A talented, qualified, engaged and diverse workforce is at the heart of America’s health care system. However, hospitals and health systems now face mounting and critical staffing shortages that could jeopardize access to care in the communities they serve. For example, AHA survey data show that between 2019 and 2020, job vacancies for various types of nursing personnel increased by up to 30%, and for respiratory therapists by 31%. These shortages are expected to persist, with an analysis of EMSI data showing there will be a shortage of up to 3.2 million health care workers by 2026.
The COVID-19 pandemic has taken a heavy toll on health care teams who have been on the front lines of the pandemic with many suffering from stress, trauma, burnout and increased behavioral health challenges. A 2021 Washington Post-Kaiser Family Foundation survey found that nearly 30% of health care workers are considering leaving their profession altogether, and nearly 60% reported impacts to their mental health stemming from their work during the COVID-19 pandemic.
However, the daunting challenge of sustaining the health care workforce predates the COVID-19 pandemic. America will face a shortage of up to 124,000 physicians by 2033, and will need to hire at least 200,000 nurses per year to meet increased demand and to replace retiring nurses. There also are critical shortages of allied health and behavioral health professionals, especially in historically marginalized rural and urban communities. These workforce shortages — combined with an aging population, a rise in chronic diseases and behavioral health conditions, and advancements in the “state-of-the-art” of care delivery — all contribute to the need for supportive policies so that America’s health care workforce can ensure access to care and be adequately prepared for the delivery system of the future.
The AHA urges Congress and the Biden Administration to prioritize funding that supports the health care workforce needs of the country in the wake of the COVID-19 pandemic and into the future. AHA urges Congress to pass the legislative priorities referenced below in any legislation enacted this year.
- The health care workforce supports American jobs, serves American communities and spurs American economic activity. Indeed, hospitals and health systems alone employed more than 6 million individuals in full- or part-time positions in 2019; purchased more than $1 trillion in goods and services from other businesses; supported almost 18 million, or one out of nine, jobs; and supported roughly $2.30 of additional business activity in the economy for every dollar they spent. Yet the pandemic is taking its toll on health care jobs. According to the U.S. Bureau of Labor Statistics, employment in the field is still down by over 80,000 jobs since February 2020.
- Physician shortages are growing, exacerbated by caps on the number of Medicare-funded residency slots. The Association of American Medical Colleges projects a national shortage of up to 124,000 physicians by 2033, including shortages of primary care physicians and specialists, such as pathologists, neurologists, radiologists and psychiatrists. While the aging of the U.S. population and the physician workforce drives some of the projected shortage, much of it stems from the caps on Medicare-funded residency slots imposed by Congress nearly 25 years ago as a cost-saving measure. While the number of medical school graduates has increased significantly over the past two decades, Medicare-funded training opportunities for these graduates has remained frozen at 1996 levels. As a result, over 3,100 applicants lacked residency slots in 2019. Furthermore, the caps have created imbalances that favor allocation of slots toward lower-cost and higher-reimbursement specialties, rather than more urgently needed primary care and behavioral health. While some hospitals are filling in gaps by self- funding a portion of their residency slots, this model is not sustainable over the long haul, as evidenced by the -8.7% Medicare margins for teaching hospitals in 2019.
- Lifting the cap on Medicare residency positions would enhance access to care and help America’s hospitals better meet the needs of the communities they serve. Increasing Medicare-funded residency slots would provide hospitals more flexibility to diversify and maintain more training programs, including both primary care and specialty programs. In addition, an increase in slots would allow health systems to train residents in more diverse types of facilities, such as smaller rural hospitals, which may not be able to operate their own training programs. This would benefit both the quality of physician education and the patients they would serve. The AHA supports the Resident Physician Shortage Reduction Act of 2021, which would add 14,000 Medicare-funded residency slots over the next seven years. Additionally, the AHA supports the Pathway to Practice Training Programs, which would fund 1,000 post-baccalaureate and medical school scholarships annually, increase physician diversity, promote cultural and structural competency training, improve access to physicians in communities dealing with sustained hardship, and lift the caps on Medicare-funded residency slots by 4,000 over the next two years, dedicating 25% of those slots to primary care and ob/gyn and 15% to psychiatry.
