Most states have seen an increase in nursing licenses. So why

are there still shortages?

by Lauren Liebhaber

Black hearing from a constituent. “We need to take the extra steps that mean saving women’s lives.”

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A population’s health depends on and reflects the capacity of its health care system. The U.S. health care system is facing a shortage of doctors and nurses.

As a result, almost 100 million Americans live in primary health care shortage areas where staffing doesn’t meet demand.

A rapidly aging and ailing population, an exodus of experienced nurses from the workforce, and bottlenecks along the path to becoming a nurse, from classrooms to licensure, are just a few of the reasons why the U.S. cannot meet its health care demands.

About 1 million registered nurses in the U.S. are age 50 or older. In 10-15 years, this cohort, which also includes nurse faculty, will reach retirement age. In recent years, the U.S. has experienced an uptick in the number of new nursing licenses—some of which is driven by young professionals joining the field, and some of which reflects the expansion of interstate nursing practices during the pandemic—but not yet enough to close the gap between supply and demand.

Enrollment in entry-level bachelor’s degree programs in nursing increased by 3% in 2021, according to the American Association of Colleges of Nursing. However, enrollment in Ph.D. and master’s nursing programs both declined. These trends raise concerns about whether the demand for nurses with the clinical autonomy to serve as primary care providers can be met. The U.S. also faces a shortage of nursing educators at these advanced levels, creating a bottleneck for nurses who do wish to pursue advanced degrees. For nurses who earn their degrees and pass their examinations, more hurdles often await. An NPR analysis found that approximately 10% of nurses waited six months or longer to receive their licenses, without which they could not treat patients. More than one- third of registered nurses and licensed practical nurses waited three months or longer. Many more sit in limbo due to clerical errors like misplaced files or missed emails. some Midwestern states saw decreases

For those considering a career in nursing, wage stagnation, stressful or dangerous working conditions, and burnout continue to be deterrents to entering the field.

Incredible Health investigated why there are still nursing shortages when most states have seen an increase in nursing licenses using data from NCSBN.A map of the U.S. showing that most states saw an increase in nursing licenses from 2020 to 2022. There is a portion of the middle of the U.S. that primarily saw small decreases.

In recent years, some states have fast-tracked nursing licensure to meet the demand caused by unexpected waves of illness. For example, in 2022, Nevada fast-tracked some nursing licenses to treat pediatric patients suffering from RSV. This nationwide trend of a growing number of nursing licenses can also be partially attributed to the adoption of travel nursing and the issuance of temporary interstate nursing licenses during COVID-19. Many nurses who received temporary emergency licenses, which are now expired, have applied for permanent licenses in various states. States like Oregon, for example, are now working through a backlog summer. Avera’s South Dakota program will use grant money to reach more than 10,000 pregnant patients in the eastern part of the state and the region’s tribal communities.

Several current grant winners said the federal agency does provide extensive technical assistance and is responsive to questions and concerns — but they also described how difficult it was to win the grants, which amounted to $1 million or less for last year’s winners.

“It’s an intimidating grant to apply for,” said Johnna Nynas, an obstetrician and gynecologist who wrote the maternal grant application for Sanford Bemidji Medical Center in Minnesota.

“I don’t want to admit how much of my own personal time I dedicated to this grant, writing it,” she said. Sanford won the grant in 2021.

Unlike applicants from smaller, cash-strapped health organizations, Nynas was able to solicit help from the internal grant team at Sanford Health, which operates a regional system including a health plan as well as hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota.

Nynas said four hospitals in the remote region of northern Minnesota, where Bemidji is located, have closed their labor and delivery units in recent years, leaving residents — including a significant number of Indigenous women — to drive 60 miles or more one way for care.

Among the previous grant winners, only the Texas winner is from a non-Medicaid expansion state. HRSA spokesperson Elana Ross said 10 of 38 applications won grants since 2019. She declined to release a list of unsuccessful applicants, citing privacy concerns.

