Letter on the health care workforce shortage

States and territories are working to address healthcare workforce challenges by advancing nursing, direct care, and behavioral health career pathways, supporting healthcare provider mental health and wellbeing, improving the collection of healthcare supply and demand data, and creating a more diverse healthcare workforce.

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Dear Chairman Sanders and Ranking Member Cassidy,

On behalf of the National Governors Association (NGA), we appreciate the opportunity to provide feedback on the root causes of the current health care workforce shortage and potential ways to address it. We would also like to commend the Senate Committee on Health, Education, Labor and Pensions, for your efforts in developing bipartisan legislation to tackle one of the critical issues facing our states and territories.

As you have noted, according to the American Hospital Association, the United States will face a shortage of up to 124,000 physicians by 2033 and will need to hire 200,000 nurses per year to meet demand. Governors have taken innovative steps to address the healthcare workforce shortage facing their states and territories by boosting recruitment efforts, loosening licensing requirements, expanding training programs and raising providers’ pay.

Shortages in healthcare workers is not a new challenge but has only worsened in the past three years due to the COVID-19 pandemic. Burnout and stress have only exacerbated this issue. Concerns about healthcare workforce supply and preparing the next generation of the healthcare workforce have been building for several years for a variety of reasons. The retirement and aging of an entire generation is front and center of the healthcare workforce shortage, particularly impacting rural communities. Like in other sectors, the healthcare workforce is rapidly aging: over a quarter of all physicians are over 60 years old, the average age of a nurse is over 50. Nearly 20% of the healthcare workforce have left positions since the beginning of the pandemic, up to 47% of the healthcare workforce plan to leave their positions by 2025.

As a result, states and territories have taken innovative approaches to meet the growing healthcare workforce shortage that existed prior to COVID-19 but which has only added additional pressures to staffing shortages and an unfilled talent pipeline. Combatting workforce shortages is a critical issue facing all Governors, for this reason at NGA’s 2023 Winter meeting Governors led a discussion on workforce shortages and opportunities. In addition, NGA is working with States and Territories in a learning collaborative and knowledge exchange network on strategies to grow and retain the next generation of the healthcare workforce. This project includes 20+ states and territories and is funded by Health Resources and Services Administration (HRSA). These states and territories are working to address healthcare workforce challenges by advancing nursing, direct care, and behavioral health career pathways, supporting healthcare provider mental health and wellbeing, improving the collection of healthcare supply and demand data, and creating a more diverse healthcare workforce.

Governors have also been vocal in pointing to immigration reform as an obvious and important way to find more workers, including more healthcare workers.

Please find attached state and territorial examples, feedback and recommendations to help address the health care workforce shortage. Governors stand ready to assist you as you develop bipartisan legislation that will help ensure that our States and Territories have sustainable funding and resources necessary to build and retain the healthcare workforce.

Sincerely,

Bill McBride
Executive Director
National Governors Association

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Making Education More Accessible

Academic financial assistance programs help with improving retention and having less turnover of employees in an institution, which is especially crucial in hospital and direct care settings. Providing financial support through tuition assistance and loan repayment are tools to help with recruitment and retainment of staff. The Association of American Medical Colleges reported that the median medical school debt among the Class of 2021 was $200,000, not including their undergraduate debt. According to the American Association of Colleges of Nursing, 69% of graduate nursing students take out student loans, and borrowers owe between $40,000 and $54,999 at the end of their graduate programs, according to 2017 data, the most recent available. Research is trending toward addressing this issue in a two-pronged – both prospective tuition assistance and scholarship programs to attract new healthcare workers into the field and in specific types of communities where noted shortages exist (e.g. rural, communities of color, etc.) and in loan repayment programs to help those already working in the field repay the frequently overwhelming amount of educational debt healthcare providers of varying education and experience levels (e.g. physicians, all nursing types, direct care workers, allied professionals, etc.). The financial barriers and burden of a healthcare career can preclude the ability of individuals to gain entry to the field and stay in the field. In addition, apprenticeship programs are another avenue for both younger students and adults seeking career change to gain valuable insights and experience in the field.

