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Donna G. Matias, an attorney in Pacific Legal Foundation’s economic opportunity practice, is representing Marcy Markes in her lawsuit.
For more than 30 years, nurse practitioner Marcy Markes has cared for patients in intensive care units and small-town clinics across Missouri. She holds degrees from the University of Missouri and runs an allergy and asthma clinic in Columbia, Missouri. The state has a serious health care access problem, and its residents would be better off if experienced providers like Markes were free to provide the care they are licensed to give. Instead, a state law requires nurse practitioners to contract with a physician, which by some estimates can cost an average of $7,000 per year. The price tag for Markes to practice? $50,000 a year.
The law mandates that nurse practitioners have a “collaborative practice agreement” — a contract Markes must enter with a physician to provide care. Without a CPA, she cannot legally order a routine lab test or write a prescription, despite holding a license that certifies her to do so.
Collaborating physicians can set their fees with no cap. There is, however, a limit on the number of CPAs a physician can participate in, which creates demand and drives up prices. This structure restricts nurse practitioners’ abilities to expand their businesses and provide care. A physician who collaborates with a maximum of six nurse practitioners could collect more than $300,000 annually just for signing paperwork.
Markes is suing the state of Missouri, with pro bono representation from the Pacific Legal Foundation, arguing that the CPA requirement is unconstitutional. Her case carries implications well beyond her clinic.
About 80 percent of Missouri is considered a “physician desert,” meaning that routine primary care is distant or essentially inaccessible for a large portion of the state’s population. Missouri has a substantial supply of licensed, trained nurse practitioners who could help fill that void. According to a 2025 study by the Rural Health Research Center at the University of Washington, there were 1,358 primary care physicians practicing in rural areas, compared to 1,761 nurse practitioners. There likely would be more of the latter if Missouri loosened licensing requirements.
The CPA requirement can make practicing financially prohibitive for many — and the consequences for those who practice without one are significant. A nurse practitioner who sees patients without a valid CPA faces license revocation, and practicing without a license could result in a fine of $10,000 per patient and criminal prosecution under a felony statute that could carry up to seven years in prison.
Defenders of CPAs argue that they exist to protect patients through physician oversight. But that rationale has grown harder to defend. Thirty-five states don’t require CPAs, and there’s no significant evidence that residents in these states receive inferior care as a result. Plus, those states consistently have better access: more providers, more clinics, more options in rural and underserved communities. If the agreements genuinely improved safety, their absence would show up in outcomes. It doesn’t. A studypublished in 2018 found that patients in states with independent nurse practitioners reported less travel times for a visit, more convenient scheduling and increased access to a consistent provider. It also found that increased availability of nurse practitioners in medically underserved communities would lead to a 30 percent increase in access to primary care services.
CPAs give physicians government-backed leverage over a competing class of licensed professionals, along with the power to extract fees from them indefinitely. Missouri is one of 12 states that still impose full CPA requirements, and its rules are among the harshest in the country. The arrangement fits a familiar pattern in occupational licensing: a restriction framed in public-safety terms that functions, in practice, as protection for incumbent economic interests.
The constitutional argument in Markes’s lawsuit reflects that reality. The Missouri Constitution guarantees every person “the enjoyment of the gains of their own industry.” Requiring a licensed professional to purchase permission from a private party to exercise that license sits uneasily with that promise. The complaint also raises federal due process claims, arguing that imposing arbitrary and irrational burdens on a licensed profession — with severe criminal penalties attached — cannot survive constitutional scrutiny.
Courts have increasingly been willing to reassess occupational licensing laws that appear to serve entrenched economic interests more than consumer protection. Missouri’s CPA regime presents a fairly clear case: a mandate with no demonstrated safety benefit, no fee limits and penalties severe enough to deter even well-credentialed professionals from practicing in the communities that need them most.
Missouri’s legislature has had ample opportunity to follow the lead of the states that have loosened or eliminated CPA requirements. The failure of lawmakers to reform Missouri’s licensing regime leaves practitioners like Markes fighting in court for the right to do work that her training, license and three decades of experience say she is fully capable of doing — without writing a $50,000 check each year to prove it.
The post In this state, nurse practitioners pay for the right to do their job appeared first on Washington Post.
