KEY POINTS:
• The Department of Veterans Affairs excluded CRNAs from receiving full practice authority in December 2016 after receiving 104,256 opposing comments according to the Federal Register
• A study by The Lewin Group examining “almost 6 million cases” found no safety difference between supervised and independent CRNA practice according to Clinician.com
• As of 2025, all new CRNAs must have doctorate degrees, while the AANA claims approximately 12,000-13,000 anesthesiologists lack board certification according to multiple sources
The Department of Veterans Affairs’ decision to exclude Certified Registered Nurse Anesthetists from full practice authority continues to generate debate years after the agency’s 2016 final rule. According to the Federal Register published December 14, 2016, the VA received 223,296 total comments on its proposed rule to grant independent practice to advanced practice registered nurses, with 104,256 specifically opposing CRNA independence.
The VA initially proposed granting full practice authority to all four APRN roles in a rule published “on May 25, 2016” according to the Federal Register. However, the final rule granted independence only to nurse practitioners, clinical nurse specialists, and certified nurse-midwives. VA News reported on December 14, 2016 that the agency “will not finalize the provision including CRNAs in the final rule as one of the APRN roles that may be granted full practice authority at this time.”
According to the Federal Register, the American Society of Anesthesiologists “lobbied heavily against VA CRNAs having full practice authority” and “established a Web site that would facilitate comments against the CRNAs.” The VA characterized these opposition comments as “not substantive in nature and were akin to votes in a ballot box.”
Supporting organizations included “more than 60 organizations, including the American Nurses Association and AARP” according to Clinician.com. The Federal Register documented that supporters submitted 45,915 comments favoring the proposal, with 9,613 specifically supporting CRNA full practice authority.
Central to the debate was research on safety outcomes. Clinician.com reported that The Lewin Group study “examined almost 6 million cases” and found that “scope of practice restrictions and physician supervision requirements for nurse anesthetists have no impact on anesthesia patient safety.” The Wisconsin Association of Nurse Anesthetists stated the 2010 study found CRNAs “acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model.”
The ASA disputed the study’s validity. Clinician.com quoted ASA President Daniel J. Cole stating that “in the acknowledgements at the end of the Medical Care study, the authors thank members of the study’s technical expert panel. The first person listed is Juan F. Quintana, AANA president.”
Educational requirements have evolved significantly. Nurse.org reported on CRNA education that “all schools are required to graduate only clinical doctorate educated CRNAs starting in the year 2025.” AMN Healthcare confirmed that “By 2025, all new Certified Registered Nurse Anesthetists (CRNAs) will need to hold a doctorate degree.”
This represents a substantial change from current requirements. Clinician.com quoted the AANA stating that “CRNAs have a minimum of 7-8 years of focused education in nurse anesthesia” and “most CRNAs are masters prepared.” The Council on Accreditation’s website confirmed that “entry-into-practice graduates from accredited nurse anesthesia programs as of 2025 will meet the competencies as outlined in the COA’s Practice Doctorate Standards.”
Board certification statistics reveal disparities between professions. According to Clinician.com, the AANA stated that “25%, or approximately 12,000-13,000 anesthesiologists, are not board certified.” The article characterized this as “a big number, a scary statistic, and a fact” according to AANA President Juan Quintana.
Congressional action has continued since 2016. PR Newswire reported on October 31, 2022 that “Rep. Lauren Underwood (IL-D) along with 12 Congressional colleagues” sent a letter to VA Secretary Denis McDonough urging the department to “swiftly complete the Department’s National Standards of Practice development process for CRNAs.”
The letter cited staffing shortages, stating that “a national review of staffing shortages at the Veterans Health Administration (VHA) for fiscal year 2021 found anesthesiology shortages at numerous VHA facilities” across multiple states according to PR Newswire.
Temporary measures during COVID-19 demonstrated CRNA capabilities. PR Newswire reported on November 10, 2020 that “To help meet the needs of veterans during the COVID-19 pandemic, the VA issued Directive 1899 in April 2020, which encouraged VA medical facilities to utilize VA healthcare professionals to practice and operate within the full scope of their” training.
Opposition efforts have also persisted. Nurse.org reported that “the ASA is supporting a bill introduced by Congressman David Scott (GA-13), Congressman Mike Turner (OH-10) and Congressman Andrew Garbarino (NY-02) that’s called Protect Lifesaving Anesthesia Care for Veterans Act.”
The VA’s rationale for excluding CRNAs focused on access rather than capability. According to the Federal Register, “VA’s position to not include the CRNAs in this final rule does not stem from the CRNAs’ inability to practice to the full extent of their professional competence, but rather from VA’s lack of access problems in the area of anesthesiology.”
However, the agency left the door open for future changes. The Federal Register stated that VA requested “comment on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.”
Military precedent supports CRNA independence. PR Newswire quoted AANA leadership stating that “CRNAs have full practice authority in the Army, Navy, and Air Force and are the predominant provider of anesthesia on forward surgical teams and in combat support hospitals.”
As healthcare demands increase and the CRNA profession transitions to doctoral education, the debate over independent practice at VA facilities remains unresolved, with both sides continuing to advocate for their positions through legislative and regulatory channels.
