Texas has a lot going for it, starting with its geographical size and population—it is the largest state on the mainland and the second most populous, after California. The Lone Star State is known for its booming commodities and agricultural industries, as well as its mouth-watering BBQ cuisine.
However, it also has decidedly mixed ratings regarding the quality of healthcare. While there are some fluctuations depending on which organization is analyzing the state’s access to healthcare and how other states are performing in comparison, Texas consistently rates in the 80th percentile—between 40th and 51st place.
Reasons why are not clear. Some blame demographics. With so many residents spread over a such a wide area, Texas needs more resources to provide access to healthcare than a smaller state would need. What’s more, providers tend to be located in larger population areas, so the medical community has been trying to find solutions to serve Texans better.
According to the National Center for Health Workforce Analysis, prepared in 2016 by the U.S. Department of Health and Human Services Administration’s Bureau of Health Workforce, Texas has the most substantial shortage of primary care physicians to meet population demand, by approximately 28,400. However, Texas is not the only state to have this issue: 28 other states had shortages as well, a number that is projected to grow to 37 states by 2025.
Nationwide, there were about 216,000 active primary care physicians in the U.S. This number is expected to grow to almost 240,000 by 2025; however, demand is expected to grow more quickly. The national demand for primary care physicians is projected to reach 263,000 in 2025, largely because of the aging and growth of the U.S. population, resulting in a national shortfall of about 23,000. The Association of American Medical Colleges came up with a similar range for the lack of primary care physicians nationwide by 2025, which was between 14,900 and 35,600.
According to the report, the following states had the highest difference between supply and demand for primary care physicians in 2013. The below table also includes 2025 projections for supply and demand differences. (Please note that the colors indicate the NP level of practice authority in the state. More on that below.)
| 2013 Estimates | 2025 Projections | |||||
| State | Supply | Demand | Difference | Supply | Demand | Difference |
| Texas | 144,900 | 173,300 | -28,400 | 193,900 | 211,500 | -17,600 |
| Florida | 122,500 | 141,600 | -19,100 | 146,200 | 176,800 | -30,600 |
| Alabama | 27,200 | 35,400 | -8,200 | 26,800 | 38,700 | -11,900 |
| Indiana | 40,400 | 48,100 | -7,700 | 39,200 | 51,000 | -11,800 |
| Georgia | 59,300 | 66,900 | -7,600 | 70,000 | 83,100 | -13,100 |
| Arizona | 40,200 | 47,400 | -7,100 | 60,500 | 70,400 | -9,900 |
| Kentucky | 26,600 | 33,300 | -6,700 | 25,600 | 35,200 | -9,600 |
| Tennessee | 42,200 | 47,800 | -5,600 | 44,100 | 54,600 | -10,500 |
| New Jersey | 60,500 | 65,900 | -5,400 | 64,700 | 75,300 | -10,600 |
| Oklahoma | 22,900 | 28,300 | -5,400 | 23,200 | 31,500 | -8,300 |
| Mississippi | 14,700 | 20,100 | -5,400 | 14,900 | 22,200 | -7,300 |
| North Carolina | 64,800 | 69,600 | -4,800 | 76,200 | 86,400 | -10,200 |
| Louisiana | 27,700 | 32,200 | -4,500 | 28,300 | 35,000 | -6,700 |
| Utah | 15,200 | 1,970 | -4,500 | 17,700 | 23,700 | -6,000 |
| South Carolina | 29,100 | 33,400 | -4,300 | 32,200 | 39,400 | -720 |
In contrast with above states, Massachusetts has much more supply than demand—which is an entirely different issue that should also be addressed. In 2013, the state counted more than 64,000 physicians with a need of less than 51,000. However, that difference is projected to lessen by 2025 from more than 12,000 additional physicians to less than 9,000. However, a unique case is California, which, in 2013, had a surplus of more than 2,2000 physicians but by 2025, is expected to have a shortfall of as many as 15,500 doctors.
The Appeal of Nurse Practitioners
Several states are proposing solutions to reduce this deficit, such as offering incentives to encourage more people to go into medicine, especially if they are willing to practice in rural areas. Some have suggested offering to forgive or reduce student loans for new doctors stationed in rural areas, and other even believe telemedicine, where doctors consult patients remotely through digital communication, may be the best solution.
