RALEIGH — The North Carolina General Assembly has made our state a more attractive place to live, work, and do business by reforming our tax code, reshaping our regulatory system, renovating how we fund infrastructure, and taking some initial steps toward a more competitive hospital market.

John Hood

When it comes to health care more broadly, however, lawmakers haven’t been ambitious enough. For example, bills to empower advanced-practice nurses to deliver more services at an affordable cost have repeatedly failed to gain traction in the legislature. As a result, North Carolina is losing some of our best health care professionals to a neighboring state, Virginia.
That’s the finding of a new study conducted by scholars at West Virginia University’s Knee Regulatory Research Center. They examined changes in the number of nurse practitioners in North Carolina and its neighboring states from 2016 to 2023. (Disclosure: the Pope Foundation, for which I serve as president, provided some funding for the study.)
In most of the country — including such states as Massachusetts, New York, Kansas and Utah — nurse practitioners are free to deliver medical services for which they are licensed as independent providers, rather than having to be supervised by (and surrender part of their incomes to) physicians.
A second category of states such as Pennsylvania and Illinois offer nurse practitioners some freedom but limits their independence or service delivery. A third group of states, including North Carolina and its neighbors, have long imposed major restrictions on one or more elements of nursing practice.
In 2018, Virginia passed a measure to give nurse practitioners more independence. That set up a “natural experiment,” allowing researchers to compare nursing populations and health outcomes in contiguous, otherwise comparable states. Here’s what they found:
• Before Virginia’s reform, it had significant fewer nurse practitioners per capita than North Carolina did. By 2023, the gap shrank by about half.
• “Relative to bordering counties in Virginia,” the authors wrote, “North Carolina interior counties experienced a 20% decline in the number of nurse practitioners per 100,000 residents.” They found no such difference when comparing North Carolina counties to bordering counties in Georgia, South Carolina, and Tennessee, none of which enacted major scope-of-practice reform during the period.
• That relative decline in nurse practitioners may have had adverse health consequences. Although the researchers found no significant differences in vaccinations, mammograms, or preventable hospital stays, they did detect an increase in the share of North Carolinians reporting poor health.
“Previous studies show this relationship holding in the opposite direction as well,” the authors concluded, suggesting that “increasing the number of nurse practitioners and allowing them to practice independently would improve patient health outcomes. Coupled with our findings, this suggests that North Carolina can improve access to primary care and ultimately improve patient outcomes by allowing nurse practitioners to work to the full extent of their training.”
In the General Assembly, debate about scope-of-practice reform is often viewed as an insular power struggle between physicians on one side and nurses on the other. But that’s not the full picture.
As these and other studies confirm, the interests of patients are also at stake. Expanding access to primary care is clearly a good thing. And if the predictions of reform opponents were justified — that nurses practicing without physician supervision posed a significant risk to patients — there’d be evidence for that in the data. As I noted, the West Virginia University study found no such adverse effects after scope-of-practice reform in Virginia.
Because government accounts for a large chunk of medical spending, taxpayers also have a stake in the debate. A 2019 study in the Journal of Nursing Regulation looked specifically at the effects of scope-of-practice reforms on Medicaid recipients. They found that outpatient costs were 17% lower and prescription costs 11% lower in states where nurses enjoy full practice authority.
It’s time for North Carolina to follow the lead of our northern neighbor. It’s time to free our nurses to do the job for which they are well-trained.

John Hood is a John Locke Foundation board member.