Dying for care

How can we improve access to health care for rural Arkansans? Recently states such as Kansas and New York have expanded the use of nurse practitioners (NPs). Last year the Arkansas Legislature passed two bills to do this exact thing. But one of them, Act 412, is stifled because the rules accompanying it are stuck in committee.

Changing the rules will not change the amount of clinical hours required for NPs, but it will reduce financial burden for them to practice independently.

Allowing full scope of practice for NPs means that they can perform many of the same functions as physicians without oversight. More than 80 percent of NPs are certified in primary care, which is comprehensive treatment for ailments that do not require a specialist, just the kind of care people in Arkansas need more of.

Our upcoming research in the Southern Economic Journal shows that full scope of practice authority for NPs good children’s health. This is especially true for poor children. Expanding scope of practice helps people.

Health care is expensive. Many policies like the Affordable Care Act are designed to help people pay for health care. But a good health policy is more than throwing an insurance card at someone. Patients need a provider to benefit, and finding a provider can be tough.

The US Health Resources Services Administration (HRSA) says that 84 million Americans live in a health professional shortage area. HRSA designates shortage areas by examining population-to-provider ratio, the percentage of population below 100 percent of federal poverty level, and the distance people must travel outside the area for health care.

There are 18 geographic areas in Arkansas designated as health professional shortage areas. Just looking at the population numbers, we see that many places in Arkansas simply do not have enough providers to care for their populations. Data from HRSA shows that Lincoln, Cleveland, and Newton counties have zero primary-care physicians.

Even if you do not love NPs the way we do, they can provide lifesaving and life-changing care where there would otherwise be none. NPs must complete extensive training. They are registered nurses with additional graduate training including coursework and clinical hours. They pass a national certification exam and are licensed by the Arkansas Board of Nursing.

Expanding the scope of responsibilities for NPs is not a radical idea. Where NPs have full authority, they provide some of the unmet needs of the poor, rural, and other underserved communities. Act 569 lets NPs get paid by state Medicaid to provide services. This is important because areas with many Medicaid patients have fewer providers, and NPs can only fill the need if they can be paid.

Just like other practitioners, nurse practitioners will continue to be licensed by their state and will continue to answer to their professional review boards.

Physicians sometimes oppose expanded scope of practice, arguing that doctors go to school longer than nurse practitioners. Some doctors also stand to lose money if NPs work independently. The AMA is proudly opposed to expanding the scope of practice for practitioners.

Lee Johnson is an MD and state legislator; he’s also a sponsor of the bill. It’s impressive that Representative Johnson is more concerned about his constituents than the approval of fellow physicians.

Act 412 allows nurse practitioners to work and prescribe independently after they complete 6,240 hours under a collaborative practice agreement. They would still make referrals for specialist care, but could treat primary-care patients without paying for a collaborative practice agreement. Without this rules change, NPs cannot work independently. That prevents Arkansans from getting the care they deserve.

Unfortunately, the change has not cleared the regulation committee.

Sensible on the surface, collaborative practice rules are cumbersome and expensive for NPs and their patients. A 2020 study published in Nursing Economics NPs in Florida and found that they paid an average of over $1,000 per month to collaborating physicians. Worse, the risk that physicians will cancel these agreements deters NPs from investing in practices.

Simply put, more NPs mean improved access to care. Research published this year by Professors Sara Markowitz and Kathleen Adams at Emory University found that states with full practice authority get more NPs who work more hours. Importantly for Arkansas, Towson University Professor Bo Yang publishing in Medical Care Research and Review found that expanding state NP scope of practice regulations “were associated with greater NP supply and improved access to care among rural and underserved populations without decreasing care quality.”

We can hardly wait to see primary-care clinics run by NPs all over Arkansas. Many of those clinics will be in patient-rich areas like Little Rock or northwest Arkansas, but some of them will be in places literally dying for care.


Dr. Moiz Bhai is an associate professor of economics at the University of Arkansas Little Rock. Dr. David Mitchell is a professor of economics at the University of Central Arkansas and director of the Arkansas Center for Research in Economics. The views express are those of the authors and do not certainly reflect those of UALR or UCA.

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