A recent regulatory proposal put forth by the VA to ensure that veterans have direct access to advanced practice registered nurses (APRNs), including nurse practitioners (NPs), has caused a lot of controversy. If authorized, the proposal will allow NPs to practice to the top of their education scope, improving veterans’ access to high-quality care and a streamlined delivery of their much-needed health services.
After a lot of backlash from several physician’s groups and an attack on nurses from Fox News which failed to mention that that NPs are graduate-educated health professionals, the American Association of Nurse Practitioners (AANP) started a grassroots campaign called Veterans Deserve Care to support the VA’s proposed rule with backing from veterans, caregivers, and nurse practitioners.
As part of the Veterans Deserve Care campaign, the AANP released a national survey that found 88 percent of Americans are in support of the US Department of Veterans Affairs proposed rule to give veterans direct access to nurse practitioners in VA facilities. The survey received results from 1,006 adults. Among the survey results it was found that 91 percent of Republicans and 90 percent of Democrats support the proposed rule. Further results show that 75 percent of Americans and 80 percent of Americans who have seen a nurse practitioner strongly support the VA proposal.
According to the VA, their proposal is an effort to modernize the VA system, adopting a 21st century approach to health care delivery and access for veterans. VA statistics have recorded that 505,000 veterans are wait-listed 30 days and almost 300,000 veterans wait between 31 and 60 days to receive health services. NPs are the primary care providers of choice for millions of Americans and with these new survey results it is clear that Americans are in agreement for allowing nurse practitioners to be an essential component in answering veterans’ health care needs.
There are currently over 4,800 nurse practitioners working across VA facilities, providing clinical assessments, ordering and interpreting diagnostic test results, making diagnoses, and initiating treatment plans that include prescribing medications. 21 states and the District of Columbia already offer direct access to NP care, with proven outcomes equivalent to or better than those of physicians.
NPs hold a 50-year track record providing care to patients, including veterans, at zero risk, zero cost, and zero delay for high-quality care. With graduate degrees, national certification, and years of academic and clinical education, nurse practitioners are qualified to be an immediate benefit to hundreds of thousands of veterans waiting for necessary care.
Following a proposed rule change from the Department of Veterans Affairs (VA) to allow full practice authority to all VA advanced practice registered nurses (APRNs) when acting within the scope of their VA employment, Fox News hosted a video report with the headline “Vets may have to settle for a visit with the nurse at the VA.” The report from Fox was initiated by a press conference where several physician anesthesiologist groups voiced strong objections to the proposed ruling by the VA. Fox News was also aware of a strong rebuttal to physicians’ arguments from the American Association of Nurse Anesthetists (AANA) which Fox ignored, failing to convey in their report that advanced practice nurses like nurse practitioners (NPs) are graduate-educated health professionals with independent licenses and an autonomous nursing practice model that is broader and more holistic than the medical model.
The bitter debate over the roles of doctors and nurses is not a new one, and the VA proposal has only further sparked the argument. Many of the country’s largest doctors’ groups have argued that the VA proposal would lower the standard of care for veterans and that all patients deserve access to physician expertise. These arguments caused intervention from nursing groups like the American Nurses Association (ANA), the American Association of Nurse Practitioners (AANP), and AANA. AANA President, Juan Quintana, believes the solution to improve health care for veterans doesn’t involve increasing budgets or staff; it is as simple as removing barriers that prevent advanced practice nurses from practicing to the full extent of their education, training, and certification. ANA also stepped up to state that the longstanding limits on the scope of care for nurses with advanced training is what has harmed veterans in the past because staff shortages lead to backlogs and growing wait lists.
The proposed VA specific rule is intended to increase veterans’ access to VA health care by providing a larger pool of qualified health care professionals who are authorized to provide primary care and other related health care services to the full extent of their education, training, and certification without clinical supervision from physicians. Allowing APRNs full practice authority to provide primary care to veterans is a more effective use of VA resources in a manner consistent with the role of APRNS in non-VA health care sectors while maintaining the patient-centered, safe, and high-quality health care that veterans receive from the VA.
