The roles of nurse practitioners (NPs) and physician assistants (PAs) have expanded significantly over the past decade as healthcare systems grapple with provider shortages and rising demand for services. With an aging population and a projected shortage of up to 124,000 physicians by 2034, policymakers are increasingly looking to NPs and PAs to fill gaps in care. One major policy trend in U.S. healthcare is the push for Full Practice Authority (FPA) – the ability of advanced practitioners to evaluate, diagnose, and treat patients without mandated physician oversight.
Proponents argue that granting NPs and PAs greater autonomy will improve access, especially in underserved areas, and help contain costs. Critics, however, voice concerns about patient safety and the differing levels of training between physicians and these advanced practice providers.
We will explore what FPA means, examine the current policy landscape at both state and federal levels, and review recent legislative developments for NPs and PAs. We will also discuss the support and resistance from various stakeholders – including professional organizations, hospitals, and lawmakers – and analyze how FPA impacts patient care, provider shortages, costs, and health equity.
A nurse practitioner or physician assistant collaborating with a physician. Healthcare teams are evolving as NPs and PAs take on greater responsibilities in patient care.
What is Full Practice Authority (FPA)?
Full Practice Authority (FPA) refers to the legal authorization for NPs (and, in a similar spirit, PAs) to practice to the full extent of their education and clinical training without requiring a formal supervisory or collaborative agreement with a physician.
In practical terms, FPA means an NP can independently evaluate patients, order and interpret diagnostic tests, make diagnoses, initiate and manage treatments, and prescribe medications – including controlled substances – under their own licensure.
In states with FPA, NPs are truly independent healthcare providers; they can even establish and run their own clinics if they choose. This model aligns with recommendations from the National Academy of Medicine (formerly the Institute of Medicine) that nurses should be allowed to practice to the full extent of their training.
For physician assistants, the concept of independence is often framed as Optimal Team Practice (OTP) rather than “full practice authority” per se. Historically, PAs have always worked in partnership with physicians, and all states still require some degree of physician involvement in PA practice.
However, OTP – a policy adopted by the American Academy of PAs (AAPA) in 2017 – aims to remove the legal mandate for a specific physician supervisory agreement, allowing PAs to collaborate more flexibly with healthcare teams. Under OTP, PAs continue to consult or refer to physicians as needed for patient care, but the “burdensome administrative constraints” (like written agreements tying a PA to one doctor) are eliminated. In essence, both FPA and OTP are about untethering advanced practitioners from outdated rules so they can practice to the top of their license while still working within a healthcare team.
It’s important to note that FPA does not mean NPs or PAs are “practicing medicine” exactly like physicians or trying to replace them. Instead, FPA focuses on scope of practice – what services these providers are licensed to deliver. Nurse practitioners are trained in the nursing model with advanced clinical skills, often specializing in primary care, pediatrics, women’s health, psychiatry, or acute care.
Physician assistants are educated in a medical model as generalists and historically required physician oversight in all settings. Full practice authority for NPs (and greater autonomy for PAs) enables these clinicians to use their training fully, especially in areas where physician supply is limited. As we’ll see, the movement toward FPA is driven by workforce needs and evidence that NPs and PAs provide high-quality care within their scope, but it remains a subject of debate in healthcare policy.
State vs. Federal Authority in Scope-of-Practice Laws
In the United States, healthcare practice authority is primarily regulated at the state level. Each state’s laws and regulations define the scope of practice for NPs and PAs, leading to considerable variation nationwide. State legislatures decide whether NPs must work under physician supervision, collaborate under certain terms, or can practice independently. As of 2025, states generally fall into three categories for NP practice authority:
- Full Practice – NPs have full autonomy to practice and prescribe independently under the exclusive licensure of the state nursing board. No physician involvement is required by law.
- Reduced Practice – NPs can perform many duties but face some limitations. Often they must have a collaborative agreement with a physician for certain aspects of care (for example, prescribing certain medications or operating a private practice). These states require an ongoing, regulated collaboration but not necessarily direct on-site supervision.
- Restricted Practice – NPs in these states have the most stringent limits, typically requiring career-long physician supervision or delegation for most or all aspects of practice. Essentially, an NP cannot practice without a physician overseeing their work to some degree in these jurisdictions.
