Medical Licensing in the States: Room for Agreement & Reform


Even before Obamacare, many states faced the prospect of a doctor shortage due to an aging population and a limited supply of physicians. Obamacare will exacerbate this shortage by expanding insurance coverage to some degree, which will further increase the demand for care. One study projects that this increased demand will require between 4,300 and 7,000 more physicians by 2019.

Earlier this week, the New York Times reported that state medical boards across the country “have drafted a model law that would make it much easier for doctors licensed in one state to treat patients in other states, whether in person, by videoconference or online,” in what they are saying has the potential to be “the biggest change in medical licensing in decades.” This is a positive development, especially given that it seems to have a measure of bipartisan support, with 10 Republicans and 6 Democrats endorsing the plan in a recent letter.  If ultimately enacted, it could go a long way to increasing access to care, especially in underserved areas, but there are still many obstacles to seeing this plan become a reality, and it is far from the only option at the disposal of policymakers.

Another proposal to address this doctor shortfall is to expand the role of nurse practitioners (NP’s), who are registered nurses who have also received a graduate degree in nursing. States determine what services these NP’s can perform, and their scope of practice varies significantly. States that currently have reduced or restricted scope of practice should explore loosening these restrictions, because doing so could go some way to addressing the looming doctor shortage and increase access to care without a reduction in quality.

This idea has been explored in the past, garnering support from non-partisan organizations, and some states have already made progress in expanding scope of practice for NP’s. A 2010 Institute of Medicine report recommended that state legislatures “remove scope of practice barriers,” and a 2012 National Governor’s Association report suggested states “consider changing scope of practice legislation” as a way to increase the role of NP’s in providing primary care.  Despite this support that in some ways transcends traditional partisan lines, there is still much to be done, as this map shows:

State Regulatory Map_NursesLegend_RegMap_Nurses

Source: American Association of Nurse Practitioners, “2014 Nurse Practitioner State Practice Environment,”

This year, 19 states (and D.C.)  allow nurse practitioners to diagnose and, to some extent, treat patients without a physician’s involvement, otherwise known as ‘full practice.’ The remaining states only allow ‘reduced’ or ‘restricted’ practice, which means NP’s require some degree of physician involvement.

There has been some progress in recent years; Massachusetts and Minnesota transitioned from ‘reduced’ to ‘full’ practice this past year, but many of the most populous states like Florida, Texas and California still have restrictive scope of practice laws in place.

Skeptics of expanded scope of practice raise the concern that the quality of care could suffer as some duties are shifted from physicians to NP’s, but a systematic review of 26 recent studies in a Health Policy Brief for Health Affairs found that “health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians.” Some studies even find that NP’s score higher in patient satisfaction than physicians for certain services.

In a time when health care policy at the state level so often seems to be gridlocked, there are still channels to improve the access to care without increasing costs or reducing quality. This is not to say state lawmakers should shift all focus from the many pervasive problems with Obamacare, but perhaps, on this specific issue, there could be a separate peace and real, positive reform can be enacted.

Cato Institute Adjunct Scholar Shirley Svorny has explored the many problems posed by medical licensing in depth, and you can find her research here.

Charles Hughes is a Research Assistant at the CATO Institute.

Used with permission. Cato Institute / CC BY-NC-SA 3.0