The role of nurse practitioner turns 50 next year. In 1965, after the new Medicare and Medicaid programs began providing health coverage to seniors, low-income women, children and people with disabilities, the country’s health care system found itself short of primary care providers. The role of nurse practitioner was created to help ease the crunch.
Half a century later, after passage of the Affordable Care Act, there is widespread acknowledgement that the current crop of primary care providers may be insufficient to care for millions of newly insured. To help fill the gaps, state legislatures are considering expanding the scope of practice for nurse practitioners, granting them greater authority to act as primary care providers.
But not in California.
Despite a report last month by the Bay Area Council Economic Institute that suggests California could reduce health care spending by $1.8 billion over the next decade if nurse practitioners were allowed a broader scope of practice, the issue is not being discussed in the California Legislature.
A bill expanding NPs’ scope of practice was taken off the California legislative calendar this session in response to heavy lobbying against the idea from the California Medical Association.
“We haven’t given up by any means,” said Jeff Wagner, communications director for the California Association for Nurse Practitioners. “We fully expect to be back in the Legislature next year. We’re clearly the underdogs, but we’ve made some good inroads this year and with new research like the study from the Bay Area Council, we’ll be in a much better place than we were last year.”
Study Shows Economic Incentive
According to the Bay Area Council report last month, expanding nurse practitioners’ scope of practice and allowing them to practice independently from physicians is “one of the most effective steps” to increase access to primary care services, particularly as 3.3 million Californians have gained coverage under the ACA. The report, sponsored by the Robert Wood Johnson Foundation and AARP, predicts the move could save California about $1.8 billion over the next 10 years.
“This is bigger than just CMA versus CANP,” said Micah Weinberg, senior fellow at the Bay Area Council Economic Institute and co-author of the report. “This is part of a national movement. This research project of ours is going to have resonance beyond California.”
So far, 17 states and the District of Columbia have approved legislation granting unrestricted authority to NPs. Legislation is pending in several other states.
On an online practice environment map posted by American Association of Nurse Practitioners, California is one of the most restrictive states in the country and the only western state that doesn’t allow full and open access to nurse practitioners. California and 12 other states — mostly in the South — fall into the AANP’s restricted-practice category.
“Connecticut is right on the edge and Nebraska’s Legislature just passed a bill that was vetoed by the governor,” Weinberg said.
“When we have this conversation again next year in California, this research will be part of it. We consider this an educational opportunity. It’s almost good to release this study while California is not in the heat of legislative battle. Maybe its import will have time to sink in,” Weinberg said.
CMA Remains Opposed
CMA remains steadfast in its opposition. In an email response to questions, CMA President Richard Thorp said, “Allowing allied health professionals to practice beyond the scope of their training can put patients in danger and result in a fragmented health care delivery system.”
Thorp suggested other ways to beef up the primary care provider corps.
“Creating new residency programs, expanding successful programs like the Steve Thompson Loan Repayment program and restoring cuts in the state’s Medicaid program will help to ensure patients have access to care they need,” Thorp said. CMA “is working to ensure all patients have access to safe, quality medical care. We are presented with an opportunity to provide care in innovate and efficient team based settings led by a physicians that utilize all health care practitioners to the top of their training and education.”
The phrase “led by a physician” is a key part of the debate and part of the reason a bill in the Legislature was shelved.
SB 491, authored by Ed Hernandez (D-West Covina), was one of four bills in the Legislature last year seeking to expand scope of practice for health care providers. Two bills — Hernandez’ SB 493, giving pharmacists broader authority to prescribe drugs and perform other primary care services, and SB 352, by Sen. Fran Pavley (D-Agoura Hills), allowing physician assistants and other providers to oversee work by medical assistants — were approved by the Legislature and signed by Gov. Jerry Brown (D).
The nurse practitioner bill met strong resistance from CMA. In an effort to gain support, Hernandez removed language that would have granted nurse practitioners the authority to operate independent of doctor oversight after finishing 6,240 hours of supervised work.
A separate amendment specified that nurse practitioners could not replace a physician or surgeon, requiring them instead to work in a “collaborative setting.”
“Those changes moved the bill to be about regulating business and commerce, not about improving health care delivery,” said Tay Kopanos, vice president of state government health policy for AANP.
The changes caused AARP and CANP to drop their support of the bill, which in turn, caused Hernandez to pull the proposal off the table.
If the bill is reintroduced next year, as Hernandez said it will be, the language will be carefully scrutinized.
Hernandez praised the Bay Area Council report, saying it “adds to the staggering amount of evidence clearly showing that allowing nurse practitioners more authority to practice will help increase access to care, improve the quality of that care, and help lower overall health care costs.”
“If we truly want to increase access to quality care, especially in areas of our state where the provider shortage is at its worst, then we must allow trained medical professionals like purse practitioners the ability to practice to the full extent of their training,” Hernandez said.
The arrival of the ACA — like the arrival 50 years ago of Medicare and Medicaid — changes the situation.
“It’s unacceptable to mandate people purchase health coverage without taking steps to ensure those same people are able to use their coverage to see a qualified health care provider,” Hernandez said.