senate Bill SB922 into law on May 19, 2025, he restored something we never thought we would need to fight for: the right for patients to receive life-changing medical test results from their clinicians, and the right for physicians to deliver this information in a timely, informative, and compassionate manner.
Taking effect on September 1, 2025, SB922 represents the third state-level legislation to counteract some of the unintended consequences of the 21st Century Cures Act. The Cures Act, a comprehensive federal law comparable in scope to the Affordable Care Act, is designed to accelerate medical
innovation and enhance patient access to healthcare. It expands STEM education, allows for the modernization of clinical trial designs, streamlines regulatory pathways for drug and device approvals, and promotes the interoperability of electronic health records. Among these and other provisions, the Cures Act also contains an Information Blocking Rule.
Designed to ensure that all patients have reliable access to their medical records, the Information Blocking Rule, which took effect on April 5, 2021, requires the immediate release of all medical information—including test results—to patients, generally via electronic portals. The legislation provides an exception for cases where disclosing the information could harm the patient. While we, as clinicians, can envision many such scenarios, the Office of the National Coordinator (ONC), under the Department of Health and Human Services, has repeatedly made it clear that this exception applies only to mental health care records.
If patients cannot access their medical records, they may have difficulty coordinating their care, arranging referrals, or understanding their conditions. Information sharing may also increase transparency, thereby fostering patient engagement and participation in their healthcare. That
said, it seems that there might be multiple approaches in between no access and immediate access that could achieve these goals. When essentially all test results are sent to patients immediately, it means that people learn they have cancer from smartphone notifications during business dinners, during rush hour commutes, at a parent’s wedding, or while reading a bedtime story to a toddler. One woman received the autopsy report from her second-trimester miscarriage while folding laundry alone in her apartment at night. It has led to a patient leaving an emergency department after seeing the results of an ankle x-ray showing no fracture, before being examined, only to return days later with worsening symptoms from an Achilles tendon rupture. Another left the emergency department when the triage Strep test came back negative, also before being seen by a clinician, coming back later in the week with an enlarging peri-tonsillar abscess. The wife of one patient needed acute treatment for an anxiety attack because she had seen a radiology report she thought described a rapid and potentially lethal progression of her husband’s lung cancer. Still, the CT scan actually showed the treatment was working. A man harmed himself after reading a pathology report he thought showed a new cancer diagnosis, but it didn’t. Beyond these dramatic examples are thousands of cases where patients and their families spend entire weekends worrying about—and frantically researching online—terms such as “white matter changes” on a brain MRI, “tree-in-bud” on a chest CT, or “submucosal fibrosis” from a pathology report.
Many proponents of the Information Blocking Rule cite personal preferences to receive their test results immediately, even when the results are worrisome. There is little doubt that the ONC has interpreted this rule with good intentions; however, there is a concern that the rules were designed to facilitate the wishes of those with extraordinary access to care, where questions regarding test results are immediately answered with a personal call to their physician. Unfortunately, most Texans have traditional medical care. Their physicians are scheduled back-to-back with patient appointments or procedures, and cannot immediately return a patient’s phone call or portal message. It is during this time that we hear the stories of anxiety, misinformation, and, in some cases, irreparable harm.
The Information Blocking Rule is not the first time the pendulum has swung too far in medicine. Nor will it be the last. Following the results of a single study suggesting that hormonal therapy could increase the risk of cardiovascular disease and certain cancers, the use of hormone replacement therapy (HRT) to alleviate menopausal and post-menopausal symptoms virtually disappeared. Decades later, we have recognized the disservice done to millions of women for whom the benefits of HRT clearly outweigh the risks. Similarly, the 1990s and early 2000s saw an intense focus on pain management and a low threshold for prescribing opiate analgesics, even the suggestion that these agents might be preferred to nonsteroidal anti-inflammatory drugs in older populations. Today, with physicians and pharmacists under intense scrutiny regarding controlled substances, even patients with widely metastatic cancer may have trouble accessing effective pain relief.
