Christy Blanco's health clinic in El Paso, Texas, has all the necessary equipment and a waiting list of patients. Yet the clinic sits empty.
50 miles away, in Las Cruces, N.M., dozens of nurse practitioners at clinics like Blanco's are busy caring for patients with a range of diseases from diabetes to asthma to depression.
The only difference between the facilities is that in Texas, nurse practitioners are required to have a doctor under contract approve 10 percent of medical charts and spend one of 10 days at the clinic. In New Mexico, no doctor is needed.
"I just want to get started," said Blanco, who has a Ph.D. in nursing and for two years has sought a doctor for her clinic geared for low- income women. "I'm trying to work for the poor. I've spent thousands of dollars of my own money. I have a waiting list of patients, and I have to tell them I can't practice yet."
Blanco is caught in a tug-of-war between doctors and nurses over who will provide basic primary care for the 30 million U.S. citizens expected to get health insurance under the 2010 health-care law.
Nurse practitioners say they can do their jobs just fine without doctors and they're lobbying lawmakers to end restrictions in more than a dozen of the 34 states that require physician oversight. Despite the need for increased care, doctors are fighting for restrictions with their own lobbying efforts as well as with lawsuits nationwide, arguing that patients' basic care is at risk.
"Doctors are under a lot of pressure financially and feel like they are losing some of their patient volumes and traditional position as captain of the ship," said John Rowe, former chief executive officer of Aetna and of Mount Sinai NYU Health. At the same time, "nurses find it demeaning and unprofessional to be in a situation where they are restricted from doing what they know they can do."
The showdown comes as the United States faces a shortage of more than 13,000 doctors, a gap expected to grow to 130,000 by 2025, according to the Association of American Medical Colleges, a Washington-based nonprofit that represents medical schools. That may leave 7 million Americans living in areas without enough primary care doctors, according to a study last month in the journal Health Affairs.
The American Association of Nurse Practitioners says some of the country's 155,000 nurse practitioners could help fill the need and at a lower cost than doctor-provided care. Insurers typically reimburse them 15 percent less than doctors.
"There just aren't going to be enough health-care providers in the workforce unless we get nurse practitioners out there," said Bobbie Berkowitz, dean of the Columbia University School of Nursing in New York. "They are educated to prescribe and manage disease, and licensed to do that. The restrictions are seen as unnecessary, at best."
A panel of health officials led by University of Miami President Donna Shalala, a former secretary of Health and Human Services, found that state laws limiting nurse practitioners need to be changed so nurses can practice without the oversight of a doctor, according to a 2010 report published by the Institute of Medicine, a division of the National Academy of Sciences. In a 2009 report by the Rand Corp., a Santa Monica, Calif.-based policy institute, researchers found no evidence that nurses provide lower quality care and estimated they could reduce the costs of office visits by as much as 35 percent.
"It is absolutely proven, according to the National Academies, that nurses can provide core primary care services as effectively as physicians," said Rowe, now a professor of health policy at Columbia University in New York.
Under the current system, each state regulates the level of oversight required for nurse practitioners, who are registered nurses that hold either a master's degree or doctorate in nursing. In 16 states, including Colorado, New Hampshire, and Washington, nurse practitioners have full authority to evaluate and diagnose patients, order diagnostic tests and prescribe drugs. That enables them to open a practice or work in a retail clinic with no doctor on staff.
The remaining states have a patch work of legislation with a variety of restrictions and limitations. In Florida and Alabama, for example, nurses can't prescribe certain drugs for pain, insomnia or attention deficit disorder that are considered controlled substances. In New York, nurses need a written collaboration agreement with a doctor and there is a limit on how many nurse practitioners each doctor can work with, creating a cap on nurse practitioners in the state.