Rural healthcare is at an inflection point. Hospitals are closing or scaling back essential services. Labor and delivery units are disappearing. Rural operating rooms sit idle not due to a lack of patients, but to a shortage of clinicians. At the same time, policymakers are advancing initiatives like the President’s Rural Health Transformation Program (RHTP), aimed at rethinking how care is delivered in rural communities.
This is a moment for bold thinking. But transformation cannot succeed if outdated regulatory barriers remain. While the RHTP has made progress by easing restrictions on nurse practitioners and physician assistants, significant barriers persist for specialized providers like nurse anesthetists.
If we are serious about strengthening rural healthcare, policy should be assessed through a simple framework: Effectiveness, Efficiency, and Enhanced Access.
Effectiveness: Proven Care, Proven Outcomes
Certified Registered Nurse Anesthetists (CRNAs) have safely delivered anesthesia care for more than a century. In many rural hospitals, they are the primary and many times, the only anesthesia professionals.
The evidence is clear: anesthesia care delivered by CRNAs is safe, high-quality, and comparable to other delivery models. This is not a new workforce. CRNAs are a mature, well-established profession with a long track record of safety across all practice settings, including the most resource-constrained environments.
When access to anesthesia determines whether a hospital can sustain surgical, obstetric, or emergency services, effective policy must ensure that care can actually be delivered.
Efficiency: Lower Costs, Sustainable Systems
Rural hospitals face extraordinary financial pressure. Thin margins, workforce shortages, and declining reimbursement make every operational decision high-stakes.
CRNAs are the most cost-efficient solution to sustain anesthesia services. Allowing them to practice to the full extent of their licensure enables high-quality care while better managing labor costs – often the single largest expense hospitals face.
By contrast, unnecessary supervision adds cost and administrative complexity without improving outcomes. These requirements can delay care, limit staffing flexibility, and even force service line closures. Medicare’s physician supervision requirement, which persists despite opt-out policies in half of states and no supervision requirement in the laws of 45 states, often results in non-anesthesia-trained physicians “supervising” highly-trained anesthesia professionals. Hospitals are then left with two poor options: reduced access to anesthesia services or adoption of significantly more expensive care models that further strain fragile finances.
If rural health transformation is meant to create reliable systems of care, removing artificial barriers should be a shared priority.
Enhanced Access: Providing Care Where It’s Needed Most
Access to healthcare is often discussed in abstract. In rural communities, it is more straightforward: access is everything.
When an expecting mother must travel hours for a C-section, a farmer delays surgery, or a child’s emergency care is limited by anesthesia availability, the system is not delivering.
CRNAs are uniquely positioned to address this: they are more likely to practice in rural and underserved areas and already serve as the backbone of anesthesia delivery in many of these communities.
Policies that restrict their ability to practice fully directly reduce access; policies that empower them expand access immediately.
Looking Ahead: A Workforce Reality We Can’t Ignore
The nation faces a growing shortage of physician anesthesiologists. Training pipelines have not kept pace, and geographic maldistribution continues to widen gaps, especially in rural areas with aging populations.
In contrast, the number of CRNAs is growing steadily, with strong representation in rural America and a demonstrated willingness to serve where need is greatest.
This is not a future concern, it is a present reality. Policymakers can either align regulations with workforce trends, now or confront worsening consequences later. Delays carry real risk, as rural hospital closures are often permanent.
Addressing the Safety Argument
Opposition to full scope of practice for CRNAs is often framed around patient safety. That argument does not withstand scrutiny. More than a century of clinical practice, supported by decades of research, shows no credible evidence of compromised safety. These arguments persist not because of data, but because of longstanding professional and economic interests.
Healthcare policy should be guided by evidence and patient needs, not protectionism.
A Clear Opportunity
The RHTP represents an opportunity to modernize care delivery in underserved communities. Meaningful transformation should:
• Remove unnecessary barriers limiting CRNA practice
• Align scope-of-practice policy with licensure and outcomes
• Prioritize workforce models that improve access and reduce costs
• Support rural hospitals with flexible, evidence-based staffing solutions
This is not about choosing one provider over another. It is about ensuring access to safe, timely, and affordable care, regardless of geography.
Conclusion
Rural healthcare does not need more complexity. It needs practical solutions grounded in reality.
Applying the framework of effectiveness, efficiency, and enhanced access leads to a clear conclusion: allowing CRNAs to practice to the full extent of their licensure is one of the most immediate, impactful steps available to stabilize rural healthcare.
The tools already exist. The question is whether we are willing to use them.
Tracy Young, MS, MBA, CRNA, is a healthcare executive and Certified Registered Nurse Anesthetist who leads large‑scale anesthesia operations as Chief Operating Officer of Essential Anesthesia Services. He currently serves as President‑Elect of the American Association of Nurse Anesthesiology.
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