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Health Workforce Reform, Stat: Demand for Care Outpacing Supply of Workers

Forecast ’24: Other health policy priorities for 2024 include expanding behavioral health care, fighting fentanyl and making the most of Medicaid coverage.

By NCSL Staff  |  November 28, 2023

State legislators introduced more than 23,000 bills on health policy in 2023, not including resolutions and budget bills. Health policy will continue to be a focus in legislatures in 2024, as states grapple with health workforce shortages and increased behavioral health challenges.

Perennial topics such as Medicaid, which takes about 30% of state budgets, will continue to receive attention from policymakers across the country.

NCSL Forecast ’24

This special report from State Legislatures News covers the topics NCSL’s policy experts anticipate will occupy state lawmakers’ time in 2024 legislative sessions. Read the full report here.

Hot Topic: Bolstering the Health Workforce

Demand for health care continues to outpace the supply of health professionals. Nearly two-thirds of primary care workforce shortage areas are rural, and nearly half of Americans live in a mental health workforce shortage area. Meanwhile, the U.S. population is projected to grow, especially among adults over 65.

ACTION: States continue to bolster the long-term care workforce by establishing career pathways, expanding recruitment and retention initiatives, and incentivizing nurses to serve as educators to train future nurses.

Long-term care facilities face significant shortages of nurses and direct care staff. More than two-thirds of Americans over 50 prefer to age in their homes, increasing demand for home- and community-based services. Facilities report turning to staffing agencies, reducing new admissions and scheduling overtime to meet staffing needs.

Proposed federal staffing requirements for nursing facilities and accountability for direct care wages underscore these challenges. More than 80% of facilities may need to hire additional registered nurses and certified nursing assistants to meet proposed requirements.

Trending: Retaining Existing Workers

States are pursuing policies to address workplace violence, build provider resiliency, establish mentoring relationships, facilitate continuing education and provide mental health supports.

While most professions saw a decrease in turnover last year, certified nursing assistants and patient care technicians still report turnover rates above 30%. Long-term care staff, workers from historically marginalized racial and ethnic groups and women with young children have been slower to recover post-pandemic. Many health workers have left the profession due to burnout, stress, anxiety and depression. Health care workers are five times more likely to experience workplace violence than workers overall.

Hot Topic: Expanding Behavioral Health Care

Data shows that the pandemic and other stresses may have triggered or exacerbated behavioral health conditions including depression, anxiety, severe mental illnesses and substance use disorders. About 1 in 5 adults and 1 in 6 young people ages 6-17 report experiencing a mental health disorder. Overdose deaths, which surged during and after the pandemic, topped 100,000 for the second consecutive year. In 2021, opioids were involved in more than 80,000 overdose deaths, with fentanyl, a synthetic opioid 100 times stronger than morphine, becoming the leading contributor to opioid overdoses.

Trending: Fighting Fentanyl

Beginning with the third wave of the opioid overdose epidemic in 2013, illicitly manufactured fentanyl and other synthetic drugs have caused the deaths of more than 150 people every day. Because of its low cost and high potency, illicit fentanyl often is mixed—sometimes unintentionally—with other drugs, including heroin, methamphetamine and cocaine. Unfortunately, fentanyl is undetectable through taste, smell or sight when mixed in drugs, and even if its presence is detected using a fentanyl test strip, the amount within a substance is unknown. And, because of its potency, it can often lead to an overdose without users ever knowing they are at risk.

ACTION: Of the more than 600 fentanyl bills introduced during the 2023 legislative session, at least 103 were enacted. Most of the bills intersected with the criminal justice and public health systems. MississippiHawaiiKansas and Arkansas joined at least 10 other states since 2018 in excluding fentanyl test strips from their definition of drug paraphernalia. Other states, including Mississippi, Texas and California, created or modified public and school-based education programs to raise awareness of the dangers of fentanyl.

Trending: Funding 988 and Crisis Response

States continue working to implement the 988 Suicide and Crisis Lifeline, which is entering its second year of operation, increase access to behavioral health services and improve crisis response. Since the rollout of the 988 Lifeline in July 2022, 29 states have appropriated funds for at least one of its services. States also are working to better understand the role of law enforcement in mental health crises and have taken steps to improve behavioral health care and treatment options for people while incarcerated.

Hot Topic: Overseeing Medicaid

In recent years, over 20% of the U.S. population had Medicaid or Children’s Health Insurance Program coverage, and Medicaid is consistently one of the largest spending categories for states.

Nationwide, Medicaid remains the subject of legislative attention as states unwind from the continuous coverage requirement and reevaluate budget projections; consider new types of Section 1115 waivers; and consider the potential impact of new federal regulations on access, managed care and nursing facility staffing.

ACTION: Every state continues to oversee Medicaid managed care through bills addressing provider credentialing and prior authorizations. Eight states and the Virgin Islands have also used the Medicaid program to address maternal health through postpartum coverage extensions. Other legislative trends include using Medicaid to cover innovative services (prescription digital therapeutics, biomarker testing, transportation of patients by ambulance to alternate designations) and the services of community-based providers, including community health workers and doulas.

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