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object(Timber\Post)#3742 (44) { ["ImageClass"]=> string(12) "Timber\Image" ["PostClass"]=> string(11) "Timber\Post" ["TermClass"]=> string(11) "Timber\Term" ["object_type"]=> string(4) "post" ["custom"]=> array(5) { ["_wp_attached_file"]=> string(12) "R_914SMR.pdf" ["wpmf_size"]=> string(7) "3481090" ["wpmf_filetype"]=> string(3) "pdf" ["wpmf_order"]=> string(1) "0" ["searchwp_content"]=> string(94618) "www.ppic.org California’s Health Workforce Needs Training Allied Workers September 2014 Shannon McConville • Sarah Bohn • Laurel Beck SUMMARY O ver the next decade, California’s health workforce is expected to require almost 450,000 new workers—mostly due to population growth and aging, but also to expanded cov- erage under the Afordable Care Act. While physicians and other highly trained clini - cians are critical to health care delivery, the majority of health care jobs are technical and support positions—referred to in this report as the allied health workforce—that tend to require associate degrees or vocational certifcates. Overall, about 40 percent of all health care jobs that need to be flled over the next decade will require some college but less than a bachelor’s degree. The need for an adequately trained allied health workforce is an important component of California’s overall “skills gap”: in addition to a shortfall of workers with college degrees, by 2025 the state is projected to have a shortage of more than 1.5 million workers with some col - lege education but less than a bachelor’s degree. To respond to this looming workforce gap, California’s two-year higher education institutions need to provide training opportunities for jobs that are well matched with future workforce demand. Current trends in degree comple - tion in allied health programs indicate that there is room for improvement. Recent growth in the number of associate degrees and postsecondary certifcates in health programs has largely been driven by for-proft institutions. These institutions serve a high number of underrepresented students, but the higher cost of for-proft programs, their focus on short-term certifcates that may not provide labor market returns, and the GETTY IMAGES California’s Health Workforce Needs: Training Allied Workers 2 www.ppic.org mismatch between the training these institutions provide and health workforce demand are causes for concern. Given the importance of associate degrees and postsecondary cer - tifcates in growing health care occupations—and the need for a workforce that can serve California’s increasingly diverse population—the state needs to ensure that its two-year institutions are meeting demands and providing good employment opportunities. To plan and prepare for future needs, state and regional decisionmakers need accurate information and timely analysis. The state has some capacity to monitor health workforce needs but would beneft from more information about training across the many occupa - tional areas in the health care sector. In the absence of a state entity that coordinates policy planning and research across the state’s higher education system, individual public systems could share and combine their information. Linkages to employment information via the state Employment Development Department could be developed, and legislative action could improve the accessibility and consistency of health workforce training, employment, and wage information. The state could increase and diversify its health workforce through California’s diverse and well-situated public two-year institutions. But to meet future workforce demands, com - munity colleges will need to increase access to high-demand and high-return programs and improve student outcomes without losing sight of their open-access mandate. Targeted poli - cies—involving the level and allocation of resources at state schools—could signifcantly increase the number of graduates in health felds within the next decade. The health workforce is a large and growing part of California’s economy, but many addi - tional workers will be needed over the near term to keep up with demand. With careful analy- sis, planning, and investment, the state can meet future health care needs and ofer career opportunities to a diverse group of Californians. For the full report and related resources, please visit our publication page: www.ppic.org/main/publication.asp?i=1109 3 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Demand for Health Care Services Is Growing Building and maintaining a well-trained workforce that can provide quality health care to California’s diverse population has long been an important policy goal. Te Afordable Care Act (ACA) has brought renewed attention to the health workforce, as millions of Californians are expected to gain insurance coverage over the next several years. But the biggest challenge faced by California’s health care system is the large number of baby boomers reaching retirement age. As a result of the ACA’s expansion of Medi-Cal (California’s Medicaid program) and subsidized cover- age available through Covered California, the state’s new insurance marketplace, the number of insured Califor- nians is projected to increase by as much as three million over the next fve years (California Simulation of Insurance Markets 2013). Te success of the frst ACA enrollment period, which ended in April of this year, indicates that California will see a large increase in the number of people with health insurance. Te ACA includes several provi- sions intended to help meet this new demand, including measures to support workforce development and invest in training programs. 1 But funding for many of these work- force investments has been reduced or eliminated through the annual appropriations process and because of other federal budgetary issues. 2 Despite the uncertainty of how the ACA will change health coverage and delivery systems, recent studies have projected changes in health workforce needs resulting from the law’s passage. Focusing mostly on physicians and the primary care workforce (including nurse practitioners and physician assistants), these studies estimate a 2 to 3 per- cent increase in demand nationwide over the next fve years (Hofer, Abraham, and Moscovice 2011; Huang and Fine- gold 2 013). 3 Tis is consistent with projections made by the U.S. Health Resources Service Administration (HRSA), the arm of the federal Health and Human Services Depart- ment focused on health workforce issues. But population growth—particularly the growth in the number of older adults—will have by far the biggest impact on the demand for health care. National projections of primary care workforce needs—including physicians, nurse practitioners, and physician assistants—estimate that more than 80 percent of the increase in demand for health care services through 2020 will result from aging and population growth rather than from ACA coverage expansions (U.S. Department of Health and Human Services, Health Resources and Services Administration 2 013). 4 Tis is partly because of the projected increase in the older adult population and partly because people’s use of health care services increases substantially as they age (Institute of Medicine 2008). Over the next decade, California’s population is projected to increase by about More than 80 percent of the increase in demand for health care services through 2020 will result from aging and population growth rather than from ACA coverage expansions. The growth in demand for skilled health workers will be driven primarily by California’s growing—and aging—population, but expanded cover- age under the Afordable Care Act will also play a role. A P PHOTO/REED S AXON California’s Health Workforce Needs: Training Allied Workers 4 www.ppic.org 10 percent, but the older adult population (age 65 or older) is expected to increase by nearly 50 percent, with an especially large increase in the population age 75 to 85. (By contrast, the increase among children and working- age adults is expected to be only 5 percent.) More than 92 percent of older adults nationwide report at least one chronic condition, and more than 70 percent report two or more (Hung et al. 2011). To meet the health care needs of the aging population, there have been repeated calls to expand and improve training for many types of health care workers, including technicians and support staf (Institute of Medicine 2008). According to employment projections, California will need to add nearly half a million health care workers by 2020. 5 Moreover, the changing demographics of health care demand add urgency to the state’s long-standing goal of diversif ying its health workforce. Some California regions—particularly the Northern Sierra and the Central Valley—will experience especially high rates of growth in their older adult populations. Te racial and ethnic com- position of California’s elderly population will also change considerably in the coming decade. California’s Latino and Asian populations age 65 and over are projected to grow by 85 percent and 66 percent, respectively, between 2014 and 2025. Statewide, nearly half (48%) of California’s total population age 65 and over will be nonwhite in 2025, com- pared with about 40 percent today. 6 While physicians and other highly trained clinicians are critical to health care delivery, many new health care jobs require some college credentials but less than a bach- elor’s degree. Tis makes educational programs that ofer vocational degrees below the bachelor’s level—associate degrees and certifcates that require less than two years of training—very important. Both public and private insti- tutions play a large role in training workers with less than a college degree for health care occupations. California’s community college system ofers a number of health programs that confer certifcates and associate degrees. Private, predominantly for-proft institutions also train many people in health care felds, with a large focus on less-than-two-year certifcates. Meeting the state’s growing health workforce needs will require considerable planning and coordination across multiple state and regional actors involved with workforce development, health care services and planning, and educa - tion and training. It will also require accurate and up-to- date sources of information on health workforce supply and demand, training program capacity and success, and the ability to conduct timely analysis and share informa- tion across diferent segments. Tis report seeks to provide context and analysis that can help inform the discussion. We begin with a broad overview of California’s current health workforce, examin- ing the occupational distribution, education levels, and other key characteristics of California workers employed in health care jobs. We then discuss projected job growth and potential workforce shortages among health care occupations, as well as factors that may afect the supply of California’s health workforce. Ten we turn to a detailed examination of health training programs in California two-year institutions, including community colleges and for-proft colleges. Finally, we assess the state’s options in meeting health workforce needs. Health Workforce Overview Te health workforce is a large and growing sector of the California economy; the number of Californians working in health care occupations is projected to grow about 23 percent by 2020 and to account for nearly 10 percent of all new jobs. 7 Employment in the health care sector has been growing over the past decade, and it weathered the recent recession much better than the economy as a Many new health care jobs require some college credentials but less than a bachelor’s degree. 5 California’s Health Workforce Needs: Training Allied Workers www.ppic.org whole (Figure 1). While total employment in the state has declined by more than 1 million jobs since 2000, employ- ment for health care practitioners, technical workers, and support staf has increased by more than 200,000 jobs. Tis growth has occurred across all health categories, with the largest increases among high-level clinicians—including physicians and other treating practitioners—and health care support staf.In 2012, more than 1.3 million Californians reported working in health care occupations, accounting for nearly 7 percent of California’s total workforce. 8 California’s health workforce comprises a diverse set of occupations and workers. Physicians and nurses are perhaps the most widely recognized members of the health workforce, and they make up about one-third of health care workers. But dozens of other occupations providing clinical and thera- peutic services, technical services, and direct care support also play essential roles. About 15 percent of health care workers are physi- cians—including primary care doctors, specialists, and surgeons—or other clinicians with professional, doctoral- level degrees, such as dentists and pharmacists (Figure 2). Registered nurses, including nurse practitioners and certi- fed midwives, account for 22 percent of the health work- force. Several types of therapists—including occupational and physical therapists and other practitioners such as physician assistants—make up another 9 percent. More than half of health care workers are technicians or support staf; they are ofen referred to as the allied health work- force. 9 About one in fve health care workers is a techni- cian or diagnostic support worker—for example, licensed vocational nurses, dental hygienists, and imaging tech- nologists. Te largest share of workers—one-third—are nursing assistants, home health aides, medical and dental assistants, and other direct care support staf. Figure 1. Health care employment has grown over the past decade despite the recession 2000 20012002200320042005200620072008 2011 2010 2009 2012 Total employment (all occupations) SOURCE: Bureau of Labor Statistics, Occupational Employment System. NOTES: The occupational sectors are defned based on 2-digit standard occupational system (SOC) coding (Health Care Practitioners is 29 and Health Care Support is 31). Both vertical axes show employment; the left-hand side shows total employment in all occupations, and the right-hand side shows total employment in the health workforce occupations. 0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 10,000,000 11,000,000 12,000,000 13,000,000 14,000,000 15,000,000 16,000,000 Total employment (health occupations) All occupations (left axis) Health care practioner and technical occupations (right axis) Health care support occupations (right axis) Figure 2. The majority of California’s health care workers are in technical and support roles SOURCE: Authors’ calculations from California Employment Development Department 2010–2020 occupation projections. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings, please refer to the technical appendix. Doctors 7% Therapists9% Nurses 22% Other clinicians 7% Health care support 33% Technicians and diagnostic support 22% The number of Californians working in health care occupations is projected to grow about 23 percent by 2020 and to account for nearly 10 percent of all new jobs. California’s Health Workforce Needs: Training Allied Workers 6 www.ppic.org Educational Diversity Te health workforce is highly educated but has a wide distribution across education levels. More than a quarter of California’s health workforce has a degree beyond the bachelor’s level, compared with only one in ten workers in the non–health workforce (Table 1). But slightly more than half of health care workers have less than a bachelor’s degree. About 36 percent have an associate degree, certif- cate, or some education beyond high school. According to U.S. Bureau of Labor Statistics (BLS) estimates, an even larger share of health care jobs—53 percent—requires such credentials for entr y. 10 In health care jobs, however, employers tend to choose workers with more than the minimum required education, indicating high demand for skills among employers. Not only are workers more likely to have higher-than-minimum skills, they also earn more than those with less education. For example, in California, health care support workers with some college education or an associate degree earn 11 percent more than workers in similar jobs who have only a high school education. Te returns to higher edu- cation beyond the minimum required are even higher— 33 percent—for all other health care workers. 