Expand Access to Primary Care: Remove Barriers to Assistant Physicians

Since the early 1950s, hospitals and medical centers that offer postgraduate training (residency) programs have been participating in the National Resident Matching Program (NRMP), which matches graduating medical students with available residency programs.² Many medical school graduates do not match with positions in accredited programs because the number of residency slots available has not increased at the same rate as the number of medical students.³ The graduates are stuck in limbo, unable to apply the knowledge and clinical skills acquired with their doctorate degrees to care for patients while also being unable to further hone and develop those clinical skills with postgraduate training. According to the American Medical Association, in 2021, roughly 7 percent of doctor of medicine graduates and 10 percent of doctor of osteopathy graduates found themselves in that state of limbo.⁴

Some states have reduced the legal barriers that prevent unmatched medical school graduates from rendering primary care services. In 2014, Missouri became the first state to allow these physicians to practice as APs, a type of apprenticeship where medical school graduates work for and collaborate with licensed primary care physicians who have clinics in underserved areas of the state. APs are, in short, apprentice physicians, which was a common way to train physicians before the modern era of residency programs.⁵

The Missouri program launched in 2017.⁶ By February 2023, APs increased the state’s primary care provider workforce by 3 percent. Since Missouri launched its program, Arkansas, Idaho, Kansas, Louisiana, Utah, and Arizona have enacted laws to license APs (see Appendix B).⁷

States should lift barriers that prevent unmatched medical school graduates from providing primary care services. States also should offer the AP option to licensed foreign physicians who wish to immigrate to the United States. States further should amend their licensing laws to allow experienced APs to use their experience as an alternative pathway toward a full medical license. Legalizing APs would help solve the primary care shortage.

America lacks enough primary health care clinicians to serve its growing and aging population. The Health Resources and Services Administration determines primary care health professional shortage areas (HPSAs) in the United States using four parameters: population-to-provider ratio, percent of the population below 100 percent of the federal poverty level, infant health index, and travel time to the nearest source of care.⁸ As of December 31, 2022, more than 98 million U.S. residents lived in HPSAs, or areas with enough primary care providers to meet only 47.3 percent of the population’s medical needs.⁹ Higher HPSA scores reflect more severe shortages. Figure 1 illustrates primary care HPSAs as of January 2023.

A July 2021 Association of American Medical Colleges report projected that in 2034 there will be a shortage of 17,800 to 48,000 primary care physicians.¹⁰ A December 2021 survey in the Mayo Clinic Proceedings on Innovations, Quality and Outcomes reported that one in three physicians and advanced practice registered nurses intends to reduce work hours and that one in five physicians intends to quit practicing entirely.¹¹ A 2020 study published in Human Resources for Health projects that California, Texas, and Florida will have the most significant scarcity of physicians by 2030.¹² Rural and underserved urban communities have lacked enough primary care providers to meet the medical demands of the population for a long time.¹³ Now the problem is spreading into more populated areas across the country.¹⁴

The Accreditation Council for Graduate Medical Education is a private nonprofit organization that accredits more than 12,000 residency and fellowship programs in the United States.¹⁵ State licensing boards grant licenses to applicants who have completed at least one year (in most cases) of an accredited residency program. The Association of American Medical Colleges and the National Student Internship Committee created the National Resident Matching Program (NRMP) in the 1950s to assign graduating medical school students to accredited residency programs.¹⁶ Applicants communicate directly with the residency programs they are interested in attending. The program directors determine the applicants’ eligibility and may invite them to interview. The applicants and programs submit lists to the NRMP ranking their preferences. The NRMP uses a mathematical algorithm to match the applicants to programs.¹⁷ The NRMP announces the match results on Monday of Match Week, the third week of March. The match serves as a binding agreement between the applicant and the program. The NRMP provides a Supplemental Offer and Acceptance Program (SOAP) to eligible applicants who have not matched with any program.¹⁸ SOAP involves a series of two-hour-long rounds that include remote interviews conducted Monday through Thursday of Match Week, during which programs offer available positions to unmatched applicants, both parties rank their preferences, and the NRMP applies the matching algorithm. Not all programs with open positions choose to participate in SOAP.¹⁹ And not all unmatched applicants are able to find an accredited position.

According to the 2022 NRMP results, 6.8 percent of doctor of medicine (MD) senior applicants and 8.2 percent of doctor of osteopathy (DO) senior applicants failed to match with a residency program. While there were lower percentages of primary care specialty applicants who failed to match than percentages of surgical specialty applicants who failed to match, 13.2 percent of MD and 28.4 percent of DO obstetrics and gynecology applicants failed to match, well above the total average rate.²⁰ Table 1 shows the 2022 NRMP results for residency programs in four specialty categories that provide primary health care services: family medicine, internal medicine, pediatrics, and obstetrics and gynecology.