For physician assistants, state scope-of-practice laws historically mandated close supervisory relationships. Many states limited the number of PAs a physician can supervise or required the physician to be physically present a certain amount of time. Over time, states have moved from strict “supervision” to more flexible “collaboration” requirements.
Today, some states still require a detailed supervision agreement filed with the medical board, while others allow PAs to practice with a more general collaborative understanding with physicians. No state yet gives PAs fully independent practice in the way that many do for NPs, but a growing number have removed the requirement for a specific physician partner, which is a key element of Optimal Team Practice.
At the federal level, scope of practice is also relevant in certain contexts. Federal agencies and programs can set practice rules within their purview. A notable example is the Veterans Health Administration (VA). In 2016, the VA (a federal health system) granted full practice authority to its nurse practitioners, allowing NPs to provide care to veterans in VA facilities without physician supervision, even if located in states that otherwise restrict NPs.
This uniform federal policy was intended to improve veterans’ access to care. (Physician groups lobbied against it, and the VA stopped short of including certified nurse anesthetists in that FPA policy at the time, but NPs, Clinical Nurse Specialists, and Nurse Midwives in the VA were included.) Outside the VA, Medicare and Medicaid laws at the federal level also influence NP and PA practice by determining reimbursement rules.
For instance, Medicare will reimburse NPs and PAs for many of the same services as physicians (typically at 85% of the physician fee), and since 1997 PAs have been able to bill Medicare, but these providers must adhere to state scope laws when billing.
Overall, while federal policy sets some broad parameters (and can encourage states to modernize laws through guidance and incentives), the battle over FPA is fought mostly state by state. This state authority explains why, as we discuss next, the legislative landscape for NPs and PAs is a patchwork – with some states embracing full autonomy and others maintaining strict physician oversight rules.
Nurse Practitioners: State Policy Trends Toward Full Autonomy
More than half of U.S. states have now adopted full practice authority for nurse practitioners, and the number keeps growing each year. As of late 2024, 27 states plus Washington, D.C. allow NPs to practice independently, without mandated physician supervision. This is a dramatic increase from a decade ago. For example, in 2010 only around 12–16 states had FPA for NPs. By February 2023, 26 states had implemented some form of full practice authority, and importantly, no state that granted FPA has ever reversed course. The trajectory is clearly toward more autonomy for NPs.
A 2022 American Association of Nurse Practitioners (AANP) map highlighting states with Full Practice Authority (in green). Kansas became the 26th FPA state in 2022, joining over half the country.
Several recent legislative wins have propelled this momentum. During 2020–2023, a number of states with historically reduced or restricted NP laws passed bills to expand NP practice:
- New York (2022): Made permanent a pandemic-era waiver that had suspended the physician collaboration requirement. As of 2022, experienced NPs in New York no longer need a written practice agreement, effectively achieving FPA.
- Kansas (2022): Passed a bipartisan law (HB 2279) that granted FPA to NPs, making Kansas the 26th state to adopt full practice authority. The law was celebrated as improving patient access, especially in rural Kansas.
- Utah (2023): Enacted a law to grant NPs full practice authority after a transition period, becoming the first state in 2023 to do so.
- Massachusetts (2021): As part of a COVID-19 policy reform, MA adjusted its laws to allow NPs to practice independently after 2 years of supervised practice, moving from “reduced” to “full” practice authority.
- Delaware (2021): Similarly, Delaware had long required a collaborating physician for the first two years of an NP’s career, but now NPs can practice independently after completing that initial period. Delaware is thus often counted among FPA states (with a transitional caveat).
- California (2020 law, implemented 2023–2025): California’s AB-890 created a pathway for NPs to practice without formal physician supervision. As of 2023, California NPs who meet certain experience and certification requirements can practice independently in specific settings, and by 2025, California is expected to fully implement independent practice for qualified NPs. This is a major development, given California’s size (though it’s not fully independent from day one, it’s moving toward FPA via a transition model).
