New PLF Research: Let nurses work—Removing supervision rules expands patient access

Washington, DC; May 7, 2025: A new report from Pacific Legal Foundation (PLF) reveals that outdated laws requiring Collaborative Practice Agreements (CPAs) are holding back healthcare access and entrepreneurship, especially in rural and underserved communities. These regulations force advanced practice registered nurses (APRNs), a category that includes nurse practitioners and certified nurse-midwives, to secure costly and unnecessary supervision contracts with physicians before they can operate independently.

“APRNs are highly trained professionals on the frontlines of care,” said Donna Matias, an attorney at Pacific Legal Foundation. “Our research shows that these licensing barriers not only restrict their right to work and serve their communities but also increase costs and reduce healthcare access for patients, without any proven benefits to safety.”

PLF’s research identifies how CPA requirements burden APRNs financially, sometimes costing them thousands of dollars annually to maintain supervisory relationships, even when the physician oversight is nominal or nonexistent. At the same time, scholarly evidence consistently finds no improvement in patient outcomes due to CPA mandates.

Key findings from PLF’s report include:

• Sixteen states still require full CPAs or similar supervision mandates, limiting entrepreneurial opportunities for APRNs.
• States that allow independent practice see lower healthcare costs, better access in rural areas, and higher patient satisfaction.
• Women and mental health patients particularly benefit from independent midwifery and mental health nurse practitioner services, without impacting safety or patient outcomes.

PLF is currently challenging CPA laws in two states:

• In California, nurse practitioners are fighting restrictions that prevent them from operating independent practices despite their qualifications (Kerstin Helgason and Jamie Sorenson v. Loretta Melby).
• In Nebraska, certified nurse-midwife Elizabeth Swanson is challenging state mandates requiring physician supervision to serve her patients (Swanson v. Hilgers).

“APRNs deserve the freedom to practice to the full extent of their training,” said Jaimie Cavanaugh, legal policy counsel at Pacific Legal Foundation. “Patients deserve more options, lower costs, and timely care—not bureaucratic roadblocks.”

States that still enforce CPA mandates should follow the lead of the 35 others that have embraced reforms, empowering APRNs to meet growing healthcare needs without arbitrary government interference.

Read the full report: Restrictions to Care: How Collaborative Practice Agreements for Advanced Practice Registered Nurses and Certified Nurse-Midwives Limit Patient Access.