Broaden the Scope

AB 890 was recently passed by the California State Legislature and is awaiting Gov. Gavin Newsom’s signature. The idea behind the bill—allowing more nurse practitioners (NPs) to independently perform the tasks they were trained to do—is neither unusual nor particularly contentious in a growing number of states. However, some still fear the ramifications of a slightly freer healthcare market. Here are a few facts about NP scope-of-practice restrictions:

Under current California law, NPs are required to enter into written agreements with physicians to supervise their work. They are typically required to pay the supervising physician anywhere from $5,000 to $15,000 per year. The bill would grant NPs the authority to work independently from physicians after three years of supervision.

Nurse practitioners are highly trained medical professionals, and California would not be going out on a limb by granting them more autonomy. In 22 states, NPs are permitted to work to the full extent of their training without physician supervision.

There is a mountain of evidence in the existing academic literature showing that NPs can increase patients’ access to care without sacrificing quality or raising costs. In my own research, I have estimated the effects on the cost and amount of care received by Medicaid patients. In states that allow NPs to work independently, Medicaid patients receive 8 percent more care than patients in states (including California) that restrict NPs. In addition, the increase in care to Medicaid patients is achieved without higher costs.

As is often the case when attempts are made to modernize NP legislation and give more healthcare workers the authority to fully contribute to the healthcare market, there is one well-funded voice in opposition. The executive vice president and CEO of the American Medical Association (AMA) penned a letter to Gov. Newsom urging him to veto AB 890. The letter makes the argument that allowing NPs to work without physician supervision would increase the cost of care for patients and threaten their safety. While the letter does not go into much detail about the latter, it does cite three papers that suggest NPs might prescribe more opioids or perform more X-rays than doctors.

The letter ignores other evidence. One study, for example, finds no indication that allowing full practice authority for NPs affects opioid prescribing patterns. Research also suggests that all medical providers, not just NPs, would benefit from more knowledge on the proper use of opioids. As noted previously, it’s very clear that the vast majority of studies find just the opposite: that granting NPs full practice authority means more quality healthcare for more people.

Of course, the AMA represents physicians and understandably values their clients’ role in all aspects of patient care. It’s also true that California physicians would potentially lose out on the payments they receive for supervising nurse practitioners. They also would face more competition—particularly the case with primary care physicians.

Regardless of one’s stance on the issue, in the midst of a pandemic, the letter seems tone deaf. Even before the pandemic, the United States faced a shortage of primary care physicians. Recent evidence suggests that the AMA bears some responsibility for this shortage as a result of incorrect forecasts of primary care surpluses.

Here’s one thing everyone should agree on: the crisis that the healthcare system is currently experiencing is real. We can’t let fear of change, petty turf wars, or a failure to pay attention to the facts prevent patients from getting the care they need.

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