Nurse Practitioners Slowly Gain Autonomy

In Portland, Oregon, nurse practitioner Kirsten Roberts exams a newborn. Oregon is one of the 17 states that allow nurse practitioners to work without a doctor’s supervision, and more states are considering it. (AP)

When the federal health law takes effect in January, some 30 million more Americans are expected to have health insurance, many for the first time. An already critical shortage of primary care providers may make a doctor’s appointment hard to come by. Increasingly, you might hear, “The nurse will see you now.”

Some states are trying to fill the primary care physician shortage with nurses who have advanced degrees in family medicine. That requires relaxing decades-old medical licensing restrictions, known as “scope of practice” laws that prevent these nurse practitioners from playing the lead role in providing basic health services. At least 17 states now allow them to work without a supervising physician, and lawmakers in five big states are considering similar measures.

Advocates for patients, hospitals and insurers agree that allowing nurse practitioners (NPs) to fill in for doctors makes sense when it comes to basic services. But physician groups vigorously oppose the changes, arguing that nurses lack the training to safely diagnose, treat, refer to specialists, admit to hospitals and prescribe medications for patients, without a doctor’s oversight.

After six years of legislative debate, Nevada became the most recent state to allow NPs to practice independently. Signed by Republican Gov. Brian Sandoval in June, the new law allows nurse practitioners with at least two years of experience to set up practice. They can open their own autonomous health clinics and provide the same range of primary care services as physicians do.

The hope is that the state, which ranks fifth from the bottom in doctors per capita, will prompt more nurse practitioners to offer primary care services to more patients, particularly in remote areas.

The need for the law, advocates say, was urgent, particularly because Sandoval welcomed the Affordable Care Act’s Medicaid expansion in his state, one of only six Republican governors to do so. Starting Jan. 1, an estimated 300,000 currently uninsured adults will get a new Medicaid card in Nevada, and many will want to see a primary care provider.

Incremental Change

Alaska, New Hampshire, Oregon and Washington were the first states to adopt broader licensing authority for nurses in the 1980s to increase the supply of primary care providers, especially in remote areas. A handful of other largely rural states, many with severe doctor shortages, followed in the 1990s. 

A few more states joined them after passage of the Affordable Care Act in 2010, but this year, five big states — California, Massachusetts, Michigan, Pennsylvania and New Jersey — are considering laws giving NPs total independence. If they are successful, the number of patients in the US with greater access to primary care will increase substantially.

The National Conference of State Legislatures reports that state legislatures considered 349 measures aimed at loosening NP licensing restrictions in 2011 and 2012. So far this year, 178 proposals have been considered. Several states that require physician supervision expanded the types of services that NPs can offer, such as prescribing certain drugs and signing death certificates and other official health records.

But for the nursing profession, the gold standard is full independence. That is the only way, advocates argue, that NPs will be able to make a dent in patients’ access to care.

According to the American Association of Nurse Practitioners, 17 states allow NPs full autonomy (see list). Other organizations, including the national Institute of Medicine, include two other states in that category: Maryland and Utah. (The discrepancy hinges on the precise language in the laws describing an NP’s ties to a doctor.)