If Not You, Then Who? Reflections on Legislative Advocacy and Licensing Barriers as a Physician Associate

The Licensing Catch-22

My initial frustration began with a seemingly illogical policy: to obtain an active South Dakota PA license to practice, I first had to secure a supervising physician. But without an active license to practice, securing a job was nearly impossible. It was a bureaucratic loop with no clear exit. One might call it a classic catch-22.

In an attempt to navigate this barrier, I requested a temporary license from the medical board. Their response? An affidavit swearing that I would not practice until a supervising physician signed their private practice agreement. Reasonable on paper yet problematic in execution. The affidavit was logged into the medical board's public-facing portal—not as a procedural form, but as a disciplinary action on my license (see Appendix). To any potential employer, my record now looked tainted.

Obviously, this was not merely a clerical annoyance; it was a profound structural barrier with real consequences to my economic contribution to the state. It sent a confusing message: South Dakota, along with many other rural states, is in desperate need to attract and retain PAs, yet had erected administrative and regulatory walls that disincentivize PA practice. ¹ As a state with significantly underserved geographical regions that seek quality clinicians, the state laws were not attractive to potential PAs; instead, they were creating proverbial red tape.

Advocacy as a Professional Imperative

These regulatory frustrations were not new to me. Early in my career, I learned that the role of a PA is not confined to exam rooms and procedure suites. Rather, the PA role must also include policy engagement for sustained viability as a profession. The outdated laws were creating barriers for PAs serving patients in rural communities, like mine, especially if the listed supervising physician retired or left the practice. ⁴ As a newly minted clinician, I joined the legislative committee in Nebraska, knowing little about healthcare law but armed with lived experience and a willingness to learn.

Over the years, that involvement not only shaped my understanding of systems but also enhanced my confidence in navigating them. I co-chaired legislative efforts, gained insight into the intricacies of state policy, and established relationships with key decision-makers to enhance the understanding of PA education and training. So, when I returned to South Dakota with over six years of clinical PA experience and encountered another broken system, it wasn't an issue that I could ignore. It was a clear call-to-action.

Professional advocacy has long been emphasized as a necessary skill for PAs to ensure an optimal scope of practice and care delivery; yet, most PAs are not educated on advocacy during their formal training. ^5,6 Conversely, nurse practitioners (NPs) commonly obtain advocacy training in their nursing education, which may be one facet that helps explain the differences in state policy between PAs and NPs. ⁷ This discrepancy often confuses policymakers and patients alike, reinforcing the urgency of modernization efforts, such as title change and enhancing public awareness of PA education (see Appendix). While the clinical roles of PAs and NPs are similar, the training and education differ significantly. When archaic laws persist, they have a direct impact on both clinicians and patients. ⁷ As I found throughout the last decade, without our voices, outdated or obstructive laws remain unchallenged.

Neighboring states may maintain markedly different PA practice environments. While the scope of practice for a PA is nearly identical in the two adjacent states where I have practiced, the way the state medical boards interpret and implement the law differs significantly. One requires a collaborative agreement with a physician to be on file at the practice level, rather than submitting it to the state medical board for licensure purposes. In essence, while the clinical practice is the same in both states, the administrative barrier to entry for clinicians that I experienced differed. These variations shaped my experience and underscore the inconsistency of interstate laws, which complicate clinician mobility and patient care.

Patient Care Implications

Licensing and workforce barriers prevented me from practicing medicine in my community, despite years of education and clinical experience. These obstacles are more than bureaucratic red tape; they're a public health issue. According to the National Academies of Sciences, eliminating these administrative burdens is a critical component of healthcare reform and vital to achieving high-quality primary care. ⁸ Further literature supports this claim, reporting that easing licensing restrictions in rural and underserved areas can help address provider shortages and even improve life expectancy. ^3,9 When clinicians face fewer administrative burdens, patients gain greater access to timely care.

This challenge is especially pressing in underserved states, where the recruitment and retention of healthcare clinicians are already challenging. ^3,4 But this isn't just an issue for South Dakota or other rural regions. This is a national problem. The widespread shortage of healthcare clinicians impacts every state. ^2,3,9 As healthcare delivery rapidly evolves to meet growing needs, so must the laws that govern how providers enter the workforce. Updating outdated licensing policies isn't about lowering standards; it's about aligning regulation with reality. ^3,7 We need systems that support, not hinder, the clinicians ready to serve where they're most needed.

Although conceived as safeguards for patients, many administrative barriers have become obstacles to timely patient care—a reality I've experienced firsthand. The literature is expanding on the downsides of strict licensing requirements, showing more significant burden than benefits, and indicating a clear need for careful review and reform. ^4,7,10 Policies meant to protect patients are inadvertently delaying care and creating unnecessary roadblocks for highly trained professionals.

