Two states are about to pass significant health care legislation and you may not even notice.

by Mike Miesen

In the last two weeks, our two most populous states, California and Texas, have begun the process of significantly expanding the scope of practice for non-physician providers. Though you’ve probably been reading about that other news coming out of California, this is arguably more important, and will undoubtedly affect the way you use the health care system—but you may not even notice a difference.

Two weeks ago, the Texas House approved Senate Bill 406, which would

eliminate the requirement for on-site physician supervision to allow doctors to delegate the authority to prescribe and order medical devices to advanced practitioner nurses and physician assistants. It will increase the number of advanced practice nurses a physician can supervise from four to seven…It will also allow physicians to delegate authority to advanced practice nurses and physician assistants to prescribe Schedule II controlled substances, which are classified as having a higher potential for abuse, in hospitals and hospice settings.

In other words, it allows nurse practitioners to “practice at the top of their training,” as state Senator Jane Nelson put it.

Out west, California’s Senate approved a law that would “allow nurse practitioners to have stand-alone practices to prove primary health care services independent of physicians, including certification of disability claims, prescription drugs, and approving many treatments.”

Partially, these laws are a reaction to the projected doctor shortage, which, according to some estimates, could be as high as 130,600 physicians (65,800 or which are primary care physicians) by 2025. Potential cuts to Indirect Medical Education in President Obama’s 2014 budget (which won’t pass, but I looked at the details and background here) could make the shortage much larger in the coming years.

We’ve covered this before. I’m skeptical about the looming shortage for a number of reasons—one of which is precisely what we’re seeing: states are noticing that it’s the rent-seeking regulations that are preventing advanced practitioners from appropriately caring for patients “at the top of their training,” not the top of their training itself. Advanced practitioners will reduce the number of physicians we’re short.

While California and Texas are late to the game—play with ths interactive graph to compare them with other states—the sheer size of these states will make the heath care community notice. If enacted, these bills would change how health care is delivered for tens of millions of people, and could help nudge the other ten “restricted practice” states (see below) towards their own similar expansions.


We can expect the loosening of regulations to lead to cheaper, more efficient care in the long term; a nurse practitioner’s hourly rate is lower than a physician’s and, assuming they can both conduct a high-quality, basic check-up—and evidence suggests that quality and patient satisfaction is higher along some metrics nurse practitioners compared to physicians—everyone is better off. It’ll also mean shorter wait times, as the supply of available clinicians will rise.

Significantly, both of these factors could lead to clinicians accepting Medicaid patients at a higher rate than before. Worrying research has shown that, increasingly, physicians have been unwilling to take on new Medicaid patients due to the low reimbursement rate relative to Medicare or private insurance. Relaxing scope-of-practice regulations will mean that these patients may soon be able to more easily receive the care they need.

But back to you, average consumer of health care: how might these changes affect you (assuming you live in California or Texas, of course). Rather than see a physician for a simple physical or check-up, in the coming months you may be able to see a nurse practitioner or other advanced care provider. He or she will be able to administer injections and prescribe medications.

Honestly, you may not even notice a difference—unless you notice the cheaper care and shorter wait times. Which is really all the evidence you need to support Texas and California’s legislation to expand the scope of practice for advanced practitioners.


Mike is a healthcare consultant turned aid worker turned traveler (currently: East Africa) and freelance journalist. Follow him on Twitter @MikeMiesen or subscribe to the blog.


6 thoughts on “Two states are about to pass significant health care legislation and you may not even notice.

  1. USMD says:

    ”The studies used many different outcome measures, reflecting the difficulty in measuring changes in health outcomes after single consultations predominantly about minor illnesses. None of the studies in our review was adequately powered to detect rare but serious adverse outcomes. Since one important function of primary care is to detect potentially serious illness at an early stage, a large study with adequate length of follow up is now justified.”