11 Postsecondary schooling that does not result in an associate degree is referred to in Table 1 as “some college” (but could be a certifcate or other short-term credential); this level of education is a common requirement among health care occupations. 12 More than 20 percent of work- ers fall into this category, and this level of education is a minimum entry requirement for more than 25 percent of positions (compared with only 6 percent of nonhealth positions). Te highest share of health care workers with this level of education is in support occupations (Figure 3). While some workers—home health aides, for example— are required only to have a high school education, other positions typically require postsecondary certifcation. Tis includes nursing assistants, the single largest employ- ment category of California health care support workers. Medical and dental assistants also account for a large share of health care support workers, and these occupations also require a postsecondary certifcate. Slightly more than 10 percent of health workforce jobs require a bachelor’s degree, but more than twice as many workers have one. Most of the workers with educational levels higher than those required to enter the feld are in the nursing profession: an associate degree is the minimum requirement for entry (per BLS), but almost two-thirds of all nurses in 2012 report a bachelor’s degree or higher (Fi g u re 3). Te educational levels of workers in some health care occupations have changed over time. Understanding these changes is critical to designing training programs that Table 1. The health workforce is highly educated but also educationally diverse Current education levels Minimum education for entry Non–health workforce (%) Health workforce (%) Non–health workforce (%) Health workforce (%) Doctoral/professional 3.015 . 3 2.016 .7 Master’s degree 7. 310.0 1.16.4 Bachelor’s degree 20.324. 2 21. 510.9 Associate degree 7. 215 . 5 1. 626 .1 Some college 25.620.6 6.02 7. 3 High school diploma or less 36.714 . 4 6 7. 812.6 SOURCES: Current education levels are based on estimates from the American Community Survey (ACS), 2010–2012 3-year Public Use Microdata Sample (PUMS). Data on minimum education for entry are from the BLS education-training matrix. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings and the method for assigning BLS training and education requirements to occupational codes in the ACS, refer to the technical appendix. 7 California’s Health Workforce Needs: Training Allied Workers www.ppic.org address the need of California’s future health workforce. In some areas, including nursing and health care support occupations, the number of workers with higher levels of training has increased in the past decade. In 2000, more than 42 percent of health care support workers had a high school education or less. By 2012, only 36 percent had a high school education or less, and a higher share had some college (including postsecondary certifcates) or an associate degree. Tese higher educa - tion levels could indicate that employers are demanding more from health care support workers. Although there has been a general increase in the proportion of workers with at least some college across all occupations in Cali - fornia, this growth is more pronounced among health care support workers. Tis is consistent with fndings that certifcates generally do not bring signifcant returns for workers, but that certifcates and associate degrees from health care programs do confer benefts (Lang and Wein - stein 2012). Tis trend is likely to continue as the aging population demands more and possibly higher-quality health care services. Te percentage of nurses with at least a bachelor’s degree has also increased, from 56 percent in 2000 to 65 percent in 2012. Tis increase in educational attainment among nurses may refect an increase in wage returns for degree holders, a shif in the composition of nurses, changes in the prefer- ences of employers, or some combination of these factors. 13 Many senior positions now require at least a bachelor of science in nursing (BSN), and there is some evidence that more entry-level positions require or prefer a BSN (Cali- fornia Institute for Nursing and Health Care 2014). In addition, the Institute of Medicine recently recommended that 80 percent of the nursing workforce have at least a bachelor’s degree by 2020, to keep up with the increasing complexity of care (Institute of Medicine 2010). Racial and Ethnic Diversity Increasing the racial and ethnic diversity of California’s health workforce to better refect the state’s population is also essential to meeting health workforce needs. A wide body of research has found that racial/ethnic concor- dance among providers and patients is crucial to quality care (LaVeist and Nuru-Jeter 2002; Cooper et al. 2006). 14 In particular, provider cultural competence and Spanish language profciency are important indicators of improved health care quality for Latino populations (Fiscella et al. 2002; Fernandez et al. 2004). Tis is a particularly salient issue in California, where nearly 40 percent of the popula- tion is Latino. Te state’s health workforce has become more diverse over the past decade but is still not representative of Cali- fornia’s racial/ethnic makeup. Latinos are underrepresented in the health workforce, relative to both their share of the Figure 3. Most technicians and health care support workers have some college training SOURCE: ACS 2010–2012 3-year PUMS. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings, please refer to the technical appendix. 100 90 80 70 60 50 40 30 20 100 Percentage of workers High school or less Some college Associate degree Bachelor’s degree Master’s degree Doctoral degree Doctors Therapists Registered nurses Other clinicians Health care support Technicians and diagnostic support A wide body of research has found that racial/ethnic concordance among providers and patients is crucial to quality care. California’s Health Workforce Needs: Training Allied Workers 8 www.ppic.org state’s total population and their share in non–health care occupations. Tere has been growth in the share of Latino health care workers across some occupational categories: in 2012, nearly 25 percent of all health care workers were Latino, compared with 17 percent in 2000. But the propor- tion of Latino nurses, doctors, and other clinicians has not grown much: for example, only 12 percent of nurses were Latino in 2012, up slightly from 9 percent in 2000 (Figure 4). 15 Asian and Pacifc Islanders are generally overrepresented across all health care occupations, particularly among physicians, other clinicians, and nurses. Future Health Workforce D e m a n d s Studies suggest that there may not be enough Californians in the workforce with college degrees or some college training to meet economic demands over the next decade (Johnson 2005; Neumark 2005; Johnson and Reed 2007; and Bohn 2014). Although the shortage of college-educated workers has been the subject of much discussion, the projected shortfall of workers with some college training is actually higher. By 2025, California is projected to face a gap of more than 1.5 million workers with some college training but less than a bachelor’s degree (Bohn 2014). A shortage of trained workers in specifc occupations may keep the state from reaching its economic potential—or from meeting the needs of the population. California’s health workforce is projected to require an additional 250,000 workers by 2020 to meet the growing demand for services (see technical appendix Table A2). In the same time frame, another 200,000 health care workers are expected to leave the workforce and will need to be replaced. Rates of retirement will difer across occupa- tional groups. For example, a larger share of new health care support openings will result from job growth due to Figure 4. Latinos have made small gains but are still underrepresented in the health workforce SOURCES: Authors’ calculations from the Census 2000 5% PUMS and the ACS 2010–2012 3-year PUMS. 2000 2012 Total health workforce 100 90 80 70 60 50 40 30 20 100 Percentage Latino Doctors Therapists Registered nurses Other clinicians Health care support Technicians and diagnostic support Health workforce data sources The workforce information presented in this report comes from state and federal labor agencies—including the Cali- fornia Employment Development Department and the U.S. Bureau of Labor Statistics—and from Census Bureau surveys. These sources allow us to provide a broad overview of the state’s total health workforce, as well as wage and current employment information. Licensing data are another source of information on the supply of health care workers in specifc occupations; however, some health care occupations do not require licensing and thus are not captured by these data and also do not provide any information on wages. The California state agency responsible for overseeing most licensing information is the Department of Consumer Afairs, although the actual licensing process and data col- lection in most cases is left to the various boards and profes- sional organizations governing diferent health care occupa - tions. For a detailed analysis of licensing data across several health care occupations, see Bates et al. (2011). California’s Ofce of Statewide Healthcare Planning and Development has created a clearinghouse for available health care licensing and workforce data (www.oshpd.ca.gov/hwdd/hwc/). At the federal level, the Health Resources and Services Administration, a division of the U.S. Department of Health and Human Services, maintains the Area Health Resource File, a county-level data set assembled from multiple sources that contains estimates for some health care professions as well as health care facilities and service use and population demo- graphics. There are also federal eforts under way to develop a “minimum data set” for various health care occupations; these eforts are intended to support health workforce planning and development at the state and national level. 9 California’s Health Workforce Needs: Training Allied Workers www.ppic.org increased demand for services, whereas several other occu- pational groups will see a larger share of new job openings due to retirement of existing workers. In total, the state is expected to need nearly half a million health care workers by 2020 in order to meet demand. Job growth is projected across all areas of the health workforce. In all except the “other clinicians” category, employment is projected to grow faster than overall state employment. Te highest job growth—in both number and rate—is expected in health care support occupations, already the largest subgroup of health care workers. More than a third of new jobs in health will be in health care support roles, and about a quarter will be in technical allied health care occupations (Figure 5). Of the new jobs needed in the health sector, about 190,000 or 42 percent are likely to require an associate degree or postsecondary certifcate. Tese rigorous estimates of workforce needs are pre- mised on healthy economic conditions. But, as the recent recession showed, economic conditions can afect the demand for health care services—and in ways that are dif - cult to predict. Also, ACA’s impact on the health workforce is uncertain and not fully accounted for in Employment Development Department and BLS projections. 16 Gaps Projected in Several Health Care Occupations California’s ability to augment its health workforce in response to future needs hinges on the postsecondary edu- cational credentials of workers. But at the same time that employers are demanding more skilled workers—in the health care industry and elsewhere—the education levels achieved by the workforce are stagnating. Retiring workers are more likely to have attended college than young work- ers who are entering the California labor market. Tese trends portend skills gaps in California’s future workforce. Of course, unforeseen economic changes, altered migra- tion patterns to and from California, workers’ responses to educational and job opportunities, and other factors may afect these trends. Tus, projections are simply a lens Figure 5. Nearly half of new health jobs will require associate degrees or postsecondary certifcates SOURCES: California Employment Development Department 2010–2020 occupational projections; ACS 2010–2012 3-year PUMS. See the technical appendix for further details. NOTES: “All other groups” combines doctors, other clinicians, and therapists. The proportion of new jobs requiring an associate degree or certifcate is calculated by applying the share of current workers in detailed (6-digit) occupations with these training levels to projected total new jobs. The proportion of jobs requiring all other levels of training includes jobs requiring both higher and lower than an associate/certifcate level. 500,000 400,000 300,000 200,000 100,000 0 New health workforce jobs, 2020 Jobs requiring all other levels of training Jobs requiring associate degree or certifcate Total health workforce All other groups Registered nurses Technicians Health care support Demand for skilled workers is projected across all areas of the health workforce, though the largest increase is expected to be in health care support occupations. AP PHOTO/R ICH PED RONCELL I The state is expected to need nearly half a million health care workers by 2020 in order to meet demand. California’s Health Workforce Needs: Training Allied Workers 10 www.ppic.org into how economic demands may or may not be met in the future, highlighting areas worthy of policy attention. Overall, by 2025 the state is likely to face a shortfall of about 2.5 million workers with postsecondary training— 1.5 million with less than a bachelor’s degree and 1 million with a bachelor’s degree or above (Bohn 2014). Recent esti- mates suggest that health care felds may be among those afected by workforce shortages. Moreover, health work- force shortages vary along geographical and demographic lines. California’s health care workers need to be located throughout California’s regions and need be able to commu - nicate with and provide care to the state’s diverse population. In addition to meeting the demand for physicians, California needs to address skills gaps among other health care workers—the overwhelming majority of the work - force. Te fast-growing allied technical and support felds are also likely to face shortages of workers over the next decade. One recent study estimated that, despite some growth in training capacity, the state will face a gap of between 55,000 and 145,000 allied workers by 2020 and as many as 375,000 by 2030 (Fenton Communications and Beacon Economics 2010; see the technical appendix for details). Projections at this level of detail have fairly wide margins of error due to the range of assumptions that must be made. However, by harnessing a variety of data sources and reasonable models of expected changes in health care delivery, these estimates can provide useful insights. In particular, the projections suggest that the supply of workers will be sufcient in some allied health care occu- pations but not in others. Te largest shortages are expected among licensed vocational nurses, dental hygienists, and dental assistants (see technical appendix Table A4). Sur- pluses are projected in a few other areas by 2020—among medical assistants, emergency medical technicians, and pharmacy technicians. Tese projections of large gaps and large surpluses in the allied workforce underline the importance of carefully allocating human resources and training opportunities. Many Factors Influence the Future Supply of Health Care Workers Te state and national economy, relative wage levels across sectors, and workforce participation rates all play an important role in determining the supply of workers for any given health care occupation. For instance, the recent recession was a factor in easing California’s nursing short- age between 2005 and 2011 (Spetz 2011). Te state may have some ability to meet demand by altering the “scope of practice” of some health care occupations. But it has In addition to meeting the demand for physicians, California needs to address skills gaps among other health care workers— the overwhelming majority of the workforce. Scope of practice One policy option that might help address shortages is to change the roles and responsibilities—often referred to as the scope of practice—of health care occupations. Across the country, many states have passed or are considering laws that expand the types of services that certain health care workers can provide. The goal of these laws is to expand patient access and fully utilize the training that health care professionals are required to receive. In California, recent legislative changes have expanded the scope of practice for certifed nurse midwives and pharmacists, but changes for other health professionals, including nurse practitioners and optometrists, have not succeeded. There are similar initiatives to extend the roles of health care workers with less training, including dental hygien - ists, medical assistants, and other allied health workers. For example, a current workforce pilot project in California is evalu - ating an expanded role for emergency medical technicians/ paramedics to improve efciency and improve access (Ofce of Statewide Health Planning and Development, State of California 2014). As changes to the scope of practice are implemented for more highly trained health care workers, other members of the health workforce could perform additional tasks to relieve some of the increased clinical workload. 