A bill to give some nurses greater autonomy appears destined for a veto. What happened?

For the second legislative session in a row, a bill with bipartisan support that would grant more professional autonomy to nurses with advanced credentials appears at risk of being killed by the governor’s veto.

Wisconsin Health News reported Jan. 26 that Gov. Tony Evers will veto the measure. This week, Evers stopped short of declaring that in response to a Wisconsin Examiner question. But he underscored that changes he has said would guarantee his support were absent.

“I’m not saying I won’t sign it,” Evers said as he was leaving a lunch Tuesday after being interviewed by WisPolitics.com President Jeff Mayers. “I want to sign it, that’s why I met with a legislator and I made it very specific. Three things that would bring me to sign it, and none of those three things happened.”

The legislation, SB-145, would create a new license for advanced practice registered nurses (APRNs), administered by the Wisconsin state nursing board. APRNs would include certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists and nurse practitioners. Supporters say it would improve Wisconsinites’ access to health care, especially in rural parts of the state.

Currently nurses who have qualified as nurse practitioners or the equivalent must practice in collaboration with a physician or dentist. Certified nurse-midwives must practice in collaboration with an obstetrician.

The bill would allow certified APRNs to practice on their own after they’ve worked with a doctor or dentist for about three years.

“This legislation does not look to replace the role that physicians have in the delivery of health care here in the state,” said the bill’s author, Sen. Patrick Testin (R-Stevens Point) at an Assembly public hearing in November 2023. The intent, he said, was to enable duly certified advanced practice nurses “to operate at the highest level of their license and their scope of practice.”

Testin and other advocates of the bill have emphasized that during the federal COVID-19 health emergency that began in early 2020 and ended in the spring of 2023, an order directed by Evers allowed nurse practitioners greater latitude to operate without physician collaboration agreements. The aim was to improve health care access in the midst of the pandemic.

“All of us in this room did a hell of a good job during COVID without this collaborating physician agreement [requirement] hanging over our heads, and we’re very proud of that,” said Sen. Rachael Cabral-Guevara (R-Appleton), a nurse practitioner, at the Nov. 15 hearing before the Assembly Health, Aging and Long Term Care Committee.

Evers vetoed a bill in the 2021-22 session to make that temporary independence permanent. In his April 2022 veto message, he praised nurses for their “acts of selflessness and service” during the pandemic, but said that the bill didn’t address issues raised by doctors.

The bill and the objections

Testin and Rep. Gae Magnafici (R-Dresser) introduced successor legislation in April 2023,  AB-154 and SB-145. From the day it was introduced, a coalition of doctors’ groups listed three changes that would end their opposition to the bill:

• Requiring four years of supervision before an APRN is able to practice independently, two of them after the nurse attains the formal APRN certification;
• Setting additional supervision requirements for some APRNs working in pain management;
• Language barring non-doctors, including APRNs, from using certain titles associated with doctors — such as surgeon, physician, psychiatrist and other specialist titles.

Those are the “three things” that Evers referred to in his brief comment Tuesday. Throughout the debate on the bill, Democrats in the Legislature and the doctors’ coalition have pointed to them as the key to ensuring he would sign the legislation.

Mark Grapentine, lobbyist for the Wisconsin Medical Society, said in an interview that the doctors’ conditions and Evers’ expressed priorities offered “a clear path toward compromise” on the legislation.

The state Senate passed SB-145 on Oct. 17 after approving an amendment that Testin introduced. Where the bill had required an APRN to complete about two years — 3,840 hours — with a physician before practicing independently, the amendment increased that to about three years: 5,760 hours.

Testin did not respond to a message left with his office requesting an interview. At the November Assembly hearing, however, he testified that with his amendment, “we actually move closer to where the governor was with the APRN proposal that he put within his proposed budget” by increasing the requirement to three years.

“Now, again, the governor is at four years,” Testin said. “I will not move to four years — I just cannot do that.” The increase “would fundamentally move the profession of APRNs in a negative and wrong direction.”

