Overview

New data from the Congressional Budget Office (CBO) indicates that 27 million people are expected gain health insurance by 2017. Legislatures across the U.S. are examining both the health care workforce and health facilities within their states..

In many parts of the country—especially rural and frontier areas and low-income urban neighborhoods—the number of health care professionals, including those who provide primary care, is insufficient. In addition, some specialties are in especially short supply across the country, among them pediatric dentists and child psychiatrists.

Policymakers are charged with attempting to restrain rising health care costs while also helping to ensure that the health care workforce is appropriately distributed and delivers high-quality care. In attempting to meet these goals, states are taking action by developing and maintaining medical schools and residency programs, providing incentives to practice in underserved areas, as well as addressing health professionals scopes of practice.

The health care workforce also receives attention simply because it is a significant part of the nation’s economy. According to the Bureau of Labor Statistics, health care provides about 13.4 million jobs, including about 19 percent of all the wage and salary jobs that will be created between 2004 and 2014. The elderly population will grow faster than the total population between 2000 and 2010, increasing the demand for health services. Advances in medical technology will continue to improve the survival rate of severely ill and injured patients, who then may need extensive therapy and ongoing support.

The Role of the States

One of the main ways that states support health professionals is by providing general revenue appropriations for (mostly undergraduate) medical, dental, nursing and allied health education, including behavioral health professionals, pharmacists and others. In 2004-2005, medical school revenues from state and local government general funds totaled more than $4 billion.

State Medicaid programs are not obligated to pay for graduate medical education (GME), but since the inception of Medicaid in 1965, some states have used revenue to pay for a portion of GME. State support for GME may include some or all of the following:

• Operating subsidies to teaching hospitals and clinics;
• Direct support of clinical education programs such as residencies, internships and preceptorships; and
• Medicaid reimbursement to hospitals for certain teaching costs. 

Most states also appropriate funds for residencies in family medicine and primary care. Legislators in many states say support for residency training is one solution to the health care access problems many rural residents and indigent populations face. Recent studies also have found that state support is important to many nurse practitioner and physician assistant training programs.

Beginning in the 1980s, many states began to require that recipients of health professions scholarship and loan programs (in nursing, dentistry and some allied health fields) repay that assistance by practicing in a medically underserved area of the state for a set period of time. However, it is not clear how effective these initiatives have been in improving recruitment and retention of health professionals in these settings.

Hospitals and the States

"Hospitals are the cornerstone of our health care system – a system that has contributed to longer and better lives for Americans. Studies show that a person born in 2000 can expect to live more than three years longer than one born in 1980.  But these advances have increased the demand for hospital care and the costs to provide that care."  This description by the American Hospital Association (AHA) is one starting point for understanding the substantive role of hospitals, and in turn, the special role that state regulation and changing state laws play in U.S. health care.

For 2007, CMS projected that 30.8% of all "national health expenditures" in the U.S. went to hospitals. In 2006, the national hospital bill totaled almost $950 billion for nearly 39.4 million hospital stays. These charges do not include hospital outpatient care, emergency care for patients not admitted to the hospital, or physician fees for the admissions. In 2006, almost two-thirds of the national bill for hospital care was billed to two government payers, Medicare ($444 billion) and Medicaid ($135 billion), while $287 billion was billed to private insurance.

Community Health Centers and Clinics

Health centers are community-based  organizations that provide populations who have limited access to health care with basic primary and preventive care. These include low income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing.

Resources on Community Health Centers

Community Health Center Spotlight. This feature highlights specific community health centers, relating stories about their role in promoting the health of their communities and discussing the unique public policy settings they operate within. Click here for past spotlights.

Frequently Asked Questions. This section addresses key questions about community health centers, from what they are and who they serve to what studies say about the role of health centers for health and the economy.

State Profiles. This feature examines select state actions that show innovation in the state role supporting community health centers.