The US has a primary care shortage — scope of practice reform can help

The staggering costs and time commitment to medical education push aspiring physicians to pursue more lucrative specialization rather than practice primary care. Increasing physician specialization is creating a shortage of primary care providers. Unfortunately, it comes with a troubling side effect: obtaining basic medical care in the U.S. is becoming more and more difficult. The shortage of primary care providers in rural and low-income areas is particularly acute. This is why it is urgent that we expand the scope of practice for nurse practitioners (NPs) and physician assistants (PAs), making basic medical care accessible and affordable to all Americans.

Between the price tag (around $800 thousand dollars per physician) and the time commitment (four years in college, four years in medical school, and a three-to-seven year medical residency) it’s unsurprising that once able to practice, doctors will choose the higher-paying specialized care route over primary care. 

This is why some states–faced with enormous and ever-growing health care costs–are experimenting with reforms that allow primary care treatments to be performed by highly-skilled, non-physician health care professionals. 

“Scope of practice” (SOP) reforms apply to professionals with Master’s Degrees (namely, NPs and PAs). These reforms would allow qualified health professionals to perform basic medical procedures and to prescribe treatments without government-mandated hand-holding by a physician. 

Expanding SOP for mid-level providers is a time-tested strategy for improving American health care, with the majority of states have enacted some level of reform over the last few decades. Yet such reforms are often unreasonably timid, retaining years of excessive physician hand-holding. 

Over 30 years ago, the U.S. Office of Technology Assessment concluded that 75 percent of general primary care and over 90 percent of pediatric primary care could be just as safely and effectively provided by nurse practitioners. Yet today, no state comes even close to realizing the full potential of mid-level healthcare providers. 

Reforming SOP can improve the U.S. health care system on multiple fronts. First of all, bogging down highly specialized physicians with the most basic caregiving doesn’t make sense when they can be using their more in-demand skills elsewhere. The scope of practice reforms would enable qualified NPs and PAs to fill this gap in primary care provision.

Enabling physicians to focus on procedures where their extraordinary level of training is most needed will also help alleviate another problem: doctors are overworked. Almost a third of U.S. doctors report working between 60 and 100 hours per week. Contrast this to Europe, where physicians are typically on-duty less than 48 per week. While its uncertain whether grueling hours result in increased medical errors, the fact remains that medical professionals are being stretched to capacity–in large part because they are tasked with providing the most routine care and preventative medical treatments. 

This is why it’s crucial that states enable non-physicians to deliver basic primary care, helping to release pressure from the healthcare system. 

Critics of expanded SOP often claim that the grueling training process for physicians is necessary to ensure quality.

Yet fears about decreased quality or malpractice have been undermined by research showing no such deterioration in states that have expanded the scope of practice. On the contrary, in some cases quality actually improved. 

Conservatives, in particular, should understand that calls for a radical overhaul of the health care system are in response to very real problems. In a truly free market, the supply of healthcare practitioners would expand to meet demand. Yet current rules make it excessively difficult for potential care providers to respond to market incentives.

Opening up primary care delivery to qualified alternative providers would, therefore, make markets in healthcare work better. The fact that rural and low-income communities are much more likely to rely on nurses for primary care than denser, wealthier areas should really drive this point home.

Liberalizing the scope of practice laws will grant Americans access to a wealth of talented healthcare providers. State legislators should grant NPs with full authority to both prescribe and practice independently. 

For PAs, states should allow physicians to flexibly delegate treatment and prescribing duties at the practice level. Mid-level healthcare providers have in-demand, and desperately needed, skills that can help alleviate our primary care shortage–if only states will let them.

Robert Orr is a welfare policy analyst at the Niskanen Center.