Legislative effort to expand nurses' authority could move forward despite drama-filled hearing

MADISON – Despite losing a co-sponsor, a proposal to expand the scope of authority for some Wisconsin nurses still has a pathway to becoming law, those involved in negotiations told an Assembly committee.

The "APRN Modernization Act" would create a new system that would allow registered nurses who meet certain qualifications to be licensed by the state board of nursing as advanced practice registered nurses, or APRNs. Lawmakers and nursing groups have been advocating its passage for more than a decade — and their failure to get it across the finish line elicited fiery testimony from a state senator during a committee hearing last week.

"I’m frustrated that we’re here again," said Sen. Rachael Cabral-Guevara, R-Appleton, who is a nurse practitioner. "I'm pissed."

Cabral-Guevara and Sen. Patrick Testin, R-Stevens Point, are spearheading the legislation in the state Senate alongside Rep. Gae Magnafici, R-Dresser, in the Assembly. The legislation has Republican support in both chambers, along with the backing of Sens. Kelda Roys, D-Madison, Lena Taylor, D-Milwaukee, and Chris Larson, D-Milwaukee. The bill passed the Senate on a 23-9 vote last month.

"(The legislation) is about taking a decisive step towards ensuring that every Wisconsinite, regardless of where they live, has the access to the quality health care they deserve," Magnafici told members of the Assembly Committee on Health, Aging and Long-Term Care.

Democratic Gov. Tony Evers vetoed a version of the legislation passed with bipartisan support last spring, but generally supports its intent. Cabral-Guevara told the committee she thought the governor failed to make it clear to the bill's supporters why he did not sign it into law.

"It’s vague. It’s a bunch of crap. Give me some detail," she said.

In his veto message, Evers noted the legislation did not address several issues raised by physician groups. The governor wrote that he objects to "altering current licensure standards for APRNs, allowing practices functionally equivalent to those of physicians or potentially omitting physicians from a patient's care altogether notwithstanding significant differences in required education, training, and expertise."

Cabral-Guevara also trained her ire on Wisconsin Medical Society lobbyist Mark Grapentine, who sat in the hearing room and testified hours later.

"If anybody is looking for a great lobbyist, I would say Mark Grapentine is the man that you would like to hire. Well-spoken, coy, chooses words beautifully. Great personality, Mark. You know I love you," she said before suggesting he wielded strong influence over the governor's office.

"You know, Mark’s like one of those patients that I go into the room and put in an IV, but I miss? Gotta be honest, Mark, I don’t feel bad if I missed," she continued. "And I might go back to that storage room, and I dunno, gotta get more supplies, we gotta get the IV in, Mark. I dunno, we could go 18, 16, 14 (gauge). But we’ll get that IV there, Mark."

At that point, committee chair Rep. Clint Moses, R-Menomonie, asked Cabral-Guevara to "wrap it up," telling her "we get the point."

The testimony didn't sit well with Rep. Barbara Dittrich, R-Oconomowoc, who characterized it as a "tantrum." Dittrich has supported the bill as a co-sponsor in its current and previous iteration.

"I think the way you have behaved and talked about doing venipuncture is a disgrace to your profession," Dittrich said. "And I will be pulling my name off this legislation."

According to legislative records, Dittrich withdrew herself as a co-sponsor later that day.

"I’m sorry you feel that way, Barb," Cabral-Guevara said during the hearing. "But it’s also disgraceful that after all of these years of working together with groups, supposedly together, that that hasn’t been the case, Barb. That hasn’t been the case."

Asked later about the exchange and loss of Dittrich's support, Cabral-Guevara said, "To those who were truly offended by a poorly worded medical joke, I sincerely apologize."

"I am frustrated that some folks in Madison lack the understanding that families are struggling to put food on the table and pay their bills. Health care costs are artificially high and medical debt is contributing to bankruptcies at an alarming rate," the senator told the Milwaukee Journal Sentinel. "This bill has been blocked for over a decade by lobbyists and petty politics. Wisconsinites have not been given every possible tool to lower costs, which this bill can achieve."

As the state faces a health care workforce shortage, backers of the APRN bill say it would expand access to quality, affordable health care throughout the state, especially in underserved areas.

Under the legislation, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and certified nurse-midwives would automatically receive APRN licenses. APRNs would generally have the authority to practice independently without a collaborative or supervisory agreement with a physician, prescribe medication, delegate some tasks to other clinically trained health care workers and use the title “A.P.R.N.”

Advanced Practiced Registered Nurses could gain 'full practice' authority

If the bill becomes law, Wisconsin would join more than two dozen other states that grant "full practice" authority to advanced practice registered nurses. The bill's authors estimate that Wisconsin has about 8,000 registered nurses who would qualify as APRNs under the legislation, about 80% of whom are nurse practitioners.

Under current law, advanced practice nurses are required to have a documented collaborative agreement with a physician. The legislation would generally remove that requirement once an APRN had worked for three years under a physician's supervision (the bill was amended in the Senate to increase the requirement from two years to three).

Similar proposals have been introduced dating back to 2015, but the COVID-19 pandemic reinvigorated the effort. That's in part because the collaborative agreement requirement was temporarily suspended under the state's public health emergency. Nurses backing the legislation argue that if it was OK for them to practice independently during the pandemic, there's no reason they shouldn't be able to continue.

In his 2023-25 budget proposal, Evers included a provision with language similar to that of the APRN bill. The measure was one of hundreds stripped from the governor's proposal as the Legislature revised it.

The governor's proposal would have required four years of work in collaboration with a physician or dentist. Both proposals would require APRNs providing pain management to collaborate with a physician, but the governor's version included an additional requirement that the physician must specialize in pain medicine.

The governor's office and physician groups have maintained that four years is an appropriate requirement, while the bill's authors have said they won't go higher than three.

Evers' budget also included a provision that would restrict a person without an M.D. or D.O. degree from using language representing them as a physician. That measure is not included in the APRN legislation but has been introduced as a separate bill by Cabral-Guevara. The governor's office has indicated that Evers will not support the APRN changes without the titling legislation.

"In something like this, incremental change is better than no change over 13 years. Even if this committee moves this, (if) the governor vetoes it, you’re no better off," said Rep. Rob Brooks, R-Saukville. "It seems we're very close to a compromise and it seems like both sides have dug in."

In his testimony toward the end of the hearing, Grapentine said "there is a deal to be had here."

"There’s a path," Grapentine said. "I urge this committee to take it, and if you do, the chances are much greater … that the governor will sign the bill."

The proposal is backed by groups including the Wisconsin Nurses Association, the Wisconsin Association of Nurse Anesthetists, the Wisconsin Counties Association, Americans for Prosperity, the Oneida Nation and several health insurance providers.

It is opposed by groups including the Wisconsin Medical Society, the Wisconsin Academy of Family Physicians, the Wisconsin Dermatological Society, the Wisconsin Society of Anesthesiologists and the Wisconsin Chapter of the American Academy of Pediatrics.

Jessie Opoien can be reached at jessie.opoien@jrn.com.

This article originally appeared on Milwaukee Journal Sentinel: Effort to expand nurses' authority endures drama-filled hearing