By Shalina Chatlani, Stateline.org

Mercedes Dodge was raised by first-generation immigrant parents from Peru in a modest home in a rural part of southeastern Texas, where there weren’t many health care providers. Sometimes they had to travel to Houston, over an hour and a half away, to get basic health care.

Partly because of that experience, Dodge became a physician assistant. Since 2008, she has provided psychiatric and primary care services to adults and children, many of whom come from communities like hers.

Dodge, who now lives in Austin, Texas, has built up a loyal base of patients, including many who are part of military families. But when any of them move out of Texas, she has to stop treating them, even via telehealth, unless she gets a license to practice in that state.

“I do my best and collaborate with them, but they already feel alone,” Dodge told Stateline. “I wonder, ‘Why can’t I be the glue? Why can’t I step over state lines and provide the care that they deserve?’”

Mercedes Dodge, a physician assistant in Austin, Tex. Dodge holds PA licenses in multiple states so she can continue to see patients who move away from Texas. More states are joining a multistate compact that allows PAs to practice across state lines. (Courtesy of Mercedes Dodge/TNS)

Physician assistants, commonly known as PAs, are licensed clinicians who have a master’s degree and can practice in a range of specialties. Their three years of training typically includes 3,000 hours of direct patient care, and they are an increasingly critical part of the health care workforce, which in many states isn’t keeping pace with a growing and aging population.

By 2028, the nation as a whole will be short some 100,000 critical health care workers — doctors, nurses and home health aides — according to a new report from Mercer, a management consulting firm.

The looming shortage is one reason why 13 states have joined the PA Licensure Compact, a multistate agreement that allows PAs to practice in any participating state, without having to get an additional license.

Delaware, Utah, and Wisconsin enacted the legislation in 2023.

Colorado, Maine, Minnesota, Nebraska, Oklahoma, Tennessee, Virginia, Washington and West Virginia followed suit this year. Ohio became the latest state to enact it in July.

The PA compact is one of several that have emerged over the past several years, especially since the expansion of telehealth services during the COVID-19 pandemic. There are similar compacts for doctors, nurses, occupational therapists and social workers.

One challenge has been completing the background checks required for providers who want to practice under the compacts. For example, Pennsylvania’s participation in the nursing and medical licensure compacts was delayed as the FBI denied the state access to its fingerprint database. They later reached an agreement on how to move forward.

The PA compact grants a “privilege to practice,” allowing PAs to practice in participating states without getting an additional license. The nursing compact gives nurses a multistate license, while the physician licensure compact just expedites the licensing process.

Some large states, such as California and New York, don’t participate in compacts for doctors, nurses, social workers or PAs. Some state lawmakers in those states say joining interstate compacts would reduce the quality of their states’ health care workforces, because other states require lower standards of education and training.

“We are proud that New York’s high standards have resulted in our state being an international destination in health care,” New York Democratic Assemblymember Deborah Glick wrote in an op-ed last year for the Times Union newspaper in Albany. “While it’s possible that it may make sense at some point for New York to join a licensure compact, we should pause before we allow a quick fix to lower New York’s standards.”

In other states, such as Texas, doctors who have succeeded in limiting the “scope of practice” of Texas PAs oppose the compact because they believe it might allow out-of-state PAs to go beyond those limits for their patients who reside in Texas. The American Medical Association and its state affiliates argue that allowing PAs to provide care traditionally provided by physicians puts patients at risk.

Dr. G. Ray Callas, president of the Texas Medical Association, said he values the role that physician assistants play in the health care system, but that his organization objects to any measure that might “give PAs authority to do more in health care than they are trained to do.”

“TMA is not opposed to appropriate, expedited licensure, but we do oppose these compacts when they expand scope of practice and create a patient safety issue, lowering the standard of care in Texas,” Callas said in a statement.

Supporters of the compact say that fear is unfounded, and that the agreement has no effect on state scope of practice rules. The model legislation for the compact specifies that PAs who treat patients in another state can only do so “under the Remote State’s laws and regulations.”

Last year, the Texas legislature considered legislation to join the PA compact, but it died in the state Senate.

Monica Ward, president of the Texas Academy of Physician Assistants, said her group will keep pushing for the bill.

“In the rural areas of Texas, there is absolutely a need and a shortage of health care providers,” Ward said. “We’re surrounded by multiple states, so it’s nice to be able to reduce those administrative burdens, paperwork and possibly fees for those that are looking to work in Texas.”

It will take 18 to 24 months for the compact to become fully operational and for PAs to apply for the privilege to practice in other areas. The compact commission also needs to create a data system to keep track of licenses.

This model of licensure may not have worked even five years ago, said Tennessee Republican state Rep. Jeremy Faison, who sponsored his state’s compact legislation.

“It would have had major pushback and people would have asked, ‘What are you trying to do? We like to control what we’re doing in our state,’” said Faison. “But because we live in a global society and people move around so much more than ever before, I think the average person has embraced this.”

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Faison told Stateline that for states such as Tennessee, which borders eight states, joining the compact makes economic sense because it will encourage people to move to the state.

Financial stability was 32-year-old Aneil Prasad’s motivation for getting a compact nursing license. He moved from New Orleans to Asheville, North Carolina, last year.

“It allows people to seek out better-paying jobs and move themselves ahead, buy houses and have better health and education and all that,” Prasad said. “And then the less competitive places are forced to raise their wages in order to attract people.”

