Opinion: Expand Options To Ease Medical Costs

By John Hood

RALEIGH — As the North Carolina General Assembly begins its 2025 session, lawmakers have many pressing issues to tackle. Topping the list will be addressing the immediate needs of Hurricane Helene victims and rebuilding the billions of dollars worth of infrastructure damaged or washed away by the storm. Legislators must also fashion a state budget for the next two fiscal years, funding key education and public-safety priorities while plugging a hole in the health plan for teachers and state employees.

Speaking of which, health care costs aren’t just a problem for the public sector. North Carolinians and their employers are struggling to keep up with rising bills. Although our state compares favorably with competing states in many areas, from tax rates to highway capacity, U.S. News ranks us an unimpressive 37th in health care affordability, measured by the share of adults who report a time in the past 12 months when they needed to see a doctor but couldn’t because of the cost.

I’ve written many times about strategies the General Assembly could pursue to reduce these costs through regulatory reform. North Carolina has a relatively concentrated market for hospital services, for example. Scrapping or at least substantially restructuring our certificate-of-need system — government permission slips for adding new services or facilities — would break up those cartels and encourage more price competition.

Similarly, I’ve argued that giving advanced-practice nurses more freedom to deliver care for which they are licensed would expand primary-care practices, especially in rural areas, and offer patients a less-expensive option.

The same logic applies to physician assistants. North Carolina happens to be the birthplace of the profession, with Duke University graduating the first PAs in 1967. Emily Adams, CEO of the North Carolina Academy of Physician Assistants, recently told Triangle Business Journal that while our state was a leader in the field for decades, our physician-assistant laws haven’t been updated since 1993. Adams and her members support state legislation to rewrite the administrative and supervisory requirements placed on physician assistants.

“Other states have taken steps to evolve their PA practice laws so there’s not a requirement relationship with a specific physician,” Adams told TBJ. She’d like to see North Carolina allow PAs with 4,000 hours or more of clinical practice to work more flexibly, within larger health care teams but not necessarily for a single supervising physician.

Academic research demonstrates that in states where physician assistants enjoy more freedom, there are more practicing PAs per capita and patients find it easier to get appointments for care, especially in rural areas and high-poverty communities. In a 2021 review of 39 high-quality studies of PA utilization across the developed world, the authors found that “PAs delivered the same or better care outcomes as physicians with the same or less cost of care.”

“Sometimes this efficiency was due to their reduced labor cost,” they concluded, “and sometimes because they were more effective as producers of care and activity.”

None of which is to suggest North Carolina ought to end all licensing and oversight of PAs and other providers. One test for the reasonableness of a regulatory change is whether it has already been implemented successfully elsewhere. Giving PAs more freedom to deliver care isn’t a new, untested idea. It’s already happening in other places.

Indeed, last year the North Carolina House passed an initial reform that would have added our state to the National Physician Assistant Compact. This allows PAs licensed in one member state to practice in another without having to obtain another license. Our neighbors Virginia and Tennessee are already part of the compact. The Senate ought to join the House in pursuing this common-sense reform.

Lawmakers in 2025 will encounter more fiscal constraints than they have in recent years. State revenues aren’t growing like gangbusters, and even North Carolina’s healthy cash reserves will be significantly depleted by Helene reconstruction and other needs. Fortunately, regulatory reforms don’t cost money. They save money, public and private. Sounds like a plan.

John Hood is a John Locke Foundation board member. His books Mountain Folk, Forest Folk, and Water Folk combine epic fantasy with American history (FolkloreCycle.com).