    Given the poor study methodology and poorly powered studies in the metastudy , it CANNOT be said that nurse practitioners and other non-physician are as capable as physicians in diagnosing and treating patients or for that matter able to interpret rays or other imaging modalities. The advanced training that nurses receive does not in any way resemble that of a physicians. To say otherwise would be disingenuous.

    Physicians accept less Medicare and Medicaid patients because of decreased reimbursements. One cannot run a successful practice if the reimbursements received per patient are less than the cost of seeing that patient. Before long that physician will need to close her doors. Physicians will either stop accepting new patients on public insurance or change their practice to a concierge only / private insurance only.

    • mikemiesen says:

      Thanks for your input. Could you point me in the direction of another literature review that could help elucidate the differences between NPs and physicians when it comes to patient satisfaction, health outcomes, imaging, etc.? Adrianna found this study, and it seems quite thorough.

      You mention that physicians MUST be more qualified at these – and, by extension, other – attributes of clinical work, because of the quality and quantity of education. Has there been a study that’s shown this? I understand your point, but I think you’re making a number of assumptions, the primary one being that, in order to fulfill this type of work, one needs to go to medical school; anything “lesser” doesn’t cut it.

      I can cook a pretty good meal for friends/family without chef school, but I couldn’t cut it at Le Cirque without some pretty extensive training. Le Cirque’s chef wouldn’t need his training to cook my friends/family a meal they’d enjoy. Maybe it’s best if I do what I’m qualified to do, and he/she does the same – we “practice at the top of our training.”

      To your second point: as I write in my article, one of the benefits of expanding the scope of practice is that seeing each patient will be cheaper, as NPs/PAs “cost” less to train and make less than physicians.

  2. Tina Larson says:

    There’s one HUGE difference – California’s bill would take physicians out of the equation, while Texas’ bill is structured to ensure communication and collaboration of physicians and nurse practitioners.

    • mikemiesen says:

      Very true – thanks for the great point, Tina! Texas’s bill still gives more leeway and independence than the status quo, so I see it as a step in the right direction. I would guess that it’s more politically or culturally palatable to take it one step at a time there.

  3. jason webster says:

    Obamacare mandates that NPs and physicians get paid the same (exemption for Medicare).

    So I’m very curious how this is going to save money? Also, insurance companies charge the same copay regardless of whether you see an NP, PA, or MD. Again, hard to see how NPs are going to save us money.

    • I’ve genuinely never heard that such a provision was part of the Affordable Care Act. Could you direct me to a source on that?

      The most recent analysis of NPs I’m aware of is this policy brief from Health Affairs, updated last month. It stipulates the following:

      Nurse practitioners are nearly always paid less than physicians for providing the same
      services. Medicare pays nurse practitioners practicing independently 85 percent of the
      physician rate for the same services. The Medicare Payment Advisory Commission, the federal agency that advises Congress on Medicare issues, found that there was no analytical foundation for this difference. But revising the payment methodology would require Congress to change the Medicare law. Doing so, however, could increase total Medicare spending if increased payment rates are not offset by savings in other areas

      In addition, Medicaid fee-for-service programs pay certified pediatric and family practice nurse practitioners directly, but these rates vary by state. Some states pay nurses the same rates as they pay physicians for some or all services, but more than half of the states pay nurse practitioners a smaller percentage of physician rates. The Affordable Care Act provides for enhanced Medicaid payment for primary care services furnished by physicians, and an Institute of Medicine (IOM) report recommended Congress apply those same rates to nurse practitioners providing similar primary care services. Health insurance plans have significant discretion to determine what services they cover and which providers they recognize. Not all plans cover nurse practitioner services.

      Granted, this does not speak to PAs. But I’d be very curious to read an account of such a provision.

      You’re correct on the copays. NPs and PAs may not save an individual consumer money, but less spending by insurance companies (because—to my knowledge—NPs and PAs are reiumbursed at lower rates) could save money in the overall scheme of the health care system.

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