11 California’s Health Workforce Needs: Training Allied Workers www.ppic.org relatively little direct control over business cycles and wage-setting. Te most direct way for the state to spur growth in the supply of health care workers lies in the realm of education— particularly in allied technical and support felds that require only some college training and thus have shorter completion timelines. Te supply of health care workers in California will depend heavily on the ability of the state’s institutions to recruit and educate qualifed students for these positions. Because community colleges are spread throughout the state and serve a large and diverse student population, they may be especially helpful in training an occupationally relevant and culturally competent workforce. Targeted policies—mostly involving the allocation and level of funding at state schools—have the potential to signifcantly increase the number of graduates in these felds within the next decade. However, to make informed decisions, we need to know more about the health care programs in California’s higher education institutions, particularly the public and for-proft two-year institutions that provide training to much of California’s nursing and allied health workforce. Allied Health Training Programs in California Te past decade has witnessed growth in health degrees across most educational levels. Te most sizable increase has been in the number of associate and other sub-baccalaureate health degrees, mostly driven by private institutions. Te state’s public institutions, particularly its community colleges, continue to play an important role, especially in nursing. But private, for-proft institutions have expanded their presence considerably. Given the importance of associate degrees and postsecondary certifcates in grow- ing health occupations, it is vital to maximize the efective- ness of the state’s two-year institutions so that they meet employment demands and provide good employment opportunities for their students. In 2012, nearly 100,000 health degrees were conferred by higher education institutions in California (Figure 6). Te total number of health degrees has increased signif- cantly over the past decade, and most of the growth has been driven by associate degrees and certifcates completed in less than two years. Growth in the number of bachelor’s degrees has been driven by an increase in the number of registered nurses who pursue four-year degrees. Nursing Figure 6. The number of health degrees has increased signifcantly over the past decade SOURCE: Integrated Postsecondary Education Data System (IPEDS), U.S. Department of Education, National Center for Education Statistics. NOTE: Certifcates include both short-term awards requiring less than 1 year to complete and long-term awards requiring more than 1 year, but less than 2 to complete. 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total completed health degrees Certifcate Associate degree Bachelor’s degree Master’s degree Doctoral degree The most direct way for the state to spur growth in the supply of health care workers lies in the realm of education—particularly in allied technical and support felds that require only some college training and thus have shorter completion timelines. California’s Health Workforce Needs: Training Allied Workers 12 www.ppic.org accounts for more than half of bachelor’s degrees conferred by health programs, and the number of BSN degrees completed has more than doubled over the past decade. 17 In contrast, the number of doctoral degrees awarded in California has remained relatively constant. Te number of associate degrees and postsecondary certifcates in health programs awarded by the state’s public institutions, particularly community colleges, has increased slightly over the past decade; most of the addi- tional associate degrees were in nursing (Figure 7). Tere has been considerable growth in both associate degrees and certifcates awarded by private institutions, mostly by for-proft institutions. By 2012, these private institutions conferred almost as many associate degrees in health pro- grams as did the community colleges. Tere are considerable diferences in the level and type of degrees awarded by public and private, for-proft schools (Figure 8). Te community college system confers almost 90 percent of all associate degrees in nursing in the state, and nursing degrees constituted nearly 60 percent of asso- ciate degrees in health programs awarded by community colleges in 2012. Te state’s recent intervention to address the shortage of nurses seems to have solidifed the commu- nity college system’s role in training the nursing workforce with associate degrees. As the labor market continues to demand higher education levels among nurses, the state may need to consider additional pathways to bachelor’s degrees in nursing. 18 At private, for-proft institutions, most students earn associate degrees and certifcates for health care support occupations. Te majority of certifcates awarded by public institutions—both community colleges and adult voca - tional education programs—are in allied technical support felds. Figure 7. The number of associate and postsecondary degrees conferred by private, for-profts has grown considerably over the past decade SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics. NOTES: Associate degrees at public institutions are all completed at community colleges. Certifcates at public institutions are completed at community colleges (80%) and vocational education programs (20%). Private institutions include both for-proft and nonproft private institutions, although nonproft private institutions make up a very small proportion of sub-baccalaureate health degrees. About 3% of associate degrees and 1% of certifcates completed at private institutions are at nonprofts; the remainder are completed at private, for-proft institutions. 0 10,000 20,000 30,000 40,000 50,000 60,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of completed health degrees Associate degree, public Associate degree, private Certifcate, public Certifcate, private Figure 8. There are large diferences in the level and type of degrees conferred by private and public institutions SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTES: Private, nonproft institutions are not shown in the fgure, because they produce a very small share of sub-baccalaureate health degrees relative to public and private, for-proft institutions. The categories are based on groupings of Classifcation of Program (CIP) codes; for more information on the specifc groupings, refer to the technical appendix. The “Other” category includes medical administration, premedical preparatory programs, massage therapy, and other bodywork/alternative medicine programs. Other Support Technical Nursing50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Total completed health degrees Public, associate degrees Private, for-proft, associate degrees Public, certifcates Private, for-proft, certifcates The majority of certifcates awarded by public institutions—both community colleges and adult vocational education programs— are in allied technical support felds. 13 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Tere also appear to be diferences in the programs being completed at public and for-proft institutions (Table 2). For instance, more than 90 percent of emergency medical technicians are certifed by public schools, while private schools award large shares of licensed vocational nurse and pharmacy technician credentials. Private, for-proft institu- tions also confer an overwhelming majority of certifcates in health care support felds. Nearly four in ten certifcates in health programs completed at private, for-proft institu- tions are awarded to medical assistants—one of relatively few occupations in the health workforce with projected surpluses over the next several years. To look more closely at degree production in the context of labor market demands and opportunities, we examined data on wages earned in these occupations. Te fnal column of Table 2 presents wage information for occupations related to select health degree programs. In general, workers with associate degrees in allied health technical support occupa - tions earn more than those with less-than-two-year degrees. But there is a substantial amount of variation in earnings across occupations. Tis may refect labor market demand, worker characteristics, hours worked, or a variety of other factors unrelated to training program alignment (or mis - alignment). However, it is worth noting that more than half Table 2. The degrees awarded most frequently by private, for-profit schools are in occupations with the lowest wages Type of health degrees A ssociate degree Public Private, For-Proft Median Wage, 2012 Nursing 5,668475$70,000 Technical support 2,8494,684 Licensed vocational nurse 367788$42,000 Dental hygienist 298206$50,000 Respiratory therapist 488747$61, 242 Imaging technology 5751, 030$63,283 Health care support 5893,244 Medical assistant 2712,753$2 5 , 517 Dental assistant 13 0308$ 2 7, 8 5 2 Total associate degrees 9,8849,769 Certifcate (less-than-2-year awards) Technical support 4,80712,969 Emergency medical technician 1, 8 81162$33,500 Licensed vocational nurse 8064,0 01$39,807 Pharmacy technician 3363, 516$33,010 Health care support 2 ,14 923,530 Medical assistant 92017, 314 $2 5 , 517 Dental assistant 5214,284 $25,789 Nursing assistant/home health aide 5581, 357$19,500 Total certifcates 7, 7 9 646,805 SOURCES: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. Wage information is from the ACS 2010–2012 3-year PUMS. NOTES: Only select degrees are shown for each category, and they do not sum to total for the group. Total associate degrees and total certifcates include all degrees conferred, including those not categorized in technical or health care support, such as medical administration degrees, massage therapy, and premedical preparatory degrees. Median wages are calculated from ACS 2010–2012 3-year PUMS that matches the health training program (based on CIP codes) and to occupational codes (based on SOC codes). Median wages presented are restricted to the California adult sample with the same education level of the degree program; in the case of certifcates, reported education level in the ACS is “Some College.” California’s Health Workforce Needs: Training Allied Workers 14 www.ppic.org of the degrees awarded by private, for-proft schools in 2012 are certifcates for health care support—occupations with the lowest median wages. It is also important to consider how well these pro- grams are meeting the needs of those who enroll, particu- larly among underrepresented students. We now turn to an examination of students completing associate and certif- cate degrees in health programs with a focus on the racial/ ethnic distribution of students across programs and insti- tutions. Given the growing need for diversity in the health care sector, ensuring training opportunities for California’s diverse population is particularly important. Relative to California’s college-age (18 to 34) population— which is 44 percent Latino, 33 percent white, 13 percent Asian, and 6 percent black—Latino, Asian, and black stu- dents are well represented in health program completions for associate degrees and postsecondary certifcates, while white students are underrepresented (Figure 9). When we look beyond these aggregate groupings, we fnd large diferences in the level of degree and type of institutions. Nearly three-quarters of all degrees below the bachelor level earned by black and Latino students are certifcates from for-proft institutions (Figure 10). Only 7 percent are associate degrees from community colleges— as compared to about 20 percent among white students and 25 percent among Asian students. Moreover, white and Asian students receive more certifcates from public institutions than do black and Latino students. Te diferences between public and for-proft institu- tions in the type of degrees completed and the students completing them point to an important aspect of training opportunities for the allied health workforce: the growing role of private, for-proft institutions. The Rise of Health Degrees from For-Profit Institutions For-proft institutions focus on health degrees: one-quarter of all associate degrees and certifcates conferred by private, Figure 9. Nonwhite students are well represented in health associate degree and postsecondary certifcate completions relative to California’s college-age population SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTE: The “Other” racial/ethnic category includes American Indians, Alaskan Natives, Pacifc Islanders, multirace categories, and a nonresident alien category. White 25% Black 9%Asian 12% Latino43% Unknown 6% Other 5% Figure 10. A large share of black and Latino students complete health certifcate degrees from private for-profts SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTE: The “Other” racial/ethnic category includes American Indians, Alaskan Natives, Pacifc Islanders, multirace categories, and a nonresident alien category. 100 90 80 70 60 50 40 30 20 100 Percentage of completed health degreesWhite Latino Black Asian Other Unknown Certifcate, private, for-proft Certifcate, publicAssociate degree, private, for-proft Associate degree, public Latino, Asian, and black students are well represented in health program completions for associate degrees and postsecondary certifcates, while white students are underrepresented. 15 California’s Health Workforce Needs: Training Allied Workers www.ppic.org for-proft institutions in California are for health-related programs. As public institutions have grappled with budget cuts and funding constraints, for-proft schools have met some of the excess demand for associate education (Deming, Goldin, and Katz 2013). In California in particular, there is strong evidence that budgetary constraints in community colleges have led to an increase in for-proft colleges enter - ing the market (Cellini 2009). But the poorer labor market outcomes among gradu- ates of for-proft institutions are cause for concern. Nation- wide studies have found that, among students completing health programs, those at for-proft institutions are more than twice as likely as community college graduates to be unemployed, and the earnings of those who are employed are about 12 percent lower (Deming, Goldin, and Katz 2013). For-proft institutions are more likely to ofer cer- tifcate programs in health care support felds that tend to have lower wages. Related research suggests that fnancial returns on postsecondary certifcates in health degree pro- grams may be lower relative to associate degrees in related felds (Lang and Weinstein 2012). It should be noted that the student population at private, for-proft institutions appears to be more disadvantaged than the population at community colleges—there are fewer high school gradu- ates and more single parents and lower-income students (Deming, Goldin, and Katz 2013). Tis raises the pos- sibility that students who complete programs at for-proft schools are better of than they would be without any postsecondary schooling. However, we also need to consider the high cost of attending these schools. Health degree programs in private, for-proft schools are generally more expensive than com- munity college programs. We do not have comprehensive cost data, but information available through the College Navigator run by the National Center for Education Statistics suggests a wide gap in costs for health programs between for-proft and community colleges in California. For example, the tuition and fees for a licensed vocational nurse certifcate program at a group of for-proft institu- tions ranged from $20,000 to $35,000. By contrast, tuition costs for the same program at community colleges are about $2,500 and total program costs (including books and other fees) are about $4,500. Most fnancial aid comes from federal loans that students must repay rather than grants or other institutional support. More than half of California students in default in 2011 attended a private, for-proft college (Johnson et al. 2013). To regulate for-proft postsecondary institutions, fed- eral and state governments have relied mainly on control- ling the availability of fnancial aid. At the federal level, “gainful employment” regulations have been proposed to provide enhanced oversight of vocational programs beyond the existing requirement that for-proft schools obtain at least 10 percent of their revenues from sources other than federal student aid (this is ofen referred to as the 90/10 rule). 