Expanding Access to Care: Scope of Practice Laws

The United States is experiencing a deficit in healthcare providers, especially physicians. This deficit is expected to increase as the population segment aged sixty-five and older continues to rapidly age. As a result of the increasing demand, some state boards are expanding the scope of practice for advanced practice nurses (nurse practitioners), physicians assistants, and other clinicians (clinical psychologists and others) to perform duties traditionally reserved for a licensed physician. For example, in some states, nurse practitioners have the authority to prescribe medications. Likewise, pharmacists are permitted to provide flu shots.

Despite intentions to fill the gap of a provider deficit, changing the scope of practice for healthcare professionals has received mixed reviews. Many healthcare associations and medical societies are voicing their strong opposition against these practices.

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  • Expanding Access to Care: Scope of Practice Laws

Considering the recent paradigm shift in healthcare, discuss this movement and its implications for competition. How can changing the prescribed privileges of a provider affect competition? What benefits and challenges exist as a result of expanding the scope of practice for a clinician? Considering this new entry into the market, is this type of competition considered disruptive innovation? Why or why not?

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2016 public health law conference • spring 2017 33

The Journal of Law, Medicine & Ethics, 45 S1 (2017): 33-36. © 2017 The Author(s)

DOI: 10.1177/1073110517703316

A
llied healthcare professionals play an integral
role in the healthcare system: healthcare teams
depend on nurses; comprehensive patient care

often cannot be achieved without a pharmacist; den-
tal offices thrive with the work of dental hygienists;
and emergency medical technicians play a vital role in
emergency care. The contributions of these and other
allied healthcare professionals are typically defined
by state laws governing the particular practice. These
laws may be hurdles or enablers to expanding access
to care in a community. We examine scope of practice
laws for nurse practitioners (NPs) and allied dental
providers to demonstrate how these laws may impact
access to care and population health.

Nurse Practitioners
Nurse practitioners (NPs) have rapidly become inte-
gral to the healthcare workforce, particularly primary
care. In 21 states and the District of Columbia, NPs
have “full practice authority,” meaning they can prac-
tice to the full extent of their education and training
without physician oversight.1 In the remaining 39
states, NPs can practice to their full scope — including
prescribing medications and serving as primary care
providers — if they have a physician practice, or “col-
laborative,” agreement.

Multiple independent bodies have synthesized
decades of research on NP care and consistently iden-
tify NPs as high-quality providers of cost-efficient care
that can expand access. Thus, fully leveraging the NP

role can advance the Triple Aim: better care, reduced
costs, and improved health. Yet while research on the
potential of optimizing NP practice abounds, fewer
studies explore the practical implications of remov-
ing barriers to independent practice and the actual
impact on care, cost, and health.

Better Care
The National Governors’ Association conducted a
30-year literature review and concluded that NPs pro-
vide primary care equal in quality to physicians; and
on several indicators, including patient satisfaction,
NPs perform better.2 In 2014, the Federal Trade Com-
mission questioned the value of legislative restraints
on NP practice, which have historically protected
physicians, and called upon states to narrowly tai-
lor limitations on practice “to address well-founded
health and safety concerns.”3 There is no evidence
that care provided by NPs in states requiring physi-
cian collaboration is better — or worse — than in
states that enable NPs to practice independent of such
agreements. Administrative burdens that arise from
requiring a collaborative practice agreement arguably
threaten patient satisfaction and reduce time for care
in both physician and NP practices. Evidence from
progressive states supports that care quality is not
compromised; further research is needed to better
understand that dynamic.

Reduced Cost
Since 1981, studies have found that NP care matches
the quality of physician care at equal or lower cost.4
Research on the cost of NP care has increasingly
focused on the cost savings due to the type of care typi-
cally provided by nurse practitioners (e.g., noninvasive
treatments, self-managed chronic conditions), beyond

Expanding Access to Care:
Scope of Practice Laws
Kathleen Hoke and Sarah Hexem

Kathleen Hoke, J.D., is the Director of the Network for Public
Health Law — Eastern Region and a professor at the Uni-
versity of Maryland Carey School of Law. Sarah Hexem,
J.D., is the Policy Director at the National Nurse-Led Care
Consortium.

