Introduction
For patients living in rural North Carolina, quality health care can be hard to find. Currently, more than 2.3 million people — one-fifth of the state’s population — live in a designated primary care health professional shortage area.
Unlike other states, North Carolina does not have a physician shortage. The supply of doctors in the state is increasing, relative to population growth. Instead, it has a physician distribution problem. As of 2018 (the latest data readily available), only 18 percent of North Carolina’s family physicians practice in rural areas.
As lawmakers consider ways to increase access to primary care across the state, it would be wise for them to pass legislation that allows nurse practitioners (NPs) to treat patients to the full extent of their clinical training and without physician oversight. NPs are advanced-practice nurses who have graduate-level clinical knowledge and training to provide patient care directly. They assess patients’ medical history, diagnose ailments, order lab work, and prescribe medications.
As of 2025, if nurse practitioners want to practice in North Carolina, they must establish a collaborative practice agreement with a physician. The agreement outlines patient management and describes how the providers will interact. Interestingly, NPs are not required to be in the same geographic location as the overseeing physician, and they are required to meet only twice a year. The lack of oversight, then, demands asking why the contracts are even necessary.
Because NPs in North Carolina aren’t geographically tied to their collaborating physicians’ practice location, one might think that the state’s existing practice arrangements wouldn’t necessarily hold them back from providing care in underserved areas. These contracts can add uncertainty to the NPs’ practice, however. For example, if an NP wanted to operate independently but the collaborating physician moved to another state, the NP would have to find another physician who is willing to sign onto a new collaborative practice agreement.
If a collaborating physician becomes employed by a hospital system, that hospital’s policy may also prevent the physician from signing or renewing a collaborative agreement with a nurse practitioner. Moreover, collaborative practice agreements can be expensive, which makes it difficult for some NPs to grow their own clinics. An NP who desires to add a clinic partner may find it cost-prohibitive because the collaborating provider would request a specific percentage of the clinic’s revenue.
Key Facts
- As of 2025, 27 states and Washington, D.C., have granted full practice authority to nurse practitioners.
- NPs are valuable assets to the health care workforce. According to KFF, there were 5,410 professionally active NPs in North Carolina in 2025, many of whom work in primary-care settings and focus on managing chronic disease.
- Nurse practitioners will likely play a huge role in the future of the health care workforce in North Carolina. Although there are still significantly more physicians than NPs, the share of NPs as a percentage of the clinical workforce in nonmetropolitan counties grew from just under 10 percent in 2000 to nearly 30 percent in 2022.
- A 2015 report conducted by Dr. Chris Conover of Duke University found that the economic benefits of extending full practice authority to advanced practice registered nurses would result in potential annual health cost savings ranging from $433 million to $4.3 billion.
- Ending the requirement for a contract with a physician would create opportunities for nurse practitioners to deliver patient care in more rural and underserved areas. Arizona, for example, granted NPs full practice authority in 2002. Five years later, the state reported a 73 percent increase in the number of NPs serving rural counties.
- Over the past several legislative sessions, bills have been regularly introduced that would have granted full practice authority to advanced practice registered nurses in North Carolina. Despite garnering significant sponsorship, these bills — often referred to as “SAVE Acts” — have failed to secure the necessary votes to pass.
Recommendations
1. Grant full practice authority to highly trained nursing professionals.
North Carolina lawmakers should change how nurse practitioners and other advanced practice nursing professionals, i.e., certified nurse midwives, nurse anesthetists, and clinical nurse specialists, are governed in order to free them from their current constraints. Passing the SAVE Act would accomplish that.
