professional resistance to expanded roles for nurses, fragmentation of the health care system, outdated insurance policies, high rates of nurse turnover, difficulties for nurses transitioning from school into practice, and an aging workforce and other demographic challenges. Many of these barriers have developed as a result of structural flaws in the U.S. health care system; others reflect limitations of the present work environment or the capacity and demographic makeup of the nursing workforce itself.

As the committee considered how the additional 32 million people covered by health insurance under the ACA would receive care in the coming years, it identified as a serious barrier overly restrictive scope-of-practice regulations for APRNs that vary by state. Scope-of-practice issues are of concern for CNMs, certified registered nurse anesthetists (CRNAs), NPs, and clinical nurse specialists (CNSs). The committee understands that physicians are highly trained and skilled providers and believes strongly that there clearly are services that should be provided by these health professionals, who have received more extensive and specialized education and training than APRNs. However, regulations in many states result in APRNs not being able to give care they were trained to provide. The committee believes all health professionals should practice to the full extent of their education and training so that more patients may benefit.

A paper commissioned by the committee¹³ points out that the United States was one of the first countries to regulate health care providers and that this regulation occurred at the state—not the federal—level. Legislatively, physician practice was recognized before that of any other health profession (Rostant and Cady, 1999). For example, legislators in Washington defined the practice of medicine broadly as any action to “diagnose, cure, advise or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality” or to administer or prescribe “drugs or medicinal preparations to be used by any other person” or to “[sever or penetrate] the tissues of human beings.”¹⁴ Even more important were corresponding provisions making it illegal for anyone not licensed as a physician to undertake any of the acts included in this definition. These provisions