After years of attempts, and an eventual compromise between nurses and doctors, nurse practitioners' rights have expanded.
A new law gives them elevated prescribing power in South Carolina and changes how they are supervised.
For years, the S.C. Medical Association worried such a move would be a disservice to patients, while nurses argued that South Carolina laws were outdated and barred them from providing basic primary care to their patients, especially in rural areas.
This year the bill won support early in the legislative session from Gov. Henry McMaster. The Post and Courier reported in February he would sign the law to improve the health of residents in rural parts of the state where health care providers are scarce.
There will be a ceremonial signing Wednesday. McMaster already signed the measure May 18 and it took effect July 1.
Since then, nurse practitioners have enjoyed new authority — with caveats.
Here's how the new law will impact patients and the health care industry in South Carolina:
New allowances for these nurses to prescribe controlled substances could mean major differences for some patients.
The law signed in May gives them new authority to prescribe Schedule II medications. Those drugs include powerful painkillers such as morphine or Dilaudid and stimulants like Ritalin. Before, they could prescribe from the lower schedules.
There are restrictions, though. The nurses will generally be able to prescribe five days' worth of opioids, for example, and 30 days' worth of Ritalin or Adderall.
Nurse practitioners will also be able to put patients in hospice.
Their "prescriptive authority" has to be outlined in a written agreement with a doctor. Nurse practitioners in the state will not be required to have one but the agreement could expand what they're allowed to do.
Addressing a shortage
Nurse practitioners slightly outnumber family practice physicians in South Carolina. There is a shortage of both.
"The whole objective behind this is to increase the number of providers of care," Sen. Tom Davis, R-Beaufort, the bill's sponsor, said.
Of the almost 40,000 nurses in the state, 2,036 are nurse practitioners, according to the South Carolina Office for Healthcare Workforce.
The new law also applies to nurse midwives and other specialists. All must hold at least a graduate degree.
Parts of all 46 of South Carolina's counties are considered "medically underserved," according to the Department of Health and Environmental Control. In some counties, nurse practitioners outnumber family physicians. In Calhoun County, there is no physician at all.
Aligning with other states
Despite its shortage of providers, South Carolina has been considered a restrictive state to practice as a nurse practitioner. The American Association of Nurse Practitioners lists 12 states as having restrictive policies. Most are in the South.
Previous South Carolina law stated the nurse had to practice within 45 miles of their supervising physician. After years of efforts to have that restriction lifted, the law now no longer requires it.
The new law also increases the number of nurse practitioners a physician can supervise. It was three before. Now it is six. Physicians still may be liable, however, if the nurse practitioner they have an agreement with violates any rules or mishandles someone's care.
Davis said the old laws were outdated, based upon what nurses were taught to do decades ago.
Some studies have also shown it could cost less to see a nurse practitioner than a doctor.
Medical students are also increasingly choosing specialty fields as their student debt mounts.
More than half of graduating family medicine doctors have more than $150,000 of educational debt. About a quarter of those doctors have more than $250,000 in debt, according to a 2016 study.
That drives more doctors into higher-paying fields, and fewer into primary care.
Preparing a nurse practitioner costs about 25 percent of what it costs to educate a physician, according to the American Association of Colleges of Nursing.
Those lower educational costs can trickle down to patients. Still, nurses will be required to refer to doctors for any kind of specialty care, including chronic pain.
This story has been updated to correct information about who the law about new nursing regulations applies to. It does not apply to nurse anesthetists; rather, the law specifically excepts them from the new privileges.