Americans have witnessed fierce debates on health-care policy focused on various proposals, including Medicare-for-all. Whatever your take on such proposals, it’s important to remember that there are other ways to expand access to affordable health care. One promising idea — which wouldn’t cost taxpayers a dime and may actually save money — is to expand the role of highly trained nurse practitioners in providing primary care.
Consider the fact that 6 in 10 American adults have a chronic disease, requiring frequent access to timely primary care services. As a consequence, the demand for such services has increased exponentially and will continue to grow. Unfortunately, the supply of primary care doctors isn’t keeping up with the demand. More than 50,000 additional physicians are needed by 2025 to meet projected needs, yet about 80 percent of internal medicine residents, including nearly two-thirds of primary care internal medicine residents, do not plan to have a career in primary care as other specialties are so much more lucrative.
As a health services researcher, I have spent more than a decade studying how to increase Americans’ access to high-quality, cost-effective primary care. I know firsthand that the growing nurse practitioner workforce is well positioned to meet this need. All NPs must complete either a master’s or doctoral degree program and have advanced clinical training after their registered nurse preparation. NPs also undergo a rigorous national certification process to be recognized as expert health-care providers. Their numbers have increased from 120,000 in 2007 to 270,000 in 2018, and projections show that the overall NP workforce will almost double between 2013 and 2025. Nearly 90 percent of NPs are capable of delivering primary care services: They can assess patients, diagnose illnesses, prescribe medications, order tests and medical equipment, and admit patients to hospitals.
But here’s the problem: Only 22 states and the District of Columbia allow NPs “full practice authority” — the right to deliver all aspects of patient care independently, without physician oversight. In the remaining states, scope-of-practice laws impose unnecessary restrictions, requiring NPs to collaborate with a medical doctor or work under the supervision of one. Many of the most populous states — including California, Texas, Florida, Georgia, North Carolina and Michigan — are among the most restrictive.
These regulatory barriers serve no valid health purpose. Their defenders claim NPs can’t be counted on to provide safe care because they spend fewer years in school than physicians, but these arguments have been thoroughly debunked. In study after rigorous study, evidence demonstrates that NPs offer significant cost savings with no sacrifice of quality of care. Indeed, they show that NPs often provide superior care, including spending more time with patients on prevention and counseling.
The Federal Trade Commission, the National Governors Association, the National Academy of Medicine and other major organizations have criticized scope-of-practice restrictions — and with good reason. In states granting NPs greater practice authority, research shows that health-care services are better utilized and primary care capacity is increased.
Fortunately, across the country some states are moving in the right direction. Eight states loosened scope-of-practice restrictions from 2011 to 2016, and others are considering similar moves. And the Department of Veterans Affairs expanded the role of NPs in 2016, allowing them to independently deliver care in the VA system regardless of the scope-of-practice rules in their states. Veterans who previously might have had to wait several months for needed treatment now have access to uniform, timely, high-quality health-care services across the country.
But there’s still a long way to go. Almost 60 million Americans live in primary care “shortage areas.” And efforts to liberalize scope-of-practice rules often must overcome fierce opposition from cash-rich medical organizations.
Freeing up nurse practitioners to provide primary care is not a panacea; any single reform can have only a modest impact on the overall picture. But given the extent of political polarization and the depth of distrust, grand schemes to remake the whole system from scratch are unlikely to go anywhere.
The more practical approach is to build confidence and momentum with a series of incremental reforms, beginning with steps to effectively utilize the resources we already have. A growing, qualified and capable NP workforce is undeniably an underutilized resource. Here the issue isn’t left vs. right or progressives vs. conservatives. Allowing greater practice authority for NPs across the nation would be one of those happy instances in which Republicans and Democrats can join forces to do the right thing.