To address these workforce challenges, Governors have utilized some of the following strategies:

• Former Massachusetts Governor, signed a $4 billion pandemic relief bill, which included $110 million for a college loan repayment program for mental health professionals who work in community health centers. Those eligible for the loan repayment program include psychiatrists, psychologists, registered nurses and nurse practitioners, and others who work in behavioral health care settings. Includes, $15 million diverted from a state fund that collects money from opioid settlements to cover workers who provide acute care, stabilization services and residential treatment for substance use disorders.
• In Ohio, the Department of Health offers a Substance Use Disorder Professionals Loan Repayment Program to recruit and retain providers at community-based settings serving Medicaid patients and uninsured patients. The state gives providers up to $50,000 a year in loan assistance in exchange for a two year service commitment.
• Chicago, Illinois offers high school students in economically depressed communities free training and the guarantee of a job interview for entry-level positions. Healthcare Forward, a partnership amongst health systems, is focused on recruiting individuals – particularly those on the West and South Sides of Chicago – for a wide range of entry-level jobs in healthcare that require only a high school diploma or GED equivalent.
• The Kentucky Council on Postsecondary Education’s Healthcare Workforce Collaborative distributed $8 million in grants to Kentucky’s public 2- and 4-year colleges and universities to help address the healthcare workforce shortage. The grants, funded by an appropriation from the General Assembly, will help the institutions expand their programs and provide student supports to get more frontline healthcare workers trained and into the workforce.
• The Murphy Administration announced the Behavioral Healthcare Provider Loan Redemption Program in New Jersey. The purpose of the program is to help recruit and maintain a qualified workforce of behavioral healthcare professionals to expand access to mental health care. Through funding in the Fiscal Year 2023 budget, this career-specific loan redemption program was created to help address the critical shortage of behavioral health providers in New Jersey. Under the program, behavioral healthcare professionals can apply to have the Higher Education Student Assistance Authority pay off up to $150,000 of their student loan balance in exchange for agreeing to work at an approved community behavioral and mental health provider located in New Jersey.
• The West Virginia Nursing Scholarship program requires nursing students in LPN, RN, LPN teaching certificate, masters, and doctoral programs to complete two years of service for every year of scholarship support they receive. This program has seen high retention and kept nursing students practicing in the state.

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Ensuring Health Professionals Can Practice at the Top of their Scope of Practice

During the COVID-19 pandemic many states and territories made temporary changes to increase the flexibility or regulatory practices to help address the pandemic-related workforce crisis. It is important for the federal government to remove any barriers for state and territories to have the option to support full practice authority if they choose to do so.

For example, during the COVID-19 pandemic, federal and state governments removed the scope of practice restrictions on nurse practitioners (NPs), allowing them to deliver care to patients without restrictions. On March 30, 2020, the Centers for Medicare and Medicaid Services authorized an emergency declaration to allow NPs to practice to the full extent of their license. Before COVID-19, only 23 states and the District of Columbia supported full practice authority for NPs, allowing NPs to care for their patients to the fullest extent of their education and licensure. However, waivers that allowed advanced practice registered nurses (APRNs) to practice at the top of their license will expire on October 9 absent further Congressional action.

While the PHE ends on May 11, Centers for Medicare and Medicaid Services (CMS) has extended the waivers for an additional 152 days to allow providers time to undo the waivers, this extension ends on October 9.

In 2020, (CMS) reported that every state in the country activated emergency-response licensure laws. States temporarily waived the requirement that physicians be licensed in the state their patients are located.

To address these workforce challenges, Governors have utilized some of the following strategies:

• Wyoming passed legislation to give physician assistants full independence and expand their scope of practice, removing the requirement that they be under supervision of a physician to practice.
• Colorado lowered its physician licensure requirements to align with national standards, reducing potential barriers to licensure for these providers.

