Dear Chairman Hughes, Vice-Chairman Paxton, and distinguished members of the committee:

My name is Jeffrey A. Singer. I am a Senior Fellow in Health Policy Studies at the Cato Institute. I am also a medical doctor specializing in general surgery and have been practicing that specialty in Phoenix, Arizona, for over 40 years. The Cato Institute is a 501(c)(3) non-partisan, non-profit, tax-exempt educational foundation dedicated to the principles of individual liberty, limited government, free markets, and peace. Cato scholars conduct independent research on a wide range of policy issues. To maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 80 percent of its funding through tax-deductible contributions from individuals. The remainder of its support comes from foundations, corporations, and the sale of books and other publications. The Cato Institute does not take positions on legislation.

When it comes to improving patients’ access to health care providers, Texas lags behind 30 other states that have already removed barriers limiting patient access to primary care from Nurse Practitioners (NPs) by granting NPs independent full practice authority.1 In many of Texas’s rural areas, NPs are often the sole health care providers available, yet outdated regulations restrict their ability to fully serve their communities. Under current law, NPs must maintain a formal agreement with a licensed physician who “supervises” their work — even if that physician practices miles away and checks in only once a month. This arrangement effectively forces NPs to pay for permission to care for patients, funneling fees to physicians without meaningful oversight.

This situation could change under S.B. 3055, a bill that aims to reform the licensing and regulation of advanced practice registered nurses (APRNs) in Texas. The legislation would empower APRNs, including nurse practitioners and nurse midwives, to diagnose, prescribe medications, and provide primary care independently. APRNs are registered nurses who have completed advanced graduate-level education to deliver specialized health services. Depending on the state, NPs may practice with or without physician supervision.

The nation’s first nurse practitioner program was launched at the University of Colorado in 1965. Since then, medical and advanced practice nursing groups have sparred over whether nurse practitioners should be allowed to deliver primary care without a physician’s involvement. At the heart of the debate is whether NPs provide care on par with physicians.

Both sides can cite studies comparing NP- and physician-delivered care. Physician groups often stress the disparity in training — physicians accumulate between 10,000 and 16,000 clinical hours, compared to roughly 500 to 720 hours for NPs. Advocates for NP autonomy, including public health researchers, highlight evidence showing that patient outcomes are comparable whether a physician or an NP provides primary care.

A recent major study supports the case for expanding NP authority.2 Researchers used Veterans Health Administration (VHA) data to conduct a large, real-world comparison of patients whose primary care providers left the VHA system. Patients were reassigned either to physicians or to NPs largely at random, creating a natural experiment. The study tracked over 800,000 patients across 530 VHA facilities nationwide. Researchers found that patients under NP care had similar health outcomes and overall costs compared to those treated by physicians — and were indeed less likely to be hospitalized.

This isn’t an outlier. Another large-scale study, published in the Annals of Internal Medicine, examined Medicare Part D data from 2013 to 2019 across 29 states that had given NPs prescriptive authority at that time.3 Researchers at UCLA, Stanford, and Yale looked at rates of inappropriate prescribing to adults over age 65, using the American Geriatrics Society’s Beers Criteria.4 Their finding: nurse practitioners were no more likely than physicians to prescribe potentially harmful medications. Their conclusion was clear: rather than limiting NP authority, efforts should focus on improving prescribing practices across all clinicians.

Today, over 431,000 certified nurse practitioners work across the United States, with nearly 75 percent delivering primary care.5 However, in many states, NPs still need to be employed by or have a contractual relationship with a physician to practice. Additionally, states vary significantly in the services they permit NPs to provide to patients.

As of March 2024, 30 states had granted NPs “full practice authority,” letting them operate independently — diagnosing, prescribing, and treating patients without physician supervision or collaboration.6

It’s true that nurse practitioners undergo less training than physicians, especially specialists. However, when it comes to primary care, research consistently shows that NPs deliver high-quality services. Like physicians, NPs adhere to professional standards and ethics and refer patients to appropriate specialists when a case surpasses their expertise.

Some policymakers may personally prefer that patients seek care from physicians rather than NPs. However, that decision belongs to patients, not lawmakers. Patients should be free to choose the qualified provider who best meets their needs.

With a growing shortage of primary care doctors, an expanding health care workforce gap, and an aging population, Texas has the opportunity to enhance access to care and respect patient choice by empowering nurse practitioners to practice independently to the full extent of their training.

Respectfully submitted,
Jeffrey A. Singer, MD, FACS
Senior Fellow
Cato Institute