Most states require domestic applicants for a physician’s license to graduate and receive an MD from an accredited U.S. or Canadian medical school, complete at least one year of a residency program, and pass Step 3 of the standardized three-part United States Medical Licensing Examination (USMLE) to receive an unrestricted license to practice medicine. Graduates with a DO from an accredited osteopathic medical school must pass Level 3 of the three-part Comprehensive Osteopathic Medical Licensure Examination (COMLEX). (Medical students take the first two parts of both the USMLE and the COMLEX midway through medical school and just before graduation, respectively.) Some states require two or more years of postgraduate training, and a few require applicants to complete a residency program in a medical specialty to receive a license (see Appendix A).²¹ Physicians also can seek certification from specialty boards when they complete specialty residency programs. For example, the American Board of Family Medicine (ABFM) certifies family practitioners who complete a three-year residency in family medicine, pass a standardized certification examination, and meet other criteria.²²

Physicians who participated in a residency program long enough to satisfy their state’s licensing requirement but not long enough to complete the residency program practice as general practitioners (GPs). GPs can practice medicine but cannot claim they are certified in any medical specialty. Many GPs choose to complete only enough years of residency to satisfy state licensing requirements. Most then provide primary care services without getting certified in a specialty.

Not long ago, most primary care physicians were GPs. The first residency programs preparing graduates for ABFM certification began in 1968.²³ A 2020 study found that the United States had 6,545 self-designated GPs who were not ABFM-certified in 2016 with ages ranging from 30 to 96 (mean age 64.6).²⁴

Graduates of medical schools outside the United States and Canada, including graduates of accredited Caribbean medical schools, may apply for residency programs in the United States. These international medical graduates (IMGs) must graduate from a medical school that the Educational Commission for Foreign Medical Graduates (ECFMG) has certified before they can enter U.S. graduate medical programs. The ECFMG began in 1956 as a nonprofit organization with a mission to “evaluate the readiness” of IMGs to enter graduate medical education programs (residencies and fellowships) in the United States.²⁵ The ECFMG sponsors visas for IMGs who are not U.S. citizens or permanent legal residents.²⁶ All 50 states and the District of Columbia require IMGs to complete more than one year of residency and pass Step 3 of the USMLE to obtain an unrestricted GP license (see Appendix A). Figure 2 and Figure 3 compare the licensing requirements for U.S./Canadian medical graduates and IMGs among the 50 states and the District of Columbia.

IMGs who received their diplomas more than five years before applying to a graduate medical education program and have been practicing medicine outside of the United States—often for many years—must go through a process resembling that of fresh medical school graduates. This means they must pass ECFMG certification, pass all three USMLE steps, and undergo a residency training program all over again. However, unlike recent medical school graduates, barriers are higher for older IMGs. Older IMGs may only apply for state medical licenses when they complete a residency program. Many experienced foreign-trained doctors take positions in ancillary medical occupations, such as nurses, lab technicians, and radiology technicians, instead of starting over. Some enter residency programs in a completely different specialty than the one they have mastered so that they can work as a doctor in the United States. Some even work in nonmedical sectors or occupations, wasting years of medical training and experience.²⁷

One way to mitigate the shortage of primary care clinicians is for states to remove barriers that prevent APs from serving patients. In 2014, the governor of Missouri signed a law creating a new category of licensed professionals called assistant physicians (APs) for people who graduated from U.S. medical schools but hadn’t been placed in residency programs.²⁸ The law permits APs to practice primary care in rural and underserved areas of the state with limited supervision by a licensed physician, with whom they must have signed a collaborative practice agreement. The Missouri Board of Registration for the Healing Arts began accepting AP applications in January 2017. Applicants must submit letters of recommendation, proof that they graduated from an accredited medical school, and their scores from Step 1 and Step 2 of the USMLE.

The law has already started lessening the primary care shortage. Missouri had 10,060 fully licensed primary care physicians engaged in direct patient care as of January 2023.²⁹ As of mid-February 2023, the Missouri Division of Professional Registration listed 292 licensed APs.³⁰ These figures suggest that APs increased the number of primary care physicians in Missouri by nearly 3 percent.

Six other states have subsequently passed similar laws: Arkansas, Kansas, Utah, Arizona, Louisiana, and most recently, Idaho (see Figure 4).³¹ Arkansas law calls APs “graduate registered physicians,” and Utah law calls them “associate physicians.” Louisiana and Idaho refer to APs as “bridge physicians” because they define the license as a bridge to the next residency match. AP licensing laws vary by state (see Appendix B). However, states typically require APs to sign an agreement with a fully licensed physician who can bill third-party payers for their services. All of these laws require third-party payers to pay for AP services at the same rate as physician assistants. Supervising physicians need not be present when APs are providing services. APs in Missouri can renew their licenses indefinitely. The other states limit the number of years APs may serve patients, after which the government expects them to have obtained a position in an accredited residency program and will block them from practicing as APs. For example, Idaho’s bridge physician license is not renewable, while Louisiana allows bridge physicians to renew for two additional years. Yet, even if APs complete one or more years in primary care practice, attend continuing medical education courses, and pass Step 3 of the USMLE, they will not qualify for the unrestricted licenses that many GPs receive after fewer years of postgraduate experience.