19 In California, Cal Grants are the primary source of state aid; they are available to students enrolled at qualifed insti - tutions, with a special category for vocational and techni - cal programs. Te 2011–2012 state budget included major changes to the Cal Grant program: institutional eligibility is now based on student outcomes (graduation rates and fnancial aid default rates), and the California State Com - mission on Student Assistance develops lists of ineligible institutions for each school year. Institutions are deemed ineligible if their graduation rates are below 30 percent or their federal student loan cohort default rates are above 15.5 percent. 20 More than 60 percent of health care certif - cates and associate degrees conferred by private, for-proft schools are conferred by institutions that have not been eli - gible for Cal Grants at least one year since these rules took efect. 21 Tis means that students attending many private, for-proft institutions are not eligible for Cal Grant fnancial aid, which does not need to be repaid. Health degree programs in private, for-proft schools are generally more expensive than community college programs. California’s Health Workforce Needs: Training Allied Workers 16 www.ppic.org Te distribution of degrees across training programs and institutional sectors suggests mismatches in training capacity and employment demands. Te large diferences in the racial and ethnic distribution of students across institutions and programs also suggest that there is room for improvement. Tere may be avenues for state institu- tions, in particular the community college system, to better address both health workforce and student needs. The Importance of Community Colleges California’s community college system is poised to play a major role in training the nearly 200,000 workers needed by 2020 to fll occupations in the health care sector likely to require some college education below a bachelor’s degree. California’s is the largest public higher education system in the country, educating more than 2 million students in 112 community colleges across the state. Te success of the Nurse Education Initiative in increasing training opportunities and associate degrees in nursing over the past decade suggests that the system can expand programs and produce more workers in high-demand occupations. 22 Between 2005—when the state, facing a dramatic shortage of nurses, launched the initiative—and the end of 2009, the number of students enrolled in nursing programs increased by more than 75 percent, and 35 new nursing programs were established (California Nurse Education Initiative 2010). Tough other factors—including the labor force dynamics of the recent recession and wage increases—also played a role in addressing the shortage, it is clear that strong state action, including fnancial investment, can help improve health workforce supply over a relatively short period of time. Tere has been concern about relatively low levels of student success in the community colleges (California Community Colleges Chancellor’s Ofce 2012a), but suc- cess rates are higher in allied health programs (82%) and registered nursing (91%) than in other courses (70%). 23 Tese successful outcomes are probably driven by a num- ber of factors, including the selectivity of health care pro- grams, 24 student ability, and program or teaching quality. While these higher rates of student success suggest that state policy can increase health workforce skills, access may not be broad enough to meet future workforce demands. Bohn, Reyes, and Johnson (2013) estimate that constric - tions during the Great Recession brought the enrollment rate for college-age Californians close to a two-decade low. While community colleges ostensibly shielded high-priority courses from severe cuts, most areas were afected—including health programs. During the most severe years of the state budget crisis, 26 percent of health care courses were cut— a higher share than in other programs (see technical appen - dix Table B1). Some areas of health care training were more deeply afected than others—for example, the relatively small dental hygienist and respiratory therapist programs actually expanded, while fewer registered nursing courses were ofered. It is worth noting there may have been some consolidation into larger courses and therefore no decline in prerequisite course availability. And because most community college students are not required to declare or apply for a particular program of study, excess demand for programs or courses is difcult to measure. A full under - standing of whether access to health care programs was— and continues to be—constricted would require additional research. Community colleges are intended to be an open entry point to higher education for all Californians, with low fees and high use of need-based aid. Participation rates are substantially higher among historically underrepresented minority groups, such as African American and Latino students, relative to whites (California Community Colleges Chancellor’s Ofce 2012b, 2013). Tis positions the com- munity college system to become a key player in closing gaps in educational achievement—and ultimately fostering Strong state action, including fnancial investments, can help improve health workforce supply over a relatively short period of time. 17 California’s Health Workforce Needs: Training Allied Workers www.ppic.org employment opportunity—in California. Te system may also be able to diversify the state’s health workforce, a long- standing goal that is becoming increasingly important as older Californians become more and more diverse. How- ever, our examination of recent health degree completions suggests that black and Latino students are not utilizing the community college system for health training opportu- nities at the same levels as other groups. Moving Forward California may not be on track to meet future health work- force needs for occupations requiring only some college training. Tis workforce skills gap could constrain the delivery and quality of health care services, particularly to California’s growing elderly population. At the same time, many Californians will miss opportunities for employment in a fast-growing sector. How can the state address these workforce needs, and how can it monitor the progress of state and private institutions in training and serving the needs of students? Data Coordination and Planning To ensure that California can meet health workforce needs and train an adequate number of workers, state and regional policymakers require good data. Te state has infrastructure devoted to monitoring health workforce needs and supporting training opportunities across dif - ferent education levels. Te Ofce of Statewide Health Planning and Development’s Healthcare Workforce Devel - opment Division coordinates state planning related to the health workforce. It also administers several programs that provide fnancial assistance and in-kind support to institu - tions and individuals in a wide variety of training areas. 25 In addition, legislation passed in 2007 tasked the agency with assembling licensing, employment, and education data on the health workforce. Te resulting Healthcare Work - force Clearinghouse has done an admirable job pulling together data from a variety of sources, but it is limited by the availability and type of information collected. Information about workforce training has been further limited by the decommissioning of the California Post- secondary Education Commission in 2011—formerly a clearinghouse for comprehensive higher education train- ing information. But individual public systems—including the California Community College Chancellor’s Ofce (already a leader in making data publicly available), the California State University system, and the University of California system—could coordinate information on health workforce training within their institutions. Link - ages to employment information via the state Employment Development Department would be an important next step. Legislative action could improve the accessibility and consistency of workforce training, employment, and wage information across the many occupational groups that make up the health workforce. Oversight of For-Profit Institutions As part of its efort to meet workforce needs, the state must monitor the quality of existing health programs. As we have shown, for-proft colleges are playing a large and growing role in training health care workers with less than a college degree, but they may not be ofering the best opportunities for students, particularly those from disadvantaged back - grounds. Tese schools typically have higher costs, and many have been cited recently for misleading practices, low graduation rates, and high loan-default rates among their graduates. In October 2013, California’s attorney general fled a suit against Corinthian Colleges, Inc., and its sub - sidiaries, which operate many colleges around the state and nation, accusing them of false and predatory advertising and making intentional misrepresentations to students, among To ensure that California can meet health workforce needs and train an adequate number of workers, state and regional policymakers require good data. California’s Health Workforce Needs: Training Allied Workers 18 www.ppic.org other violations (Ofce of the Attorney General 2013). Federal sanctions against Corinthian Colleges, including withholding of federal fnancial aid funding, led Corinthian Colleges to recently announce the sale and closure of many of its campuses, including several in California.Te agency responsible for overseeing the state’s for- proft higher education institutions is the Bureau of Private Postsecondary Education, housed within the Department of Consumer Afairs. In a March 2014 report, the Califor- nia State Auditor concluded that the bureau “consistently failed to meet its responsibility to protect the public’s interests” and recommended shutting it down. Te report found that the bureau had failed to respond to numerous student complaints regarding practices at private, for-proft schools, failed to regulate the information the schools provided to students on expected graduation rates and salaries, and mismanaged the Student Tuition Recovery Fund (California State Auditor 2014). Te lawsuit and auditor’s report indicate a need for improved state oversight and monitoring of private, for- proft institutions and the educational opportunities they can ofer to students. As discussed earlier, one state strat- egy has been to tie state fnancial aid for students through the Cal Grant program to school performance. Te Cali- fornia Student Aid Commission maintains a list of schools that are ineligible to participate in the Cal Grant program because they do not meet minimum criteria for student graduation rates and fnancial aid default rates. Many Community colleges could play a key role in preparing Californians to enter the fast-growing health care sector. D ON BA RTLET T I / LOS A N G ELES TIMES /CO PYRIG HT C 2012. LOS A N G ELES TIMES. RE PRINTED W ITH PE R M I SSION. 19 California’s Health Workforce Needs: Training Allied Workers www.ppic.org private, for-proft colleges have been deemed ineligible for Cal Grants, so students attending these schools cannot receive these state grants, which do not need to be repaid. Te higher costs and poorer labor market outcomes of for-proft institutions indicate that the state’s community college system could play a larger role in providing train- ing opportunities for students in health programs. Expanded Access to Community Colleges California’s community colleges serve a number of mis- sions, including preparing students to meet workforce needs. As part of its mission to bridge workforce needs, the Chancellor’s Ofce Division of Workforce and Eco- nomic Development coordinates the eforts of employers, labor organizations, government training programs, and individual college districts within regions. Supported by an overarching Health Workforce Initiative, the ofce has made the health sector a planning and investment priority in each region of the state.To increase the number of allied health care workers, community colleges could expand access to high-demand and high-return programs and improve student outcomes. 26 As noted previously, the recent recession spurred cuts that limited the availability of courses and ultimately lowered col - lege attendance in the state. Because technical courses (and many other health care courses) are among the most expen - sive to administer (Shulock, Moore, and Ofenstein 2011; Shulock, Lewis, and Tan 2013), it may be more difcult to increase their availability to pre-recession levels and beyond than to restore access to less technical or low-infrastructure courses. 27 For example, in 2011–2012, respiratory care therapy courses nationwide cost $265 per student hour, and allied health and medical assisting courses cost $131 per stu - dent hour, compared with only $52 per hour in the humani - ties and $73 per hour in engineering (Shulock, Lewis, and Tan 2013). In addition to high costs, budget fuctuations from year to year and categorical funding streams may impede the ability of colleges to plan for workforce training needs. Another important step toward meeting the state’s health workforce needs is to improve access to train- ing programs among underrepresented student groups. Strengthening outreach and mentoring to minority students is important, as many would be frst-time college- goers. Te relatively small increase over the past decade in the number of Latino nurses, despite the state’s largely successful expansion of nursing training opportunities, indicates that there is room for improvement in engag- ing and supporting underrepresented students in health programs. A number of state health foundations and local initiatives ofer grants and targeted programs to diversify the pipeline of students in health degree training. Closer collaboration and coordination with these programs could help community colleges expand their outreach to under- represented students. But diversifying and broadening access to training programs is unlikely to meet broad workforce needs unless steps are taken to foster student success rates within those programs. Community college health courses have rela - tively high success rates, in part because, unlike many other courses of study, a number of them have admission require - ments. But most community college students struggle to complete degrees or certifcates within a reasonable amount of time. Te Student Success Task Force and a number of research studies have identifed ways for the community college system to improve student outcomes (California Community College Chancellor’s Ofce 2012a). Several recommendations have been or will soon be implemented, and it will be important to measure their impact on student success. In the feld of health care, requiring admission procedures similar to those in nursing programs for allied health training may incentivize student success, or at least ensure that training slots are allocated efciently. In fact, it To increase the number of allied health care workers, community colleges could expand access to high-demand and high-return programs and improve student outcomes. California’s Health Workforce Needs: Training Allied Workers 20 www.ppic.org would be useful to develop a better understanding of student intentions upon entering a community college, so that pit- falls could be identifed and addressed. Of course, the system must balance its eforts to improve outcomes with its open- access mission and its goal of diversifying the student body. In general, a more comprehensive analysis is needed of the role played by student- and institutional-level charac - teristics in the success of students in health care programs and the labor market outcomes of those working in health care professions. Tis analysis could inform the extent to which health care workers are able to climb a career lad - der with skills accumulated on the job or via successive educational credentials. For example, some schools have programs that are structured to provide a training pipe - line in nursing, from certifed nursing assistant to licensed vocational nurse to registered nurse. 