34 journal of law, medicine & ethics

J L M E S U P P L E M E N T

The Journal of Law, Medicine & Ethics, 45 S1 (2017): 33-36. © 2017 The Author(s)

the historical focus on lower salaries, reimbursements
rates, and cost of education.5 However, little research
exists quantifying the cost of practice barriers. Anec-
dotal evidence suggests that the cost NP practices pay
for collaborative agreements can be prohibitive and
varies by market. The administrative burden associ-
ated with collaboration also has a cost for which the
collaborating NP practice is not compensated. Thus,
while the NP care is cost-effective, cost barriers may
limit the extent to which NPs can deliver that care.
Laws enabling full practice alleviate those burdens
and costs for NPs as well as collaborating physicians.

Improved Health
With 20 million newly insured, an aging population,
and pervasive health disparities, the need for mean-
ingful access to high-quality, cost-effective primary

and preventive care has never been greater. Improv-
ing population health by securing access to care for
more individuals has been a driving force in the push
to remove barriers to NP care.6 One study found a
strong association between restrictions on NP prac-
tice and the percentage of patients with NP primary
care providers; the fewer barriers to access to NPs, the
higher the percentage of patients receiving primary
care from NPs.7 As states continue to modernize their
laws, the natural experiment of federalism provides
an opportunity to explore variations across states. An
even greater research gap stems from full appreciation
of the barriers to access beyond state laws requiring
physician oversight. For example, a law may require
collaborative agreements, but leave the terms of that
agreement to providers’ discretion. State law might
provide NPs with full practice authority, yet the man-
aged care organizations in the state might not include
NPs within their network or contract with NPs as pri-
mary care providers. As states increasingly remove
legislative barriers to practice, it is imperative that
researchers continue to analyze the impact of those
policies to fully optimize the care delivered by NPs.

Evidence-based policy on NP practice has evolved
over decades. Lessons learned from this experience
can be helpful in developing policy on enhanced scope
of practice for other allied health professionals, though
each area of practice involves different issues of train-
ing, education, access, and types of care.

Allied Dental Providers
Timely preventive dental care is critical to both oral
health and overall health. Lack of access to dental care
is particularly acute among the elderly and individu-
als from low-income and rural communities; people
of color disproportionately lack access to dental care.8
Many factors contribute to lack of access, including
low income, lack of insurance, low health literacy, and
a dearth of dentists in some areas.9 One approach to
increasing access is expanding the scope of practice

of allied dental providers, such as dental hygienists,
therapists and assistants. Allied dental providers may
be more plentiful in and available to rural and under-
served communities where dentists may be sparse or
unavailable.10 States have explored expanded scope
options and researchers are encouraged to evaluate
the new provisions and pilot programs to determine
whether the goal of increased access is met without
diminution in quality of care.

Telemedicine
State laws govern the practice of allied dental provid-
ers, including defining the scope of practice for each
type of provider. These scope provisions generally
address the required level of supervision by a dentist,
including variations in certain settings, and the type
of services allied dental providers may perform.11 One
approach to enhancing the reach of allied dental pro-
viders is to permit the required supervision by a den-
tist via telemedicine. Alaska now allows telemedicine
for supervision in designated remote areas;12 Califor-
nia recently expanded a pilot program that broadens
the scope of practice for allied dental providers to

Multiple independent bodies have synthesized decades of research
on NP care and consistently identify NPs as high-quality providers of cost-
efficient care that can expand access. Thus, fully leveraging the NP role can

advance the Triple Aim: better care, reduced costs, and improved health.
Yet while research on the potential of optimizing NP practice abounds,
fewer studies explore the practical implications of removing barriers to
independent practice and the actual impact on care, cost, and health.

