Caitlin Hartsell

Imagine being a working mother in rural Missouri with a sick child. He needs medical attention but there are no doctors available within 50 miles. This situation is not a stretch: many rural Missourians struggle to find nearby medical care. While nearly 40 percent of Missourians live in rural areas, less than 20 percent of the state’s primary care physicians practice in rural areas. There is a simple solution, one that Iowa employs: Give certified nurse practitioners more autonomy.

Nurse practitioners are one type of “advanced practice registered nurses” (APRNs) who have national certification and post-graduate education. Their training well equips them to deal with primary care concerns, which generally includes most basic health issues. Indeed, numerous studies have found that nurse practitioners provide similar quality of care as physicians.

Unfortunately, Missourians are not able to take full advantage of nurse practitioners. Missouri has more limitations than most other states. A recent report named Missouri the 44th most restrictive state for nurse practitioners. Seventeen states and the District of Columbia allow APRNs to practice without any physician oversight. Missouri, however, requires an APRN to work with a physician in a “collaborative practice arrangement.”

Collaborative practice arrangements exist on the theory that physician oversight is necessary to ensure quality care. However, the data has not shown that to be true. In fact, many studies show that even when nurse practitioners work independently, their patients do just as well as if doctors had treated them.

These restrictions limit the amount of care nurse practitioners can provide in Missouri. Physicians can only collaborate with three APRNs, and the doctor must regularly review a portion of the APRN’s charts — even if she has been practicing for years. The arrangements also curtail when the nurse practitioner can provide care, as the physician must be immediately available via electronic communication. Until recently, collaborating physicians also had to be within 50 miles of rural APRNs. While legislation this year loosened that requirement, collaborative practice arrangements still prevent nurses from practicing to the full extent of their training.

Nurse practitioners provide high-quality care, which makes expanding their role in Missouri obvious. The main issue for many in rural areas is having access to any care. It is not a question of doctors versus nurses, but health care versus no care. Additionally, nurse practitioners tend to move to states where there are fewer limitations. If Missouri continues to over-regulate its nurse practitioners, many rural Missourians will not have health care.

One-fifth of Missourians live in rural areas without sufficient access to primary care providers, but a solution is available. The collaborative practice arrangement rules for nurse practitioners are not protecting Missourians; instead, they are preventing affordable health care. Whether it is a mother with a sick child or a 60-year-old man seeking care, nurse practitioners are competent providers. Missouri should consider eliminating the unnecessary restrictions that help keep access to quality care from more than a million Missourians.

Caitlin Hartsell, J.D., M.P.H., was a research assistant at the Show-Me Institute, which promotes market solutions for Missouri public policy.


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Caitlin Hartsell