28 Tese kinds of pathways are ofen cited in discussions about career devel - opment options for economically disadvantaged Califor - nians. 29 We lack empirical evidence on the efectiveness of this strategy, but it is clear that the capacity to adequately train nursing and allied technical and support workers is a policy goal, and that meeting this goal would beneft Californians who need health care services as well as the workers themselves. Technical appendices to this report are available on the PPIC website: www.ppic.org/content/pubs/other/914SMR_appendix.pdf 21 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Notes 1 Tese investments included large funding increases to the National Health Service Corps (NHSC), which ofers scholarships and loan repayment to health professionals who practice in feder - ally designated shortage areas; new grant programs aimed at allied health professionals and direct care workers; and changes to gradu - ate medical education to support primary care physician training. 2 For example, the National Health Care Workforce Commis - sion, a new federal entity to coordinate and inform national health workforce policy, has not received any congressional funding and thus has never become operational; the additional support for NHSC is now the sole program investment, and it is scheduled to sunset in 2015 (Redhead 2013). Tere are limited health workforce demonstration programs moving forward, including grant programs for states, higher education institu- tions, and workforce investment boards to assist low-income individuals with education and training in health care jobs that pay well and are in high demand, as well as much smaller state grant programs to develop core training competencies and certi- fcation programs for personal and home care aides. 3 Other studies have projected that changes in nursing and allied workforce needs resulting from the ACA represent a small share of projected employment growth (Spetz 2013; Spetz et al. 2014). While these and other projection models ofer a reason- able source of information on future workforce needs, most are limited to the extent that they base future trends on historical use patterns (Ricketts 2011; Dall 2013). 4 HRSA projections assume that all states will expand Medicaid under the ACA and have not been adjusted to account for the fact that several states have chosen not to expand the Medicaid program, suggesting that the increase in demand driven by the ACA nationwide will be smaller. 5 California Employment Development Department 2010–2020 occupational projections. Includes new jobs and job replacement. See Figure 5. 6 Based on authors’ calculations of California Department of Finance population projections. 7 Based on California Employment Development Department 2010–2020 occupational projections that count workers in wage and salary jobs as well as self-employed persons. Similar statistics based on industry projections suggest slightly stronger growth, but exclude self-employed persons, agricultural workers, and unpaid family workers. 8 Employment fgures for 2012 are estimates based on the ACS. In some analysis that follows, we use slightly older employ- ment data (2010) from the California Employment Development Department in order to obtain additional detail on types of jobs within the health care sector. Te total employment estimates range between 1.1 and 1.3 million over this time period. 9 Tere is not an ofcial set of occupations that constitute the allied health workforce. Some therapists are ofen considered part of the allied health workforce, as are other, more technical occupations. We have included most therapists with advanced training in a separate category, choosing to focus our examina- tion of the allied health workforce on those with lower educa- tional requirements. 10 Te BLS reports training and education requirements for entry into occupations for which the BLS produces employment projections. Te level of education and training assigned to occupations is based on quantitative and qualitative informa- tion, including review of available data, interviews with experts and workers in a given occupation, and examination of specifc job postings. Te education assignments are based on the typi- cal education needed to get an entry-level job in an occupation. (Richards and Terkanian 2013). For more information, refer to the BLS Employment Projections, Education and Training Data (www.bls.gov/emp/ep_education_training_system.htm). 11 Bohn (2014) estimates wage premiums for large occupational groups using ACS 2010–2012 data. Tese estimates compare regression-adjusted earnings between workers with some college education and workers in the same occupational category but with only a high school education. 12 Te education information collected in the ACS does not allow us to distinguish between certifcates or awards of less than two years and college coursework that does not result in a degree. 13 Reed (2008) estimates that the regression-adjusted premium to having a college degree (compared with a high school diploma) increased from 55 percent in 1990 to 75 percent in 2005–2006. Given simultaneous increases in the supply of workers, the exis- tence of an increasing wage premium signals increasing demand for skill in the registered nursing profession. 14 Studies suggest that patients prefer providers who are of their own race, are less likely to postpone care when they have a physician of their own race, and report higher levels of satis - faction with their medical care when they have a physician of their own race. California’s Health Workforce Needs: Training Allied Workers 22 www.ppic.org 22 15 For a more detailed discussion of racial/ethnic diversity among California’s nursing workforce, see Waneka and Spetz (2012). 16 Te most recent BLS occupational projections to 2022, released in December 2013, do account for some expected changes in health care industry employment as the result of the ACA, but those are not yet included in state-level estimates. 17 In 2012, about 5,500 of the nearly 12,000 nursing degrees con- ferred in the state were bachelor’s degrees. 18 In fact, the legislature is considering SB 850, a pilot program that would involve community colleges awarding applied bachelor’s degrees in nursing (and other areas). Policies like this might help respond to employers’ demand for more nurses with bachelor’s degrees, but questions remain about training quality and other issues. 19 Gainful employment regulations require public and private college vocational programs to meet certain standards related to student debt loads and employment outcomes in order to remain eligible to receive federal fnancial aid. Te U.S. Depart- ment of Education released revised regulations in March 2014, afer previous attempts at developing federal rules were struck down by the courts in 2012. Te revised regulations establish standards for student loan default rates and debt-to-earnings ratios, whereby if institutions exceed a certain percentage, their students will not be eligible to receive federal fnancial aid. 20 Te minimum graduation and default rates eligibility standards apply only to qualifed institutions where at least 40 percent of the student population is receiving federal fnancial assistance. 21 Based on authors’ calculations of IPEDs data merged with information from California Student Aid Commission (CSAC) Cal Grant Eligible and Ineligible Institutions listing for school years 2011–2012, 2012–2013, and 2013–2014. Te CSAC provides listings of both ineligible and eligible institutions. Another one- third of sub-baccalaureate health degrees completed at for-proft institutions is at schools on neither the eligible nor the ineligible list, suggesting they do not participate in the Cal Grant pro- gram. 22 Te initiative provided state funding and additional public/ private investments to support the expansion of nurse train- ing programs across all California public higher education institutions, including $90 million over fve years to increase educational capacity at California community colleges through a competitive grants process. It also added capacity to bachelor’s, master’s, and doctoral levels of nurse training, created nurse faculty loan programs to incentivize teaching, and invested in clinical simulation laboratories to improve access for rural and medically underserved areas. For more information, refer to annual reports available from the California Labor and Work- force Development Agency. 23 California Community Colleges Student Success Task Force (2013), “Advancing Student Success in California Community Colleges.” 23 Authors’ calculation from California Community Colleges Chancellor’s Ofce Data Mart. See technical appendix Figure B1 for details and categorization of courses. Success rates are share of students with a passing grade (on a course-by-course level). 24 Student success measures, particularly high retention rates, may refect external incentives to stay in and successfully com- plete a course. Many health programs at community colleges are unusual in that they require admittance to a particular program of study, and thus are rationed. Tis rationing may increase stu- dent incentives to keep a course and to pass. Most community college courses are essentially open to all, and course seats are allocated based on student priority, determined by continuing status and other factors. Indeed, this enrollment priority system is one focus of statewide eforts to improve student success at the community colleges, and changes were adopted in 2012 intended to incentivize completion. Recent changes to the priority enroll- ment system may result in improvements to course success rates. 25 Te Health Professions Education Foundation, California State Loan Repayment Program, and National Health Services Corps support scholarship and loan repayment programs for health training in allied health professions, nursing programs, licensed vocational nursing, and others. Te Song-Brown Pro- gram provides fnancial support to accredited training programs for registered nursing—among others—with a goal of providing health care in medically underserved areas. 26 Te California Community Colleges Chancellor’s Ofce has received state funding in the past and distributed grants to col- leges to provide diagnostic and support service to reduce student attrition in nursing programs and promote retention (California Community Colleges Chancellor’s Ofce 2010). 27 Te funding formula for community colleges is set by Propo- sition 98 and is based on student enrollment, not the cost of providing various programs. Te fnancial incentives embedded in Proposition 98 thus discourage high-cost programs, since all funding is allocated at the same rate, regardless of program cost. Additional funding to support high-cost training programs, such as nursing, is sometimes available through various sources on mostly a competitive basis. 23 California’s Health Workforce Needs: Training Allied Workers www.ppic.org 28 Te pathway for nurses reaches beyond the community colleges. Te percentage of students pursuing a bachelor’s or master’s degree in nursing has grown signifcantly over the past 20 years. Califor- nia can encourage this pipeline to higher skills in a few ways. Te frst would be to increase capacity in the community college sys- tem, allowing qualifed students a gateway into the feld of health care. A further step would be to simplify the process of transfer- ring from a community college campus to a California State Uni- versity or University of California campus. Students would beneft from a guaranteed path to higher degrees. Finally, Senate Bill 850 suggests that a limited number of bachelor’s degrees, including nursing, could be awarded at community colleges. 29 For example, see California Workforce Investment Board (2013). References Bates, Tim, Lisel Blash, Susan Chapman, Catherine Dower, and Edward O’Neil. 2011. California’s Health Care Workforce: Readi- ness for the ACA Era . Center for the Health Professions, UCSF. Available at http://futurehealth.ucsf.edu/Content/29/2011_11 _California_Healthcare_Workforce_ACA_v2.pdf. Bohn, Sarah. 2014. California’s Need for Skilled Workers . San Francisco: Public Policy Institute of California. Bohn, Sarah, Belinda Reyes, and Hans Johnson. 2013. Te Impact of Budget Cuts on California’s Community Colleges . San Francisco: Public Policy Institute of California. Available at www.ppic.org/main/publication.asp?i=1048. California Community Colleges Chancellor’s Ofce. 2010. Nursing Education Programs . Available at http://california communitycolleges.cccco.edu/Portals/0/Reports/Nursing 2010 toPr i nt (3).pd f. California Community Colleges Chancellor’s Ofce. 2012a. Advancing Student Success in the California Community Colleges: Recommendations of the California Community Colleges Student Ta s k F o r c e . Available at http://californiacommunitycolleges.cccco .edu/PolicyinAction/StudentSuccessTaskForce.aspx. California Community Colleges Chancellor’s Ofce. 2012b. “Focus on Results: Accountability Reporting for the California Community Colleges.” Available at http://extranet.cccco.edu /Portals/1/TRIS/Research/Accountability/ARCC/ARCC2012 MarchFinal.pdf. California Community Colleges Chancellor’s Ofce. 2013. Student Success Scorecard: 2013 State of the System Report . Available at http://extranet.cccco.edu/Portals/1/TRIS/Research/Accountability /ARCC2_0/stateofthesystem2013.pdf. California Institute for Nursing and Health Care. 2014. “2012–2013 California New Graduate Hiring Survey.” Available at http://cinhc .wpengine.netdna-cdn.com/wp-content/uploads/2013/02/2012-2013 -Californa-New-Grad-Hiring-Survey.pdf. California Nurse Education Initiative. 2010. Annual Report, 2009 . Available at w w w.labor.ca.gov/pdf/NEI_Annual_Report_2009.pdf. California Simulation of Insurance Markets. 2013. CalSIM Version 1.8 Statewide Data Book 2014–2019. UCLA Center for Health Policy Research and UC Berkeley Labor Center. California State Auditor. 2014. “Bureau for Private Postsecondary Education: It Has Consistently Failed to Meet Its Responsibility to Protect the Public’s Interests.” Report 2013-045. Available at www.bsa.ca.gov/pdfs/reports/2013-045.pdf. California Workforce Investment Board. 2013. Shared Strategy for a Shared Prosperity: California’s Strategic Workforce Develop- me nt Pl an: 2 013 –2 017 . Available at www.cwib.ca.gov/res/docs /state_plans/FinalApprovedStatePlan/California StrategicWorkforceDevelopmentPlan_2013-2017.pdf. Cellini, Stephanie R. 2009. “Crowded Colleges and College Crowd-Out: Te Impact of Public Subsidies on the Two-Year College Market.” American Economic Journal: Economic Policy 1 (2): 1–30. Cooper, Lisa A., Mary Catherin Beach, Rachel L. Johnson, and Tomas S. Inui. 2006. “Delving Below the Surface: Understand- ing How Race and Ethnicity Infuence Relationships in Health C a re .” Journal of General Internal Medicine 21 (1). Dall, Timothy M., Paul D. Gallo, Ritasree Chakrabarti, Terry West, April P. Semilla, and Michael V. Storm. 2013. “An Aging Population and Growing Disease Burden Will Require a Large and Specialized Workforce by 2025.” Health Afairs 32 (11): 2013–2020. Deming, David, Claudia Goldin, and Lawrence Katz. 2013. “For-Proft Colleges.” Future of Children 23 (1): 137–163. California’s Health Workforce Needs: Training Allied Workers 24 www.ppic.org Fenton Communications and Beacon Economics. 