Hoke and Hexem

2016 public health law conference • spring 2017 35
The Journal of Law, Medicine & Ethics, 45 S1 (2017): 33-36. © 2017 The Author(s)

better enable the use of telemedicine.13 Delaware and
Arizona allow dentists to practice via telemedicine in
certain circumstances,14 and given the trend in this
direction, we can expect other states to pass such laws.
States should be encouraged to make clear in these
provisions that telemedicine may be used to satisfy the
supervision requirement.

Practice by Setting
Another approach is to permit independent practice by
allied dental providers in certain settings. Many state
laws describe the different practice settings in which
allied dental providers may perform dental services;
these provisions typically allow for lesser supervision
by a dentist but balance that with a slightly modified
scope of practice or impose certain qualifications on
the providers who may practice in the special settings.
Although most patients receive dental care in the
traditional setting of a private dentist’s office, many
receive care in institutional or public practice settings.
This is particularly true for vulnerable populations.
Increasing access to care in these settings could allow
for care to reach those who otherwise cannot physi-
cally or financially gain access.

Public health settings are the most common prac-
tice setting in which an allied dental provider may
practice independently or with less supervision than
in the private setting. What qualifies as a public health
setting is determined by state law; states commonly
include federally qualified health centers, state or
local public health facilities, long-term care institu-
tions, Head Start and WIC centers, and schools. Some
programs provide care to homebound individuals. In
2015, Illinois created the “public health dental hygien-
ist” who may practice independently in a variety of
public settings.15 Maryland recently expanded its law
to include long-term care facilities,16 and Arizona
expanded its law to include long-term care facilities,
private schools, and homebound settings.17 Modifying
the supervision rules in these settings may increase
access to care and improve public health as long as
patient safety and quality of care are assured.

Dental Therapists
Emerging state laws are addressing the access issue
by expanding the type of allied dental providers per-
mitted to practice, particularly creating the dental
therapist, mid-level professionals who provide basic
preventive and restorative oral healthcare. Compared
to other allied dental providers, state and tribal laws
tend to grant an expansive scope of practice, require
less supervision, and may specify permissible practice
settings for therapists. The Commission on Dental
Accreditation recently approved national accredita-

tion standards for dental therapy education, which
may facilitate development of a consistent scope of
practice for the field.18 The Alaska Native Tribal Health
Consortium created the first U.S. dental therapists in
2005. Minnesota law has recognized dental thera-
pists and advanced dental therapists since 2009.19
Like some NPs, these dental therapists must enter
into a written collaborative management agreement
with a dentist and must practice primarily in settings
that serve low income, uninsured, and underserved
patients or in a dental health professional shortage
area. Maine and Vermont recently passed laws creat-
ing the dental therapist, who may practice more inde-
pendently.20 With more rigorous education and train-
ing requirements than dental hygienists, the dental
therapist may safely provide quality care, increasing
access particularly to vulnerable populations.

Conclusion
While the nurse practitioner example is illuminating
for those seeking to increase access to oral health-
care through expanded scope of practice, research on
the effectiveness and impact of the various state law
approaches on oral health is nascent. And there are
confounding issues, such as the fact that health insur-
ance rarely includes dental care and dental insurance
can be costly. Yet innovative policy approaches to
expanding access to oral healthcare should be encour-
aged — then evaluated. Given the high demand for
oral healthcare — indeed all healthcare — policymak-
ers should consider options that are rational but may
not yet have a full evidence base. Pilot programs can
help in that regard.

Public health improves as access to quality health-
care expands. One mechanism to expand access to
care is allowing allied healthcare providers to practice
at the top of their license. As state and tribal laws take
on this issue, we encourage researchers to study the
public health and economic impact, informing poli-
cymakers and public health officials of the factors that
will help meet the Triple Aim: better care, reduced
costs, and improved health across the population.

References
1. K. Thompson and S. Hexem, “National Nurse-Led Care Con-

sortium,” Nurse Practitioner Prescribing Laws, available at
(last visited
January 11, 2017).