Having studied aspects of the patient portal, particularly in oncology practice, for the past decade, we examined the effect the
Cures Act Information Blocking Rule had on patient behavior. Following its implementation in early 2021, the median time between result posting and patient viewing decreased to 6 1/2 hours. The proportion of test results viewed by patients before they were viewed by the ordering clinician increased to 75%, with the greatest increases seen with radiology and pathology results—precisely those test results that are most difficult to understand and most likely to convey life-changing information.
As we started publishing our findings and concerns, we met a range of responses. Some individuals felt strongly that we were threatening patient rights, that we had touched the third rail. Some organizations and medical journals saw no need to investigate the implications of information blocking legislation on medical practice, as the law was already established. Yet over time, a growing number of physicians shared their concerns and their own examples, including those described above. In the New Yorker, primary care physician Danielle Ofri described the challenges of reviewing complex test results with patients before having an opportunity to formulate a plan. “We should not be lulled into treating transparency as a first-order good, like compassion, respect, avoiding harm, or putting the patient first,” she wrote.
Amid this discourse, a group of physicians and healthcare administrators in Kentucky (including author P.A.B.) recognized a provision in the Information Blocking Rule that allows exceptions for certain state law requirements. With broad support from professional, hospital, and patient advocacy organizations, they worked with state legislators to craft and champion Kentucky HB 529. Passed on April 5, 2022, this law allows a 72-hour delay in the release of electronic test results that have a reasonable likelihood of revealing malignancy or genetic markers. Later that year, California passed SB 1419, an even broader piece of legislation stating that test results related to HIV, hepatitis, drug abuse, or new or recurrent malignancy should not be disclosed to patients electronically unless requested by the patient and deemed appropriate by the healthcare professional.
With those states as precedent, we approached the Dallas County Medical Society to share our concerns and propose that Texas also consider tempering the unintended consequences of the Cures Act Information Blocking Rule. Within days, we met with Texas Medical Association lobbyists, healthcare technology experts, and attorneys. As in other states, we found widespread support among patient and professional organizations. We drafted a bill (SB 1467), modeled after Kentucky’s legislation, that would allow a 72-hour delay in releasing medical information related to a cancer diagnosis or genetic disease, thereby enabling healthcare teams to convey the news and next steps in a clear and compassionate manner first. We identified sponsors in both the House and Senate, and in the spring of 2023, testified before the Texas Senate Committee on Health & Human Services and the Texas House Committee on Public Health. Committee members had few questions, expressed surprise that communication in healthcare had taken this turn, and readily passed the bill. Once before the full Senate and full House, SB 1467 received near-unanimous approval, with 169 yeas, 10 abstentions, and two nays.
Only then did we encounter our first major obstacle: on June 18, 2023, Gov. Greg Abbott vetoed SB 1467, along with more than 70 other bills that session. His decision did not reflect his opinion on our bill, which he had previously stated he was in favor of, but instead arose from a legislative impasse over school vouchers. Among the vetoed legislation that year were bills pertaining to fire alarm technician training, police depart-
ment accreditation, prosecution and punishment of human trafficking, establishment of a statewide sickle cell registry, Gulf Coast protection, coal-to-nuclear plant conversion, aquifer storage and recovery, dietitian licensing and regulation, and designation of a Hospice and Palliative Care Day.
With the Texas legislature convening every other year, it was not until 2025 that we could try again. Working with the same DCMS and TMA staff, we brought forward HB 1699 and SB 922. Again, we found widespread support among advocacy and healthcare organizations. Again, we readily identified State Senator Kelly Hancock and State Representative Caroline Fairly to sponsor bills that asked for the same 72-hour delay in test result release.