These changes reflect a bipartisan trend: both liberal and conservative states have moved to empower NPs, often driven by the practical needs of increasing healthcare access. For instance, states like Kansas, Utah, and Idaho – not just coastal states – have embraced FPA. Lawmakers have been swayed by research showing that NPs provide safe, effective care and by mounting pressure to alleviate provider shortages in primary care. During the COVID-19 pandemic, many states temporarily suspended practice agreement rules to deploy NPs more flexibly, and finding that patient care did not suffer, some made those changes permanent.
Under full practice authority laws, states may still impose safeguards or transition periods. Several FPA states require newly minted NPs to work under a collaborative agreement for a certain number of hours or years before practicing solo. This is analogous to a residency period. For example, Minnesota requires a 2,080-hour collaborative period for new NPs; Nevada had required 2 years (though recent updates may have removed that).
These measures aim to ensure new NPs have mentoring and support early on, after which they are trusted to practice independently. Even with such provisions, these states are counted as “full practice” because the collaboration is not indefinite – once completed, the NP has full authority.
The impact of these FPA policies is already evident. States with full practice for NPs tend to have more NPs working in rural and underserved areas than states with restrictions. Studies have found that rural patients in FPA states drive shorter distances to access primary care, and rural NPs are more likely to provide primary care when they have full autonomy.
In New Mexico – a state that has had FPA for over 25 years – NPs are an integral part of the healthcare system, and communities accept NPs as primary care providers without hesitation. By contrast, many states that cling to strict oversight rules also suffer severe rural healthcare shortages, highlighting an unfortunate correlation between restrictive laws and unmet needs.
The legislative trend for nurse practitioners is unmistakably toward greater autonomy. Roughly half the states now recognize NPs as full practice providers, and more are considering bills each year. As one policy expert noted, “the trajectory is towards full practice authority” for NPs nationwide. It is widely seen as one key piece to strengthening the primary care workforce for the future.
Physician Assistants: Modernizing Scope and Optimal Team Practice
Physician assistants are also experiencing an evolution in their practice laws, though not as uniformly or rapidly as NPs. By tradition, PAs have worked “dependent” on physician oversight – the very title “assistant” implies it. However, the PA profession and its advocates have been pushing to modernize these rules to better reflect how care is delivered on the ground. The concept of Optimal Team Practice (OTP) encapsulates these efforts, aiming for a team-based model where legal tethering of PAs to doctors is loosened.
Significant progress has been made in the past few years. As of 2024, six states – Iowa, Montana, New Hampshire, North Dakota, Utah, and Wyoming – have eliminated the legal requirement for PAs to have a specific physician contract or supervisor. These states are considered to have the most PA-friendly (or “optimal”) practice environments. In practical terms, PAs in these states can diagnose, treat, and prescribe within their scope without needing a named physician on state paperwork.
They still collaborate with physicians and refer patients as appropriate, but the bureaucratic requirement of a supervision agreement is gone. This provides much more flexibility: healthcare teams or employers can determine how PAs collaborate, rather than rigid state mandates.
Other states have taken intermediary steps: replacing the word “supervision” with “collaboration” in statutes, lifting limits on the number of PAs one physician can work with, or allowing PAs with a certain amount of experience to practice under fewer restrictions. North Carolina is one example of recent reform.
In 2023, North Carolina enacted the “PA Team-Based Practice Act,” which removed the permanent supervision requirement for experienced PAs. Now, PAs in NC with over 4,000 hours of experience no longer need a formal supervisory agreement – a huge change in a state that was formerly restrictive.
South Dakota (2023) similarly passed a law to ease supervision rules, and Oklahoma (2022) updated its PA practice act to allow more autonomy. By 2023, at least 10-15 states had made notable moves toward modernizing PA scope laws, even if only 6 achieved the full “no specific relationship” standard.
It’s worth noting that even in states with the most autonomy, PAs do not have “independent” practice in the same way NPs do because PAs are still ultimately regulated under medical boards (often composed of physicians). PAs also generally cannot open their own practice outright unless a state explicitly allows it.
However, in those optimal-practice states, a PA can, in theory, start a clinic and then hire or consult with physicians as needed, rather than legally requiring a physician owner. The AAPA emphasizes that PAs practicing to the full extent of their training means they will still work in teams – OTP is about removing paperwork, not removing teamwork. In fact, surveys show PAs largely prefer collaborative relationships; they just don’t want laws mandating the terms of those relationships.
