Three nurses wheel a patient into surgery.

Congress, States Weigh Extending Full Practice Authority to Nurses

January 2, 2024 | Purdue Global Law School

Amid a widespread and growing physician shortage, the U.S. Congress is considering whether to grant full practice authority to qualified nurses. In 2022, Congress considered the Improving Care and Access to Nurses (ICAN) Act, but the bill failed due to opposition from physician groups. The ICAN Act was reintroduced in the House in April 2023 and the Senate in July 2023. The bipartisan measure would reduce barriers to health care access among Medicare and Medicaid participants.

More than half the states, the District of Columbia, Guam, and the Northern Mariana Islands have adopted full practice authority (FPA) licensure laws. These laws enable advanced practice registered nurses (APRNs) to evaluate patients, order and interpret tests, make diagnoses, and prescribe and manage treatment. The APRNs are subject to the regulatory oversight of the state nursing board without oversight by a physician collaborator or state medical board.

FPA laws have the broad support of nursing associations, public health experts, the insurance industry, and some lobbying groups; however, physicians and medical groups continue to oppose the measures.

The Growing Shortage of Doctors

According to a 2021 report from the Association of American Medical Colleges, demand for physicians will exceed supply by as many as 124,000 by 2034. This includes a deficit of up to 48,000 primary care physicians. The analysis was conducted in 2019, before the COVID-19 pandemic intensified burnout among clinicians.

The shortfall is driven primarily by an aging U.S. population. The number of Americans aged 65 and older is expected to increase 42.4% by 2034. This includes active physicians who are approaching traditional retirement age. Their retirement plans would further impact the level of shortages.

The problem is particularly acute among underserved populations, including rural and marginalized minority populations and people without health care. The report notes that for these groups to have better access to health care, an additional 180,400 doctors would be needed today.

Lifting the Cap on Resident Training

In 1997, Congress imposed a cap on the number of graduate medical education (GME) positions funded by Medicare amid a concern that the U.S. was training too many doctors. GME payments go to teaching hospitals to offset training costs and the residents’ salaries. Congress lifted the cap in 2020, and has added 1,200 new GME positions in the past three years. The Resident Physician Shortage Reduction Act of 2021 would have increased the resident limit by 2,000 per year from 2023 through 2029. That bill failed but was reintroduced in the House in March 2023 and the Senate in April 2023.

The House bill specifies that at least 10% of the 14,000 residency positions must be in rural or noncontiguous areas and serve designated health professional shortage areas. The hospitals must have exceeded their GME cap, with priority given to those affiliated with historically Black medical schools. Even if the bill passes, however, it will do little to fill the massive need for doctors in the U.S.

FPA Licensing Requirements

The ICAN Act and state FPA laws seek to bridge that gap with APRNs, which include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. These practitioners cover a wide range of clinical practices, including primary care, pediatrics, geriatrics, and mental health. Many of these practice areas already face provider shortages.

At a minimum, APRNs must have earned a bachelor’s degree in nursing and hold a registered nurse license. They must also graduate from a nationally accredited nurse practitioner-focused master’s or doctoral program and pass a board certification exam. Individual states impose additional requirements for FPA licensing. For example, Illinois requires APRNs to complete 4,000 clinical hours with a collaborating physician and an additional 250 hours of continuing education. To maintain their Illinois FPA license, APRNs must complete up to 60 hours of continuing education each renewal cycle.

FPA has delivered proven benefits to patients. It increases access to care and decreases costs by increasing efficiency and eliminating duplicative services. It also enables patients to see the provider of their choice.

Roadblocks Remain

Federal, state, and local policymakers expanded FPA licensing temporarily during the COVID-19 pandemic, enabling APRNs to deliver care with fewer restrictions. Approximately 40% of Medicare beneficiaries received care from APRNs during the health crisis. As pandemic-era policies expired, however, restrictions on FPA were reinstated.

Despite the success of FPA licensing, many physicians and medical groups remain opposed. The American Medical Association (AMA) argues that the ICAN Act would allow APRNs to deliver services outside their training, putting patients at risk. The AMA also states that the ICAN Act would increase costs and use of diagnostic tests and other services while not increasing access to care in underserved areas. If APRN licensing is allowed, the AMA recommends that it be “regulated jointly by the state medical and nursing boards.”

However, physicians in some states recognize that policies must be updated to address the acute shortage of providers. Furthermore, states that still have licensing restrictions are finding that nurses are moving to states that allow them to practice to the full extent of their training and licensure. It remains to be seen if Congress will pass legislation allowing FPA licensing at the national level.

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