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Increasing Professional Development Opportunities

As the population ages and experienced healthcare workers drop out of the workforce, leveraging the experience that these workers have before they leave is critical. A key tool for employee retention is to invest in employees through upskilling and reskilling opportunities. Providing professional development opportunities to obtain new skills and explore new avenues in their careers will improve employee morale and incentivize employees to remain in that healthcare organization. It is important for these training opportunities to be accessible to employees when convenient for them, such as increasing access to online healthcare degrees and certificates.

To address these workforce challenges, Governors have utilized some of the following strategies:

• In Tennessee, the state Medicaid agency (TennCare) and Board of Regents have partnered to develop the QuILTSS Workforce Development Training program for direct care workers. The program offers training in areas like cultural competency and patient-centered care and provides higher compensation for workers supporting TennCare’s long-term services and supports programs.
• In Maine, Healthcare Training for ME is a statewide collaboration of educational institutions and government agency partners convened to ensure Maine’s workers and employers can easily access healthcare training opportunities and supports. Funding for Training for ME is provided through the Maine Jobs & Recovery Plan to advance Maine’s workforce and economic goals and additional philanthropic funds.

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Increasing Faculty and Residency Slots

The lack of educators and residency slots for graduating medical students, and clinical training for nurses and others, is a critical part in addressing healthcare shortages across the country. Despite the nursing shortage some schools reject applicants due to lack of faculty and educators available – sometimes because they are working or have returned to working in the clinical setting due to the demands of the workforce shortage and the effects of the pandemic. Providers in these settings are having to spend high amounts of time engaged in training new personnel on the job and often in vital care settings, in front of patients and their families to support these needs. According to the American Association of Colleges of Nursing (AACN) report on 2021- 2022 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, U.S. nursing schools turned away 91,938 qualified applications from baccalaureate and graduate nursing programs in 2021 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.

To address these workforce challenges, Governors have utilized some of the following strategies:

• New Mexico allows part-time faculty to serve without a graduate degree if they have a master’s prepared faculty member they report to.
• The Maryland Higher Education Commission has provided nearly $27 million to support 938 nurse faculty members through a variety of programs, including the New Nurse Faculty Fellowship Program. This program is funded by the Maryland Health Services Cost Review Commission and supported by an annual percentage of Maryland hospitals’ patient revenue.

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Improving Health Information Technology (Health IT), Data Systems and Data Skills

Now more than ever, the U.S. healthcare system is amassing data at unprecedented rates. With the increase of an aging population, efforts to improve health outcomes and an increase in data improvement efforts, modernizing health IT, data systems and data skills across the healthcare system is crucial. Clinical care systems benefit from laws incentivizing and investments that will improve access to quality care, expand access to affordable health care, while containing costs. Healthcare personnel and healthcare organizations need data to identify patterns that may improve a patient’s health outcome.

For physicians, computer-related and insurance-related tasks were the top low-value activities after administrative work. Getting rid of these low-value tasks could offer some quick fixes for optimizing workflows and reducing burnout.

To address these workforce challenges, Governors have utilized some of the following strategies:

• North Dakota’s rural providers transitioned from paper-based COVID-19 data reporting to electronic reporting, for required public health reporting for lab reporting, syndromic surveillance, and immunization data through bidirectional queries to providers’ electronic health records (EHRs).

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Making Permanent Telehealth Flexibilities

During the COVID-19 pandemic, the federal government, states and territories reduced regulatory barriers for individuals to access telemedicine. Permanently doing away with some of these barriers will make the healthcare system more accessible and efficient, which will help ease the burden on the workforce.

Internet access is now available in or within reach of most homes in the U.S., making basic health consultation and remote health monitoring services accessible to wider segments of the population while also making it easier for overloaded practitioners and facilities to serve more patients. At the same time, some healthcare groups are offering their doctors and nurses the option of working remotely for part of their schedules, an incentive for those who might have considered leaving the profession because of family or other responsibilities at home. Telehealth also has the added benefits of being more cost-effective for providers and more convenient for many patients. Plus, it’s safer for caregivers and patients alike amid infectious disease breakouts. Additionally, telehealth flexibilities enable physician compacts across states to play a role in filling some of the gaps that may exist in both primary and specialty care, especially for the elderly and in rural areas.

