Why Occupational Licensing is a Progressive Issue

Sarah Kliff looks at a campaign by the American Academy of Nurse Practitioners to expand the number of medical procedures they are allowed to perform.

The issue here is that different states have different “scope of practice” laws that determine the level of training necessary to perform a procedure.

For instance, some states require a dentist to be in the room when a dental hygienist cleans your teeth. Naturally this makes teeth cleanings much more expensive. It also means that a hygienist can’t just open a walk-in teeth cleaning practice in a low-income neighborhood, because she’d need to have a dentist on-site, and this would make the service prohibitively expensive for a lot of people.

This is one of the reasons American health care is so expensive. Incumbent service-providers are constantly adding to the list of jobs you need state approval to do, and this is pushing up prices. We could have much cheaper primary care in this state if we increased the number of procedures that nurse practitioners could perform, which would be great for nurse practitioners and great for middle class and lower income consumers of medical care:

The campaign looks to exploit what many say is a looming doctor shortage. The Association of American Medical College predicts that the country will have 63,000 too few doctors as soon as 2015.

“With the serious shortage of family doctors in many parts of the country, nurse practitioners — or NPs as they are known — can provide expert, compassionate and affordable care,” the group will contend in a radio public service announcement.

The AANP will follow up on the public relations blitz with state-level lobbying efforts, looking to pass bills that will expand the range of medical procedures that their membership can perform.

“A fully enabled nurse practitioner workforce will increase access to quality health care, improve outcomes and make the health-care system more affordable for patients all across America,” Jensen said.

All states have “scope of practice” laws, which regulate what medical procedures each profession can, and cannot, perform, given their level of education. These laws regulate everyone from dental hygienists to physician assistants up to nurse practitioners, who all hold graduate degrees in medical education.

In 16 states, nurse practitioners can practice without the supervision of another professional such as a doctor. Other states, however, require a physician to sign off on a nurse practitioner’s prescriptions, for example, or diagnostic tests.

As the health insurance expansion looms, expanding those rules to other states has become a crucial priority for nurse practitioners. “We’re all educated and prepared to provide a full range of services,” said Taynin Kopanos, AANP’s director of state government affairs.


  1. This is an area of study that needs a LOT more attention, and you are quite right to bring it up.

    A few years ago in Massachusetts a drugstore wanted to have NPs in the stores in poorer neighborhoods to do basic medical checks for a low flat fee. Naturally, the local AMA and the mayor of Boston raised holy heck, because their “standard” is being seen by a doctor. Leaving aside that a NP today has much of the training that a doctor did decades ago–folks lose sight that the choice is often between seeing an NP and being seen by nobody.

  2. I am an RN and do not believe that nurse practitioners should be given a larger scope of practice. If a nurse thinks she should have that privilege, then she should enroll in medical school and earn it. You can dress up a nurse in all kinds of fashion, but, in the end, a nurse is a nurse is a nurse…..fancy name tags with silver linings only mean one thing…A NURSE….by practice and by scope will always be a nurse, not a doctor.

    There is no shortage of family physicians…this is propaganda being spread around by nurse associations to glorify undertrained nurses….in the hopes that they will be empowered to have an “expanded scope of practice” that will eventually kill more people, so there will be less people consuming the costly OBAMACARE

    • Jon Geeting says:

      I think the fact that you see different standards in every state shows that politics plays a role in this. Why is a dental hygienist allowed to clean your teeth for cheaper without a dentist in the room in one state, but not in another? It doesn’t seem to be a safety issue. I would chalk it up to the relative political power of dentists to lobby for a more restrictive licensing regime. The more procedures you need a dentist in the room for, the higher dentists’ wages will be, and more expensive dental care will be. We need to be trying to reduce the prices of medical care.

  3. Jon,
    You hit the nail on the head with that point you made. I’m not sure if you are aware that politics plays a large role in the nursing field also. For example, one must be a licensed nurse to pass medication in a skilled nursing home or a hospital in PA. But go right next door to “Assisted Living” or in a “doctors office” or a “Personal Care Home” or “Home Care” in PA, and no nurse is needed at all, to pass the identical set of pills. In fact, this is why elderly persons choose home care or Assisted Living…it is more affordable, because the regulations are not nearly as strict.

    Another example shows that a home care nurse is allowed to teach family and caregivers how to administer IV medication in a home environment, so that they can complete the task independently. However, I keep seeing hospitals that are expanding their outpatient services. These “outpatient facilities “require licensed nurses to do what can be done at home, without any licensed personnel, at a much cheaper price.

    Things that make you go HMMMMM!!!

    • Trish says, “Another example shows that a home care nurse is allowed to teach family and caregivers how to administer IV medication in a home environment..”

      A “home care nurse” can be an LPN. An LPN cannot “administer” medications they themselves. That would be illegal even in the home environment (unless they were an RN or above). LPN’s serve only an instructional role as prescribed by a “qualified “medical professional (Dr. or PhA) who assumes responsibility for a medically prescribed treatment..

      An LPN is not medically educated enough to qualify for prescribing nor the administering of medications. LPN’s cannot assume the responsibilities thereof because they didn’t receive this kind of training. It’s one thing to show people how to take their medications (as prescribed). Another entirely different from pushing the medications themselves.

      It’s legally assumed the untrained patient accepts responsibility for the acceptance to carry out his/hers doctor’s orders.

      Now if you want to take on the liability on such matters by changing the laws, I would consider that a “political” disadvantage. I’d recommend quit while your ahead.

  4. Jon,
    I also wanted to make you aware that the fictional “looming doctor shortage” is a bunch of BS. Did you notice the last decade of false media propaganda which declared a “national nursing shortage?” There never was a nursing shortage. It was a scheme to send people to nursing school in droves. It was successful in saturating the market with nurses. Thanks to that fake media drive, there is about 300-400 nurses looking for every 1 job that comes along. And because the supply/demand element was intentionally slanted in favor of the employer, nursing are taking low wage/ no benefit jobs, low wage part time jobs, and unpaid internships, just to get their foot in the door.

    The fake “shortage” drove down the cost of care. I see that the same propoganda is starting for doctors as well, in hopes that this will have the same effect. There is no doctor shortage, and I doubt very much there will be in the future. Same with nurses…there are too many of us already.

    • Jon Geeting says:

      I’m skeptical about it too. I think that’s just a news hook they were using since a lot of health policy people seem worried about that. I don’t really think it weakens their point though.

  5. You’re wrong. In the homecare environment LPNs can do exactly the same work as RNs. In a hospital, they can start IVs, administer all oral meds sublingual meds and topical meds. . They are allowed by law, in a hospital to administer IV meds, if its a drip antibiotic or combination fluid. They are not allowed to do “IV push” or IV cardiac meds that must be tirated up and down. If its a straight drip, such as potassium …they can do that too. They are not supposed to do anything with a PICC line or a central line, but a regular IV is OK.

    In an Ambulatory Surgical Facility, they do everything. In a doctors office, they also do everything. There’s very little difference between RN and LPN in PA……they can take a doctors order and write it, but the RN must co-sign in a nursing home. Not so in a hospital. Different rules under different roofs….I’ve been in this 10 years, so unless the law changed overnight…..which it didnt, you have your facts mixed up.

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