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MASSACHUSETTS HAS LONG benefited from its reputation as a national leader in health care policy and delivery. That leadership, however, also brings fiscal exposure. Because the Commonwealth expanded Medicaid earlier and more comprehensively than most states, it is particularly vulnerable as federal Medicaid financing erodes and discretionary funding plays a larger role in health care financing.

In this environment, the state must do all it can to maximize its ability to secure federal health care funding. One meaningful step — rarely discussed outside workforce policy circles — would be to modernize regulations and licensing requirements for physician assistants. Here’s why that matters.

Last year, the federal government launched the Rural Health Transformation Program, a new initiative that reflects this shift in health care toward discretionary funding. The $50 billion, multi-year program allocates funding not only on population or need, but on workforce capacity, access, and state policy alignment. First-year awards averaged around $200 million per state, though allocations varied widely. Massachusetts received just over $160 million, while multiple states received well above $230 million. These differences underscore how closely federal funding is now tied to workforce policy choices.

Under the program’s framework, states are assessed on clinician mobility, service continuity, telehealth readiness, and whether regulatory structures enable providers to practice efficiently within modern care models. Importantly, funding levels are recalibrated annually, meaning statutory and regulatory decisions have ongoing fiscal implications. In this environment, workforce law has become a material determinant of federal investment.

Physician assistants sit squarely within this policy calculus. PAs are nationally certified, state-licensed clinicians who diagnose, treat, and prescribe across specialties and settings. They are well represented in rural and underserved communities and frequently practice in primary care and community-based environments.

Massachusetts’s regulatory framework for PA practice has not fully kept pace with that reality. The Commonwealth continues to require all physician assistants to work under the direction of an individual supervising physician, who is legally responsible for overseeing that PA’s clinical practice. This requirement is a vestige of an earlier era, when PAs were typically employed directly by individual physicians in small or independent practices. In that model, a one-to-one supervisory relationship reflected both an employment relationship and a legal responsibility for the care provided.

That is no longer how health care is organized. Today, the vast majority of PAs practice within large hospital systems, community health centers, and multispecialty groups. Teams deliver care, oversight is institutional, and responsibility is shared, not anchored to a single supervising physician. This shift has occurred at the same moment the physician workforce is under growing strain.

In Massachusetts, nearly one in four physicians report plans to leave clinical practice within two years, according to the Massachusetts Medical Society. Meanwhile, federal labor projections show PA employment growing by roughly 20 percent over the next decade, reflecting increased reliance on team-based models of care. Health care access in the coming years will depend less on any single profession and more on teams and how effectively states align workforce policy to deliver care.

From a policy standpoint, the consequences are tangible. Requiring physician assistants to file notice of a single supervising physician can slow recruitment and limit staffing flexibility across sites, particularly in rural hospitals and safety-net settings where adaptability is essential.

When a supervising physician leaves a practice or health system, that departure can temporarily call into question a PA’s legal authority to practice, even when the PA remains otherwise fully licensed, credentialed, and employed by the institution. This creates regulatory vulnerability tied to personnel changes rather than patient safety and misaligns licensure with how accountability, credentialing, and quality oversight function contemporaneously.

This misalignment matters, since the new rural health program evaluates whether states have created an optimal practice environment that allows clinicians to practice at the top of their training and be deployed efficiently to meet access needs. States that retain unnecessary supervisory or administrative constraints score lower on workforce and state policy factors that directly affect eligibility for the program’s workload-based funding, which accounts for half of total Rural Health Transformation Program dollars each budget period.

Massachusetts is close to—but not yet at—the federal definition of “optimal” practice environment. Two pieces of pending legislation before the Legislature could help close that gap.

One, An Act relative to removing barriers to care for physician assistants, modernizes PA licensure by aligning supervision with contemporary, team-based care models and removing the requirement to file notice of an individual supervising physician as a condition of licensure.

The second bill, An Act relative to physician assistant interstate compact, authorizes Massachusetts’s participation in the PA Licensure Compact, which would facilitate patient care across state lines.

Together, these reforms would improve access to care while strengthening the Commonwealth’s competitiveness for future rural health funding rounds, particularly as Medicaid shortfalls will disproportionately affect Massachusetts. The interstate compact also benefits patients seeking care across state lines and in remote regions within our state. In New England’s interconnected health care market, licensure compacts support timely follow-up, coordinated post-discharge care, and continuity when patients receive specialty treatment at Massachusetts’s academic medical centers but return home for ongoing management.

This is not a debate about deregulation or professional hierarchy. It is a question of whether licensure law reflects contemporary delivery models and the fiscal environment states now face.

As the Legislature debates primary care reform, the physician assistant modernization bill and the interstate compact legislation should be part of that conversation. With federal health care funding becoming more competitive and increasingly tied to demonstrated policy readiness, PA workforce modernization should be understood for what it is: a strategic legislative decision with real consequences for access, equity, and the Commonwealth’s long-term financial sustainability.

Duncan Daviau is president of the Massachusetts Association of Physician Assistants.