To address these workforce challenges, Governors have utilized some of the following strategies:

• In 2021, Governor Spencer Cox from Utah signed a bill requiring payment parity for remote mental health visits.
• In 2020, Governor Chris Sununu signed a bill permanently requiring Medicaid and commercial payers to reimburse telehealth services at the same rate as in-person care in New Hampshire.

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Diversifying the Healthcare Workforce

The COVID-19 pandemic highlighted the significant healthcare disparities that exist in Black, Indigenous, and people of color (BIPOC) communities. BIPOC communities experienced higher levels of infections, hospitalizations, and deaths associated with the pandemic, which in turn has underscored the importance of increasing the size and diversity of the healthcare workforce, including nursing. Currently, 90% of the nursing workforce is women, and 75% are white, suggesting the nursing workforce’s relative homogeneity persists despite the significant increase in the diversity of the U.S. population. Conversely, women and people of color represent a majority of the direct care workforce. It is imperative that schools intentionally recruit and train students who reflect underrepresented communities and provide opportunities to eliminate financial barriers that might otherwise prevent diverse applicants from seeking out nursing and other healthcare training programs. In addition, creating pathways for additional training and education for direct care workers creates opportunities to recruit a more diverse pool of applications to higher trained nursing and other skilled healthcare professions as well as creates economic opportunities these workers to obtain training that might otherwise be unaffordable as direct care jobs are frequently low paying roles. Increased wage opportunities for direct care workers can increase longevity in the field for consistency of care in clinical settings for patients and provide economic advancement opportunities through additional education and training.

To address these workforce challenges, Governors have utilized some of the following strategies:

• Oregon collects and analyzes data on the diversity of its healthcare workforce through the Health Care Workforce Reporting Program. The program gathers data from 17 health licensing boards from renewal surveys and produces insights to better understand the composition of the state’s healthcare workforce, inform policy recommendations, and steer educational and workforce investments. Oregon’s most recent report, the Diversity of Oregon’s Licensed Health Care Workforce, analyzes gender, racial, and ethnic data to identify workforce trends over time. The report also includes data on languages spoken by the healthcare workforce, helping to inform the cultural responsiveness of providers and potential need for interpreters.
• The University of Illinois College of Nursing is among the most diverse campuses in the nation, and the student body in the College of Nursing (CON) reflects that diversity. Their efforts to recruit and retain students from underrepresented groups go hand in hand with their drive to eliminate health disparities and advance health equity.
• In November 2021, through Montana’s CARE Program, the state is funding participating employers to reimburse new employees up to $12,500 in moving costs and another 35% to offset taxes in relation to the reimbursement amount. In order for a new employee to qualify for reimbursement, they must accept a health care job, move to Montana, and work the job for at least 12 consecutive months.
• Connecticut launched a collaborative partnership between Connecticut state higher education institutions, multiple state agencies, and the Connecticut Hospital Association to Tuition assistance to incentivize low-income and minority students to enter accelerated and cost-effective nursing and social work programs; recruitment and retention of faculty to rapidly expand seat capacity and train the next generation of nursing and behavioral health workers; and innovative education/workforce programs to build career pathways. This effort was launched utilizing ARPA funds.
• Several states have increased wage floors for direct care workers to encourage retention of workers in the sector and advance economic opportunities for advanced training. These wage increases will exponentially affect women and people of color. At least 19 states are actively implementing strategies to address direct care worker wages through reporting and/or enforcement mechanisms.

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Recruiting Foreign Healthcare Workers

It is critical that the U.S. invest in training American healthcare workers here at home, while also ensuring that we are recruiting qualified foreign healthcare personnel to fill in some of the immediate gaps. The American Association of International Healthcare Recruitment reported that more than 5,000 international nurses are awaiting final visa approval. The demand has been so great that a backlog has been created of healthcare professionals awaiting clearance, much of this has also been due to changes during the COVID-19 pandemic. On January 11, 2022, 8 bipartisan Governors sent a letter to President Biden regarding the labor shortage in their states and repurposing unused visas for doctors and nurses who can help relieve pressure on our healthcare workforce.

