State Policies Bolster Rural Health Care Workforce

July 05, 2024 | Chikamso Chukwu

Workforce shortages are a significant challenge across both the public health and health care sectors. These shortages are especially acute in rural communities and within behavioral and oral health. The Health Resources and Services Administration (HRSA) projects a shortage of approximately 70,000 mental health counselors, 338,000 registered nurses, and 68,000 primary care physicians over the next 12 years.

HRSA is working to address the shortages via programs that support health care provider training and placement. Additionally, state policymakers are tackling this issue through legislation aimed at bolstering recruitment, training, and retention of health care professionals and widening the scope of practice for critical professions.

HRSA Leadership in Building health Care Workforce Pipelines

HRSA manages many grant programs that build and diversify the health care workforce, as well as connect skilled health care providers to the people who need it most. HRSA’s Bureau of Health Workforce provides financial assistance to health care providers through loan repayment programs for licensed health care professionals in return for practicing in an underserved community for a set amount of time, and scholarship programs for students in health programs and professions to cover educational expenses. Some of these programs include:

• National Health Service Corps, which utilizes scholarships and loan repayment to support health professionals in underserved communities with significant shortages. This program supports over 18,000 health professionals and almost 19 million U.S.
• Nurse Corps Scholarship Program, which provides loan repayment for registered nurses and advanced practice registered nurses employed in health care facilities located in Health Professional Shortage Areas (HPSAs).
• State Loan Repayment Program, which provides grant funding to states to manage their loan repayment programs.
• Substance Use Disorder Treatment and Recovery Loan Repayment Program, which provides loan repayment for health professionals providing treatment for substance use disorder at approved facilities.
• School-Administered Loan Programs for undergraduate and graduate institutions to provide loan assistance to students pursuing degrees in primary care, nursing, and other health professions, who then practice in areas with health care shortages.

State Legislation Related to Grant, Scholarship, and Loan Repayment Programs

Public health agencies also play a significant role in health care workforce development through state/territorial Primary Care Offices (PCOs), which receive direct investment from HRSA to track health care professional shortage areas in their jurisdiction and administer HRSA workforce programs to address those shortages. In addition, PCOs and other state agencies can fund and administer their own, state-based scholarship and loan repayment programs. In recent years, several states enacted legislation that increases funding or expands the list of eligible providers who can participate in these programs, described in more detail below.

In 2023, at least three states enacted laws expanding financing programs for health professions supporting underserved communities. California enacted AB 118, which adds pharmacists to the list of professions eligible to participate in the California Reproductive Health Service Corps to help underserved areas. Illinois enacted SB 1590, which made chiropractic students eligible for the Underserved Healthcare Provider Workforce Program. Washington enacted SB 5582 which expands educational opportunities for nursing students, including a pathway program for home care aides to become a Licensed Practical Nurse. In 2024, Washington enacted HB 1946 expanding eligibility for the Washington Health Corps Program to include behavioral health professionals serving in underserved areas.

Workforce Planning and Diversification

Analyzing the health care workforce is important for jurisdictions to understand potential shortages and how to address them in the future. In the last few years, states have enacted legislation that looks at shortages in specific segments of the health care workforce. California enacted AB 1311 in 2023, requiring an assessment of state university and community college health education programs including how these programs fulfill health care workforce shortages and graduate job placement.

This year, Virginia enacted HB 1499, which allows the Virginia Health Workforce Development Authority to partner with other state agencies to manage and analyze health workforce data and authorizes them to request data to reach a broader understanding of the state and address longstanding shortages. Washington enacted SB 6286 directing the University of Washington to study and report on the workforce shortages in the state’s anesthesia care, the current training pipeline, and barriers to entering the profession.

Strategies to mitigate health care workforce gaps include expanding pipelines for various health care professions and creating programs or licenses that allow paraprofessionals to practice under supervision. For example, Washington enacted HB 2247 that created credentials for licensed psychological associates (e.g., students in training and practicing under supervision of a licensed psychologist). Wisconsin enacted SB 689, which allows for the licensure of dental therapists who would practice in designated dental shortage areas and under the supervision of a licensed dentist.

Medicaid State Plan Amendments Related to Federally Qualified Health Centers (FQHCs)

Legislation is not the only policy lever available to expand access to care. State Medicaid agencies can amend their program’s services, provider types, or eligibility standards by submitting a State Plans Amendment (SPA) for approval by the Center for Medicare and Medicaid Services (CMS). In May 2024, California received CMS approval to allow Associate Professional Clinical Counselors, who practice under the supervision of a licensed billable practitioner, as a covered service within Federally Qualified Health Centers (FQHCs), rural health clinics, and Tribal FQHCs to expand access for Medicaid members to behavioral health providers. In the same month, Illinois received approval for an SPA to increase FQHC payment rates for behavioral health encounters in FQHCs and RHCs. Louisiana amended their state plan to provide a recruitment bonus or monthly retention bonuses to nurses participating in a Home Health Program, made possible under the American Rescue Plan Act.

Having a robust health care workforce requires increasing the number of providers, building diverse and skilled workforces, and connecting professionals to the communities who need them most. States are committed to addressing current health care workforce shortages while preparing for the future needs of the workforce. ASTHO will continue to track legislation to address health workforce shortages, as well as offer programmatic support to PCOs and state/territorial health departments in their critical work to ensure access to care.