Outdated law makes Missouri nurse practitioners pay for a permission slip | Opinion

I’ve been a nurse practitioner for more than 25 years. I have worked in intensive care units, management positions and small-town clinics. I’ve earned multiple degrees from the University of Missouri and have worked as a family nurse practitioner for decades. In 2007, I opened Columbia Allergy and Asthma Specialists, where my team provides life-altering allergy, asthma and immunotherapy services to patients of all ages.

And yet, despite a career of trying to heal people, Missouri law requires me to pay tens of thousands of dollars to someone else in order to do a job I have been educated, trained and licensed to do.

Every year, I must pay more than $50,000 to obtain a collaborative practice agreement or CPA with a physician, which allows me to treat patients outside a hospital setting. This fee is nothing more than a formality, allowing me to do the work I have been trained to do for over three decades.

Without that permission slip, I can’t even order a routine lab test or prescribe a common medication.

I don’t mean permission in a symbolic sense. I literally have to pay a physician thousands of dollars every year just to keep my doors open.

I have nothing but respect for these doctors. I work alongside them all the time, and they’re vital members of our health care system. But this arrangement isn’t about patient safety or quality of care. It’s about government-mandated control.

Supporters of CPAs often claim they’re necessary to protect patients. But that argument doesn’t hold up. The vast majority of states — 39 of them — don’t require CPAs, and their patients are doing just fine. In fact, those states have more providers, lower costs and better access to care, especially in rural areas.

So what do CPAs actually do? They give physicians the power to dictate whether I can practice my profession. They allow doctors to charge whatever they want for that power. And if I dare to work without one, I risk losing my license, facing fines of up to $10,000 per patient, or even being charged with a felony and sent to prison for up to seven years.

Think about that: After decades of education, experience and public service, I could go to jail for treating someone’s asthma without paying another professional supposedly to supervise me — on paper.

This is more than just bad policy. It’s a moral and constitutional problem. The Missouri’s Constitution promises every person “the enjoyment of the gains of their own industry.” Yet the state has created a system that forces nurse practitioners to buy back the right to do our jobs. It’s an irrational and protectionist setup that benefits no one except the small number of physicians collecting checks from professionals like me.

Meanwhile, ordinary Missourians are paying the price. About 80% of the state is considered a physician desert, meaning that for many people, getting an appointment with a doctor can take weeks or even months. Nurse practitioners could help close that gap. But the CPA law makes it nearly impossible for many of us to serve those communities without first going broke.

That’s why I’ve decided to fight back. With free legal representation from the nonprofit Pacific Legal Foundation, I’ve filed a lawsuit challenging Missouri’s collaborative practice agreement law. I’m doing it not just for myself, but for the hundreds of nurse practitioners across the state who are being held back by this outdated, protectionist rule — and for the thousands of patients who deserve timely, affordable care.

I’ve spent three decades helping Missourians breathe easier. Now, I’m fighting for the chance to keep doing it—without government permission slips or unnecessary middlemen standing between me and my patients. It is time for Missouri to trust its nurse practitioners to do what we’ve always done: provide safe, effective care to the people who need it most.

Marcy Markes is a nurse practitioner and owner of Columbia Allergy and Asthma Specialists in Columbia.