In the two years since we’d been at the Capitol, impressions had changed somewhat. This time, the House Committee on Public Health initially expressed numerous concerns. Isn’t the information the patient’s to decide when and how to view? Won’t the anxiety of waiting be worse than seeing the results? How will patients arrange referrals without having this information? So we carefully explained the rationale and implementation of our proposed legislation. Human nature leads most of us to look at electronic notifications immediately, and these deliveries do not distinguish between everyday tests such as blood sugar levels and life-altering information such as a new or recurrent cancer. By allowing up to a 72-hour delay in the electronic release of such data, physicians will have time to contact patients before that point—not to block information but to enhance it by providing context, clear explanations, future steps, and compassion. The test results in question are generally not welldefined lab values accompanied by reference ranges for interpretation,
but instead comprise multiple pages of free-text comments. Medical practices typically handle referral details, including exchanging health records, allowing patients and their families to step back from these details and focus on the broader implications of new diagnoses. At one point, we asked committee members about their last airline trip. Did you relax in your seat, getting updates from the flight deck about weather and arrival times periodically? Or did you sit behind the pilot and try to understand the slightest fluctuations in hundreds of gauges lining the cockpit in real time? With that, they seemed to understand our intent. The bill passed committee, passed the full chambers (Yeas 137, Abstaining 3, Nays 7), was signed into law, and will take effect on September 1, 2025.
Before these events, neither of us had been particularly active in advocacy or legislation. One of us is a pediatric critical care physician who has also overseen medical informatics at major healthcare centers. The other is a physician-investigator, who spends his time designing and conducting clinical trials, biomarker analyses, and epidemiologic studies, in addition to providing clinical care. Yet in this case, we found ourselves compelled to act well beyond our usual operations.
The practice of medicine will continue to evolve. While many of these changes may improve healthcare delivery and outcomes, some will inevitably worsen them. The learned helplessness that has characterized so much of our profession over the years can no longer suffice. May our experience show that you can indeed influence the direction of the field, and you won’t be alone in doing so.
DMJ
NEW DCMS HEADQUARTERS IN THE HEART OF UPTOWN
CAMPAIGN FOR THE FUTURE
CMS Rolls out Aggressive Strategy to Accelerate RADV Audits
by Sabrina Skeldon, JD, CPC, CPMA, CPB
AS OF MAY 21, 2025, THE CENTERS FOR MEDICARE & Medicaid Services (CMS) announced a significant expansion of its auditing efforts for Medicare Advantage plans. CMS will now audit all eligible Medicare Advantage contracts for each payment year and invest additional resources to expedite the completion of audits for payment years 2018 through 2024.
Currently, CMS is several years behind in completing these audits. To address this backlog, CMS has introduced a plan to complete all remaining RADV audits for Plan Year 2018 to Plan Year 2024 by early 2026. Key elements of the plan include:
• Enhanced Technology: CMS will deploy advanced systems to review medical records and flag unsupported diagnoses efficiently.
• Workforce Expansion: CMS will increase its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses to ensure accuracy.
• Increased Audit Volume: CMS intends to increase its audits from roughly 60 Medicare Advantage plans a year to all eligible Medicare Advantage plans each year in all newly initiated audits (approximately 550 Medicare Advantage plans).
• CMS will also be able to increase the number of records audited from 35 per health plan per year to between 35 and 200 records per health plan per year in all newly initiated audits, based on the size of the health plan, to extrapolate overpayments using more data.
Medicare Advantage plans can expect a significant rise in medical records requests to validate reported diagnoses, for which they receive risk-adjusted payments. This will result in an increased workload for providers and health systems to supply clinical documentation in a timely manner. Due to CMS’s aggressive strategy, providers should prioritize ensuring the accuracy of clinical documentation and implementing processes for handling document requests from Medicare Advantage plans.