In 2021, the Missouri legislature considered a bill that would have allowed APs to apply for an unrestricted license as a GP. Applicants would have had to complete five years of collaborative practice with a licensed supervising physician and 100 hours per year of continuing medical education classes. Applicants would also have had to pass Step 3 of the USMLE.³² The bill did not pass.

In 2021, Washington became the first state to allow practicing IMGs in other countries to immigrate to the state and obtain an AP license.³³ Applicants must graduate from ECFMG-certified programs, pass all three USMLE steps, present three letters of recommendation, and reside in the state for at least one year. Applicants must also comply with federal immigration law, which requires that immigrating physicians obtain a visa. Congress caps the annual number of visas, impeding many foreign doctors from immigrating.³⁴ Visa applicants can spend more than six months in limbo and incur legal and processing fees that, for many IMGs, can be cost-prohibitive.³⁵ Recipients of a “limited license for clinical experience” must sign a collaborative agreement with a supervising physician who “must retain professional and personal responsibility for any act that constitutes the practice of medicine … when performed by an IMG under their supervision.”³⁶ A supervising physician may not collaborate with more than two IMGs. The limited license is valid for two years, but licensees may renew them once. Unlike the other states that have enacted AP laws, Washington’s law only applies to non-Canadian IMGs.

Other states have also removed barriers to IMGs providing health care services. Responding to the COVID-19 public health emergency, Governor Phil Murphy of New Jersey ordered temporary emergency licensure of experienced foreign physicians willing to provide health care services to New Jersey residents.³⁷ Similar to the law in Washington, the measure required the temporarily licensed foreign physicians to work in designated locations where licensed New Jersey physicians would supervise them. The state licensing board only processed 35 of the 1,110 applications by the time the program ended in March 2022.³⁸

Ideally, states should repeal medical licensing laws.³⁹ In conjunction with that reform, states could accredit independent third-party certification organizations to perform the functions that licensing boards perform.⁴⁰ Such organizations could review the credentials, education, and real-world experience of domestic and international applicants and certify them as competent to provide various health care services. Christina Sandefur, Byron Schlomach, and Murray Feldstein have proposed a voluntary alternative pathway involving third-party certification that could coexist with state licensing schemes and gradually replace them.⁴¹

Alternatively, as a second-best solution, states should enact laws recognizing practitioners’ licenses in other states. In 2019, Arizona became the first state to enact a “universal licensing” law, and several states have since passed different versions of such laws.⁴² Such laws should not require that practitioners reside in the state. This would enable licensed APs to provide health care services in other states.

Additionally, Congress should define the “locus of care” for telehealth purposes as the state that has licensed the health care practitioner. This would enable APs to provide telehealth services across state lines.⁴³

If those reforms are politically infeasible, all states should reduce barriers to medical school graduates becoming APs by establishing a licensure category for them. Of the seven states that license APs, Missouri’s AP law has the fewest obstacles to medical school graduates who wish to work as APs. Graduates of foreign medical schools and licensed and experienced physicians from other countries should also be eligible to become APs. Washington’s AP law sets such an example. Lawmakers should not limit the number of years APs may practice. Lawmakers should not restrict APs to practicing in rural or underserved areas and should not require licensed APs to continue attempting to enroll in residency programs.

State lawmakers should enable medical school graduates to use their experience as APs as an alternative pathway to unrestricted licensure as GPs. If one or two years of residency plus passing Step 3 of the USMLE qualifies physicians in most states to practice medicine as GPs, then three or more years of experience as an AP and passing the same exam should suffice as well.

The AP to GP alternative pathway could lead to innovations in how specialty boards certify clinicians. For example, GPs who wish to specialize nowadays apply to specialty residency training programs. When they complete residency training, they take standardized specialty examinations and seek certification from specialty boards such as the American Board of Internal Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Obstetrics and Gynecology. Thus, increasing the number of GPs might incentivize some certifying organizations to develop alternative pathways to certification that place greater emphasis on real-world experience. Certifying organizations might even develop various levels of certification based on applicants’ backgrounds and experience.

Increasing the supply of APs and, in turn, GPs, while promoting innovation in specialty certification would increase primary health care access and choice.

States should lift constraints and allow domestic and international medical school graduates to become assistant physicians and to use their experience as an alternative pathway to independent, general medical practice. By thus increasing the number and variety of primary care providers, state lawmakers will help to improve primary care access while reducing cost.