- The nursing and allied professional workforce also faces critical shortages. The U.S. needs more than 200,000 new registered nurses (RNs) each year to meet increasing health care needs and to replace nurses entering retirement. In 2017, more than half of all nurses were age 50 or older, and almost 30% were age 60 or older. Workforce pressures also exist across a variety of allied health professions. According to one recent survey, the annual turnover rate of hospital certified nursing assistants (CNAs) was 27.7% (nearly double the turnover rate of nurses and physician assistants). Meanwhile, the Bureau of Labor Statistics projects a need for 11% more CNAs by 2025. The lack of laboratory technicians may be particularly acute — a 2017 survey conducted by the American Society for Clinical Laboratory Science concluded that there were, nationally, 7.2% lab technician positions unfilled.
- Faculty shortages severely constrain ability to meet future nursing needs. According to the American Association of Colleges of Nursing, American nursing schools turned away over 80,000 qualified applicants from baccalaureate and graduate programs in nursing in 2019 alone due to an insufficient number of qualified faculty, clinical sites, classroom space, clinical preceptors and budget constraints. The low salaries for nursing faculty also are not commensurate with their level of educational preparation (i.e., master’s degree level, or above), making recruitment a dire challenge. That is why the AHA supports the Future Advancement of Academic Nursing (FAAN) Act, which would provide resources to boost student and faculty populations, as well as support educational programming as well as partnerships and research at schools of nursing.
- Extreme nurse staffing agency prices during the pandemic are unsustainable and deserve heightened regulatory scrutiny. Hospitals have shared that nurse staffing agencies are often charging up to three times their pre-pandemic rates. Unfortunately, many hospitals have dire needs for nursing staff to care for their patients and have had little choice but to pay these exorbitant rates. The AHA urges the Administration to use its authority to investigate anti-competitive pricing by nurse staffing agencies and to take appropriate action to protect hospitals and the patients whom they treat.
- America’s behavioral health needs are reaching a crisis point rising amid gaps in the behavioral health workforce. One in five American adults has a behavioral health condition; before the pandemic, nearly 60% of adults with behavioral health disorders reported not receiving services for their conditions. The stresses of the COVID-19 pandemic have compounded these concerns: one in three adults reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019. Yet, over 100 million Americans live in areas that have a shortage of psychiatrists, as designated by the Health Resources and Services Administration (HRSA). HRSA also projects shortages of psychiatrists and addiction counselors to persist through 2030. AHA supports the Opioid Workforce Act of 2021/Substance Use Disorder Workforce Act of 2021, which would address shortages of substance use disorder treatment providers by adding 1,000 Medicare-funded training positions in approved residency programs in addiction medicine, addiction psychiatry or pain medicine.
- Several mechanisms provide good starting points for addressing workforce and faculty shortages. For example, the AHA supports Congress funding HRSA’s title VII and VIII programs, including, $517 million for the health professions program, continued funding for the National Health Service Corps, and $530 million for the nursing workforce development program, which includes loan programs for nursing faculty. Congress also should consider expanding the loan program to allied professionals and targeting any support for community college education to high priority shortage areas in the health care workforce.
- Rising clinician burnout — accelerated by the pandemic — calls for national support. A recent National Academy of Medicine report suggests that between 35% and 54% of U.S. nurses and physicians have symptoms of burnout, which it characterizes as high emotional exhaustion, high depersonalization (i.e. cynicism), and a low sense of personal accomplishment from work. Hospitals and health systems are deploying a range of programs and interventions to assist their workforce, but given the financial pressures posed by the pandemic, Congress should provide additional funding to support national research and demonstration programs related to clinician well-being. The AHA supported the passage of the Dr. Lorna Breen Health Care Provider Protection Act, which aims to prevent suicide, burnout and behavioral health disorders among health care professionals.
- Visa relief — especially during the pandemic — is critical given that many hospitals rely on foreign-born employees to serve their communities. Recent studies show that 18.2% of U.S. health care workers were born outside of the U.S. For example, 29% of U.S. physicians are born in other countries, and almost 7% are not U.S. citizens. Similarly, foreign-born nurses account for 15% of RNs in the U.S., according to a report by the Institute for Immigration Research at George Mason University. That is why the AHA supports the bipartisan Healthcare Workforce Resilience Act, which would expedite the visa authorization process for highly-trained nurses who could support hospitals facing staffing shortages, and provide protections to U.S.-trained, international physicians who are vitally important to patient care in their communities.