If the proposed rule change is approved, the VA will be following the lead of the military and 21 states plus the District of Columbia that have expanded the scope of practice for their nurse midwives, nurse practitioners, and nurse anesthetists in a variety of fields. The VA is looking to expand the role of their APRNs to meet the needs of a growing veteran population from the Vietnam era and the wars in Iraq and Afghanistan combined with a shortage of physicians on staff. Nurse practitioners are trained to provide many of the same primary care functions as doctors but state laws prohibit them from diagnosing, prescribing drugs, and providing other services. After ongoing scandals regarding long waits for veterans to schedule medical appointments, this new proposed change ensures that the VA has the authority to address these scandals caused by staffing shortages.
An organization called The Truth About Nursing whose mission is to challenge stereotypes and educate the world about the value of nursing started a petition urging Fox News to apologize for its biased report and make amends with a follow-up video report. The Truth About Nursing wants the follow-up report to include military veteran and AANA President Juan Quintana, RN, DNP, CRNA, in order to allow nurses to defend themselves and spread public knowledge about research showing that nurses are safe and effective scientific professionals.
Full practice authority for nurse practitioners has been an ongoing debate nationwide, but a new Pennsylvania bill announced last week could be a major step toward a breakthrough giving more practice rights to experienced nurse practitioners.
Officially announced last Monday, the compromise bill agreed to by Pennsylvania’s largest hospital lobby will grant nurse practitioners full practice authority after three years practicing under a physician’s supervision and completing 3,600 working hours. The proposal includes granting full practice authority to nurse practitioners licensed in another state as long as they meet the three-year, 3,600-hour requirement.
Part of the Hospital Association of Pennsylvania’s agreement to back the new bill was because it allows nurse practitioners to serve patients without signing costly collaborative agreements with physicians. These mandatory collaboration agreements make health care more expensive for patients without increasing quality of care. The agreements can cost thousands of dollars per year, while the supervising physicians rarely see patients being treated by nurse practitioners.
A nurse practitioner from Bucks County, PA said he spends $25,000 a year on collaborative agreements with two physicians, an unnecessary cost that would be better used to provide more services to patients and lower overall costs. The Pennsylvania Coalition of Nurse Practitioners is pleased with the state hospital lobby’s agreement, calling it a “game-changer” for its reform that will benefit patients, taxpayers, hospitals, and health systems.
State legislatures have long opposed giving full practice authority to nurse practitioners, arguing that the collaborative agreements ensure that physicians remain part of the overall patient treatment plan because of their additional training and medical skills. However, many studies have shown that patients treated regularly by nurse practitioners need fewer hospital visits and generally have better health outcomes due to their regular contact with medical professionals. Full practice authority for nurse practitioners could be especially beneficial in Pennsylvania where more than 16 percent of the population is over age 65, the fourth highest percentage of any state.
Now that the hospital lobby has agreed to back the plan, bills to end the mandatory collaboration agreements have been introduced to the state House and Senate, but neither has received a committee vote yet. A compromise bill will be introduced at the next meeting of the Senate Professional Licensure Committee.
As emergency changes in response to the COVID-19 pandemic were made permanent, the past year saw significant progress toward increased independent practice authority for advanced practice registered nurses (APRNs), according to the Nurse Practitioner’s34th Annual Legislative Update.
“Relaxation of existing regulations in supervision, collaboration, license renewal, and portability due to the continuing COVID-19 pandemic improved practice authority for APRNs in reduced- and restricted-practice states,” writes Susanne J. Phillips, DNP, APRN, FNP-BC, FAANP, FAAN, of the University of California, Irvine, in her introduction to the annual report on legislative developments in APRN practice.
In states that have enacted Full Practice Authority (FPA), NPs and other APRNs are having an impact. The report cites evidence from a recent study indicating that “states with FPA are associated with improved access to care in underserved and rural communities without compromising quality of care.”
Many states opting to retain emergency scope of practice expansions
As the Covid-19 pandemic spread across the US in 2020, many states adopted temporary, emergency regulations to expand the role of APRNs. These changes increased practice authority for all types of APRNs, including not only nurse practitioners and certified nurse practitioners, but also certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists.
