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Rural Texas Needs Health Care Providers, Why is a Texas Law Still Standing in the Way?

By Vicki Brooks DNP, APRN, FNP- BC, FAANP

Living in rural Texas shouldn’t mean going without access to health care.

It’s well documented that rural Texans face obstacles when it comes to providing and accessing health care services, including workforce shortages, aging infrastructure, and difficulties in getting health care coverage. This has huge negative implications on both the physical and mental health of people of all ages.

A lack of accessible health care leads to a lower quality of life and decreased life expectancy, and many times from illnesses that are preventable. A significant shortage of mental health care is directly related to a higher suicide rate among young people in rural areas.

The good news is, there is a willing workforce of skilled nurse practitioners who are ready to step in and do more, if Texas lawmakers will let them.

As a Nurse Practitioner (NP) advocating for rural health, I know the single most immediate and impactful step lawmakers can take is to remove the state mandate that nurse practitioners secure a contract, what’s called a delegation agreement, with a physician before they can provide care to patients.

The reality is clear: rural Texans want and deserve more health care access.

Nurse practitioners are one of three professions providing primary care in the United States, along with physicians and physician assistants (PA). NPs have provided safe, high-quality care for more than half a century, yet Texas state regulations still prevent them from practicing without first obtaining a contract with a physician.

Unfortunately, for a lot of rural Texans that leaves them with two options: long trips to find care, or no care at all. Far too many rural Texans go without care.

What is this contract agreement and why does it exist? It is a relic from when NPs first became a licensed profession. Texas, along with other states, required NPs and their contracted physician to work in the same office. After decades of positive health outcomes, most states, the Veterans Affairs (VA) and all branches of the US military have eliminated these contract requirements altogether.

Ten years ago, Texas removed the requirement that NPs and their contracted physician had to work in the same office. However, it still requires that NPs have a physician contract, which requires one phone call a month with a physician to discuss patients seen months ago. This physician might live in another part of the state. No other professions in Texas are required to have this kind of contract to do their job.

Finding a physician to contract with can be particularly complicated for NPs wanting to practice in the most underserved areas, like rural Texas. Even worse, if the contracting physician retires or passes away, an NP is prohibited from seeing a single patient until they find a new physician to contract with. This means if you have an appointment tomorrow, you may not have access to care.

This outdated and unnecessary mandate is causing greater barriers to getting care in an already complicated and burdened rural environment. To put it simply, NPs educated and trained in Texas can find it easier way to provide care to patients in other states with fewer obstaclesMany leave the state altogether after graduating.

NPs are more likely to work in rural areas, where the population is also aging at a faster rate than elsewhere. Rural patients trust NPs with their health. A 2022 poll conducted for AARP of Texas voters aged 50 and older found that 83% support NPs as primary care providers.

If Texas is serious about solving our health care crisis, we must address the barrier standing between patients and NPs.

That means freeing NPs to care for more patients. The future of primary care is clear, in fact the number of new NPs outpaces physicians, and two-thirds of the practitioners added to the workforce between now and 2030 will be advanced practice clinicians like NPs.

But will they be in Texas? The truth is, Texas is lagging behind and Texans are suffering the consequences. Rural Texans feel the increased suffering of these consequences.

Vicki Brooks DNP, APRN, FNP- BC, FAANP is an assistant professor of professional practice at Texas Christian University. She is the Director of the APRN programs at Harris College of Nursing & Health Sciences and practicing family nurse practitioner at a rural urgent care clinic. She is a leader and advocate for nursing and a steadfast promoter of equitable access to care and resources for rural communities.


  1. Kerrie on February 26, 2023 at 9:41 am

    Hello Vicki,
    I have moved into a rural area over 100 miles from Mineral Wells. It’s in what is called the “Big Country.” Healthcare is rather iffy as well as behind the times! The local clinic not only told me “we really don’t want to treat you”, but they also were running a scam! (I reported it and can only hope it was ended.)
    I literally have to play dumb as to my medical knowledge. Even when I seek care in a larger
    town which is 40 miles away.
    The hospitals make it extremely difficult to be able to afford co-pays for procedures because they claim ALL procedures are performed in the hospital.
    Local EMS is nothing but “load and go!”
    It is so maddening as well as saddening.
    If I knew of something I could do, I’d sure do it!
    Thanks for reading and
    Thank you Ma’am

  2. VB on February 26, 2023 at 3:24 pm

    Hi Kerrie,
    The Big Country is very rural in some areas. Rural community members need more resources for quality care. Insurance in itself can be difficult to negotiate for proper care without going broke.
    Thank you for your comment. Our state legislatures need to know what it is like in rural Texas. You can make your voice heard!

  3. Elizabeth on March 6, 2023 at 8:12 am

    I, too, live in a very rural area. the nearest hospital is not just small, but offers limited treatment. the County to the West is larger, but still transfers patients to Dallas, and the county to the East, is very much like the county to the west. There are very few providers and very limited access to care. Our families must take a complete day off of work to drive in hopes to get all of their appts done in a day. If they have no other health needs, this may be manageable. Although with limited specialties within a 100 mile radius, this poses a horrible problem.

    Our local representative, lives in the busiest of the counties. two years ago, when we conversed, he, too sees an APRN, yet stated he didn’t believe that APRNS should have the authority to practice independently. I asked him why, and his response was because of his physician friends and what he has heard from them. So, I challenged him to speak with APRN in the areas he serves, and not his friends.

    I hope each of us challenges our representatives to do the same. We do not know who is in their ear unless we ask and challenge the ideals that come with what is being told to them. Kudos for the article, I pray we all have the opportunity to work alongside all of the Texas providers with integrity and respect, while offering be most optimal care possible to all Texans.

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