Across Washington State, hospitals and surgical centers are facing an urgent challenge: a shortage of qualified anesthesia providers. As surgical demand grows and rural access becomes more critical, lawmakers are exploring two options to expand the workforce.
One approach strengthens what is already working, growing the existing pipeline of Certified Registered Nurse Anesthetists (CRNAs). The other introduces a new provider type by creating licensure for Certified Anesthesiologist Assistants (CAAs or AAs). At first glance, adding a new category of provider may appear to be a practical solution. But a closer examination reveals potential consequences that could harm patients, raise costs, and displace highly skilled professionals already serving Washington’s communities.
CRNAs are advanced practice nurses with extensive training in anesthesia delivery, patient safety, and perioperative care. There are over 65,000 CRNAs practicing across the United States, including thousands who provide services in rural and underserved areas. Each year, approximately 3,000 new graduates enter the workforce from accredited programs like the one already operating in Washington at Gonzaga University.
In states where CRNAs can practice independently, even a modest 10 percent increase in CRNA-only care has been shown to reduce the anesthesia shortage by as much as 40 percent. CRNAs can bill Medicare directly under the QZ modifier, meaning they can safely and legally provide solo coverage in a wide variety of clinical settings. This is especially important in rural communities where an anesthesiologist may not be physically present or even available.
Certified Anesthesiologist Assistants are limited by law to practice only under the supervision of a licensed anesthesiologist. They cannot work independently or bill directly for their services. Any operating room staffed by an AA must also have a physician anesthesiologist present, creating a two-provider model that increases the cost of care per case.
By contrast, CRNAs are able to function as the sole anesthesia provider, offering safe and cost-effective coverage. The introduction of AAs into facilities that previously operated under a CRNA-only model will result in significant payroll increases without any proven benefit in safety or outcomes.
Even the Washington State Department of Health’s own review noted widespread concern from healthcare professionals. Public comments indicated that allowing AAs could increase anesthesia costs and reduce CRNA job opportunities.
Washington would not be the first state to consider licensing AAs. In Missouri, CRNAs have reported a loss of positions and downward pressure on wages following the adoption of the AA model. Similar outcomes were documented during legislative hearings in Kansas and Michigan, where CRNAs testified that AA integration resulted in higher labor costs and the replacement of independent providers with more expensive care teams.
These shifts are not theoretical, they are happening now in states that pursued the same legislative path Washington is considering.
One of the most compelling reasons to invest in CRNAs is their ability to serve rural hospitals and surgical centers. In many critical-access hospitals throughout Washington, CRNAs are the only anesthesia providers legally permitted to work without on-site physician supervision. This ability to operate independently is a lifeline for smaller facilities that cannot afford to staff both a physician and an assistant.
AAs are not a solution for these settings. Their scope of practice requires anesthesiologist oversight, making them incompatible with the needs of remote communities unless a physician is also physically available. This limitation makes the AA model less flexible and far less practical for large portions of Washington State.
Nationwide, fewer than 3,500 AAs currently practice, and only a handful of university programs offer this training. Even if Washington were to pass legislation tomorrow, it would take years to establish a training program, graduate enough providers, and begin to see any impact on the workforce.
Meanwhile, CRNA programs already exist and are successfully producing qualified professionals who are ready and willing to serve. Investing in these programs offers a faster, more sustainable path forward.
Washington policymakers must weigh the consequences of their decision carefully. There are two distinct paths ahead:
If the state expands CRNA education and autonomy:
If the state licenses AAs:
At Advanced Anesthesia Services, we were founded by CRNAs and remain committed to CRNA-led, patient-first care. Our team believes that CRNAs represent the future of anesthesia delivery. They are safe, efficient, cost-effective, and adaptable to the needs of diverse clinical environments.
This conversation is not about professional rivalry, it is about choosing the path that best supports access, affordability, and safety for the people of Washington. The data clearly shows that expanding CRNA capacity is the smarter investment. It strengthens our hospitals, supports rural communities, and keeps surgical care within reach for every patient.
