You hear it all the time: One of the great unknowns and the biggest concerns for 2014, when the Affordable Care Act (ACA) extends health insurance coverage to up to 30 million people via Medicaid and private insurance, is whether there will be enough doctors to take care of all the new patients.

The Association of American Medical Colleges estimates that the country will be 90,000 primary care doctors short by the end of the decade, leading many to ask what the point of giving people health insurance is if they don’t have adequate places to go to use it.

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It's a concern that most states are taking seriously during their current legislative sessions. States can't train 90,000 doctors overnight, so they're trying to address the shortage with “scope-of-practice” legislation, which sets standards for what medical services health-care professionals can perform. This year, at least 170 scope-of-practice bills have been introduced in 39 states, according to the National Conference of State Legislatures (NCSL).

One of the more common proposals across states is to expand nurse practitioners' jobs to allow them to perform more basic primary care and even open their own clinics. At least 50 bills related to nurse practices have been introduced in 22 states. While debate over each bill is distinct, scope-of-practice legislation, particularly covering nurse practictioners, sometimes faces opposition from doctor groups that say they worry about unqualified personnel giving care without supervision.

To lessen the impact of the nation's doctor shortage, states are exploring many more options beyond letting nurses perform primary care. Here are six of the more unique ideas being floated in states, courtesy of NCSL's legislative database. All, with one exception, are still working their way through the legislative process.

1. Boost the number of community health workers

Florida lawmakers have proposed creating the Community Health Worker Task Force. Community health workers are usually volunteers and tend to work in underserved areas -- the kind that are likely to see more insured people next year. They offer a range of basic services and help connect people with primary care clinics for more involved treatment.

The task force would recommend ways to integrate community health workers into health care or Medicaid reform, such as teaming them up with doctors and nurses. The group would also consult with the state’s colleges and universities to set statewide standards for what skills potential community health workers should be taught and how to certify those that qualify.

2. Let out-of-state doctors practice

Is a medical license from one state as good as one from another? Two states, New Mexico and New York, have suggested it is. Bills in both states would allow doctors with out-of-state licenses to practice within their borders.

Each state’s proposal has some limitations though. The New Mexico bill would only allow out-of-state doctors to perform medical services in the state for up to 30 days. They would also have to be sponsored by an in-state organization, located in underserved areas and would have to work on a volunteer basis. The New York legislation also requires voluntary service and a sponsoring group, but sets no cap on how long out-of-state doctors can serve in the state.

3. Let pharmacists give vaccinations

Nothing is more routine yet more important, some say, than vaccinations. So Maine wants to make it easier for kids to get them. Under current law, pharmacists can give shots to adults but not children. A bill would loosen those rules and allow pharmacists to vaccinate kids ages 9 and older with a doctor’s prescription.

4. Loosen the rules for midwives

The term ‘midwife’ might conjure images of an earlier age when more children were born in homes instead of hospitals. But midwives are still important in helping modern women deliver their babies. Legislation in two states would give officials a better grip on the profession and allow midwives to take on more responsibility.

Indiana has proposed creating a State Midwifery Board to set firm qualifications for certified midwives and develop standards for education and training. On the flip side, it would establish penalties for practicing without a license. A New Mexico bill, which is sitting on Gov. Susana Martinez's desk, would revise the state code to allow certified midwives and nurse practitioners to perform certain ultrasound procedures under limited circumstances.

5. Allow nurses to assign physical therapy

Most bills expanding the services that nurses can provide refer to routine care like making basic diagnoses and prescribing low-level medications. But a bill in Florida has another very specific function in mind: letting nurses assign people to physical therapy. Physical therapists would be authorized to follow treatment plans outlined by not only doctors but also advance registered nurse practitioners, who usually have a Master’s degree.

6. Let nurses declare death

When the worst happens, somebody still has to officially certify people's death. New Jersey and New York have suggested streamlining that process. The former is considering letting nurse practitioners determine the cause of death and sign a death certificate if a doctor isn't available. The latter has proposed allowing physician assistants, under the supervision of a doctor, to issue a death certificate.

Checking Up on Health News

  • The Arkansas-style Medicaid expansion, using Medicaid dollars to help people purchase prviate insurance, is spreading fast in red states. It's been proposed in Florida, Ohio and Texas, to name a few of the big ones.
  • This Kaiser Health News piece explains the documented link between tighter Medicaid eligibility and adults delaying care. Delaying care, of course, often leads to higher costs down the road.
  • Conventional wisdom says we should reduce unnessary emergency room visits if we want to cut health care costs. But this New York Times post turns that perspective on its head. The crux is: People can't diagnose themselves. Mild symptoms can be the sign of a serious problem, so be cautious about turning people away from the emergency room.