Issue to Watch at the Upcoming Texas Legislative Session: Advanced Practice Nurse Practitioners

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Issue to Watch at the Upcoming Texas Legislative Session: Advanced Practice Nurse Practitioners

December 2018

Maranda Kahl

By Maranda Kahl (@marandakahl)
Center for Health and Social Policy Ambassador

Texans across the state lack adequate access to primary care services. The U.S. Department of Health and Human Services designates 185 (72.8%) out of the 254 counties in Texas as “medically underserved.” As a whole, the state ranks 47th in the nation in practicing primary care physicians (PCPs) per capita. Further complicating this primary care gap, the majority of PCPs in Texas select to practice in densely-populated cities, leaving 35 (13.8%) rural counties with no practicing physicians.

Many proposals to address the PCP shortage will be debated in the upcoming 86th Texas Legislative Session. The Texas Legislature will likely even (re)consider eliminating the regulatory limitations on advanced practice nurse practitioners (APRNs). APRNs are registered nurses who have completed a master’s or doctoral program, including graduate training in pharmacology. APRNs practice in one of four advanced roles: nurse practitioner (NP), nurse anesthetist (RNA), nurse midwife (CNM), or clinical nurse specialist (CNS). Nationally, and in Texas, the majority of APRNs function as NPs. NPs, similar to PCPs, are trained to provide independent primary care services.

In Texas though, APRNs (NPs included) face a considerable restriction on their ability to treat patients. If NPs want to prescribe medications, they must obtain a standing authorization from a physician, commonly referred to as a prescriptive authority agreement (PAA). Texas Administrative Code requires that physicians maintain these agreements by reviewing the nurses’ charts monthly. Physicians providing PAAs will typically charge a recurring fee to recoup the time cost associated with these reviews.

The monetary and time constraints associated with PAAs have largely bound APRNs to physician practices. Proponents of discarding the PAA requirement (both the Texas Public Policy Foundation and the Center for Public Policy Priorities) assert that granting full practice authority would greatly increase the number of primary care providers in the state. AARP Texas Director Bob Jackson even argued that requiring PAAs “creates a disincentive for APRNs to practice in Texas so they often go to other practice-friendly states.”

In the 85th Texas Legislative Session in 2017, House Bill 1415 and Senate Bill 681 proposed allowing full scope of practice. Both bills failed to reach a floor vote. The Texas Medical Association led the opposition to expanding APRNs’ practice authority, countering that “nurses are not physician substitutes.” The Association supported improvements under the current system to improve care in underserved areas.

Twenty-two other states, including the neighboring state of New Mexico, have now removed regulatory barriers for APRNs. With a more diverse Texas Legislature and growing dissatisfaction with the current healthcare system, it will be interesting to see if Texas follows suit.


Maranda Kahl is a first-year Master of Public Affairs student at the LBJ School of Public Affairs and 2018 CHASP Ambassador. While interested in a variety of social policy areas, she is particularly passionate about poverty alleviation and economic development. She wants to challenge unequitable economic policies and promote healthy economic growth. After LBJ, she hopes to work in economic development at either the national or international level.

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The views, information, or opinions expressed by blog contributors are solely those of the individual authors and do not necessarily represent those of the Center for Health and Social Policy, the LBJ School of Public Affairs, or The University of Texas at Austin or affiliated employees.