Texas Trails on Healthcare Access; Let’s Change That

That may soon change. Texas state Sen. Mayes Middleton, a Republican, has introduced a measure that addresses the licensing and regulation of advanced practice registered nurses (APRNs). It would allow advanced practice registered nurses in Texas, such as nurse practitioners and nurse midwives, to practice independently, diagnosing, prescribing and delivering primary care. The bill updates licensing rules and clarifies the roles of APRNs under the Texas Board of Nursing.

Advanced practice registered nurses are registered nurses with graduate training in providing specialized care. Depending on the state, NPs provide medical care to patients with or without physician supervision.

The University of Colorado established the first nurse practitioner program in the United States in 1965. Since then, the medical and advanced practice nursing professions have contested before state lawmakers whether the government should allow patients to access primary care services from nurse practitioners. The two professions debate whether NPs provide primary care services comparable in quality to those offered by physicians.

Opponents and proponents of expanding nurse practitioners’ scope of practice can cite literature comparing the care delivered by NPs to that provided by physicians. Medical associations often emphasize the discrepancies in education and training: physicians must complete 10,000 to 16,000 hours of clinical education and training, while NPs have only 500 to 720 hours. Supporters of NP autonomy, including public health advocates and researchers, point to health outcomes, citing research that indicates NPs deliver safe, comparable care to their physician counterparts.

Recently, researchers reported on a large, real-world comparison study designed to minimize confounding factors and provide the best comparison of NP to physician-provided care. The study examined the differences in clinical outcomes, service utilization, and healthcare costs between NP-assigned and physician-assigned patients. It used administrative data from the Veterans Health Administration, one of the largest integrated care systems in the United States.

For the study, the VHA reassigned patients whose primary care physician had left the VHA to either another physician or an NP, independent of the patient’s health, thus introducing a pseudo-random feature. The final sample included 806,434 patients in 530 VHA facilities across the United States. After comparing patient conditions pre‐ and post‐​reassignment and between primary care providers, the study found that NP-assigned patients had similar total costs and clinical outcomes to physician-assigned patients and were less likely to require hospitalization.

This isn’t an isolated finding. In another large-scale study, published in the Annals of Internal Medicine, researchers at the UCLA, Stanford University, and Yale University examined data from Medicare Part D beneficiaries 65 or older between 2013 and 2019 in the 29 states that had granted NPs prescriptive authority by 2019. Using the American Geriatrics Society’s Beers Criteria, they measured the rate of “inappropriate prescriptions,” defined as drugs that should not generally be prescribed to adults over 65.

Their conclusion: “Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.”

Today, more than 431,000 certified nurse practitioners are in the United States, nearly three-fourths of whom deliver primary care services. Some states allow patients to seek services from NPs but require the NPs to be either employed and supervised by physicians or to contract with physicians to “collaborate” with them in their otherwise independent practices.

States also vary regarding the scope of services they permit patients to seek from NPs. As of March 2024, 30 states had granted “full practice authority” to NPs, meaning that the NPs can practice to the full extent of their training without a supervising or collaborating physician, diagnose, order tests, prescribe medication, and otherwise independently treat patients.

To be sure, NPs don’t undergo the years of education and training endured by physicians, particularly those trained in specialties. But the data on primary care suggest that NPs provide comparable services. Like physicians, NPs are professionals with a professional code of ethics. Like physicians, if NPs encounter a patient with a clinical problem for which they lack expertise, they will consult or refer the patient to a professional with the appropriate knowledge and experience.

Some lawmakers may believe that people should choose physicians over nurse practitioners for primary care services, but that decision should not be left to lawmakers. Only patients, as autonomous adults, should make that choice. This is about providing Texans with more options, not replacing doctors.

As Texas faces a growing shortage of primary care doctors, a broader health care workforce gap, and an aging population, lawmakers can expand access to care and honor patient autonomy by allowing nurse practitioners to practice fully within their training.