However, one of the most popular solutions is to increase the use of nurse practitioners. These skilled medical professionals have extensive, graduate-level medical training and regularly interact with patients to provide them with excellent care. Because the position requires less training that a medical doctor (MD), nurse practitioners (NPs) are able to come to market more quickly than physicians and given their lower salaries, may be more appealing to budget-conscious clinics and medical centers.
That said, NPs are still earn more than twice the median income of all U.S. jobs and report high job satisfaction. In fact, U.S. News & World Report ranked NPs as one of the top jobs in the country. Also, the U.S. Bureau of Labor Statistics (BLS 2018) reported that the median annual salary for nurse practitioners was $110,930.
New NPs typically begin working with patients much faster than new physicians. It may take NPs between five and eight years to become certified to work directly with patients; however, MDs must spend about ten years in training before doing so.
What’s more, many claim that NPs can better relate to patients. Nurses generally spend more time providing direct personal care, comfort, and services, compare to doctors who typically pop in and out of rooms for a quick exam and signing off of papers.
Because nurse practitioners can begin work sooner and the career requires less of a financial and time commitment than medical school, the number of nurse practitioners is currently growing and is projected to increase at a faster rate than that of physicians.
The BLS estimates that openings for NPs in the U.S. will rise by 36 percent between 2016 and 2026, compared to 13 percent for physicians. The number of physician assistants, another position requiring advanced but not physician-level knowledge, is projected to grow on a similar track, 37 percent.
Nurse Practitioners and Practice Authority
While there is merit to this solution, there are also limitations. Some states have complex agreements establishing a firm balance between physicians and nurse practitioners, a concept called practice authority. NP practice authority varies by state, each of which may authorize different services. In some states, NPs may be able to work with patients but cannot sign prescriptions, while in others that can prescribe certain types of medications. In some states, they can sign death certificates, while in others, they must present death certificates to a doctor for signature.
Many associations are advocating in restricted and reduced NP authority states to allow more freedom to provide care to more of the population. The goal is to offer full practice authority (FPA) in every state, which would let NPs work independently and to the extent of their graduate training and abilities. More than 20 states have already adopted FPA, including Alaska, Arizona, Hawaii, Maine, and Oregon.
Interestingly, all but one of the states above projected to have serious primary care shortages keep NPs under “reduced” (yellow) or “restricted” (red) practice authority. If these states were to lift these conditions and adopt FPA to allow NPs to work to the full extent of their training and credentialing, they could dramatically reduce these primary care shortages.
So if the number of NPs continues to grow, perhaps even parallel to the demand for better access to healthcare, why do some states still keep NPs under reduced or restricted practice conditions? One answer lies with state physician groups who generally oppose efforts to provide these privileges to non-physicians. According to NPR, some physicians have expressed concerns that NPs lack a full range of skills, considering nursing school and medical school may provide different foundations.
In Texas, this topic has been discussed in the last three legislative sessions. While the Texas Medical Board has recognized that NPs can and need to play a critical role in the future of healthcare, it stopped short of advocating full independence for all NPs, according to the Houston Press.
Oklahoma has seen a 50 percent increase in nurse practitioners statewide. The state is currently evaluating whether to adopt FPA, according to the Oklahoma Gazette. However, until NPs receive full authority, there will continue to be situations like Cordell Memorial Hospital, which can’t hire any more NPs until another supervising physician is hired, a position that has been difficult to fill.
The Case for FPA Nationwide
Proponents of full authority argue it would increase access to healthcare services, especially in rural areas. Several studies have shown that advanced practice nurses had a similar patient outcomes when compared to primary care physicians. In one study, patients even said that treatment provided an advanced NPs was equal to or better than a physician regarding satisfaction, cost, and medical measures. Consultations were longer and more extensive, and patients required fewer of them.
Additionally, a 2010 report by the Institute of Medicine on the future of nursing noted that “no studies suggest that advanced practice registered nurses (APRNs) are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs.”
Various medical organizations are also backing the push to modify restrictions on NPs in different states, even if physician groups remain resistant. These include all state and national nursing organizations as well as the Department of Veterans Affairs, the AARP, the Federal Trade Commission (FTC), and the Bipartisan Policy Center, among many others. Overall, nurses and other medical organizations will continue to push for more responsibilities for nurse practitioners and less oversight from physicians.
The American Association of Nurse Practitioners plans to continue lobbying legislators, negotiating with physicians and educating its members within the states that do not yet have full authority. The need for this model will become especially apparent over the next few years as the population grows and ages. This will leave more opportunities for other medical professionals like NPs and physician assistants who are willing and eager to help their communities.