The push for PA practice modernization has been driven by many of the same pressures as with NPs: provider shortages, especially in primary care, and the inefficiencies caused by rigid supervisory rules. Many state laws were written decades ago (1960s–1970s) when the PA role was new, and medicine was very physician-centric. Those laws haven’t kept pace with how PAs are utilized today.
For example, some states require a physician to periodically chart-review a percentage of PA patient notes, or to be within a certain mile radius of the PA, rules that can be impractical in rural or underserved settings. Removing these requirements can free PAs to work in remote clinics and reduce administrative burden on practices.
Opponents of loosening PA rules, similar to the NP case, often come from physician organizations. The American Medical Association (AMA) and some specialty societies have objected to PAs gaining independent regulatory boards or too much autonomy. In 2023, the AMA even issued a policy opposing the establishment of separate PA licensing boards in states (preferring physician-led regulation).
Despite this, a few states have set up semi-autonomous PA boards (e.g. Arizona, Iowa, Massachusetts, Rhode Island, and Utah have varying models for PA boards). The trend toward OTP continues: as of 2022, only 3 states had fully adopted OTP (ND, UT, WY), but now with Iowa, Montana, NH added, the number is growing.
For PAs, concrete statistics on outcomes and workforce deployment under OTP are still emerging (since it’s newer than NP FPA). Early indications in states like North Dakota and Wyoming suggest PAs are able to staff rural clinics more easily after removing supervision contracts. PAs also report higher job satisfaction when they are not chained to one physician for their license.
One notable aspect is direct reimbursement: Under OTP, AAPA also advocates that PAs be eligible to receive direct payment from insurers (historically, some insurance programs would only credential physicians or NPs, requiring PAs to bill under a physician’s name). Federal Medicare law was changed in 2022 to allow PAs to bill and be paid directly, which was a victory for the PA profession. This change, while financial, also reinforces the concept of PAs as independent billing providers.
Physician assistant scope of practice is evolving gradually. The key changes are removal of strict supervisory mandates and recognition of PAs as licensed professionals who can collaborate with less red tape. By late 2024, six states set the example with no physician agreement requirement at all. Most other states still require some form of collaboration on paper, but the trend is to ease those rules.
Just like with NPs, the pandemic accelerated recognition of PAs’ capabilities – many states temporarily expanded PA scope during COVID-19 surges. Now, permanent legislative changes are catching up. The end goal for PA advocates is that each healthcare team can determine how best to utilize PAs without one-size-fits-all state rules, thus maximizing the PA’s role in improving access to care.
Stakeholder Perspectives: Supporters vs. Opponents of FPA
The push for full practice authority has generated vigorous debate in the healthcare community. Different stakeholders bring very different perspectives based on their professional interests, training, and concerns for patient care. A neutral, policy-focused view requires understanding both sides.
Nursing Organizations and NP Advocates
Nursing groups are the primary champions of FPA for nurse practitioners. The American Association of Nurse Practitioners (AANP) and the American Nurses Association (ANA) strongly support expanding scope-of-practice laws, seeing them as crucial to meeting healthcare demand. AANP’s official position is that removing practice barriers is “essential to providing timely, cost-effective, quality health care”.
These groups point to over 50 years of research showing NPs’ care quality is comparable to physicians on key outcomes like chronic disease management, preventive care, and patient satisfaction. They also highlight that NPs have over a billion patient visits annually in the U.S. and are well-integrated into primary care.
Nursing advocates frame FPA as a matter of patient access and healthcare equity. They often cite rural access improvements and the ability of NPs to serve communities lacking physicians. The Future of Nursing report (National Academy of Medicine, 2010) famously recommended that nurses should practice to the full extent of their education – a rallying cry for this movement. In sum, NP supporters argue that outdated regulations (“physician permission” rules) hinder the healthcare team’s efficiency and that FPA is a safe, evidence-based way to extend care to those who need it.
