This study will provide the National Council of State Boards of Nursing (NCSBN) empirical evidence for evaluating the extent to which, and under what conditions, state regulations governing nurse practitioner (NP) scope-of-practice (SOP) influence the geographic distribution of NPs in relation to vulnerable population areas.  The study can further assist the NCSBN in identifying specific states and areas within states that would most benefit from regulatory changes to NP SOP.  Vulnerable populations, such as racial and ethnic minorities and low-income groups, account for a disproportionate share of the nation’s disease burden and healthcare costs, due in part to inequities in healthcare access. Improved access to care is one of the NCSBN’s guiding principles in regulating the SOP of healthcare professions.  In this historic era of healthcare reform,  Medicaid expansion, and sizable capital investment in community health centers, the role of NPs in caring for vulnerable populations is central to the debate regarding strategies to promote the expansion and equitable distribution of the primary healthcare workforce.  Assessment of the impact of NP SOP regulation on this issue will be critical to assist national and state regulatory bodies and legislators to make evidence-based decisions in response to growing healthcare needs among vulnerable populations.

Guided by a comprehensive conceptual framework, the proposed study will use existing national datasets to examine the geographic distribution of NPs in relation to vulnerable population areas across health service areas (HSA) in all states and regions from 2009 to 2013. We will compare the geographic distribution of NPs with that of primary care physicians in relation to vulnerable population areas, and determine the impact of state NP SOP regulation on NP density and distribution relative to vulnerable populations using well-established study design and multilevel statistical modeling techniques.  Sensitivity analyses will be conducted to ensure robustness of the study findings. In summary, understanding recent changes in the supply and geographic distribution of the NP workforce in relation to vulnerable population areas, and how legislative and regulatory decisions can influence this distribution, is essential for the development of effective health policy directives and levers to meet the demand for primary care among the underserved and reduce inequity in access to care.