As the pandemic enters its third year, the 2021 report observes further progress in scope of practice laws. The report observes that “many states have permanently adopted regulations and enacted new laws authorizing full-practice authority (FPA) with and without transition to practice (TTP) periods in 2021. States that have proceeded to make their emergency regulations permanent or enacted new laws expanding practice authority for APRNs include:
Delaware and Massachusetts have passed amendments resulting in full practice authority. With its new law, Delaware joins North Dakota as the second state to join the “APRN Compact,” which allows APRNs to hold one multistate license with a privilege to practice in other compact states.
Two additional states enacted laws expanding practice authority, including a new pathway for full independent practice authority in Arkansas and a shorter time to practice period (from 5 years to 2 years) authorizing NPs to practice independently.
Several other states – including Florida, Illinois, Louisiana, North Carolina, and Oklahoma – have enacted new laws or updated regulations improving practice authority for APRNs.
Other states have adopted laws authorizing APRNs and other providers to provide and be reimbursed for home health care and telehealth services.
Arkansas, Louisiana, Maine, and Washington passed other changes improving reimbursement for APRN services.
Dr. Phillips notes that at the end of 2021, APRNs have full, autonomous practice and prescriptive authority in 14 states and the District of Columbia, and full practice authority following a transition to practice period in another 10 states.
Republican legislators in more than half of U.S. states, spurred on by voters angry about lockdowns and mask mandates, are taking away the powers state and local officials use to protect the public against infectious diseases.
A KHN review of hundreds of pieces of legislation found that, in all 50 states, legislators have proposed bills to curb such public health powers since the covid-19 pandemic began. While some governors vetoed bills that passed, at least 26 states pushed through laws that permanently weaken government authority to protect public health. In three additional states, an executive order, ballot initiative or state Supreme Court ruling limited long-held public health powers. More bills are pending in a handful of states whose legislatures are still in session.
In Arkansas, legislators banned mask mandates except in private businesses or state-run health care settings, calling them “a burden on the public peace, health, and safety of the citizens of this state.” In Idaho, county commissioners, who typically have no public health expertise, can veto countywide public health orders. And in Kansas and Tennessee, school boards, rather than health officials, have the power to close schools.
President Joe Biden last Thursday announced sweeping vaccination mandates and other covid measures, saying he was forced to act partly because of such legislation: “My plan also takes on elected officials in states that are undermining you and these lifesaving actions.”
All told:
In at least 16 states, legislators have limited the power of public health officials to order mask mandates, or quarantines or isolation. In some cases, they gave themselves or local elected politicians the authority to prevent the spread of infectious disease.
At least 17 states passed laws banning covid vaccine mandates or passports, or made it easier to get around vaccine requirements.
At least nine states have new laws banning or limiting mask mandates. Executive orders or a court ruling limit mask requirements in five more.
Much of this legislation takes effect as covid hospitalizations in some areas are climbing to the highest numbers at any point in the pandemic, and children are back in school.
“We really could see more people sick, hurt, hospitalized or even die, depending on the extremity of the legislation and curtailing of the authority,” said Lori Tremmel Freeman, head of the National Association of County and City Health Officials.
Public health academics and officials are frustrated that they, instead of the virus, have become the enemy. They argue this will have consequences that last long beyond this pandemic, diminishing their ability to fight the latest covid surge and future disease outbreaks, such as being able to quarantine people during a measles outbreak.
“It’s kind of like having your hands tied in the middle of a boxing match,” said Kelley Vollmar, executive director of the Jefferson County Health Department in Missouri.
But proponents of the new limits say they are a necessary check on executive powers and give lawmakers a voice in prolonged emergencies. Arkansas state Sen. Trent Garner, a Republican who co-sponsored his state’s successful bill to ban mask mandates, said he was trying to reflect the will of the people.
“What the people of Arkansas want is the decision to be left in their hands, to them and their family,” Garner said. “It’s time to take the power away from the so-called experts, whose ideas have been woefully inadequate.”
