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An Interstate Effort to Address Health-Care Shortages

A dozen states have joined a compact to give physician assistants a universal license. It's not a complete solution for the shortage of primary-care doctors, but it should help.

Physician Assistant-Certified Sue Covington examines a patient at a clinic in Littleton, Colo.
(Hyoung Chang/TNS)
In Brief:
  • The physician assistant (PA) profession was created decades ago to address a shortage of primary doctors. The profession has grown, but physician shortages persist.

  • A dozen states have passed legislation approving a compact so PAs can operate in more than one state with a single license.

  • PAs will not only be able to provide care locally but practice telehealth, serving remote rural areas with critical needs.

  • A total of 100 million Americans do not have a primary-care physician — a number that has nearly doubled since 2014. Through legislative changes in a growing number of states, physician assistants may soon be in a better position to help.

    The physician assistant (PA) profession was created in the 1960s, with the idea that the position could fill gaps caused by a shortage of primary-care physicians. Decades later, such gaps persist. A growing number of states are joining an interstate licensure compact that would enable PAs to practice in any participating state.

    PAs can’t do everything a doctor does, but they can take on tasks ranging from examinations, running and interpreting diagnostic tests, capturing histories, and writing prescriptions.

    As a first step, a state must adopt a version of model legislation that lays out the framework for the compact. Washington state Sen. Ron Muzzall introduced legislation enabling his state to join, which was signed by Gov. Jay Inslee in March. Washington was the fourth of the seven states needed to set activation of the compact in motion. Now, 12 have joined.

    It wasn’t the first time Muzzall had walked this road. He’d previously laid the legislative groundwork for compacts for nurses, physical therapists and occupational therapists. The PA compact hit home because there’s a naval aviation installation on Whidbey Island, which he represents and where his family has farmed for 100 years. A compact would help newly arriving military spouses with licenses from other states start practices much sooner, a benefit to them and to the state.

    “We need more of pretty much everything in the state of Washington,” says Muzzall. “Our health-care community is short in almost all the practices.”

    Such shortages exist across the country, a mismatch with a population that is both aging and increasingly unhealthy. Only about 25 percent of physicians work in primary care and the demand for physicians is expected to continue to grow faster than the supply over the next decade.

    This gap could be filled in part by allowing PAs to take their skills across state lines, whether in person or via telemedicine. Muzzall, a Republican, sees unnecessary bureaucracy in a system that keeps professionals whom communities badly need sidelined for months at a time. “If we can create a program like the interstate compact, we can save everybody time and money,” he says.

    A Decade-Old Idea

    The idea of interstate medical licensure was first proposed in 2013. The Interstate Medical Licensure Compact was activated in 2017. Licensure compacts for specialties including physical therapy, nursing and psychology have since been adopted, with others pending.

    Starting up a compact takes time because it involves establishing licensing standards that are acceptable to bodies governing the professions, as well as to the governments of the participating states. Bylaws have to be written by a compact commission. A centralized database is needed to allow PAs to apply for privileges to practice, and to hold information about who already practices in which state.

    It will be 18 to 24 months before the PA compact is activated, says Meghan Pudeler, director of state advocacy and outreach for the American Academy of Physician Associates (AAPA). “Our ultimate goal is for all states to join the compact, which will allow them to facilitate interstate practice,” she says.

    A Harris poll conducted on behalf of AAPA found that 9 out of 10 respondents agreed that PAs “should be utilized” as a remedy for health-care workforce shortages. “They recognize that PAs increase access to care and make medical appointments easier to obtain,” says Pudeler.

    In the past, most doctor visits were for primary care, not specialty care. As more doctors have pursued careers in better-paid specialties and primary-care access has diminished, the ratio has gone in the other direction, leading to bigger health problems (and costs) for patients.

    The pandemic brought weak spots in state care networks into sharp focus, exactly the kind of situation where an influx of PAs from out of state could help contain a problem.

    Health equity is another matter. The American Academy of Medical Colleges says that historically underserved communities already have shortfalls three to six times the size of those projected for the population overall.

    Moving Down the Line

    Primary care isn’t the only place workforce issues are creating significant access problems. One in 3 Americans live in an area with a shortage of behavioral health workers. PAs can practice in this specialty.

    Telemedicine has leveled off since the pandemic, says Joe Knickrehm, vice president for communications at the Federation of State Medical Boards, but it has been shown to be an effective tool. Some studies have found that both patients and clinicians prefer virtual behavioral health treatment to in-person treatment.

    As compact membership expands, more PAs will have licenses that enable them to provide telehealth services to residents in multiple states, including chronically underserved rural areas.

    Both red and blue states have enacted or proposed PA compact legislation. Muzzall hasn’t encountered much opposition to his efforts, though there was pushback on his nurses compact bill from the state nurses association, which was not convinced it would improve access or address shortages.

    The model legislation for the PA compact wasn’t completed until 2022, and 2023 legislative sessions were the first opportunity for bills to be introduced. Three enacted the compact last year. This year, their ranks grew to 12, with legislation pending in eight more states. Pudeler expects this number to grow next year. “We’ve been working closely with our state chapters,” she says. “We’re hoping to just keep moving down the line.”
    Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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