Early in 2023, my colleagues from the Colorado Society of Anesthesiologists and I were sitting in Governor Jared Polis’ office in the state capitol. The governor’s office had notified us of his intention to extend to the entire state the limited 2010 rural opt-out from the Medicare requirement for physician supervision of nurse anesthetists. This was now the fourth time since 2003 we had to fight a full state opt-out in Colorado.

It was clear the governor had already made up his mind on the issue. He had long supported expanding scope of practice for optometrists, pharmacists, physician assistants, and others. He listened to our arguments, but it was clear we were not changing his opinion.

But he paused after one of our statements. I handed him data showing that Colorado was only in the middle of the pack on 30-day mortality after surgery. He thought for a minute and then said, “Well, there must be a lot of different things that go into that.”

“Yes, exactly,” I responded. I went into a description of why this measure is so important in health care today and specifically to anesthesiologists. I pointed out our extensive work on improving care from the time surgery is determined to be needed, to the time a patient returns to work, school, or their previous level of function. Losing anesthesiologists from the care of surgical patients was not going to help 30-day mortality in Colorado or anywhere else. Most of us believe it is just the opposite.

We politely pointed out that most of the vital work in improving patient perioperative care is done by physicians. Nurse anesthetists are important parts of our health care team (I am very proud of the nurse anesthetists I have hired and worked with), but they do not drive improvements in perioperative medicine to the same degree as anesthesiologists.

During my time as ASA President, I was able to point out the importance of reducing 30-day mortality with leaders in the VA health care system and with federal legislators. I was hoping they would be as shocked as I was that this figure continues to remain in the 1%-2% range for adult inpatients in the United States. It is a staggering and sobering statistic. It will not get better by reducing anesthesiologists’ involvement in the care of our patients.

As anticipated, we were unsuccessful with Governor Polis. On October 19, 2023, Colorado added its name to those states opting out of the federal requirement for physician supervision of nurse anesthetists.

That outcome does not mean that we lost. Advocacy is not a ballgame with points scored by competing teams. Advocacy is research. Advocacy is education. Advocacy is incremental. Advocacy is a continuous effort to marshal facts and narratives to advance the public good.

ASA works tirelessly to inform the public, and those who represent the public interest, about how decisions made today affect our shared future. This issue of the ASA Monitor highlights the public health burden of 30-day mortality after surgery.

Advocacy is just one way ASA is addressing this critical public health issue. ASA and its members have compiled an impressive body of work over the last dozen years to find solutions to this challenge. These efforts include ASA’s continuing work on the Perioperative Surgical Home, perioperative medicine, and population health.

Much remains to be done, but improvements in 30-day mortality will be impossible without anesthesiologists on the front lines of patient care. Through our advocacy, we must make policymakers understand these words and the consequences of their actions.