Physician Organizations
On the other side, many physician-led organizations have resisted granting FPA to NPs or too much autonomy to PAs. The American Medical Association (AMA) has been particularly vocal, referring to the trend as “scope creep” and warning that expanded NP/PA scope threatens patient safety.
The AMA and groups like the American Academy of Family Physicians (AAFP) often emphasize the differences in training: physicians complete four years of medical school and three to seven years of residency, whereas NPs and PAs typically have 2–3 years of graduate training and less clinical hour requirements. They argue this discrepancy could impact the ability to handle complex cases.
The AMA has cited instances of diagnostic errors or patient harm in clinics run by less-experienced practitioners, though opponents counter that there is no systemic evidence of worse outcomes under NP care. Another concern raised by physicians is that allowing NPs/PAs to practice independently might fragment care or create “two tiers” of care. Physician groups sometimes frame it as patients deserve a doctor-led team, especially for complicated health issues.
That said, not all physicians oppose FPA. Many physicians work in collaborative practices with NPs/PAs daily and recognize their value. Some physician groups have taken a more moderate stance: for example, supporting “team-based care” models where all providers practice to full ability but within an integrated system.
The debate often intensifies around independent practice and reimbursement – physicians worry about losing revenue (many physicians historically billed for NP/PA services under their supervision) and about competition in primary care. As one analysis noted, doctors can stand to lose supervisory fees and referral control if NPs practice independently. The subtext of some opposition is thus as much economic as it is about safety.
Physician Assistant Organizations
The American Academy of PAs (AAPA), like AANP, supports removing unnecessary supervision rules. They carefully message it as maintaining team care but freeing the team from archaic legal tethering. AAPA’s advocacy materials highlight that current laws in many states are out-of-date and don’t reflect modern healthcare delivery. They cite that mandated relationships can “weigh down healthcare teams” and reduce flexibility.
AAPA has also pointed out that no evidence shows states with greater PA autonomy have worse outcomes, and that PAs are trained and certified via a national exam similar to physician boards. In advocating for OTP, AAPA frequently emphasizes that healthcare is evolving and that PAs practicing at the top of their license will improve access without compromising quality. The organization has faced a bit less public heat than AANP because the NP vs. MD debate has been more prominent, but in recent years, as PAs seek more independence, the AMA and others have extended their “scope creep” arguments to PAs as well.
Hospitals and Health Systems
Institutional employers often support expanded scope for NPs and PAs, albeit sometimes with internal policies to ensure quality. Hospitals, especially those in rural areas or safety-net systems, have testified in favor of FPA laws because they struggle to recruit enough physicians. Having NPs who can admit patients, lead clinics, or staff the ED in collaboration with a physician (but not necessarily on-site) is a huge asset. During COVID-19 surges, many hospital systems leaned on NPs/PAs to run testing sites, infusion centers, etc., and saw firsthand that they could perform those tasks independently.
Some hospital associations have endorsed NP FPA bills (e.g., in states like California and Massachusetts) to help address workforce shortages. On the other hand, some hospitals – particularly academic medical centers or those closely tied to physician groups – have been more cautious, sometimes echoing physicians’ concerns.
Overall, from a cost and staffing perspective, many administrators view empowered NPs/PAs as a solution to care gaps. Nurse-managed health centers and retail clinics (like CVS MinuteClinic) are examples of care models that thrive under FPA and have been supported by industry.
Patients and Advocacy Groups
Patient opinion on this issue is less organized, but surveys show that patients are generally satisfied with NP and PA care. In fact, a national survey of Medicare beneficiaries found no differences in patient satisfaction between those seen by NPs versus physicians, and some studies show NPs often score higher on measures like time spent with patient and patient education. In rural towns that have gained an NP-led clinic, patients are often the biggest proponents of NP independence because it may be the only local source of care.
Consumer advocacy groups (like AARP) have tended to support expanded NP scope, framing it as an access issue for their members. There is also an element of health equity: communities of color and low-income populations, who are more likely to live in primary care shortage areas, stand to benefit when NPs/PAs can fill provider roles. Lawmakers hear from these constituencies as well – many state legislators pushing FPA cite the pleas of constituents who simply want someone to take care of them, regardless of letters after the name.
