According to its website, the mission of the American Medical Association (AMA) is to “promote the art and science of medicine and the betterment of public health.” The AMA is also a lobbying organization that promotes the self-interest of its members: physicians and medical students. But sometimes the greater good does not mesh with the self-interest of physicians. And sometimes the AMA put self-interest first.
Such is the case with the AMA’s relentless campaign against allowing nurse practitioners (NPs) full authority to practice without physician supervision. The AMA campaign often targets pending legislation that would grant NPs greater authority to practice without supervision, as happened a few years ago in California. Here’s what the AMA said about the California legislation:
The AMA is strongly urging California Gov. Gavin Newsom to veto a bill—A.B. 890—that would allow independent practice nurse practitioners [NPs] to practice without physician supervision. In a letter to Newsom, AMA Executive Vice President and CEO James L. Madara, MD, explains that the bill “will not expand access to care in rural and underserved areas, increases overall health care costs and threatens the health and safety of patients in California.” - 3 big reasons why letting NPs practice independently is a bad idea. By Kevin B. O'Reilly , Senior News Editor/American Medical Association. September 14, 2020
I’ll tackle the first “big reason” for not letting NPs work independently in this post.
The AMA says it won’t solve the rural access problem. “Oregon, for example, has for decades allowed independent practice for NPs, yet “there is no measurable shift of nurse practitioners to the rural areas,” Dr. Madara wrote, pointing to maps illustrating the state’s health workforce patterns.” Is that actually true? Consider the following:
Current information on nurse practitioners in rural Oregon and elsewhere in US: To quote AI Overview, accessed 8/4/25 (links to original data at end of post): The number of licensed NPs in Oregon has shown remarkable growth, with an average annual growth rate of about 8.5% since 2010. There's a growing presence of NPs in rural practices. While urban areas have a larger total number of NPs, the proportion of Primary Care Nurse Practitioners (PCNPs) is actually higher in rural areas when measured against per capita population figures. The growing NP supply in rural areas is helping to offset the low physician supply, potentially increasing primary care capacity in underserved communities. Research suggests that NPs are more likely to work in rural areas compared to physicians, partly due to educational pathways that support training in local communities.
What other researchers say:
This systematic review was performed using Medline, CINAHL, PsycINFO, and PubMed according to Preferred Reporting Items for Systematic and Meta-Analysis on the literature from January 2000 to August 2019. The results indicate that expanded state NP practice regulations were associated with greater NP supply and improved access to care among rural and underserved populations without decreasing care quality. This evidence could provide guidance for policy makers in states with more restrictive NP practice regulations when they consider granting greater practice independence to NPs. – Yang et al, 2020.
State full SOP [Scope of Practice] regulation was associated with higher NP supply in rural and primary care HPSA counties [Health Professional Shortage Areas]. Regulation plays a role in maximizing capacity of the NP workforce in these underserved areas, which are most in need for improvement in access to care. This information may help inform state regulatory policies on NP supply, especially in underserved areas. – Xue et al, 2018
It should be clear here that the AMA simply ignores evidence that doesn’t support their case against NP independence. And that case is about self-interest, not the public good.
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Links:
https://pmc.ncbi.nlm.nih.gov/articles/PMC6080248/ https://www.oregoncenterfornursing.org/wp-content/uploads/2024/07/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
https://digitalcollections.ohsu.edu/record/685?v=pdf
https://pmc.ncbi.nlm.nih.gov/articles/PMC6583766/
https://healthforce.ucsf.edu/news/policy-perspective-how-nps-expand-healthcare-access-rural-areas
https://www.dailynurse.com/oregon-study-state-needs-primary-care-nps/
https://www.aanp.org/advocacy/state/state-practice-environment
https://www.beckershospitalreview.com/quality/nursing/states-by-nps-per-capita-2024/
References:
Lozada, M.J., Raji, M.A., Goodwin, J.S. et al. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J GEN INTERN MED 35, 2584–2592 (2020). https://doi.org/10.1007/s11606-020-05823-0
McMichael, B.J. (2021), Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing. The Milbank Quarterly, 99: 721-745. https://doi.org/10.1111/1468-0009.12524
Makeeva, Valeria, C. Matthew Hawkins, Andrew B. Rosenkrantz, Danny R. Hughes, Laura Chaves, and Richard Duszak Jr. "Diagnostic imaging examinations interpreted by nurse practitioners and physician assistants: a national and state-level Medicare claims analysis." American Journal of Roentgenology 213, no. 5 (2019): 992-997. https://doi.org/10.2214/AJR.19.21306
Mizrahi DJ, Parker L, Zoga AM, Levin DC. National Trends in the Utilization of Skeletal Radiography From 2003 to 2015. J Am Coll Radiol. 2018 Oct;15(10):1408-1414. DOI: 10.1016/j.jacr.2017.10.007 Epub 2018 Mar 23. PMID: 29580717.
Yang BK, Johantgen ME, Trinkoff AM, Idzik SR, Wince J, Tomlinson C. State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. 2020;78(3):183-196. doi:10.1177/1077558719901216
Xue, Ying, Viji Kannan, Elizabeth Greener, Joyce A. Smith, Judith Brasch, Brent A. Johnson, and Joanne Spetz. "Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties." Journal of Nursing Regulation 8, no. 4 (2018): 5-13.https://doi.org/10.1016/S2155-8256(17)30176-X