policy makers and state legislators are sometimes confused about (or susceptible to opponents’ mischaracterizations of) the underlying educational and training requirements when considering expanded recognition of APNs’ scopes of practice. While patience and information can overcome most of these concerns, much time and many resources are consumed in the process.

1. Care versus cure. As some voices in the current reform debates acknowledge, our emphasis for far too long has been on curing illness, rather than on promoting health. This has led to a systemic overemphasis on training in acute care, technologically robust settings, and to a payment structure skewed toward procedural interventions by increasingly sub-specialized providers. Perhaps unsurprisingly, we have correspondingly undervalued public health. More to the point, we have consistently undervalued coordinated, primary care provided throughout the patient’s life spectrum in a variety of settings, including the community, the home, long-term care facilities, and hospice. As a group, APNs have extensive experience across all these settings. Their traditional approach of blending counseling with clinical care, and coordinating health services as well as appropriate community resources in support of patients, could be a model for policies that seek a more optimal balance of providers prepared to meet the needs of the American public.

For health care providers of all types (other than physicians), the framework defining who is legally authorized to provide and be paid for what services, for whom, and under what circumstances is among the most complex and uncoordinated schemes imaginable. It reflects an amalgam of regulations, both prescriptive and incentivized, at the state, local, and federal levels. The effects of these governmental regulations are further compounded by the credentialing and payment policies of private insurers and managed care organizations.

The explicit restrictions resulting from this complex and uncoordinated scheme are many, but they can be grouped into two principal categories: (a) state-based limitations on the licensed scopes of practice for APNs (and other providers) which prevent them from practicing to the full extent of their abilities, and (a) payment or reimbursement policies (both governmental and private) that either render them ineligible for payment, or preclude their being paid directly for their services, or pay them at a sharply discounted rate for rendering the same services as physicians.

In many states, the legal framework authorizing APNs’ practices has evolved in step with their expanding skills, education, training, and abilities. In several