After moving from Louisiana to North Carolina with his multistate license, Prasad said his wage increased from $21 an hour to $36 an hour. He notes that while the multistate license for nurses costs a bit more than a regular license, it would be much more expensive for him to apply for a new license in every state.

Since Texas hasn’t joined the PA compact, Dodge maintains active licenses in her home state as well as Alaska, California, Florida, New Mexico and Washington. She said the process to get them was expensive and time-consuming. Licenses can cost upward of $500 and can take three to nine months to obtain. Dodge said it’s been worth the trouble to help her patients, but she would appreciate an easier pathway.

“I got all these state licenses to follow my patients,” she said. “So when the PA compact license gets enacted in Texas, I hope it’s going to help me continue following my patients and I’ll be the glue that they need.”

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

©2024 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

Research is revealing intriguing clues about how pregnancy changes the brain.

Studies scanning women’s brains before and after pregnancy have found that certain brain networks, especially those involved in social and emotional processing, shrink during pregnancy, possibly undergoing a fine-tuning process in preparation for parenting. Such changes correspond with surges in pregnancy hormones, especially estrogen, and some last at least two years after childbirth, researchers have found.

A new study, published Monday in the journal Nature Neuroscience, adds to the picture by documenting with MRIs brain changes throughout one woman’s pregnancy. It confirms previous results and adds detail, including that white matter fibers showed greater ability to efficiently transmit signals between brain cells, a change that evaporated once the baby was born.

“What’s very interesting about this current study is that it provides such a detailed mapping,” said Elseline Hoekzema, a neuroscientist who heads the Pregnancy and the Brain Lab at Amsterdam University Medical Center and has helped lead studies analyzing brain scans of more than 100 women before and after pregnancy.

Hoekzema, who was not involved in the new study, said it showed that along with previously documented “longer-lasting changes in brain structure and function, more subtle, transient changes also occur.”

Dr. Ronald Dahl, director of the Institute of Human Development at the University of California, Berkeley, who was not involved in the new study, said the emerging research reflected the key role of hormones in transitions such as puberty and pregnancy, guiding neurological shifts in priorities and motivations.

“There is that sense that it’s affecting so many of these systems,” he said.

The study participant, Elizabeth Chrastil, is a neuroscientist at the University of California, Irvine. She became pregnant in 2019, at 38, after in vitro fertilization. That allowed precise tracking of her pregnancy from the start.

She had 26 brain MRIs — four pre-pregnancy scans, which started three weeks before; 15 during pregnancy; and seven in the two years after her son’s birth in 2020.

“It was sort of cool being able to be a neuroscientist and to know what we don’t know,” Chrastil said, “and so to be able to say: ‘Hey, let’s do this. I’m about to become pregnant. I think we should do this.’”

She said that during pregnancy, she was unaware of any symptoms or effects linked to the brain changes. Her brain, however, exhibited profound differences.

By the ninth week of gestation, 80% of 400 brain areas analyzed showed decreases in gray matter volume and cortical thickness that continued through pregnancy, with areas shrinking by 4% on average. Change was particularly pronounced in the default mode network, which is instrumental in perceiving other people’s feelings and perspectives.

The study’s senior author, Emily Jacobs, a neuroscientist at University of California, Santa Barbara, said pregnancy brain shrinkage was “not a bad thing” and probably reflected pruning that “enables the brain to become more specialized.” Similar processes occur during puberty and infancy and some neurological disorders arise from inadequate pruning, she noted.

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As with Michelangelo’s statue of David, she said, “the artist starts off with this big block of marble and the underlying beauty is revealed through the art of removal, carefully honing and fine-tuning the material.” In this study, she said, “you can see the sculpting of the brain unfold week by week.”

The volume loss mostly persisted two years postpartum, suggesting that pregnancy hormones prompt “permanent etchings in the brain,” she said.

White matter changes, however, did not last. For unclear reasons, Chrastil said, over the first two trimesters, the fiber bundles became like roads with improved paving, which “makes things go more smoothly, information can travel more seamlessly.” By childbirth, the initial white matter condition returned.

For comparison, researchers evaluated brain imaging from eight people who were not pregnant, including two men. Their brains did not show such alterations.

But subsequent pregnancy brain scanning of several women has echoed Chrastil’s pattern, Jacobs said.

Hoekzema said the pattern was so distinctive that her team showed that a computer algorithm could identify if women were pregnant “based only on the changes in their brains.”

Her team’s research “suggests that brain changes during pregnancy relate to the way a mother’s brain and body react to infants,” she said, correlating with characteristics like “maternal-fetal bonding, nesting behavior and the way a woman’s heart rate reacts to seeing an infant.”

Dahl said pregnancy-related hormones might create neurological “windows of learning” that “sensitize individuals to learn adaptive things and create bonds and develop greater expertise in responding to an infant.” Providing social and emotional support during pregnancy would therefore be even more helpful because the brain is tuned to prioritize that information, he said.

Still, the implications for parenting are undoubtedly complex and varied. For example, Jacobs said, adoptive parents, fathers and others “may not experience gestation firsthand, yet display all of the nurturing behaviors needed to care for their children.”

Researchers say studying pregnancy brain changes might yield information about conditions like postpartum depression and neurological effects of preeclampsia.

“We’re just starting to scratch the surface of understanding,” Chrastil said.