To expand access to health care during the COVID-19 pandemic, many states relaxed or waived regulations that define the scope of health professional practice. This experience highlights the need to ensure that all health care professionals practice to the full extent of their capabilities—an issue that predates and will outlast the pandemic. In a virtual conference on November 20, 2020, Penn LDI and Penn Nursing brought together experts in law, economics, nursing, medicine, and dentistry to discuss current gaps in health professional scope of practice, what we have learned from COVID-19, and how to rethink scope of practice to better meet community and public health needs.


In each state, scope of practice (SOP) regulations primarily define the services a health professional is legally allowed to perform. The pandemic has highlighted how these regulations affect public health, equity, and patient care. In response to emergency needs, some states have modified their regulations, with questions now arising about whether to make the changes permanent. To set the stage for the conference discussions, Penn Nursing Dean Antonia Villarruel, PhD, RN pointed out four key considerations in SOP reform:

For example, should a dentist, dental hygienist, or veterinarian provide a flu shot? Should a home care nurse or physical therapist order durable medical equipment for a patient at home? Should a hospice nurse legally declare someone dead? Should a pharmacist manage some aspects of chronic illness?

Figure 1. State Pandemic-related NP regulations, December 2020 Map of US with gradient representing which states had COVID-19 executive orders pertaining to scope of practice

Economics of Professional Regulation

Protect Consumers, Not Competitors

In a keynote address, Martin Gaynor, PhD, gave a broad overview of economic implications of SOP regulations and their intended consequences. He noted that the proper role of these regulations was to protect consumers, not to impede competition. When health or safety concerns warrant certain restrictions on practice, they should be based on evidence and narrowly tailored. He offered his vision of the outcomes of appropriate SOP regulations:

State SOP Responses to COVID-19

Sydne Enlund of the National Conference of State Legislatures (NCSL) provided an update on how states have responded to the health care needs of the pandemic by temporarily amending their SOP regulations. The NCSL is currently tracking more than 80 changes enacted that affect the health care workforce. Most of the SOP changes have been by executive order of the governor, and last only through the duration of the declared emergency.

Access, Equity Gaps in SOP Regulation

Moderated by Matthew McHugh, PhD, JD, MPH, RN, a panel of practitioners and researchers discussed current gaps in SOP regulation and the implications for providers and patients. In general, patients want access to quality health care services, which they value more than the nuances of provider SOP arrangements.

Margo Brooks Carthon, PhD, RN, framed the discussion of NP SOP as an issue of equity. She noted that NPs bring specific skills, knowledge, and expertise to many underserved communities.1

Jim Carney, PA, noted that SOP problems for PAs stem not so much what they are allowed to do, but how they are required to do it. In general, SOP regulations impose frictions within the system that add costs and administrative burden without known benefits.

It is clear that regulators act in the public interest when the health of the nation is at risk. The question is, do they have the same determination to change SOP regulations for underserved communities?

Donald L. Chi, DDS, PhD, commented on known problems with access to dental care, and how dental therapists can alleviate the maldistribution of dentists.

Bianca Frogner, PhD, noted that recent studies support the call for modernizing SOP regulations for a variety of non-physician providers.3 In some cases, reimbursement decisions restrict practice even where regulators have not, creating inefficiencies within and across states.

Updating SOP Regulation, and Potential Roadblocks

Moderated by Allison Hoffman, JD, a second panel discussed how SOP regulation can promote a health care workforce that better matches the needs of the population, and some of the barriers to SOP reform.

Edward Timmons, PhD, noted that there is overwhelming evidence from 22 states that the benefits of full practice authority for NPs far outweighs the cost, and is in the best interest of patients and taxpayers.

William Sage, MD, JD, explained how the use of antitrust law can be used to overcome political forces that maintain the status quo.

Penny Kaye Jensen, DNP, APRN, discussed lessons from the VA’s 10- year battle to implement full practice authority for NPs in the nation’s largest health system, which serves 9 million veterans.

Ying Xue, PhD, RN, discussed recent work on the actual and potential effects of expanded SOP on access to primary care for vulnerable groups.

Coalitions of stakeholders, including health care providers and consumer organizations such as the AARP, are needed to ensure that the public’s voice is heard.


Julie Fairman, PhD, RN, provided historical context for SOP regulation, presented some themes from the day’s discussions, and offered some concluding remarks.


  1. Poghosyan, L., & Carthon, J.B. (2017). The Untapped Potential of the Nurse Practitioner Workforce in Reducing Health Disparities. Policy, Politics, and Nursing Practice, 18(2):84-94.
  2. Chi, D.L., Lenaker, D., Mancl, L., Dunbar, M., & Babb, M. (2018). Dental Therapists Linked to Improved Dental Outcomes for Alaska Native Communities in the Yukon-Kuskokwim Delta. Journal of Public Health Dentistry, 78: 175-182.
  3. Frogner, B.K., Fraher, E.P., Spetz, J.S., Pittman, P., Moore, J., Beck, A.J., Armstrong, D., & Buerhaus, P.I. (2020). Modernizing Scope-of-Practice Regulations — Time to Prioritize Patients. New England Journal of Medicine, 382:591-593.
  4. Sun, E., Moshfegh, J., Rishel, C.A., Cook, C.E., Goode, A.P., & George, S.Z. (2018). Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA Network Open, 1(8):e185909.
  5. Chung, B.W. (2020). The Impact of Relaxing Nurse Practitioner Licensing to Reduce COVID Mortality: Evidence from the Midwest. Illinois Labor and Employment Relations. Retrieved from
  6. Xue, Y., Smith, J.A., & Spetz, J. (2019). Primary Care Nurse Practitioners and Physicians in Low Income and Rural Areas, 2010-2016. JAMA, 321(1):102–105.