Ross said the requirement to partner with Medicaid “increases the likelihood that the pool of applicants, if selected, will be able to sustain services at the end of federal funding.” Medicaid, she noted, pays for nearly half of all births nationally and a greater share of births in rural areas.

The goal for the grants is that applicants can keep the program operating even after several years of federal funding runs out, HRSA officials said.

Stoking change

Incredible Health

Since 2019, the number of licensed nurses has trended upward. But from 2020 to 2022, of new permanent nursing applications.A nurse helping an elderly patient with a walker. continued in last 2 columns

Black women in the south at gravest risk from pregnancy

By Sarah Jane Tribble

Research Center. Hung is also a member of the health equity advisory group for the maternal grant program.

“RMOMS really means to invest in the most underserved and the most disadvantaged communities,” she said, but because the program demands applicants have a network of hospitals and other care providers, she said, “the odds are not there for them to even try.”

Hung said she favors basing the awards on need and not solely on the quality of an application.

Black women in the rural south seem to be the only group not receiving federal grant money meant to slow pregnancy related death. (Photo Courtesy of Alyssa Sieb from nappy.co)

As maternal mortality skyrockets in the United States, a federal program created to improve rural maternity care has bypassed Black mothers, who are at the highest risk of complications and death related to pregnancy.

The grant-funded initiative, administered by the Health Resources and Services Administration, began rolling out four years ago and, so far, has budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide — for instance, Hispanic women along the Rio Grande or Indigenous mothers in Minnesota.

KFF Health News found that none of the sites funded by the agency serves mothers in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. That omission exists despite a White House declaration to make Black maternal health a priority and statistics showing America’s maternal mortality rate has risen sharply in recent years. Non-Hispanic Black women — regardless of income or education level — die at nearly three times the rate of non-Hispanic white women.

“There’s a responsibility to respond to the crisis in a way that is more intentional,” said Jamila Taylor, chief executive of the National WIC Association, a nonprofit advocacy group for the federal Special Supplemental Nutrition Program for Women, Infants, and Children.

“Why isn’t HRSA stepping up to the plate, especially with this rural moms’ program?”

Taylor said. According to a 2021 analysis of federal data, Black women living in rural areas also are more likely to die or experience more severe health complications during delivery than white women living in rural areas.

Experts say the failure of HRSA’s Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, to reach predominantly Black communities in the rural South reveals structural inequities and underinvestment in a region where health care resources are scarce and have deteriorated.

The steady closure of hospitals in the region and widespread medical staffing shortages have hindered the ability of cashstrapped agencies and care providers to provide more than essential services. Many “don’t have sufficient resources” to apply for the grants, said Peiyin Hung, deputy director of the University of South Carolina’s Rural and Minority Health

Where the help is going

The rural program launched in 2019 and has awarded 10 maternal health grants nationwide to bolster telehealth and create networks between hospitals and clinics. Despite the disruption of care due to the covid-19 pandemic, the program’s earliest grant winners helped more than 5,000 women get medical treatment and recorded a decrease in preterm births during the second year of implementation, the agency reported.

When KFF Health News first asked Tom Morris, associate administrator for rural health policy at HRSA, about the lack of grants in the rural South, he said the agency has an “objective review process” and regularly reviews the program to ensure it reaches the people who need it most.

“The rural rates of maternal mortality for African Americans is a real concern,” Morris said, adding, “I think you raised a good point there, and something we can focus on moving forward.”

So far, the maternal grants have gone to health care providers in Arkansas, Maine, Minnesota, New Mexico, South Dakota, Texas, Utah, and West Virginia, as well as two awards in Missouri.

Among the initial 2019 awardees, Texas reports that 91 percent of people it served were Hispanic; New Mexico reported 59 percent of recipients were Hispanic; and the Missouri project, which was in the southeastern part of the state known as the Bootheel, said 22 percent of beneficiaries were Black patients. In all cases, the majority were Medicaid enrollees. No data was available for other grant awardees. (Hispanic people can be of any race or combination of races.) States across the rural Southeast have not expanded Medicaid coverage to larger numbers of lower-income residents, which often means lower shares of patients have health coverage.