The South Dakota PA Modernization Bill

In 2023, I reconnected with the South Dakota Academy of PAs, supporting the senate bill they were advocating for and offering to support the legislative committee in any way I could. Though I felt stretched thin by relocation and career transition, the pull toward advocacy remained undeniable.

After three failed attempts to pass legislation modernizing South Dakota PA Practice, the 2024 cycle was purposefully different. We laid the groundwork strategically by revamping our branding, hiring a new lobbyist, and organizing PA Day at the Capitol to familiarize and educate legislators about our profession. Without the pressure of an active bill, we focused on educating lawmakers and listening to the unique healthcare concerns in each of their communities, not lobbying them. Our approach had shifted from a defensive to a relationship-building stance. I met legislators for coffee, scheduled meetings, made phone calls, sent emails, and helped forge partnerships with stakeholders ranging from the Emergency Medical Services (EMS) Association to the American Association of Retired Persons (AARP).

In 2025, we introduced and passed a restructured bill based on the American Academy of Physician Associates (AAPA) Model Language and recent modernization laws from neighboring states, creating a progressive reform policy. Key components included:

• Replacing "supervising physician" with "collaborating provider"

• Removing the PA-physician ratio

• Allowing independent practice after 6000 hours

• Codified scope of practice and clarified licensing requirements

• Enabling direct payment to PAs

• Makes PAs legally responsible for the care they provide, not their supervising physician

This legislation, effective July 1, 2025, marks a pivotal shift in how PAs are regulated and how they serve South Dakota residents. ¹⁰ By improving flexibility within healthcare teams and reducing administrative barriers, South Dakota PAs have expanded opportunities to meet the needs of unique communities within the state.

Reflection

My greatest takeaway? The power of showing up. Advocacy doesn't always look like dramatic speeches or large protests. In fact, I would argue that this type of advocacy is perhaps less powerful than being the consistent, familiar face in a building full of strangers who make decisions about your chosen career.

This season of my life was exhausting—but it was also affirming. It reinforced that advocacy is not something you do only when it's convenient. It's a posture, a way of being in the profession. When policies don't make sense for your profession or the people you serve, when no one else is pushing for reform, that's when your voice matters most.

Make a phone call. Write an e-mail. Be present during your state legislative session. I often tell my students and early-career PAs: If not you, then who?

My time in the state capitol building taught me several lessons, but some of the smaller takeaways are just as valuable. For instance, procedural inefficiencies have real consequences for the recruitment and retention of PAs. In South Dakota, these archaic laws lead to reduced PA workforce opportunities, forcing PAs to seek employment elsewhere. ⁴ When rural and underserved areas compose the vast majority of the state's geographic area, administrative barriers, such as the requirement of a supervising physician, further diminish the workforce potential.

Words matter. Our legislators respond more to personal stories and examples than to data alone. The literature reports that your "why" is powerful, but we experienced it directly. ¹¹ We found that sharing our motivation to bring this legislation was an important factor in the conversation. Drafting concise one-page handouts tailored to each lawmaker's district helped keep our message clear and straightforward. Sharing my story of the barriers I faced when returning to the state highlighted the need and made the narrative more personal and noteworthy.

As mentioned earlier, consistency is more important than volume. A steady presence up to and throughout the legislative session is more effective than mass e-mails or occasional outcry. Consistently following up—rather than assuming a single conversation was sufficient—ensured maintained visibility. For example, scheduling brief, informal coffee meetings with legislators before the legislative session allowed time to build a relationship, followed by a text update on the bill's progress throughout the session. The South Dakota legislative session is held annually and lasts 40 legislative days. ¹² During this time, the legislators are constantly inundated with information. The combination of grassroots effort prior to the legislative session, coupled with the continual fostering of relationships, is perhaps the most significant component of our success.

And lastly, we're all still learning. Advocacy does not require formal training, but it does require a commitment and a willingness to grow. ¹¹ Engaging legislators starts with listening, a skill most clinicians already possess, then sharing your educational journey, and offering to collaborate on healthcare bills. Consider inviting your legislator to join you in the clinic for a few hours to gain a hands-on understanding of your role in medicine. Our success didn't come from knowing the intricacies of the bill. It stemmed from educating legislators and stakeholders about the PA profession, the initial and ongoing education required, sharing our story, and fostering relationships with decision-makers across the political and social landscape.

Looking back, that season of my life was concurrently grueling and empowering. It reminded me that advocacy isn't a role you take on only when a need arises. It's something you live out daily, something that becomes woven into the fabric of who you are as a professional. When broken systems delay care and harm the patients you serve, when policies defy common sense, and when no one else is speaking up—that is your moment to speak out. As a medical professional, your voice carries the power to heal beyond the bedside. For me, the ability to engage with legislators was supported by fluency in medical and policy language as well as professional connections. Clinicians without similar networks may face even steeper barriers, thereby compounding inequities in workforce entry and representation. In today's healthcare landscape, as a clinician, your advocacy isn't an accessory to care— it is care.

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Appendix.

Appendix