Concerned that some patients were having to wait too long for medications, Missouri lawmakers passed a bill in 2008 broadening the ability of thousands of specially trained nurses to write prescriptions.
Two years later, not a single patient has been helped by the law.
That's because it still hasn't been implemented by a bureaucracy that lacks the cash to update its database of people authorized to write prescriptions and has been moving at a meticulous pace to publish new rules governing doctors and nurses.
"It's a great example of the barriers of government," said Sen. Delbert Scott, R-Lowry City, who sponsored the 2008 law about nurses.
But it's not the only such example. Consider just a few:
— That same 2008 law also included a section authorizing the creation of a real-time electronic log of people purchasing cold medicines containing pseudoephedrine. The goal was to bolster Missouri's ability to catch people illegally stockpiling pills that can be used to make the illegal drug methamphetamine.
But the database still doesn't exist, because lawmakers never approved money for it. Earlier this month, the state announced it had selected a private company to develop the electronic tracking system for free. That system now is expected to be ready within three months.
— A 2007 law required private investigators to be licensed, undergo a background check, carry professional liability insurance and continue to take educational courses. But first a state oversight board had to be appointed, then that new board had to come up with regulations for the industry, and those rules had to go through a public-comment process.
The result was a nearly three-year delay. The state finally began accepting applications for private investigator licenses on Feb. 1.
— Last year, legislators passed a bill expanding prescription powers for physician assistants, much as they had done a year earlier for nurse practitioners. But that law has yet to be implemented, because it is awaiting the publication of administration rules spelling out the particulars of how it would work.
The 2008 legislation expanding prescription authority for nurse practitioners was the first bill endorsed by the Senate that year. Supporters argued it could improve access to health care, particularly in rural areas where a scarcity of doctors means nurse practitioners are sometimes the only ones available to see patients.
Missouri nurses with advanced training had been able since 1993 to prescribe some medicines, but not those in certain categories of controlled substances. Some off-limit medicines include pain relievers like Vicoden, muscle relaxants like Valium and children's cough medicines containing codine.
When a doctor isn't present, patients of nurse practitioners may have to wait hours — even days — before a physician can see them and write a prescription for one of those medicines, supporters of the 2008 law said.
The law's implementation was delayed partly because the Missouri Board of Nursing and the State Board of Registration for the Healing Arts (which oversees physicians) could not initially agree on the wording for a regulation governing how Missouri's 15,247 doctors and its 5,679 "advanced practice registered nurses" must work together.
The boards finally submitted a proposed regulation in January to the Division of Professional Registration, said Tina Steinman, executive director of the healing arts board. But that rule still must be reviewed by the division and the department that oversees it, then published by the secretary of state's office for a public comment period.
Once the department files a rule with the secretary of state's office, it typically takes nine additional months before it becomes final, said Travis Ford, a spokesman for the Department of Insurance, Financial Institutions and Professional Registration.
But that is not the only hang-up.
The Department of Health and Senior Services, which oversees a database of professionals with prescription authority, also must come up with a regulation implementing the law. And the database itself will need to updated with new fields capable of linking the nurse practitioners to the doctors with whom they are collaborating.
To add the nurses to the database would cost about $143,000, said department spokesman Kit Wagar. To replace the 13-year-old database — which the department says is both necessary and preferable — would cost about $775,000, Wagar said.
At this point, there is no money for either option, though a lobbyist for the Missouri Nurses Association is trying to get some money included in the 2011 budget.
"It's frustrating on the nurses' side, because it just seems like everything is a stalling tactic," said Jill Kliethermes, chief executive officer of the nurses group.
Some lawmakers are frustrated as well. And the bottom line for some patients is that nothing really has changed — even though the law was changed two years ago.
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EDITOR'S NOTE — David A. Lieb has covered state government and politics for The Associated Press since 1995.