Research & Commentary: Texas Should Ease Regulatory Burden on Nurse Practitioners

Published February 22, 2018

Like many states, Texas faces a growing health care shortage, leaving many patients looking for basic primary care services. The Robert Graham Center has estimated to maintain current rates of primary care utilization, Texas will need “an additional 6,260 primary care physicians by 2030, a 47% increase compared to the state’s current (as of 2010) 13.139 PCP workforce.” 

Avoiding a health care shortage is complicated by the fact that becoming a licensed health care provider is an expensive and slow process. Supporters of strict state licensing standards argue they assure quality, but critics argue the arduous and often expensive licensing process harms the health care market by hindering entry for new physicians and thereby impeding the competition that lowers costs and improves consumer access to healthcare services.

In Texas, nurse practitioners (NPs) are required to enter into prescriptive authority agreements, which require NPs to sign contracts with doctors to treat and write prescriptions for their patients. The agreements do not require the doctor to directly supervise the NP. Supporters of these agreements, including doctors groups in Texas, argue the agreements are needed to ensure safety, as physicians have more expertise in treating patients. These agreements are often quite costly, reaching as high as six figures.

A bill introduced by state Rep. Stephanie Klick (R-Fort Worth) would eliminate prescriptive authority agreements and move the power to regulate nurse practitioners solely to the Texas Board of Nursing. Currently, NPs are regulated by the nursing board and the Texas Medical Board. In a news conference announcing the bill, Klick argues the agreements increase the cost of medical care and often push nurses to work in other states.

Expanding the role of NPs is especially important in Texas, where NPs are frequently the only source of primary care in the rural areas of the state. While the proposed bill does take a strong step toward rolling back barriers for NPs, it did not include a major reform that would truly expand the ability of NPs to provide care. Expanding the scope of practice for nurse practitioners and allowing them to provide additional health care services is one reform that could help provide care for patients in Texas.

Allowing NPs to have an increased role in administering care would greatly improve access to care. Currently, 21 states and the District of Columbia allow NPs to diagnose and provide some form of treatment for illnesses. Although critics of these efforts claim expanding the scope of practice will reduce overall quality of care, a 2012 article in Health Affairs reviewing 26 studies on the topic noted the “health status, treatment practices, and prescribing behavior [of NPs] were consistent … [with those of] physicians.”

Eliminating the costly, and unnecessary prescriptive authority agreements nurses are forced to enter is a good first step toward amplifying the role of nurse practitioners in Texas. Expanding the scope of practice of nurse practitioners is another step Texas can take to increase the availability of health care to patients across the state.

The following articles examine the doctor shortage, scope of practice, and medical licensing from varied perspectives.

Reform for a Healthy Future: Expanding Scope of Practice for Nurse Practitioners in Texas
In this Policy Perspective, John Davidson of the Texas Public Policy Foundation argues Texas’ medical practice laws are highly restrictive compared to many other states and incentivize NPs to practice elsewhere, thereby exacerbating a growing provider shortage in the state.

Healthcare Openness and Access Project: Mapping the Frontier for the Next Generation of American Health Care
The Healthcare Openness and Access Project (HOAP) is a collection of state-by-state comparative data on the flexibility and discretion U.S. patients and providers have in managing health care. HOAP combines these data to produce 38 indicators of openness and accessibility. The project provides state-by-state rankings over a number of variables, including occupational licensing.

End State Licensing of Physicians
Shirley Svorny of the Cato Institute argues in this article for the ending of state licensing for physicians. Svorny says the state licensing system is both costly and unneeded. “The benefits of state licensing are overstated. Licensing authorities verify education and training, but little else. State licenses do not indicate an individual physician’s specialty-specific skills. Specialty certification is the purview of medical specialty boards, which are private,” wrote Svorny.

Medical Licensing: An Obstacle to Affordable, Quality Care
Shirley Svorny of the Cato Institute argues licensure not only fails to protect consumers from incompetent physicians, it also makes health care more expensive and less accessible by raising barriers to entry. Only institutional oversight and a complex network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today. 

The Medical Monopoly: Protecting Consumers or Limiting Competition?
Sue A. Blevins of the Cato Institute examines the effect of government health care policies on the health care market. Blevins finds licensure laws appear to limit the supply of health care providers and restrict competition to physicians from non-physician practitioners. The primary result is an increase in physician fees and income, driving up health care costs. 

Medical Licensing in the States: Some Room for Agreement – and Reform
Charles Hughes of the Cato Institute discusses the growing doctor shortage, how it is likely to increase with the implementation of Obamacare, and the steps some states are taking to address the issue. 

A Cure for what Ails Us
Justin Owen, Trey Moore, and Christina Weber of the Beacon Center of Tennessee analyze the current predicament facing Tennessee policymakers in the wake of the Affordable Care Act. The report also offers state-led solutions that would move the nation’s health care system in the proper direction, treating the diseases that weaken the system themselves, rather than merely treating symptoms. 

Six Reforms to Occupational Licensing Laws to Increase Jobs and Lower Costs
Byron Schlomach of the Goldwater Institute argues reforming licensing could open career opportunities and reduce costs without sacrificing consumer safety. The paper recommends six reforms. 


Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit The Heartland Institute’s website, and PolicyBot, Heartland’s free online research database. 

If you have any questions about this issue or The Heartland Institute’s website, contact Charlie Katebi, a state government relations manager at The Heartland Institute, at [email protected] or 312/377-4000.