After initially signing the bill, Republican Gov. Asa Hutchinson expressed regret, calling a special legislative session in early August to ask lawmakers to carve out an exception for schools. They declined. The law is currently blocked by an Arkansas judge who deemed it unconstitutional. Legal battles are ongoing in other states as well.
Legislators there also passed limits on local officials: If jurisdictions add public health rules stronger than state public health measures, they could lose 20% of some grants.
Losing the ability to order quarantines has left Karen Sullivan, health officer for Montana’s Butte-Silver Bow department, terrified about what’s to come — not only during the covid pandemic but for future measles and whooping cough outbreaks.
“In the midst of delta and other variants that are out there, we’re quite frankly a nervous wreck about it,” Sullivan said. “Relying on morality and goodwill is not a good public health practice.”
While some public health officials tried to fight the national wave of legislation, the underfunded public health workforce was consumed by trying to implement the largest vaccination campaign in U.S. history and had little time for political action.
Freeman said her city and county health officials’ group has meager influence and resources, especially in comparison with the American Legislative Exchange Council, a corporate-backed conservative group that promoted a model bill to restrict the emergency powers of governors and other officials. The draft legislation appears to have inspired dozens of state-level bills, according to the KHN review. At least 15 states passed laws limiting emergency powers. In some states, governors can no longer institute mask mandates or close businesses, and their executive orders can be overturned by legislators.
When North Dakota’s legislative session began in January, a long slate of bills sought to rein in public health powers, including one with language similar to ALEC’s. The state didn’t have a health director to argue against the new limits because three had resigned in 2020.
Fighting the bills not only took time, but also seemed dangerous, said Renae Moch, public health director for Bismarck, who testified against a measure prohibiting mask mandates. She then received an onslaught of hate mail and demands for her to be fired.
The new laws are meant to reduce the power of governors and restore the balance of power between states’ executive branches and legislatures, said Jonathon Hauenschild, director of the ALEC task force on communications and technology. “Governors are elected, but they were delegating a lot of authority to the public health official, often that they had appointed,” Hauenschild said.
‘Like Turning Off a Light Switch’
When the Indiana legislature overrode the governor’s veto to pass a bill that gave county commissioners the power to review public health orders, it was devastating for Dr. David Welsh, the public health officer in rural Ripley County.
People immediately stopped calling him to report covid violations, because they knew the county commissioners could overturn his authority. It was “like turning off a light switch,” Welsh said.
Another county in Indiana has already seen its health department’s mask mandate overridden by the local commissioners, Welsh said.
He’s considering stepping down after more than a quarter century in the role. If he does, he’ll join at least 303 public health leaders who have retired, resigned or been fired since the pandemic began, according to an ongoing KHN and AP analysis. That means 1 in 5 Americans have lost a local health leader during the pandemic.
“This is a deathblow,” said Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health. He called the legislative assault the last straw for many seasoned public health officials who have battled the pandemic without sufficient resources, while also being vilified.
Public health groups expect further combative legislation. ALEC’s Hauenschild said the group is looking into a Michigan law that allowed the legislature to limit the governor’s emergency powers without Democratic Gov. Gretchen Whitmer’s signature.
Curbing the authority of public health officials has also become campaign fodder, particularly among Republican candidates running further on the right. While Republican Idaho Gov. Brad Little was traveling out of state, Lt. Gov. Janice McGeachin signed a surprise executive order banning mask mandates that she later promoted for her upcoming campaign against him. He later reversed the ban, tweeting, “I do not like petty politics. I do not like political stunts over the rule of law.”
Fawbush was a sponsor of 1989 legislation during the AIDS crisis. It banned employers from requiring health care workers, as a condition of employment, to get an HIV vaccine, if one became available.
But 32 years later, that means Oregon cannot require health care workers to be vaccinated against covid. Calling lawmaking a “messy business,” Fawbush said he certainly wouldn’t have pushed the bill through if he had known then what he does now.
“Legislators need to obviously deal with immediate situations,” Fawbush said. “But we have to look over the horizon. It’s part of the job responsibility to look at consequences.”