Testin also testified that the language relating to professional titles didn’t belong in the legislation. “I don’t believe that should be in this bill,” he said. “This is a workforce bill.”

Cabral-Guevara introduced a separate bill in 2023, SB-143, containing professional title restrictions. In October the Senate Health Committee, which she chairs, voted 4-2 against recommending that bill. The only Yes votes were from Cabral-Guevara and Sen. Dianne Hesselbein (D-Middleton). Testin joined the rest of the committee in voting No.

An amendment to win over the governor

On Jan. 23, the Assembly Health, Aging and Long Term Care Committee met to vote on advancing the APRN legislation to the full Assembly. A week earlier, Rep. Lisa Subeck (D-Madison), had filed an amendment to the bill addressing each of the three issues that the doctors and Evers had previously raised.

The amendment never got a committee vote, however, and the committee took no action on the Assembly version of the APRN bill. “In my conversations with some of my Republican colleagues, it was pretty clear that this amendment had some bipartisan support,” Subeck said this week.

When the committee held a vote to recommend the Senate bill, the members tied 8-8, sending it to the Assembly without the committee’s endorsement.

On Jan. 25, the Assembly tabled Subeck’s amendment on a 64-35 party-line vote, blocking a debate or a direct vote on her proposal, then adopted SB-145 on a voice vote, sending it to Evers.

After the vote Testin issued a statement declaring that the bill, if signed, would free 8,000 already qualified nurses to “practice to the fullest extent of their training.”

It would, he added, help alleviate health care provider shortages in Wisconsin “where health care professionals are in short supply, especially in our rural communities.” With his amendment, Evers “no longer has an excuse to pull out his veto pen.”

‘Both sides have dug in’

Grapentine told the Wisconsin Examiner that he was puzzled by the turn of events. “You would think that the advocates for the bill would be more than happy to accept a compromise that gets them just about everything they want in the first place, including the most major thing, which is a sea change in Wisconsin in allowing independent practice for APRNs,” he said.

Representatives for the Wisconsin Nurses Association and the Wisconsin Association of Nurse Anesthetists, two lobbying groups that mobilized support for the legislation, did not respond to the Wisconsin Examiner’s requests for comment.

At a November public hearing in the Assembly, however, Gina Dennik-Champion,  WNA’s executive director, demurred when Rep. Robert Brooks (R-Saukville) asked whether advocates for the bill were willing to accept the changes that doctors and the governor were seeking.

“It seems we’re very close to a compromise, and it seems like both sides have dug in,” Brooks told Dennik-Champion. Brooks focused on the amended bill’s three-year supervision requirement compared with the four years that Evers and doctors have insisted on.

He asked whether the nurses could accept the longer period, with an eye toward reducing it in a future bill after the legislation has demonstrated its effectiveness. “Are you willing to go all in on … three years versus four?”

In her response, Dennik-Champion began by evoking the 13 years of efforts nurses have made to advance the legislation. “When we think of our history, and the compromises that we have made, all along the way — and I mean compromises,” she said.

After describing the disappointment in Evers’ 2022 veto as well as conversations she and colleagues have had with his staff about the current bill, she returned to Brooks’ question.

“I can’t give you that answer,” Dennik-Champion  said, adding that she wanted to allow “more time to talk and discuss, and for the governor to really hear what we’re saying, and understand what we’re saying, [so] that maybe we have a chance.”

Subeck said that with her expectation that Evers will veto the legislation, the bill’s trajectory baffled her.

“I think there’s broad consensus that this is a bill we want to get done, but in order to get it done we need to put some guardrails around it. And we are so close,” she said.

“If we were going to talk about governing, this isn’t how you do it,” Subeck added. “I really think in many ways, it is the nurses who were the big losers here. They could have had an APRN bill signed into law that would create this path to licensure as advanced practice registered nurses, that would create a path to independent practice for them. And instead, we took a symbolic vote on a bill that everybody knew would not become law. It’s really a shame.”