In state legislatures, the battle often pits the nurse practitioner associations vs. state medical societies. Lawmakers must weigh the evidence and the often intense lobbying on both sides. In recent years, the trend has been that NPs and PAs are winning more of these debates, aided by data from studies and the urgency of provider shortages. Yet, in some states the resistance remains stiff.
For example, in states like Texas, California (until recently), and Florida, physician groups managed to block or water down FPA bills for years. But even some of those holdouts are slowly changing (California’s 2020 law being a prime example of compromise).
Supporters of FPA (NPs, PAs, many healthcare organizations, and patient advocates) argue it is a common-sense modernization that improves access, and they back it up with research on quality and outcomes.
Opponents (some physicians and their associations) raise caution about training differences and potential safety issues, advocating for maintaining physician-led team structures.
The debate is both practical (how to deliver care to more people) and professional (how roles and hierarchies are defined in healthcare). The end result in each state often depends on finding a balance that assures quality while increasing flexibility – for instance, adding transitional supervision periods or collaborative practice agreements of limited duration, rather than requiring lifetime supervision.
Impact on Patient Care and Outcomes
A central question in the FPA discussion is: How does it affect patient care? Numerous studies over decades have examined NP and PA outcomes, and the overwhelming consensus in the research literature is that NPs and PAs provide care of equal quality to physicians on many primary care and preventive metrics. When allowed to practice to the full extent of their training, NPs have demonstrated comparable patient health outcomes in managing chronic conditions like diabetes and hypertension, and often excel in patient education and preventive care.
For example, a cohort study of diabetes patients in veterans’ primary care found no significant differences in blood sugar control or complication rates between patients managed by NPs, PAs, or physicians. Some outcomes were actually better for NP-managed patients, such as slightly fewer preventable hospitalizations in one study.
Patient safety indicators also show no detriment with NP care. A 2022 analysis published in the Journal of Health Economics and Outcomes Research found “no evidence that changing to FPA from a more restrictive legal environment increased rates of paid malpractice claims against NPs”. In other words, giving NPs full autonomy did not lead to more malpractice issues. This undercuts arguments that patient harm would increase. Malpractice insurers have also noted that premiums for NPs in FPA states have not spiked – another indirect sign that risk has not gone up.
Patient satisfaction tends to be very high with NPs and PAs. A massive survey of over 50,000 patient satisfaction scores found that those treated by NPs reported as high or higher satisfaction than those treated by physicians. Patients often cite NP/PA strengths as being good communicators, spending time listening, and providing holistic care. These factors contribute to adherence and positive experiences, which are important outcomes themselves.
In terms of clinical outcomes, systematic reviews (including one by the Cochrane Collaboration and others) have concluded that appropriately trained NPs in primary care can achieve outcomes equivalent to physicians in measures like blood pressure control, diabetes management, mortality, and health status. One randomized trial in primary care found no differences in patient health outcomes over two years between patients randomized to NP-led care vs physician-led care.
Additionally, some studies have noted that NPs and PAs are more likely to provide certain guideline-recommended services – for instance, NPs often document higher rates of health education, counseling, and preventive screenings. This may be due to their nursing background emphasizing patient-centered education.
Another impact area is healthcare utilization and cost. Several studies indicate that when NPs have full practice authority, there may be a cost-benefit. One analysis of Veterans Health Administration data showed patients of NPs had outcomes comparable to physician patients but with slightly lower overall healthcare expenditures.
Lower costs can result from NPs/PAs potentially ordering fewer expensive tests (findings are mixed on this – some studies show they order slightly more imaging or labs in certain scenarios, but not necessarily in a way that worsens outcomes). Importantly, increased use of NPs/PAs has been associated with reductions in emergency room visits and hospitalizations for some populations, likely because patients get timely primary care instead of delaying until a crisis. A recent review noted that states with FPA saw fewer unnecessary ED visits per capita, suggesting that patients are getting their needs met in primary care settings more effectively.
Health equity and outcomes in underserved populations also see a positive impact. As mentioned earlier, rural patients in FPA states tend to have improved access metrics, like shorter travel distances for care. Outcomes for chronic disease in rural areas can improve when an NP-led clinic opens and provides consistent management.