To address these workforce challenges, Governors have utilized some of the following strategies:

• While not specific to healthcare, in last year’s budget California funded an English Language Learning Integrated Education and Training Fund to connect the immigrant population to high quality jobs. Programs like this can bring foreign-trained healthcare professionals into the workforce.
• Utah’s Department of Commerce launched a foreign credentialing program to streamline licensing portability for immigrants with healthcare expertise.

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Increasing Direct Care Worker Wages

Recruiting and retaining direct care workers, including certified nursing assistants (CNAs), home health aides, direct support professionals, personal care aides and other non-licensed personnel, has represented a longstanding challenge in the United States due to low wages and the intense demands of these occupations. As states have grappled with staffing concerns in both facility and home and community-based (HCBS) settings, they are seeking long-term solutions to recruit and retain workers, an objective that also has significant equity implications because most direct care workers are women and people of color. Developing both wage growth and career opportunities can facilitate economic mobility, address inequities and help improve the lives of these workers and those for whom they care.

To address these workforce challenges, Governors have utilized some of the following strategies:

• Iowa used ARPA funds to provide one-time $2,500 bonuses to home care workers.
• Illinois permanently raised the minimum wage for direct service professionals by $1.50 an hour.
• Colorado now has a minimum wage of $15 an hour for home care workers.

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The Federal government can take steps to support the development and growth in supply of increasing the healthcare workforce, such as:

• Continue support for the National Health Service Corps and the National Nurse Corps to increase the number of healthcare professionals practicing in underserved rural and urban areas. In FY2021, the American Rescue Plan Act of 2021 (ARPA, P.L. 117- 2) provided a one-time appropriation of $800 million to expand the number of scholarship and loan repayment awards the program can make. ARPA also reserved $100 million for states to make loan repayment awards.
• Increase funding for Minority Serving Institutions by awarding grants to educational institutions to establish or expand medical schools, with a priority on minority-serving institutions or those that want to expand or establish schools in medically underserved areas.
• Increase funding for Health Resources and Services Administration (HRSA) Title VII health professions and Title VIII nursing workforce development programs.
• Work with the State Department to ensure backlog of visas for foreign-trained nurses and continuation of visa waivers for physicians in medically underserved areas is quickly addressed.
• Increase the number of residency slots, including Medicare-funded residency training slots and expand funding for primary care residency training programs and nursing education initiatives to keep pace with our growing healthcare needs.
• Sustain investments made through ARPA funding that helped increase direct care worker wages.
• Many states used this money to support one-time bonuses or temporary raises for direct care workers, but these investments will end once funding runs out.
• Support apprenticeship programs like the Department of Labor $80 million initiative, the Nursing Expansion Grant Program, which includes funding for the Nurse Education Professional Track to prepare experienced current or former nurses for teaching roles.
• Closely consider making permanent expired or expiring federal waivers that provided states and territories with the flexibilities on scope of practice.
• Support for Graduate Medical Education positions.
• Increasing opportunities for healthcare worker scholarships and loan repayment programs.
• Making housing for healthcare workers more affordable, especially in high-cost metropolitan areas and high-cost rural areas. USDA offers long-term loans with no or a low-down payment for healthcare workforce housing. This program is especially beneficial to people just entering the workforce who have a stable salary but may not have adequate credit or savings to buy a house.
• Increase opportunities for spouses and relatives of healthcare workers already practicing in rural and underserved areas to obtain healthcare training for a variety of healthcare careers where they live through in person or remote learning platforms to eliminate relocation and recruitment barriers.

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List of Resources available from the National Governors Association

• State Strategies for Sector Growth and Retention of the Direct Care Health Workforce
• Addressing Wages of the Direct Care Workforce Through Medicaid Policies
• Informing Healthcare Workforce Policy By Leveraging Data
• NGA Next Generation of the Healthcare Workforce Project 2022-2023
• NGA has prepared a toolkit for states with resources on topics such as sources of healthcare workforce data, state policy options for occupational regulation, and licensing compacts. Please reach out if you would like details on the toolkit as this is only shared with some states now but will be made public later.