Nearly every state now participates in major interstate compacts that let doctors and nurses practice across state lines, expanding the healthcare workforce and giving patients more options. Yet when it comes to advanced practice nurses—the clinicians who could most immediately fill the gap in primary care—fewer states have jumped on board. The nation is rapidly adopting streamlined licensing for physicians and nurses, but the Advanced Practice Registered Nurse (APRN) Compact remains stuck, and patients are paying the price.
Only four states have joined the APRN Compact, with five more considering participation. The compact has not yet taken effect, as it requires seven states to take effect. The compact would allow four additional groups of clinicians to work across state lines: Nurse Practitioners, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, and Certified Nurse-Midwives. Part of the delay is due to how new it is—the first states joined in 2021.
But newness isn’t the only obstacle. The American Medical Association (AMA) is pushing back, arguing the compact would undermine state scope-of-practice laws—regulations that limit APRNs in many states to practice only under physician supervision.
That’s a feature, not a flaw. Despite recently changing its tune, the AMA pushed for years to limit the number of new physicians entering the workforce fearing an oversupply. And now the country is living with the consequences: a severe healthcare provider shortage, especially in primary care. Meanwhile, Nurse Practitioners deliver primary care as safely and effectively as physicians—and at lower cost. Yet many states have been slow to modernize their regulations, depriving residents of vital primary care services. The APRN Compact would not only increase the supply of providers, it also allows those providers to do more.
Interstate compacts lower the barriers healthcare providers face when practicing in multiple states, expanding workforce in underserved areas and increasing patients’ choices. These benefits are greatest in rural communities, when telehealth makes it possible for patients to see specialists and primary care providers across state lines. With interstate licensing, more people reported having a personal doctor and fewer skipped visits, largely because telehealth made out-of-state care more accessible.
Doctors are empowered to practice across state lines in 39 states thanks to the Interstate Medical Licensure Compact (IMLC), with three more in the process of implementing the system and another considering legislation to join. Similarly, the Nurse Licensure Compact (NLC) allows Registered Nurses and Licensed Practical/Vocational Nurses to practice in 40 states, with one more in the process of implementing the compact and bills pending in eight others. Only California neither participates, nor has proposed legislation to join, the NLC.
The compact would also restrict APRNs from prescribing controlled substances across state lines. States certainly have the right to set and enforce laws regarding controlled substances, including who can prescribe what medicines. But this can easily be addressed by limiting APRNs to the prescription standards of the state the patient they are treating resides in, allowing cross-state prescriptions without states losing control over their laws on controlled substances. Both provisions undermine the full practice authority needed for APRNs to help close the gaps patients are slipping through.
Adopting the APRN Compact will not solve every shortage, but it would remove one of the most unnecessary barriers between patients and timely, high-quality care primary care. States have already shown through the IMLC and NLC that licensing flexibility expands access, strengthens telehealth, and gives residents more choice. Extending those same benefits to APRNs is the next logical step. If lawmakers are serious about addressing provider shortages instead of protecting outdated turf battles, joining the APRN Compact is an obvious place to start—and patients will feel the impact immediately.
