Most states allow doctors to practice across state lines through interstate licensure compacts. However, advanced practice registered nurses (APRNs), such as nurse practitioners (NPs) and certified nurse-midwives (CNMs), are excluded. While states expanded competition for doctors, this critical group of providers has been left out, limiting patients’ access to high-quality care. Expanding state compacts would help address the current healthcare provider shortages.
The United States is facing a healthcare labor shortage that is only projected to get worse. Limiting APRNs practice area exacerbates the shortage. An APRN compact would expand the supply of healthcare, especially in rural and other underserved areas where high-quality, lower cost APRN care would be most valuable.
Forty states participate in the Interstate Medical Licensure Compact for physicians, with three more in the process of adopting it. Forty states also adopted the Nurse Licensure Compact, with Massachusetts in the process of implementing it as well, allowing registered nurses (RNs) to practice across state lines.
Unlike RNs, APRNs provide independent primary and specialty care including routine checkups, midwife services, and more. However, the existing APRN compact only has a handful of states signed on—short of the threshold needed to take effect. It also faces opposition from the American Association of Nurse Practitioners due to its onerous practice-hour requirements of more than 2,000 hours. Requiring APRNs to complete a set number of hours before practicing across state lines mirrors restrictions in many states that condition independent practice on as much as four thousand supervised hours. While the compact could be improved by removing the hour requirements, in its current form, it still represents a step forward.
State APRN laws vary widely, differing both by state and for NPs, CNMs, clinical nurse specialists, and certified registered nurse anesthetists. For example, more than half of states grant NPs full practice authority, allowing them to practice independently without physician oversight. Twelve states impose reduced practice, requiring physician involvement in specific areas, such as prescribing. Ten states maintain “restricted practice,” requiring physician oversight throughout an APRN’s career. Even in full-practice states, additional hour requirements can still apply, unnecessarily limiting provider mobility.
These requirements have been demonstrated to be an unnecessary and restrictive barrier to competition. NPs have demonstrated they can provide a wide range of high quality routine care comparable to physicians. Other research has shown that CNMs independent practice reduces hospital facility costs per birth while improving health outcomes. APRNs graduate from their respective programs ready to work, and laws should facilitate this.
A consumer-focused compact would be an improvement on the current one, by allowing APRNs to practice across state lines so long as they meet the qualifications for, and comply with the regulations of, the state where they are treating patients without additional hour thresholds. For example, the fact that other states have practice hour requirements should not limit NPs from working in states without those requirements. Under such a system, some states may retain supply-reducing restrictions on independent APRN practice.
Although regulatory variation is greater for APRNs than for some other clinicians, a more flexible APRN compact would still expand competition among similarly regulated states. APRNs in full practice states could practice in other full-practice states without additional barriers. APRNs from reduced or restricted practice states could do the same where comparable rules exist, including through collaboration with a physician when required. While the benefits would grow as more states adopt full practice authority, even a limited compact would expand access and increase competition in states that have yet to reform.
Patients do not benefit from artificial limits on who can provide care. An APRN compact that prioritizes competency over arbitrary hour thresholds would expand access, lower costs, and inject much-needed competition into local healthcare markets. The evidence is clear: where APRNs are allowed to practice to the full extent of their training, patients receive safe, effective care. Extending that flexibility across state lines is the logical next step. Policymakers should stop treating APRNs as an exception and start treating them as what they are—a critical part of the solution to America’s access and affordability problems.
Justin Leventhal is a senior policy analyst for the American Consumer Institute, a nonprofit education and research organization that advocates for consumers through evidence-based analysis and data. Follow Justin on X @JustinLeventhal.