There are case studies, for example, of rural Arizona and New Mexico communities where NP-run practices have significantly increased rates of blood pressure control in the local population. While physician-led care could theoretically do the same, the presence of any provider is the first hurdle – FPA laws make it more feasible for an NP to be that provider in remote areas.
One caveat: Complex and acute cases. Opponents of FPA often concede that NPs are great for routine primary care but worry about complex diagnoses. The evidence here is also reassuring: Nurse practitioners in acute care (like ICU settings) have been studied, and outcomes for ICU patients managed by NP-physician teams were equivalent to those managed by resident physician teams in terms of mortality and length of stay. PAs in surgical roles have also shown similar post-operative outcomes when assisting in surgery and managing inpatient care.
Of course, NPs/PAs are not performing complex surgeries or high-level procedures beyond their training; FPA doesn’t change that. Instead, it allows them to do things like make referrals, order tests, or initiate treatments without jumping through hoops. In settings where collaboration is truly needed (e.g., a very complex case), NPs and PAs still collaborate and refer – FPA does not equate to practicing in isolation.
As Dr. Joanne Spetz noted, “NPs are professional clinicians. They collaborate and consult with other providers as any professional would”. FPA simply means the law doesn’t force a specific collaboration structure; it happens organically as needed for patient care.
In summary, the impact of FPA on patient care outcomes has been extensively studied and has shown neutral to positive results. Quality of care remains high, patient safety is not compromised, and patient satisfaction often improves. By enabling NPs and PAs to manage more of patients’ healthcare needs, FPA can lead to earlier interventions and better continuity of care, which in the long run improves health outcomes. These findings underpin why many healthcare policymakers and researchers support expanding practice authority – it’s seen as a win for patients, not just providers.
Addressing Provider Shortages, Costs, and Health Equity
The move toward full practice authority is frequently justified in the context of broader healthcare system challenges – notably, workforce shortages, rising costs, and inequitable access to care. Here’s how FPA and related reforms intersect with these issues:
Provider Shortages
The United States faces a well-documented shortage of primary care physicians. The Association of American Medical Colleges projects a shortfall of up to 48,000 primary care doctors (and even more specialists contributing to a total shortage of 124,000 physicians) by the early 2030s. Nurse practitioners and physician assistants are helping to mitigate this gap. In many regions, NPs/PAs are the ones stepping into roles that might otherwise remain unfilled.
Granting full practice authority is like “removing the handcuffs” – it allows the tens of thousands of NPs/PAs who could serve in underserved areas to do so without needing a physician on-site or on paperwork. Statistics back this up: the NP workforce is growing rapidly, with a projected 45% increase in NP employment from 2022 to 2032, making it one of the fastest-growing roles in healthcare. By empowering this growing workforce, states can alleviate pressure on overextended physicians. In rural America, as we’ve discussed, FPA is correlated with more NPs practicing in those communities.
Similarly, PAs with fewer practice restrictions can be deployed in community health centers, correctional facilities, and other high-need settings that struggle to recruit physicians. Full practice authority won’t single-handedly solve provider shortages – the U.S. still needs to train and retain more clinicians of all types – but it is an immediate, actionable strategy to get available providers to practice where they’re most needed.
Cost of Care
Healthcare economists are interested in FPA because of its potential to bend the cost curve. NPs and PAs generally have lower salaries than physicians, and if they can provide a large portion of services at a lower labor cost, that can translate into savings for health systems and possibly payers.
One study in Nursing Outlook found that states with full NP practice had lower outpatient costs per beneficiary in Medicare compared to restricted states, hypothesizing that increased use of NPs led to cost efficiencies. Another analysis estimated that eliminating restrictive NP laws nationwide could save billions in unnecessary health expenditures by optimizing the primary care workforce (for example, by reducing ER visits and duplicative tests). Moreover, NP- and PA-led clinics often have lower overhead and can charge less – retail clinics staffed by NPs have been shown to deliver care for minor illnesses at significantly lower cost than physician offices or urgent care, with similar outcomes.