2010. Help Wanted: Will Californians Miss Out on a Billion-Dollar Growth Industry? Available at http://calhealthjobs.org/system /files/attachments/helpwantedreport_48.pdf. Fernandez, Alicia, Dean Schillinger, Kevin Grumbach, Anne Rosenthal, Anita L. Stewart, Frances Wang, and Eliseo J Perez- Stable. 2004. “Physician Language Ability and Cultural Compe- tence.” Journal of General Internal Medicine 19 (2). Fiscella, Kevin, Peter Franks, Mark P. Doescher, and Barry G. Saver. 2002. “Disparities in Health Care by Race, Ethnicity, and Language Among the Insured: Findings from a National S a mple .” Medical Care 4 0 (1). Hofer, Adam N., Jean Marie Abraham, and Ira Moscovice. 2011. “Expansion of Coverage Under the Patient Protection and Afordable Care Act and Primary Care Utilization.” Millbank Quarterly 8 9 (1). Huang, Elbert S., and Kenneth Finegold. 2013. “Seven Million Americans Live in Areas Where Demand for Primary Care May Exceed Supply by More Tan 10 Percent.” Health Afairs 32 (3). Hung, William W., Joseph S. Ross, Kenneth S. Boockvar, and Albert L. Siu. 2011. “Recent Trends in Chronic Disease, Impair- ment and Disability Among Older Adults in the United States.” BMC Geriatrics 11 (47). Institute of Medicine. 2008. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press. Institute of Medicine. 2010. Te Future of Nursing: Leading Change, Advancing Health . Washington, DC: National Academies Press. Johnson, Hans. 2005. “California’s Population in 2025.” In Cali - fornia 2025: Taking on the Future , eds. Ellen Hanak and Mark Baldassare. San Francisco: Public Policy Institute of California. 23–48. Johnson, Hans, Marisol Cuellar Mejia, David Ezekial, and Betsey Zeiger. 2013. Student Debt and the Value of a College Degree . San Francisco: Public Policy Institute of California. Available at w w w.ppic.org/content/pubs/report/R _613HJR.pdf. Johnson, Hans, and Deborah Reed. 2007. Can California Import Enough College Graduates to Meet Workforce Needs? San Fran - cisco: Public Policy Institute of California. Available at www. ppic.org/main/publication.asp?i=750. Lang, Kevin, and Russell Weinstein. June 2012. Evaluating Student Outcomes at For-Proft Colleges . NBER Working Paper Series, No. 18201. LaVeist, Tomas A., and Amani Nuru-Jeter. 2002. “Is Doctor- Patient Race Concordance Associated with Greater Satisfaction with Care?” Journal of Health and Social Behavior 43 (3): 296–306. Neumark, David. 2005. “California’s Economic Future and Infrastructure Challenges.” In California 2025: Taking on the Future , eds. Ellen Hanak and Mark Baldassare. San Francisco: Public Policy Institute of California. 51–80. Ofce of the Attorney General, State of California Department of Justice. 2013. “Attorney General Kamala D. Harris Files Suit in Alleged For-Proft College Predatory Scheme.” October 10, 2013 Press Release. Available at http://oag.ca.gov/news/press-releases /attorney-general-kamala-d-harris-files-suit-alleged-profit-college -predatory. Ofce of Statewide Health Planning and Development, State of California. 2014. “Health Workforce Pilot Projects Program Application #173: Community Paramedicine.” Available at www. oshpd.ca.gov/hwdd/pdfs/HWPP/Abstract_HWPP173.pdf. Redhead, C. Stephen. 2013. Appropriations and Fund Transfers in the Patient Protection and Afordable Care Act (ACA) . CRS Report for Congress, Congressional Research Service. Available at www.law.umaryland.edu/marshall/crsreports/crsdocuments /R41301_05152013.pdf. Reed, Deborah. 2008. California’s Future Workforce: Will Tere Be Enough College Graduates? San Francisco: Public Policy Institute of California. Available at w w w.ppic.org/main /publication.asp?i=809. Richards, Emily, and Dave Terkanian. 2013. “Occupational Employment Projections to 2022.” Monthly Labor Review (December). Ricketts, Tomas C. 2011. “Te Health Care Workforce: Will It Be Ready as the Boomers Age? A Review of How We Can Know or (Not Know) the Answer.” Annual Review of Public Health 32. Shulock, Nancy, Jodi Lewis, and Connie Tan. 2013. “Workforce Investments: State Strategies to Preserve Higher-Cost Career Education Programs in Community and Technical Colleges.” Institute for Higher Education Leadership and Policy report, California State University Sacramento. Available at www .csus.edu/ihelp/PDFs/R _Workforce_Invest_0913.pdf. 25 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Shulock, Nancy, and Colleen Moore. 2011. “Sense of Direction: Te Importance of Helping Community College Students Select a Course of Study.” Institute for Higher Education Leadership and Policy Report, California State University Sacramento. Shulock, Nancy, Colleen Moore, and Jeremy Ofenstein. 2011. “Te Road Less Traveled: Realizing the Potential of Career Technical Education in the California Community Colleges.” Institute for Higher Education Leadership and Policy report, California State University Sacramento. Spetz, Joanne. November 2011. Forecasts of the Registered Nurse Workforce in California. University of California, San Francisco. Available at www.rn.ca.gov/pdfs/forms/forecasts2011.pdf. Spetz, Joanne. 2013. Forecasts of the Registered Nurse Workforce in California . University of California, San Francisco. Available at www.rn.ca.gov/pdfs/forms/forecasts2013.pdf. Spetz, Joanne, Ken Jacobs, Bianca Frogner, Shelley Oberlin, Steve Parente, Dylan Roby, Nigel Lo, Greg Watson, and Jack Needleman. 2014. “Impact of the 2010 Afordable Care Act on the California Labor Force.” Webinar by Health Systems Innovation Network and SEIU UHW-West. Available at www.seiu-uhweduc.org/file /pdf-documents/ACA-Labor-Force-Impact-Webinar---1-24-14.pdf. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2013. “Projecting the Supply and Demand for Primary Care Practitioners Trough 2020.” Rock- ville, MD: U.S. Department of Health and Human Services. Waneka, Renae, and Joanne Spetz. 2012. Te Diversity of California’s Registered Nursing Workforce . University of Califor- nia, San Francisco. Available at www.rn.ca.gov/pdfs/schools /diversity.pdf. California’s Health Workforce Needs: Training Allied Workers 26 www.ppic.org 26 About the Authors Shannon McConville is a research associate at PPIC. Before joining PPIC, she was a research training fellow in the Health Services and Policy Analysis program at the University of California, Berkeley; a senior research associate at the Department of Health Research and Policy at Stanford University; and a project manager at the Lewis Center for Regional Policy Studies at the Uni- versity of California, Los Angeles. Her research interests include health care access, utilization, and outcomes among vulnerable populations. She holds an M.P.P. degree from the University of California, Los Angeles. Sarah Bohn is a research fellow at PPIC. A labor economist, she focuses on issues at the intersection of public policy and labor markets, with particu - lar attention to low-income and vulnerable populations. At PPIC, her work focuses on poverty, the economy, and higher education. She has published research on California’s community colleges, underground labor markets, and the labor market impact of immigration policy. She has also conducted research on income inequality, with a focus on the role of unemployment and educational attainment on family economic outcomes. Sarah holds a Ph.D. in economics from the University of Maryland, College Park. Laurel Beck is a research fellow at PPIC. She focuses on health policy, including program evaluation, insurance markets, and issues among aging populations. She has also researched the physical and mental health of working mothers. Before joining PPIC, she was a research associate at the Federal Reserve Board of Governors and participated in doctoral trainee programs with the National Institute of Mental Health and the National Institute on Aging. She holds a Ph.D. in economics from the University of Wisconsin–Madison. Acknowledgments Te authors thank Lupe Alonzo-Diaz, David Auerbach, Caroline Danielson, Hans Johnson, and Lynette Ubois for providing very helpful feedback on earlier drafs of this report and Mary Severance for editorial support. We also thank Moreen Lane, Rosielyn Pulmano, Javier Romero, and Joanne Spetz for insightful discussions during the early stages of project development. Any errors are our own. 27 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Board of Directors DONNA LUCAS , CHAIRChief Executive Ofcer Lucas Public Afairs MAR K B ALDASSAREPresident and CEO Public Policy Institute of California RUBEN BARRALESPresident and CEO GROW Elect MAR Í A BLANCOVice President, Civic Engagement California Community Foundation BRIGITTE BRENAttorney WA LT E R B. HEWLETTMember, Board of Directors The William and Flora Hewlett Foundation PHIL ISENBERGVice Chair Delta Stewardship Council M AS MASUMOTOAuthor and Farmer STEVEN A. MERKSAMERSenior Partner Nielsen, Merksamer, Parrinello, Gross & Leoni, LLP KIM POLESEChairman ClearStreet, Inc. THOMAS C. SUT TONRetired Chairman and CEO Pacifc Life Insurance Company PPIC is a public charity. It does not take or support positions on any ballot measures or on any local, state, or federal legislation, nor does it endorse, support, or oppose any political parties or candidates for public ofce. PPIC was established in 1994 with an endowment from William R. Hewlett. Copyright © 2014 Public Policy Institute of California. All rights reserved. San Francisco, CA Mark Baldassare is President and Chief Executive Ofcer of PPIC. Donna Lucas is Chair of the Board of Directors. Short sections of text, not to exceed three paragraphs, may be quoted without written permission provided that full attribution is given to the source. Research publications refect the views of the authors and do not necessarily refect the views of the staf, ofcers, or Board of Directors of the Public Policy Institute of California. Library of Congress Cataloging-in-Publication Data are available for this publication. I S B N 978 -1-5 8213 -159 -7 PUBLIC POLIC Y INSTITUTE OF CALIFORNIA 500 Washington Street, Suite 600 San Francisco, California 94111 Telephone 415.291.4400 Fa x 415 . 2 91. 4 4 01 PPIC S ACRAMENTO CENTER Senator Ofce Building 1121 L Street, Suite 801 Sacramento, California 95814 Telephone 916.440.1120 Fax 916.440.1121 Additional resources related to health and human services and the economy are available at www.ppic.org. The Public Policy Institute of California is dedicated to informing and improving public policy in California through independent, objective, nonpartisan research." } ["___content":protected]=> string(102) "

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" ["_permalink":protected]=> string(101) "https://www.ppic.org/publication/californias-health-workforce-needs-training-allied-workers/r_914smr/" ["_next":protected]=> array(0) { } ["_prev":protected]=> array(0) { } ["_css_class":protected]=> NULL ["id"]=> int(8923) ["ID"]=> int(8923) ["post_author"]=> string(1) "1" ["post_content"]=> string(0) "" ["post_date"]=> string(19) "2017-05-20 02:42:09" ["post_excerpt"]=> string(0) "" ["post_parent"]=> int(4381) ["post_status"]=> string(7) "inherit" ["post_title"]=> string(8) "R 914SMR" ["post_type"]=> string(10) "attachment" ["slug"]=> string(8) "r_914smr" ["__type":protected]=> NULL ["_wp_attached_file"]=> string(12) "R_914SMR.pdf" ["wpmf_size"]=> string(7) "3481090" ["wpmf_filetype"]=> string(3) "pdf" ["wpmf_order"]=> string(1) "0" ["searchwp_content"]=> string(94618) "www.ppic.org California’s Health Workforce Needs Training Allied Workers September 2014 Shannon McConville • Sarah Bohn • Laurel Beck SUMMARY O ver the next decade, California’s health workforce is expected to require almost 450,000 new workers—mostly due to population growth and aging, but also to expanded cov- erage under the Afordable Care Act. While physicians and other highly trained clini - cians are critical to health care delivery, the majority of health care jobs are technical and support positions—referred to in this report as the allied health workforce—that tend to require associate degrees or vocational certifcates. Overall, about 40 percent of all health care jobs that need to be flled over the next decade will require some college but less than a bachelor’s degree. The need for an adequately trained allied health workforce is an important component of California’s overall “skills gap”: in addition to a shortfall of workers with college degrees, by 2025 the state is projected to have a shortage of more than 1.5 million workers with some col - lege education but less than a bachelor’s degree. To respond to this looming workforce gap, California’s two-year higher education institutions need to provide training opportunities for jobs that are well matched with future workforce demand. Current trends in degree comple - tion in allied health programs indicate that there is room for improvement. Recent growth in the number of associate degrees and postsecondary certifcates in health programs has largely been driven by for-proft institutions. These institutions serve a high number of underrepresented students, but the higher cost of for-proft programs, their focus on short-term certifcates that may not provide labor market returns, and the GETTY IMAGES California’s Health Workforce Needs: Training Allied Workers 2 www.ppic.org mismatch between the training these institutions provide and health workforce demand are causes for concern. Given the importance of associate degrees and postsecondary cer - tifcates in growing health care occupations—and the need for a workforce that can serve California’s increasingly diverse population—the state needs to ensure that its two-year institutions are meeting demands and providing good employment opportunities. To plan and prepare for future needs, state and regional decisionmakers need accurate information and timely analysis. The state has some capacity to monitor health workforce needs but would beneft from more information about training across the many occupa - tional areas in the health care sector. In the absence of a state entity that coordinates policy planning and research across the state’s higher education system, individual public systems could share and combine their information. Linkages to employment information via the state Employment Development Department could be developed, and legislative action could improve the accessibility and consistency of health workforce training, employment, and wage information. The state could increase and diversify its health workforce through California’s diverse and well-situated public two-year institutions. But to meet future workforce demands, com - munity colleges will need to increase access to high-demand and high-return programs and improve student outcomes without losing sight of their open-access mandate. Targeted poli - cies—involving the level and allocation of resources at state schools—could signifcantly increase the number of graduates in health felds within the next decade. The health workforce is a large and growing part of California’s economy, but many addi - tional workers will be needed over the near term to keep up with demand. With careful analy- sis, planning, and investment, the state can meet future health care needs and ofer career opportunities to a diverse group of Californians. For the full report and related resources, please visit our publication page: www.ppic.org/main/publication.asp?i=1109 3 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Demand for Health Care Services Is Growing Building and maintaining a well-trained workforce that can provide quality health care to California’s diverse population has long been an important policy goal. Te Afordable Care Act (ACA) has brought renewed attention to the health workforce, as millions of Californians are expected to gain insurance coverage over the next several years. But the biggest challenge faced by California’s health care system is the large number of baby boomers reaching retirement age. As a result of the ACA’s expansion of Medi-Cal (California’s Medicaid program) and subsidized cover- age available through Covered California, the state’s new insurance marketplace, the number of insured Califor- nians is projected to increase by as much as three million over the next fve years (California Simulation of Insurance Markets 2013). Te success of the frst ACA enrollment period, which ended in April of this year, indicates that California will see a large increase in the number of people with health insurance. Te ACA includes several provi- sions intended to help meet this new demand, including measures to support workforce development and invest in training programs. 