States Weigh Laws for Nurse Practitioner Full Practice Authority

At the height of the pandemic, states across the nation issued executive orders granting nurse practitioner full practice authority, a temporary move that leaders said would help expand patient access to care while the US faced unprecedented medical needs.

But those temporary stays are starting to expire. While some states, like California, codify expanded scope of practice laws, others, like Indiana and Pennsylvania, face the consequences of the lapsed regulations.

In California, the state’s nurse practitioner association has officially voted on regulations to expand nurse practitioner scope of practice, according to CalMatters. The vote helps bring to fruition a 2020 law granting nurse practitioners full practice authority, meaning NPs would not need to enter into a written agreement for a physician to oversee their work. The expanded scope of practice hinges on NPs passing a certification course, which the California Association of Nurse Practitioners said will go live soon.

“Hopefully we don’t crash the website, but we are very excited,” Cynthia Jovanov, president of the California Association of Nurse Practitioners, said in a statement via CalMatters. “This means that if I want to do a mobile clinic in Skid Row, I don’t have to be held hostage by paperwork to get a partnering physician who may not have the same desire.”

The law creates two designations of nurse practitioners in California. The first designation allows NPs to work without a written physician contract, but only in some facilities that also staff at least one physician or surgeon. That allows qualifying NPs, who must have completed 4,600 hours or three years of full-time practice in the state, to consult a physician as necessary.

The second designation allows NPs full practice authority. The state is taking a phased-in approach to this designation, CalMatters reported, so NPs likely won’t attain this designation until 2026.

But as California finalizes its plans for expanded scope of practice and full practice authority, other states are seeing their pandemic-era temporary expansions expire, leaving some advocates to lobby lawmakers.

In Indiana, a group of community groups has launched Hoosiers for Health Care Access (HHCA), which is calling on the Indiana General Assembly and Governor Eric Holcomb to re-up a COVID-era rule allowing NPs expanded scope of practice.

Indiana is staring down a staffing shortage that imperils patient care access and outcomes, wrote HHCA, which included member groups The Indiana Chamber, AARP Indiana, Americans for Prosperity-Indiana, the Coalition of Advanced Practice Registered Nurses of Indiana, the Convenient Care Association, the Indiana Minority Health Coalition, Purdue University NW College of Nursing, INhouse Primary Care, Rounding Providers, and Sojourner Truth House.

A whopping 2 million Indiana residents live in federally designated primary care provider shortage areas, they wrote, and 4.7 million Indiana residents lack access to mental healthcare. Moreover, access to maternity care is lacking, with about a third of Indiana counties classified as obstetric deserts.

That’s impacting local business, HHCA argued, because companies cannot attract talent to a state with limited patient access to care. Keeping the NP scope of practice rules that were enacted during the pandemic could help fill that gap, the organizations wrote.

“Over the last two years, the public health emergency temporarily empowered patients with greater health care choice through direct access to advanced practice registered nurses (APRNs),” HHCA wrote in the open letter. “We cannot turn back now. With the suspension of the Governor's executive order lapsing earlier this year, the General Assembly must act swiftly to pass legislation in the 2023 session to make this access permanent.”

In Pennsylvania, policymakers are approaching the full practice authority argument empirically, with a new report from the Commonwealth Foundation showing that expanding scope of practice could eliminate half of the state’s health professional shortage areas (HPSAs).

“Skilled professionals, like Advanced Practice Registered Nurses (APRNs), can help fill the gap,” the authors wrote in the report’s executive summary. “However, current state laws often prevent skilled APRNs from providing primary care to patients. State Scope of Practice (SOP) laws govern APRNs, limiting what tasks they can perform. These laws define each provider’s role and dictate the oversight they must have to practice.”

Compared to neighboring Maryland, where APRNs experience expanded scope of practice, Pennsylvanians face poorer care access and health outcomes, the researchers said. Despite similar physician density, Marylanders are less likely to report fair or poor mental or physical health, the report showed.

If Pennsylvania went the way of Maryland, full practice authority would increase the number of certified nurse midwives (CNMs) by an estimated 26.7 percent and the number of NPs by 29.5 percent. Full practice authority would also mean more patients could access care, with the Commonwealth Foundation researchers reporting NPs could see 1,792 more patients each week.

“Laws and regulations matter,” Elizabeth Stelle, Commonwealth Foundation director of policy analysis and the report’s editor, said in a statement emailed to journalists.

“Maryland policies that give full practice authority to nurse practitioners and nurse midwives benefit health care consumers, providing greater access and better health care outcomes. Pennsylvania and other states can address primary care physician shortages by allowing highly trained advanced practice registered nurses to do the jobs they were trained to do.”