Where help is most needed

The lack of Medicaid expansion in the region is “all the more reason funding should be going to these areas,” said the WIC association’s Taylor. She said the program’s failure to reach into the southeastern U.S. seems “incredibly odd.”

“The South is a hotbed — to be quite honest — of a whole host of chronic diseases and health challenges, particularly for people of color,” Taylor said.

Taylor, who previously worked on similar programs with community-based organizations while at the Century Foundation, said grant applications are often long and tedious and require intense data collection, adding to the “real challenges and barriers in the process of applying for the grants in the first place.”

Rep. Robin Kelly (D-Ill.), whose district spans rural and urban areas, said it is her experience that “some of the neediest places don’t apply for the grants because they don’t have the personnel.”

“There needs to be special outreach,” said Kelly, who created legislation in 2018 to extend postpartum care after

Meeting an application requirement to create a network that includes specific health clinics as partners in the grant was “the biggest challenge,” Nynas said, adding “when you look at the map, those can be very difficult to find.”

Try, try again

In South Dakota, Avera Health’s application stalled for two years because of grant criteria requiring state Medicaid agencies to sign on as network partners, said Kimberlee McKay, an OB-GYN and the program director for the South Dakota grant. Avera Health spans Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.

It wasn’t until the third round, McKay said, and after “the climate around maternal health had changed,” when the state Medicaid agency committed to fully partnering on the maternity care grant.

South Dakota voters adopted Medicaid expansion in late 2022 and will implement it this

In May, after KFF Health News began reporting this article, the agency released a new call for applicants and relaxed requirements. Only two awards will be given, and the applications, which demand detailed network plans, are due July 7. In an emailed statement released after announcing the more flexible expectations, Morris said the federal agency’s mission was to provide care for “the highest-need communities, and that means dedicating significant funds towards addressing the Black maternal health crisis.” The agency will no longer require state Medicaid programs to be partners on initial applications. It also loosened language about which clinics needed to be in the network.

And in perhaps the most significant shift, the agency said it will use newly created criteria to determine “areas of greatest need.” Alabama, Louisiana, and Mississippi all qualify as areas with shortages of maternity health care providers, according to the funding notice.

Kelly, who works on Congress’ bipartisan maternity care caucus, said of the lack of grants in the rural South: “Money matters, resources matter.”

Despite the government-wide focus on maternal care, it wasn’t clear whether the rural program continued on page 8

Most states have seen an increase in nursing licenses. So why are there still shortages?...continued are also aging, causing many to retire and exacerbating shortages

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Despite this trend, America’s aging population requires more nurses than ever, causing shortages

Roughly one out of every six Americans—many born during the post-World War II baby boom—is 65 or older. Seniors are expected to grow to nearly a quarter of the total U.S. population over the next several decades. In addition to an aging population, chronic illness is also rising, driving up the need for patient care capacity. Eighty percent of adults 65 and older— about 45 million people—have at least one chronic condition, while 68% have two or more. Arthritis, cancer, diabetes, and heart disease are among the most prevalent chronic conditions that will continue to strain the understaffed health care system.A nurse walking an elderly patient down a hallway. The nurses working in the field

The stressors of being a health care worker were exacerbated by the pandemic, not created by it. For many, the pandemic drove burnout due to increased workloads, longer hours, and emotional drainage to unsustainable levels, prompting many to retire or leave the field for a new industry. A 2022 National Nursing Workforce study found that roughly 100,000 registered nurses and 34,000 licensed practical and vocational nurses left the workforce between 2020 and 2022 because of the pandemic.

The median age of nurses has decreased over the last two years, from 52 in 2020 to 46 in 2022, due primarily to an exodus of experienced workers. Roughly 800,000 RNs and 185,000 LPNs who responded to the 2022 survey—equivalent to 20% of the licensed RN workforce in the U.S.—indicated they were likely to leave the nursing field by 2027.

This story originally appeared on Incredible Health and was produced and distributed in partnership with Stacker Studio.