2. National Governors Association, NGA Paper: The Role of Nurse
Practitioners in Meeting Increasing Demand for Primary Care
(2012).

3. Federal Trade Commission Staff, Policy Perspectives: Competi-
tion and the Regulation of Advanced Practice Nurses (2014).

4. R. Newhouse et al., “Advanced Practice Nurse Outcomes 1999-
2008: A Systematic Review,” Nursing Economics 29, no. 5
(2011): 1-22; Office of Technology Assessment, The Cost and

36 journal of law, medicine & ethics

J L M E S U P P L E M E N T
The Journal of Law, Medicine & Ethics, 45 S1 (2017): 33-36. © 2017 The Author(s)

Effectiveness of Nurse Practitioners (Washington, D.C.: US
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5. See J. A. Coddington and L. P. Sands, “Cost of Health Care
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6. T. S. Bodenheimer and M. D. Smith, “Primary Care: Pro-
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More Physicians,” Health Affairs (Project Hope) 32, no. 11
(2013): 1881-1186; D. I. Auerbach, “Nurse-Managed Health
Centers and Patient-Centered Medical Homes Could Mitigate
Expected Primary Care Physician Shortage,” Health Affairs 32
no. 11 (2013): 1933-1941; Institute of Medicine (IOM), The
Future of Nursing: Leading Change, Advancing Health (Wash-
ington, D.C.: The National Academies Press, 2011); Health
Resources and Services Administration, Department of Health
and Human Services, Projecting the Supply and Demand for
Primary Care Practitioners through 2020 (November 2013).

7. Y.-F. Kuo et al., “States with the Least Restrictive Regulations
Experienced the Largest Increase in Patients Seen by Nurse
Practitioners,” Health Affairs (Project Hope) 32, no. 7 (2013)
1236-12343.

8. Institute of Medicine and National Research Council, Com-
mittee on Oral Health Access to Services, Board on Children,
Youth, and Families, Board on Health Care Services, Improv-
ing Access to Oral Health Care for Vulnerable and Underserved
Populations, HRSA.gov. 2011, available at
(last visited January 12, 2017).

9. National Governors Association, The Role of Dental Hygienists
in Providing Access to Oral Health Care, NGA.org. 2016 [cited
1 July 2016], available at (last visited
January 12, 2017).

10. M. Doescher, Keppel G. Dentist Supply, Dental Care Utiliza-
tion, and Oral Health among Rural and Urban U.S. Residents

(Seattle, WA: WWAMI Rural Health Research Center, Univer-
sity of Washington, 2015); K. Bell, “Evaluating the Impact of
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11. The Network for Public Health Law, “Dental Auxiliary Scope of
Practice Laws,” Networkforphl.org, 2014, available at (last visited Janu-
ary 13, 2017).

12. C. Beatty, Community Oral Health Practice for the Dental
Hygienist, 4th ed. (St. Louis: Elsevier, Inc.; 2016).

13. D. Hernandez, “California to Launch Medicaid-Funded Tele-
dentistry,” September 29, 2014, available at
(last visited January 13, 2017).

14. Del. Code Ann. tit. 24, § 1101; Ariz. Rev. Stat. Ann. § 36-3601.
15. 225 Ill. Comp. Stat. Ann. 25/4.
16. Md. Code Ann., Health Occ. § 4-308.
17. Ariz. Rev. Stat. Ann. § 32-1281/
18. Commission on Dental Accreditation, Accreditation Standards

for Dental Therapy Education Programs (2016), available at

(last visited January 13, 2017).

19. W.K. Kellog Foundation, Innovation in Alaska & Minnesota:
Take a Look at Two Innovative Approaches Utilizing Mid-
Level Dental Provider Models, available at (last visited January 13, 2017).

20. ADHA, Dental Therapists Now Recognized in Vermont, Press
Release, 2016, available at (last visited January 13, 2017).

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