From a patient perspective, increased supply of qualified providers can also mean shorter wait times and potentially lower prices. Critics argue that if NPs/PAs order more tests or referrals (sometimes noted in studies), those costs could offset labor savings. However, data doesn’t indicate an explosion of costs in FPA states; if anything, the competition and improved access tend to reduce costly utilization like emergency visits. Overall, while quality is key, the cost considerations are a major reason many payers and large health employers back FPA. It’s a way to get “more bang for the buck” in healthcare delivery without sacrificing quality.
Health Equity and Access
Full practice authority is often hailed as an equity intervention. Medically underserved areas – whether inner-city neighborhoods or rural counties – bear the brunt of provider shortages. These areas often have higher proportions of minority and low-income residents, so lack of access exacerbates health disparities.
By enabling NPs and PAs to set up practice or deliver care in underserved areas without unnecessary barriers, states can improve access for marginalized populations. For instance, nurse practitioners are more likely than physicians to practice in rural areas when the state laws allow them to do so independently, as discussed earlier. FPA states have also seen growth in the number of retail and convenient care clinics, which tend to serve uninsured or underinsured populations with affordable walk-in care.
Another aspect is cultural representation: the NP workforce has a higher percentage of racial minorities and women, and many choose to work in community settings. Empowering these clinicians can improve culturally competent care in communities of color. Health equity also involves continuity of care – in underserved regions with high provider turnover, having an NP who can consistently manage patients (instead of a revolving door of distant supervising physicians or temporary docs) makes a difference. Additionally, FPA can facilitate innovative care models like telehealth.
During the pandemic, many NPs provided telehealth across state lines to underserved areas; some restrictive laws were relaxed to allow this, and making those changes permanent could ensure, say, a rural diabetic patient can consult with an NP specialist via telemedicine rather than forgoing care.
All told, FPA is seen by many public health experts as a tool to reduce geographic and socioeconomic disparities in access, by fully deploying the skilled non-physician workforce to the areas of greatest need.
A Changing Healthcare Team
The push for full practice authority for NPs and greater autonomy for PAs reflects a broader shift in healthcare delivery. Team-based care is replacing the old model of physician-as-sole-authority. In an era of complex, chronic diseases and provider shortages, healthcare teams are most effective when each member can contribute maximally. The evolving legislative landscape in the U.S. shows a clear trend of states recognizing the importance of NPs and PAs in meeting healthcare demand.
More than half the country now enables nurse practitioners to practice independently, and a growing number of states have dropped antiquated supervision rules for PAs. Evidence from these states demonstrates that patients benefit through maintained or improved quality of care and greater access.
Of course, implementing FPA is not without challenges. Transitioning to new care models requires coordination – for example, nursing and medical boards must work together on rules, and interdisciplinary training in team-based practice is essential. It’s also important to ensure that education and certification for NPs and PAs continue to evolve, preparing them for the expanded responsibilities they carry under FPA. This might include additional clinical fellowships or residencies for those going into very complex practice areas, which some states or institutions are already encouraging.
The support and resistance surrounding FPA will likely persist in some form. However, the trajectory suggests that resistance may soften as more data accumulates from FPA states and as more physicians come to value working with empowered NPs/PAs in their practices. Notably, younger physicians and those in value-based care settings often have more favorable views of NP/PA independence, seeing it as part of a high-functioning team.
For policymakers, the focus remains on how to deliver safe, effective healthcare to all Americans. Full practice authority for nurse practitioners, and optimal team practice for physician assistants, have proven to be policy levers that can increase the supply of primary care providers, improve timeliness of care, and do so without harming quality or safety. In fact, these changes can enhance quality by extending preventive and continuous care to populations that previously had limited access.
In conclusion, the evolving healthcare team is one where physicians, nurse practitioners, and physician assistants each play vital, complementary roles. The push for FPA is about updating laws to catch up with the reality that NPs and PAs are already integral to healthcare delivery. It emphasizes using our full healthcare workforce efficiently to address today’s challenges.
As more states and federal entities embrace this approach, we move closer to a system in which every provider can contribute at their highest level, and every patient can receive timely, competent care – the ultimate goals of healthcare policy. The journey is ongoing, but the momentum behind full practice authority signals a constructive change in how care is delivered by the modern healthcare team.