Because the CMS RADV Audit Final Rule has a look-back period beginning with the payment year 2018 and extending forward, CMS can recover extrapolated overpayments from that period. Medicare Advantage plans could, in turn, seek to recover a share of the recouped payments from physicians and other providers who are parties to value-added contracts. Because physicians and other providers are responsible for submitting accurate and fully supported claims, they share in the liability for inaccurate coding and insufficient documentation of diagnoses. Any recoupment of monies from earlier periods will result in an unexpected loss of revenue to physicians and other providers in years where a final reconciliation has already been made. Audits of years where no final rec-
onciliation has occurred could result in a reduction of the amount paid on claims that are not yet subject to a final reconciliation.
An increase in the number of RADV audits will lead to greater scrutiny of physician documentation, which should be an impetus for improving clinical documentation. Managing risk in this area protects physicians against not only liability for overpayment but also potential actions for fraud. The areas RADV auditors will focus on identifying overpayments mirror the fraud areas targeted by the Department of Justice (DOJ). The RADV auditor guidance identifies several areas CMS has targeted that are the foundation of recent DOJ enforcement actions under the False Claims Act:
• “Queries” from Medicare Advantage plans that direct physicians or other providers to supplement their documentation will result in no weight being applied to that documentation. Such diagnoses will be considered extraneous data from an alternative source and will not be allowed under the risk-adjustment policy.
• Amendments to medical records intended to add high-riskadjusted diagnoses that were not documented in the original record or added by parties not involved in the patient’s treatment and evaluation are considered inappropriate documentation and are found to be unsupported.
• Addenda that are not timely and are not added for an appropriate purpose (to clarify an encounter, correct an error, or add data not available at the time of the encounter) are given no weight and fail to meet the criteria for risk-adjusted diagnoses.
• Inconsistencies between problem lists and current encounter documentation, without any indication that the problem list relates to conditions currently being treated, are considered unsupported clinical documentation of a diagnosis.
Physicians and other providers should perform internal billing compliance audits to ensure that diagnosis codes are clinically supported and coding is accurate. Audit reports should be created that capture audit findings, such as incomplete documentation of patient encounters, as well as recommendations. Corrective action plans should be created, and follow-up should be performed to ensure the appropriate action has been taken. Oneon-one training of physicians and other providers should be offered, as needed, to assist them in thoroughly documenting their evaluation and treatment of patients during encounters, ensuring compliance and mitigating risk. DMJ
EMTALA v. State Abortion Restrictions
by Brandon Kulwicki and Chandani Patel, Attorneys with Hall, Render, Killian, Heath & Lyman, P.C.
ON MAY 29, 2025, THE U.S. DEPARTMENT OF HEALTH AND Human Services (“HHS”) and the Centers for Medicare & Medicaid Services (“CMS”) officially withdrew two Quality, Safety & Oversight (“QSO”) Letters issued in 2022 under the Biden administration. These letters had outlined the Biden administration’s interpretation that the Emergency Medical Treatment & Labor Act (“EMTALA”) mandates health care providers offer abortion services when needed to stabilize a pregnant patient experiencing a medical emergency and takes precedence over conflicting state laws, including those restricting abortions. In a brief statement, CMS explained that the letters were rescinded because they were not consistent with the Trump administration’s policy goals.1
What is EMTALA?
