Chapter 3Access to CareChapter 3Access to CareIn the late 1960s and the 1970s, health policyfocused on making health care accessible to allAmericans; much effort went toward helping peo-ple enter the health care system (1). A particularconcern was geographic access to primary care,because the geographic maldistribution of physi-cians and their patterns of specialization had leftmany of the Nation’s inhabitants without ade-quate access to primary care.Indeed, the creation and development of nursepractitioners (NPs) and physician assistants (PAs)occurred in large part in response to the limitedaccessibility of basic medical services, especiallyin rural and inner-city areas, where physicianswere disinclined to practice (74,169,183 ).1 Thestated purpose of the early training programs forNPs was to improve access to primary care forpeople in areas without enough physicians (236).Similarly, PAs were intended to “help remedy theshortage of primary care physicians, particularlyin medically underserved areas” (180). Much ofthe impetus for the growth in the number of cer-tified nurse-midwives (CNMs) during the 1970scan be attributed to concern about the limited sup-ply of obstetricians in the United States (180).The various barriers to providing care must beconsidered in assessing the success of NPs and PAsin improving health care in medically underservedareas. Legislation and regulations vary widely fromState to State but generally tie medical practiceby NPs, PAs, and, to some extent, CNMs to asso-ciations with physicians and limit such practicewhere physicians are not present. Although NPsmay provide nursing services independently, forthe most part neither NPs nor PAs ‘can providemedical services unless local physicians are will-ing to hire them. Medicare and Medicaid rules re-IOther factors, including improved integration of nursing andmedicine, bolstered the NP movement, which signified a deliberatemove to expand the nursing role and to meet the health-care needsof many underserved populations. Other factors that contributedto the success of NPs, PAs, and CNMs are the consumers’ andwomen’s movements, the new focus on self-help and self-care, andother pushes for social and personal change that emerged duringthe late 1960s and continue today (229).garding payment also significantly impede NPs,PAs, and CNMs by restricting payment for med-ical services to the supervising physician or insti-tution. The Rural Health Clinic Services Act (Pub-lic Law 95-210) waived the restriction for directsupervision of NPs, PAs, and CNMs practicingin certified rural health clinics located in desig-nated underserved areas (see app. B).Whether NPs, PAs, and CNMs are needed toimprove access to primary medical care in under-served areas remains an issue, even though thesupply of physicians has increased, and some phy-sicians have moved away from urban areas (174,264). Some experts believe that competitive pres-sures will eventually remedy the maldistributionof medical manpower (222) but, the proportionsof physicians in urban and rural areas have re-mained fairly constant since 1970 (255).Furthermore, large overall increases in physi-cian supply in a State may still leave some areasin the State without adequate access to medicalcare (112). The situation may worsen in thoseareas as older physicians are not replaced byyounger ones. Indeed, the Bureau of Health Pro-fessions has predicted that unmet needs for pri-mary care will persist in many currently desig-nated shortage areas. Although the dispersal ofyoung primary-care physicians is expected to re-duce overall shortages, reducing shortages in allunderserved areas may take an extensive periodof time (250).Although the need remains for NPs, PAs, andCNMs to provide care to underserved populationsand in underserved areas, interest has increasinglyfocused on these providers’ abilities to delivergood medical care in certain institutional settings,such as jails, and to specific populations, such aselderly people and poor women and their infants.In addition, by functioning as case managers, theseproviders can help patients find appropriate carein our increasingly complex health-care system.(The effect of NPs, PAs, and CNMs on access tospecific services, such as health education, coun-seling, and health promotion, is addressed morecompletely in chapter 2.)2930NURSE PRACTITIONERS’ CONTRIBUTIONS TO ACCESS TO CAREAlthough legal constraints (such as require-ments for supervision by physicians) have hin-dered NPs’ dispersal to isolated settings, NPs havehelped improve geographic access to primary care(31,86,160,168,261). In 1977, 23 percent of NPsworked in inner-city settings and 22 percent in ru-ral areas (238)—the geographic areas of greatestneed (120). In 1980, the proportion of NPs work-ing in these settings had increased to 47.3 percentin inner cities but decreased to 9.4 percent in ru-ral areas (255). In both inner cities and rural areas,more than half of NPs’ patients had annual in-comes of less than $10,000 (255).NPs alone cannot entirely resolve the problemof provider maldistribution, because the profes-sional, social, and cultural attractions of thesuburbs and cities that appeal to many physiciansalso appeal to many NPs. An early survey of NPsin six States found that generally they “do notwork in the inner city or in rural areas” (81), buta Pennsylvania NP-training program surveyed itsgraduates through 1982 and found that 70 of the102 graduates worked in urban programs withlow-income people (151).NPs tend to view themselves as being able tofunction effectively and appropriately not onlyin settings with physicians, but also in practiceswithout physicians on the premises. Starting inthe mid-1960s a significant minority of NPsworked in satellite settings as the sole providersof services; they received medical supervisionfrom physicians working in other communities.Often, the backup physicians would be availablefor telephone consultations, would visit the sat-ellite settings, and would be responsible for en-suring that the NPs adhered to the protocols guid-ing the provision of medical services. These NPsincreased access to care by working in placeswhere physicians had not located.NPs’ extension role is no longer as significantas it was in the 1960s and 1970s. A national sam-ple of 44 rural communities identified in 1975 as‘Requirements for physicians’ supervision of NPs vary from Stateto State. In many States, physicians must be on the