1 But funding for many of these work- force investments has been reduced or eliminated through the annual appropriations process and because of other federal budgetary issues. 2 Despite the uncertainty of how the ACA will change health coverage and delivery systems, recent studies have projected changes in health workforce needs resulting from the law’s passage. Focusing mostly on physicians and the primary care workforce (including nurse practitioners and physician assistants), these studies estimate a 2 to 3 per- cent increase in demand nationwide over the next fve years (Hofer, Abraham, and Moscovice 2011; Huang and Fine- gold 2 013). 3 Tis is consistent with projections made by the U.S. Health Resources Service Administration (HRSA), the arm of the federal Health and Human Services Depart- ment focused on health workforce issues. But population growth—particularly the growth in the number of older adults—will have by far the biggest impact on the demand for health care. National projections of primary care workforce needs—including physicians, nurse practitioners, and physician assistants—estimate that more than 80 percent of the increase in demand for health care services through 2020 will result from aging and population growth rather than from ACA coverage expansions (U.S. Department of Health and Human Services, Health Resources and Services Administration 2 013). 4 Tis is partly because of the projected increase in the older adult population and partly because people’s use of health care services increases substantially as they age (Institute of Medicine 2008). Over the next decade, California’s population is projected to increase by about More than 80 percent of the increase in demand for health care services through 2020 will result from aging and population growth rather than from ACA coverage expansions. The growth in demand for skilled health workers will be driven primarily by California’s growing—and aging—population, but expanded cover- age under the Afordable Care Act will also play a role. A P PHOTO/REED S AXON California’s Health Workforce Needs: Training Allied Workers 4 www.ppic.org 10 percent, but the older adult population (age 65 or older) is expected to increase by nearly 50 percent, with an especially large increase in the population age 75 to 85. (By contrast, the increase among children and working- age adults is expected to be only 5 percent.) More than 92 percent of older adults nationwide report at least one chronic condition, and more than 70 percent report two or more (Hung et al. 2011). To meet the health care needs of the aging population, there have been repeated calls to expand and improve training for many types of health care workers, including technicians and support staf (Institute of Medicine 2008). According to employment projections, California will need to add nearly half a million health care workers by 2020. 5 Moreover, the changing demographics of health care demand add urgency to the state’s long-standing goal of diversif ying its health workforce. Some California regions—particularly the Northern Sierra and the Central Valley—will experience especially high rates of growth in their older adult populations. Te racial and ethnic com- position of California’s elderly population will also change considerably in the coming decade. California’s Latino and Asian populations age 65 and over are projected to grow by 85 percent and 66 percent, respectively, between 2014 and 2025. Statewide, nearly half (48%) of California’s total population age 65 and over will be nonwhite in 2025, com- pared with about 40 percent today. 6 While physicians and other highly trained clinicians are critical to health care delivery, many new health care jobs require some college credentials but less than a bach- elor’s degree. Tis makes educational programs that ofer vocational degrees below the bachelor’s level—associate degrees and certifcates that require less than two years of training—very important. Both public and private insti- tutions play a large role in training workers with less than a college degree for health care occupations. California’s community college system ofers a number of health programs that confer certifcates and associate degrees. Private, predominantly for-proft institutions also train many people in health care felds, with a large focus on less-than-two-year certifcates. Meeting the state’s growing health workforce needs will require considerable planning and coordination across multiple state and regional actors involved with workforce development, health care services and planning, and educa - tion and training. It will also require accurate and up-to- date sources of information on health workforce supply and demand, training program capacity and success, and the ability to conduct timely analysis and share informa- tion across diferent segments. Tis report seeks to provide context and analysis that can help inform the discussion. We begin with a broad overview of California’s current health workforce, examin- ing the occupational distribution, education levels, and other key characteristics of California workers employed in health care jobs. We then discuss projected job growth and potential workforce shortages among health care occupations, as well as factors that may afect the supply of California’s health workforce. Ten we turn to a detailed examination of health training programs in California two-year institutions, including community colleges and for-proft colleges. Finally, we assess the state’s options in meeting health workforce needs. Health Workforce Overview Te health workforce is a large and growing sector of the California economy; the number of Californians working in health care occupations is projected to grow about 23 percent by 2020 and to account for nearly 10 percent of all new jobs. 7 Employment in the health care sector has been growing over the past decade, and it weathered the recent recession much better than the economy as a Many new health care jobs require some college credentials but less than a bachelor’s degree. 5 California’s Health Workforce Needs: Training Allied Workers www.ppic.org whole (Figure 1). While total employment in the state has declined by more than 1 million jobs since 2000, employ- ment for health care practitioners, technical workers, and support staf has increased by more than 200,000 jobs. Tis growth has occurred across all health categories, with the largest increases among high-level clinicians—including physicians and other treating practitioners—and health care support staf.In 2012, more than 1.3 million Californians reported working in health care occupations, accounting for nearly 7 percent of California’s total workforce. 8 California’s health workforce comprises a diverse set of occupations and workers. Physicians and nurses are perhaps the most widely recognized members of the health workforce, and they make up about one-third of health care workers. But dozens of other occupations providing clinical and thera- peutic services, technical services, and direct care support also play essential roles. About 15 percent of health care workers are physi- cians—including primary care doctors, specialists, and surgeons—or other clinicians with professional, doctoral- level degrees, such as dentists and pharmacists (Figure 2). Registered nurses, including nurse practitioners and certi- fed midwives, account for 22 percent of the health work- force. Several types of therapists—including occupational and physical therapists and other practitioners such as physician assistants—make up another 9 percent. More than half of health care workers are technicians or support staf; they are ofen referred to as the allied health work- force. 9 About one in fve health care workers is a techni- cian or diagnostic support worker—for example, licensed vocational nurses, dental hygienists, and imaging tech- nologists. Te largest share of workers—one-third—are nursing assistants, home health aides, medical and dental assistants, and other direct care support staf. Figure 1. Health care employment has grown over the past decade despite the recession 2000 20012002200320042005200620072008 2011 2010 2009 2012 Total employment (all occupations) SOURCE: Bureau of Labor Statistics, Occupational Employment System. NOTES: The occupational sectors are defned based on 2-digit standard occupational system (SOC) coding (Health Care Practitioners is 29 and Health Care Support is 31). Both vertical axes show employment; the left-hand side shows total employment in all occupations, and the right-hand side shows total employment in the health workforce occupations. 0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 10,000,000 11,000,000 12,000,000 13,000,000 14,000,000 15,000,000 16,000,000 Total employment (health occupations) All occupations (left axis) Health care practioner and technical occupations (right axis) Health care support occupations (right axis) Figure 2. The majority of California’s health care workers are in technical and support roles SOURCE: Authors’ calculations from California Employment Development Department 2010–2020 occupation projections. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings, please refer to the technical appendix. Doctors 7% Therapists9% Nurses 22% Other clinicians 7% Health care support 33% Technicians and diagnostic support 22% The number of Californians working in health care occupations is projected to grow about 23 percent by 2020 and to account for nearly 10 percent of all new jobs. California’s Health Workforce Needs: Training Allied Workers 6 www.ppic.org Educational Diversity Te health workforce is highly educated but has a wide distribution across education levels. More than a quarter of California’s health workforce has a degree beyond the bachelor’s level, compared with only one in ten workers in the non–health workforce (Table 1). But slightly more than half of health care workers have less than a bachelor’s degree. About 36 percent have an associate degree, certif- cate, or some education beyond high school. According to U.S. Bureau of Labor Statistics (BLS) estimates, an even larger share of health care jobs—53 percent—requires such credentials for entr y. 10 In health care jobs, however, employers tend to choose workers with more than the minimum required education, indicating high demand for skills among employers. Not only are workers more likely to have higher-than-minimum skills, they also earn more than those with less education. For example, in California, health care support workers with some college education or an associate degree earn 11 percent more than workers in similar jobs who have only a high school education. Te returns to higher edu- cation beyond the minimum required are even higher— 33 percent—for all other health care workers. 11 Postsecondary schooling that does not result in an associate degree is referred to in Table 1 as “some college” (but could be a certifcate or other short-term credential); this level of education is a common requirement among health care occupations. 12 More than 20 percent of work- ers fall into this category, and this level of education is a minimum entry requirement for more than 25 percent of positions (compared with only 6 percent of nonhealth positions). Te highest share of health care workers with this level of education is in support occupations (Figure 3). While some workers—home health aides, for example— are required only to have a high school education, other positions typically require postsecondary certifcation. Tis includes nursing assistants, the single largest employ- ment category of California health care support workers. Medical and dental assistants also account for a large share of health care support workers, and these occupations also require a postsecondary certifcate. Slightly more than 10 percent of health workforce jobs require a bachelor’s degree, but more than twice as many workers have one. Most of the workers with educational levels higher than those required to enter the feld are in the nursing profession: an associate degree is the minimum requirement for entry (per BLS), but almost two-thirds of all nurses in 2012 report a bachelor’s degree or higher (Fi g u re 3). Te educational levels of workers in some health care occupations have changed over time. Understanding these changes is critical to designing training programs that Table 1. The health workforce is highly educated but also educationally diverse Current education levels Minimum education for entry Non–health workforce (%) Health workforce (%) Non–health workforce (%) Health workforce (%) Doctoral/professional 3.015 . 3 2.016 .7 Master’s degree 7. 310.0 1.16.4 Bachelor’s degree 20.324. 2 21. 510.9 Associate degree 7. 215 . 5 1. 626 .1 Some college 25.620.6 6.02 7. 3 High school diploma or less 36.714 . 4 6 7. 812.6 SOURCES: Current education levels are based on estimates from the American Community Survey (ACS), 2010–2012 3-year Public Use Microdata Sample (PUMS). Data on minimum education for entry are from the BLS education-training matrix. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings and the method for assigning BLS training and education requirements to occupational codes in the ACS, refer to the technical appendix. 7 California’s Health Workforce Needs: Training Allied Workers www.ppic.org address the need of California’s future health workforce. In some areas, including nursing and health care support occupations, the number of workers with higher levels of training has increased in the past decade. In 2000, more than 42 percent of health care support workers had a high school education or less. By 2012, only 36 percent had a high school education or less, and a higher share had some college (including postsecondary certifcates) or an associate degree. Tese higher educa - tion levels could indicate that employers are demanding more from health care support workers. Although there has been a general increase in the proportion of workers with at least some college across all occupations in Cali - fornia, this growth is more pronounced among health care support workers. Tis is consistent with fndings that certifcates generally do not bring signifcant returns for workers, but that certifcates and associate degrees from health care programs do confer benefts (Lang and Wein - stein 2012). Tis trend is likely to continue as the aging population demands more and possibly higher-quality health care services. Te percentage of nurses with at least a bachelor’s degree has also increased, from 56 percent in 2000 to 65 percent in 2012. Tis increase in educational attainment among nurses may refect an increase in wage returns for degree holders, a shif in the composition of nurses, changes in the prefer- ences of employers, or some combination of these factors. 13 Many senior positions now require at least a bachelor of science in nursing (BSN), and there is some evidence that more entry-level positions require or prefer a BSN (Cali- fornia Institute for Nursing and Health Care 2014). In addition, the Institute of Medicine recently recommended that 80 percent of the nursing workforce have at least a bachelor’s degree by 2020, to keep up with the increasing complexity of care (Institute of Medicine 2010). Racial and Ethnic Diversity Increasing the racial and ethnic diversity of California’s health workforce to better refect the state’s population is also essential to meeting health workforce needs. A wide body of research has found that racial/ethnic concor- dance among providers and patients is crucial to quality care (LaVeist and Nuru-Jeter 2002; Cooper et al. 2006). 14 In particular, provider cultural competence and Spanish language profciency are important indicators of improved health care quality for Latino populations (Fiscella et al. 2002; Fernandez et al. 2004). Tis is a particularly salient issue in California, where nearly 40 percent of the popula- tion is Latino. Te state’s health workforce has become more diverse over the past decade but is still not representative of Cali- fornia’s racial/ethnic makeup. Latinos are underrepresented in the health workforce, relative to both their share of the Figure 3. Most technicians and health care support workers have some college training SOURCE: ACS 2010–2012 3-year PUMS. NOTE: For more information on the occupational codes (SOC) used to categorize health care workers into these groupings, please refer to the technical appendix. 