Enacted in 1986, EMTALA was designed to stop the practice of “patient dumping” and ensure that everyone has access to emergency care, regardless of their ability to pay. Under EMTALA, any person who arrives at the emergency department of a hospital that participates in Medicare must be given a medical screening examination to determine whether they are experiencing an emergency medical condition. An emergency medical condition, as defined by EMTALA, exists if (1) there are symptoms of sufficient severity that would reasonably result in serious jeopardy to the individual’s (or, with respect to a pregnant patient, the patient’s or unborn child’s) health, serious bodily impairment or serious bodily dysfunction; or (2) a pregnant patient is having contractions and there
is inadequate time to transfer the patient before delivery, or the transfer may pose a threat to the health or safety of the patient or unborn child. If an emergency medical condition is identified, the hospital is obligated to provide stabilizing treatment. If the hospital lacks the resources or capability to stabilize the patient, it must coordinate a medically appropriate transfer to a facility equipped to provide the necessary care.2
The Intersection of EMTALA and Abortion Legislation
Following the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health on June 24, 2022, several state legislatures enacted laws that significantly limit access to abortion, often allowing it only in cases where it is necessary to save the life of the pregnant person. These restrictions impose a narrower standard than the threshold required under EMTALA, which mandates stabilizing care for a broader range of emergency medical conditions.3
Guidance Issued under the Biden Administration
On July 11, 2022, HHS issued a letter addressing the variance in federal and state laws and clarifying the scope of hospitals’ obligations under EMTALA, particularly as it applied to pregnant patients requiring emergency care. HHS Secretary Xavier Becerra emphasized in his letter that health care providers were protected in using their clinical judgment to determine and administer appropriate emergency treatment, including abortion services, when medically necessary.4 The Guidance explicitly stated that the Supreme Court’s decision in Dobbs did not alter hospitals’ responsibilities under EMTALA. It reaffirmed that hospital providers retained their legal and ethical duty to determine whether a pregnant person was experiencing an emergency medical condition and to administer stabilizing treatment accordingly. Under the Guidance, hospitals and individual practitioners could not rely on state abortion restrictions
as a legal basis for refusing care or arranging transfers when abortion services were within the hospital’s capabilities.5
Simultaneously, CMS released updated surveyor guidance, reminding hospitals of their continuing duty to comply with EMTALA regardless of state-level abortion restrictions.6 This clarification came shortly after former President Joe Biden issued an executive order on July 8, 2022, aimed at protecting access to reproductive health care.7 CMS’ guidance further illustrated scenarios in which EMTALA may apply, including ectopic pregnancies, complications from pregnancy loss, or severe preeclampsia. It emphasized that providers must act promptly to prevent a patient’s condition from materially worsening and that EMTALA compels such action even when abortion is involved regardless of restrictive state laws.8
Together, the HHS letter and CMS guidance (referred to collectively as “the Guidance”) reflected the Biden administration’s position that EMTALA obligates hospitals to provide abortion services if such care is required to stabilize a patient experiencing an emergency medical condition. The Guidance also firmly asserted that EMTALA preempted state laws that conflict with this requirements, including those laws that prohibit or severely limit abortion access. Additionally, it outlined legal protections for health care providers who comply with EMTALA, noting that federal preemption may be invoked as a defense against state enforcement actions, as grounds for seeking a federal injunction against threatened penalties, or in retaliation claims under EMTALA when providers are sanctioned for refusing to transfer a patient who had not yet received stabilizing treatment.9
Texas’ Response to the Guidance
The release of the Guidance provoked swift opposition from states with strict abortion bans. On July 14, 2022, the State of Texas filed a lawsuit against HHS and CMS, alleging that the Guidance unlawfully expanded federal authority and imposed new regulatory mandates that effectively required hospitals to perform abortions in violation of certain state laws.10 Texas Attorney General Ken Paxton requested a temporary restraining order against the rule, stating that the Biden Administration was seeking to “transform every emergency room in the country into a walk-in abortion clinic.”11 The Justice Department filed a motion to dismiss the Texas attorney general’s lawsuit on August 15, 2022; however, on August 23, a federal judge in Texas ruled abortions are not covered under EMTALA within the state and preliminary halted its enforcement in Texas, leaving health care professionals to defer to Texas law over EMTALA for abortion in medical emergencies.12
