Of Missouri's 114 counties, 109 are struggling with shortages in primary care professionals. That means in 96 percent of the state, there are not enough health care resources to meet the area's needs.
That includes most rural parts of the state, as well as some metro areas, said Margaret Benz, a nursing professor at St. Louis University.
Benz is an advanced practice registered nurse (APRN) -- which means she has education beyond basic nursing training and additional certifications. Benz, and many APRNs, see themselves as a solution -- at least one countermeasure -- to Missouri's rural health crisis.
"We have nurse practitioners in the state in every single county except one," Benz said. "We feel like we could fulfill the shortage area because we have a tremendous shortage of physicians in the state."
But in Missouri, in order to provide care or open a practice in the state, APRNs must be located within 75 miles of their collaborating physician -- the doctor who supervises an APRN and signs off on all care plans.
APRNs argue it creates a burden for rural Missourians who live far away from a doctor, cutting off access to care. That's the thinking behind House Bill 2434, the latest bill nurses have pushed to remove the geographic standard.
But many physicians want to keep the mileage requirement, arguing it's essential to maintaining a quality standard of care. And as yet another legislative session nears its end, the bill appears to be going nowhere.
Allies of the bill note Missouri's restrictions for APRNs are some of the strictest in the country. Some states -- including most of Missouri's neighbors -- allow independent practice, in which APRNs provide care without the direct supervision of a physician. Many other states use collaborative practice agreements like Missouri, where the two professionals work together.
However, Missouri is one of only two states that has a mileage requirement for those agreements. The other is Mississippi, according to the American Medical Association.
"Why was it ever created?" said Rep. Derek Grier, R-Chesterfield, the bill's sponsor. "Nobody has an answer to that. I mean, there has been absolutely no reasonable explanation for why that 75-mile restriction exists at all."
The law that governs collaborative practice agreements has been adjusted several times. It gives the state Board of Nursing and the Board of Healing Arts -- the regulatory bodies for nurses and physicians, respectively -- the authority to enact rules for the agreements, including specifying geographic areas to be covered. In 2008, a section was added to stipulate each collaborative practice agreement must maintain "geographic proximity."
The two regulatory boards have adjusted the rule repeatedly in recent years. In 2018, the two boards agreed to extend the mileage requirement from 50 miles to 75. And in March, they agreed to extend the requirement even further for APRNs operating out of state prisons -- they must only be within 200 miles of their physicians. That rule change was made due to a severe shortage of health care workers in the state prison system.
During the pandemic, Gov. Mike Parson waived the requirement altogether, so residents would have greater access to telehealth. His waiver expired Dec. 31, 2021.
The regulatory boards also considered removing the requirement permanently, but could not agree. At a joint meeting between the two on March 28, the Board of Nursing voted to remove it and the Board of Healing Arts voted to keep it. A rule change cannot be filed unless both entities agree.
But to Grier, removing the mileage requirement from the statute just made sense -- especially since it wasn't in effect for nearly two years.
"When you're looking at legislative changes, a lot of times the dream is, 'let's test it out and see if it works,'" he said. "Well we've had that trial period. We've had two years of this now. We know it works."
Grier's bill would also allow APRNs to write and sign treatment plans for home health agencies -- a responsibility currently reserved for physicians -- and remove some restrictions to telehealth provided by nurses.
Still, some physicians and advocacy groups have concerns. They worry additional extensions of the mileage restriction -- or removing it altogether -- will hinder communication between doctor and APRN in the collaborative practice agreement, leading to declines in the quality of care. They also worry about giving more authority to APRNs, who do not have as many years' education or as many hours of supervised care as doctors.
Some physicians may not want to enter into an agreement with an APRN at all, knowing they won't have as much control over the supervision, said Brian Bowles, executive director of the Missouri Association of Osteopathic Physicians & Surgeons.
"The whole purpose of the geographic proximity was so a physician could get to a patient in an emergency in time," Bowles said. "It is kind of arbitrary at this point, but doing away with it completely means a physician could be 300 miles away from the nurse practitioner they're collaborating with. There's no chance a physician can get to a patient in that case, and it just weakens the whole arrangement."
Opponents are also skeptical APRNs could change the reality of Missouri's rural health care problem. John Burroughs, board president for the Missouri Academy of Family Physicians, said many counties have a shortage in APRNs as well as physicians -- arguing that removing the mileage requirement wouldn't make a difference. He noted Missouri's rural care crisis has persisted even as the requirement has been loosened.
"We just haven't seen the need filling as we've lengthened that distance for collaboration," Burroughs said.
APRNs argue allowing them to practice more independently does not lessen the necessity of doctors. It just gives patients another option for their basic health care needs.
"I am not trained as a physician -- that's true. That's not my argument," said Julie Miller, an APRN and nursing professor at MU. "However, I can take care of diabetes, and hypertension and immunizations and basic health care needs in a rural clinic."
Meanwhile, Missouri has struggled with access to rural health care for years. Ninety-nine of the 109 counties with a shortage in health professionals are rural or partially rural, according to data from the Health Resources and Services Administration, a federal agency. A Department of Health and Senior Services report on health in rural Missouri also notes that from 2014-20, 10 of the state's rural hospitals closed -- there are now 55 rural counties without a hospital.
APRNs argue allowing them to practice more independently in these areas would improve access to health care, decrease cost to patients and better Missouri's health outcomes. According to the latest America's Health Rankings Annual Report, Missouri is ranked 42nd in the U.S. for overall health.
"Essentially, this all culminates in: it's hindering care to rural Missourians," Miller said.
However, as the session nears its end Friday, the bill's supporters are resolved to the possibility their cause will, once again, fail.
Proponents aren't fazed, though. Nurses have been advocating for this for so long, Miller said.
They'll just try again next year.
The work of the Missouri News Network is written by Missouri School of Journalism students and editors for publication by Missouri Press Association member newspapers.