Rescission of Guidance under Trump Administration
In line with the Texas holding, three years later, on June 3, 2025, CMS formally rescinded the Guidance issued by the Biden administration in 2022.13 The withdrawal of the Guidance underscores the ongoing legal and practical uncertainty confronting hospitals and health care providers in states with restrictive abortion laws. This move signals a shift in federal enforcement priorities concerning emergency care for pregnant patients and could undermine the strength of the EMTALA-based defenses previously mentioned.14
While this action removes the previous federal directive clarifying EMTALA’s application to emergency abortion care, it does not alter the underlying federal law; EMTALA remains in effect nationwide, continuing
to require that health care providers offer stabilizing treatment to patients experiencing emergency medical conditions. However, the future enforcement of EMTALA under the Trump administration is uncertain. In March of this year, the administration withdrew a key federal lawsuit filed during the Biden era that had challenged the state of Idaho’s strict abortion ban on the grounds that it conflicted with EMTALA’s emergency care requirements. This move may provide some insight into how the current administration will address similar conflicts between federal and state laws in the area of abortion care.15
Despite rescinding the Guidance, CMS stated on June 3 that it remains committed to enforcing EMTALA and intends to “work to rectify any perceived legal confusion and instability created by the former administration’s actions.” Additionally, on June 24, the attorney generals for California, New Jersey, New York, and 19 other states signed and submitted a letter to the American Hospital Association confirming their commitments to protecting access to reproductive care under EMTALA; notably, Texas Attorney General Ken Paxton did not join in signing the letter. Despite these assurances from CMS and participating states, the legal mandates as they stand today place physicians and hospitals in the peculiar position of following conflicting directives – state law that may impose criminal penalties for providing emergency abortion care, and federal EMTALA requirements, which allow both the federal government and individual patients to take legal action against hospitals that fail to deliver stabilizing treatment in emergencies.16
While the outlook of this litigation is currently unclear, hospitals, physicians, and other health care providers should continue to track its outcomes, as the courts are likely to play a critical role in ultimately resolving conflicting standards between EMTALA and state law.17 DMJ
This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 615-2025; Chandani Patel at (214) 615-2037; or your primary Hall Render contact.
Brandon Kulwicki and Chandani Patel are attorneys with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law.
REFERENCES
1 Hall Render, HHS and CMS Rescind Guidance on Emergency Reproductive Health Care Under EMTALA (June 9, 2025), https://hallrender.com/2025/06/09/hhs-and-cms-rescind-guidanceon-emergency-reproductive-health-care-under-emtala/.
2 Id.
3 Id.
4 Becker’s Hospital Review, HHS clarifies: All US hospitals must provide abortions in emergency cases (July 12, 2022), https://www.beckershospitalreview.com/legal-regulatory-issues/hhsclarifies-all-us-hospitals-must-provide-abortions-in-emergency-cases/.
5 Hall Render, HHS and CMS Release Guidance on Emergency Reproductive Health Care Under EMTALA (July 26, 2022), https://hallrender.com/2022/07/26/hhs-and-cms-release-guidanceon-emergency-reproductive-health-care-under-emtala/.
6 Id.
7 Becker’s, supra note 4.
8 Hall Render, supra note 5.
9 Id.
10 Id.
11 Becker’s Hospital Review, Eyes on EMTALA in abortion fights (Aug. 17, 2022), https://www.beckershospitalreview.com/legal-regulatory-issues/eyes-on-emtala-in-abortion-fights/.
12 Becker’s Hospital Review, Violating EMTALA, state abortion bans: What’s at stake for physicians, hospitals (Aug. 30, 2022), https://www.beckershospitalreview.com/legal-regulatory-issues/ violating-emtala-state-abortion-bans-what-s-at-stake-for-physicians-hospitals/.
13 Becker’s Hospital Review, Pulled EMTALA guidance stirs confusion for hospitals: 6 updates (June 9, 2025), https://www.beckershospitalreview.com/legal-regulatory-issues/pulled-emtalaguidance-stirs-confusion-for-hospitals-6-updates/?origin=BHRE&utm_source=BHRE&utm_ medium=email&utm_content=newsletter&oly_enc_id=0327J3569889D1E.
14 Hall Render, supra note 1.
15 Becker’s, supra note 14
16 Id.
17 Hall Render, supra note 1.
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