100 90 80 70 60 50 40 30 20 100 Percentage of workers High school or less Some college Associate degree Bachelor’s degree Master’s degree Doctoral degree Doctors Therapists Registered nurses Other clinicians Health care support Technicians and diagnostic support A wide body of research has found that racial/ethnic concordance among providers and patients is crucial to quality care. California’s Health Workforce Needs: Training Allied Workers 8 www.ppic.org state’s total population and their share in non–health care occupations. Tere has been growth in the share of Latino health care workers across some occupational categories: in 2012, nearly 25 percent of all health care workers were Latino, compared with 17 percent in 2000. But the propor- tion of Latino nurses, doctors, and other clinicians has not grown much: for example, only 12 percent of nurses were Latino in 2012, up slightly from 9 percent in 2000 (Figure 4). 15 Asian and Pacifc Islanders are generally overrepresented across all health care occupations, particularly among physicians, other clinicians, and nurses. Future Health Workforce D e m a n d s Studies suggest that there may not be enough Californians in the workforce with college degrees or some college training to meet economic demands over the next decade (Johnson 2005; Neumark 2005; Johnson and Reed 2007; and Bohn 2014). Although the shortage of college-educated workers has been the subject of much discussion, the projected shortfall of workers with some college training is actually higher. By 2025, California is projected to face a gap of more than 1.5 million workers with some college training but less than a bachelor’s degree (Bohn 2014). A shortage of trained workers in specifc occupations may keep the state from reaching its economic potential—or from meeting the needs of the population. California’s health workforce is projected to require an additional 250,000 workers by 2020 to meet the growing demand for services (see technical appendix Table A2). In the same time frame, another 200,000 health care workers are expected to leave the workforce and will need to be replaced. Rates of retirement will difer across occupa- tional groups. For example, a larger share of new health care support openings will result from job growth due to Figure 4. Latinos have made small gains but are still underrepresented in the health workforce SOURCES: Authors’ calculations from the Census 2000 5% PUMS and the ACS 2010–2012 3-year PUMS. 2000 2012 Total health workforce 100 90 80 70 60 50 40 30 20 100 Percentage Latino Doctors Therapists Registered nurses Other clinicians Health care support Technicians and diagnostic support Health workforce data sources The workforce information presented in this report comes from state and federal labor agencies—including the Cali- fornia Employment Development Department and the U.S. Bureau of Labor Statistics—and from Census Bureau surveys. These sources allow us to provide a broad overview of the state’s total health workforce, as well as wage and current employment information. Licensing data are another source of information on the supply of health care workers in specifc occupations; however, some health care occupations do not require licensing and thus are not captured by these data and also do not provide any information on wages. The California state agency responsible for overseeing most licensing information is the Department of Consumer Afairs, although the actual licensing process and data col- lection in most cases is left to the various boards and profes- sional organizations governing diferent health care occupa - tions. For a detailed analysis of licensing data across several health care occupations, see Bates et al. (2011). California’s Ofce of Statewide Healthcare Planning and Development has created a clearinghouse for available health care licensing and workforce data (www.oshpd.ca.gov/hwdd/hwc/). At the federal level, the Health Resources and Services Administration, a division of the U.S. Department of Health and Human Services, maintains the Area Health Resource File, a county-level data set assembled from multiple sources that contains estimates for some health care professions as well as health care facilities and service use and population demo- graphics. There are also federal eforts under way to develop a “minimum data set” for various health care occupations; these eforts are intended to support health workforce planning and development at the state and national level. 9 California’s Health Workforce Needs: Training Allied Workers www.ppic.org increased demand for services, whereas several other occu- pational groups will see a larger share of new job openings due to retirement of existing workers. In total, the state is expected to need nearly half a million health care workers by 2020 in order to meet demand. Job growth is projected across all areas of the health workforce. In all except the “other clinicians” category, employment is projected to grow faster than overall state employment. Te highest job growth—in both number and rate—is expected in health care support occupations, already the largest subgroup of health care workers. More than a third of new jobs in health will be in health care support roles, and about a quarter will be in technical allied health care occupations (Figure 5). Of the new jobs needed in the health sector, about 190,000 or 42 percent are likely to require an associate degree or postsecondary certifcate. Tese rigorous estimates of workforce needs are pre- mised on healthy economic conditions. But, as the recent recession showed, economic conditions can afect the demand for health care services—and in ways that are dif - cult to predict. Also, ACA’s impact on the health workforce is uncertain and not fully accounted for in Employment Development Department and BLS projections. 16 Gaps Projected in Several Health Care Occupations California’s ability to augment its health workforce in response to future needs hinges on the postsecondary edu- cational credentials of workers. But at the same time that employers are demanding more skilled workers—in the health care industry and elsewhere—the education levels achieved by the workforce are stagnating. Retiring workers are more likely to have attended college than young work- ers who are entering the California labor market. Tese trends portend skills gaps in California’s future workforce. Of course, unforeseen economic changes, altered migra- tion patterns to and from California, workers’ responses to educational and job opportunities, and other factors may afect these trends. Tus, projections are simply a lens Figure 5. Nearly half of new health jobs will require associate degrees or postsecondary certifcates SOURCES: California Employment Development Department 2010–2020 occupational projections; ACS 2010–2012 3-year PUMS. See the technical appendix for further details. NOTES: “All other groups” combines doctors, other clinicians, and therapists. The proportion of new jobs requiring an associate degree or certifcate is calculated by applying the share of current workers in detailed (6-digit) occupations with these training levels to projected total new jobs. The proportion of jobs requiring all other levels of training includes jobs requiring both higher and lower than an associate/certifcate level. 500,000 400,000 300,000 200,000 100,000 0 New health workforce jobs, 2020 Jobs requiring all other levels of training Jobs requiring associate degree or certifcate Total health workforce All other groups Registered nurses Technicians Health care support Demand for skilled workers is projected across all areas of the health workforce, though the largest increase is expected to be in health care support occupations. AP PHOTO/R ICH PED RONCELL I The state is expected to need nearly half a million health care workers by 2020 in order to meet demand. California’s Health Workforce Needs: Training Allied Workers 10 www.ppic.org into how economic demands may or may not be met in the future, highlighting areas worthy of policy attention. Overall, by 2025 the state is likely to face a shortfall of about 2.5 million workers with postsecondary training— 1.5 million with less than a bachelor’s degree and 1 million with a bachelor’s degree or above (Bohn 2014). Recent esti- mates suggest that health care felds may be among those afected by workforce shortages. Moreover, health work- force shortages vary along geographical and demographic lines. California’s health care workers need to be located throughout California’s regions and need be able to commu - nicate with and provide care to the state’s diverse population. In addition to meeting the demand for physicians, California needs to address skills gaps among other health care workers—the overwhelming majority of the work - force. Te fast-growing allied technical and support felds are also likely to face shortages of workers over the next decade. One recent study estimated that, despite some growth in training capacity, the state will face a gap of between 55,000 and 145,000 allied workers by 2020 and as many as 375,000 by 2030 (Fenton Communications and Beacon Economics 2010; see the technical appendix for details). Projections at this level of detail have fairly wide margins of error due to the range of assumptions that must be made. However, by harnessing a variety of data sources and reasonable models of expected changes in health care delivery, these estimates can provide useful insights. In particular, the projections suggest that the supply of workers will be sufcient in some allied health care occu- pations but not in others. Te largest shortages are expected among licensed vocational nurses, dental hygienists, and dental assistants (see technical appendix Table A4). Sur- pluses are projected in a few other areas by 2020—among medical assistants, emergency medical technicians, and pharmacy technicians. Tese projections of large gaps and large surpluses in the allied workforce underline the importance of carefully allocating human resources and training opportunities. Many Factors Influence the Future Supply of Health Care Workers Te state and national economy, relative wage levels across sectors, and workforce participation rates all play an important role in determining the supply of workers for any given health care occupation. For instance, the recent recession was a factor in easing California’s nursing short- age between 2005 and 2011 (Spetz 2011). Te state may have some ability to meet demand by altering the “scope of practice” of some health care occupations. But it has In addition to meeting the demand for physicians, California needs to address skills gaps among other health care workers— the overwhelming majority of the workforce. Scope of practice One policy option that might help address shortages is to change the roles and responsibilities—often referred to as the scope of practice—of health care occupations. Across the country, many states have passed or are considering laws that expand the types of services that certain health care workers can provide. The goal of these laws is to expand patient access and fully utilize the training that health care professionals are required to receive. In California, recent legislative changes have expanded the scope of practice for certifed nurse midwives and pharmacists, but changes for other health professionals, including nurse practitioners and optometrists, have not succeeded. There are similar initiatives to extend the roles of health care workers with less training, including dental hygien - ists, medical assistants, and other allied health workers. For example, a current workforce pilot project in California is evalu - ating an expanded role for emergency medical technicians/ paramedics to improve efciency and improve access (Ofce of Statewide Health Planning and Development, State of California 2014). As changes to the scope of practice are implemented for more highly trained health care workers, other members of the health workforce could perform additional tasks to relieve some of the increased clinical workload. 11 California’s Health Workforce Needs: Training Allied Workers www.ppic.org relatively little direct control over business cycles and wage-setting. Te most direct way for the state to spur growth in the supply of health care workers lies in the realm of education— particularly in allied technical and support felds that require only some college training and thus have shorter completion timelines. Te supply of health care workers in California will depend heavily on the ability of the state’s institutions to recruit and educate qualifed students for these positions. Because community colleges are spread throughout the state and serve a large and diverse student population, they may be especially helpful in training an occupationally relevant and culturally competent workforce. Targeted policies—mostly involving the allocation and level of funding at state schools—have the potential to signifcantly increase the number of graduates in these felds within the next decade. However, to make informed decisions, we need to know more about the health care programs in California’s higher education institutions, particularly the public and for-proft two-year institutions that provide training to much of California’s nursing and allied health workforce. Allied Health Training Programs in California Te past decade has witnessed growth in health degrees across most educational levels. Te most sizable increase has been in the number of associate and other sub-baccalaureate health degrees, mostly driven by private institutions. Te state’s public institutions, particularly its community colleges, continue to play an important role, especially in nursing. But private, for-proft institutions have expanded their presence considerably. Given the importance of associate degrees and postsecondary certifcates in grow- ing health occupations, it is vital to maximize the efective- ness of the state’s two-year institutions so that they meet employment demands and provide good employment opportunities for their students. In 2012, nearly 100,000 health degrees were conferred by higher education institutions in California (Figure 6). Te total number of health degrees has increased signif- cantly over the past decade, and most of the growth has been driven by associate degrees and certifcates completed in less than two years. Growth in the number of bachelor’s degrees has been driven by an increase in the number of registered nurses who pursue four-year degrees. Nursing Figure 6. The number of health degrees has increased signifcantly over the past decade SOURCE: Integrated Postsecondary Education Data System (IPEDS), U.S. Department of Education, National Center for Education Statistics. NOTE: Certifcates include both short-term awards requiring less than 1 year to complete and long-term awards requiring more than 1 year, but less than 2 to complete. 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total completed health degrees Certifcate Associate degree Bachelor’s degree Master’s degree Doctoral degree The most direct way for the state to spur growth in the supply of health care workers lies in the realm of education—particularly in allied technical and support felds that require only some college training and thus have shorter completion timelines. California’s Health Workforce Needs: Training Allied Workers 12 www.ppic.org accounts for more than half of bachelor’s degrees conferred by health programs, and the number of BSN degrees completed has more than doubled over the past decade. 17 In contrast, the number of doctoral degrees awarded in California has remained relatively constant. Te number of associate degrees and postsecondary certifcates in health programs awarded by the state’s public institutions, particularly community colleges, has increased slightly over the past decade; most of the addi- tional associate degrees were in nursing (Figure 7). Tere has been considerable growth in both associate degrees and certifcates awarded by private institutions, mostly by for-proft institutions. By 2012, these private institutions conferred almost as many associate degrees in health pro- grams as did the community colleges. Tere are considerable diferences in the level and type of degrees awarded by public and private, for-proft schools (Figure 8). Te community college system confers almost 90 percent of all associate degrees in nursing in the state, and nursing degrees constituted nearly 60 percent of asso- ciate degrees in health programs awarded by community colleges in 2012. Te state’s recent intervention to address the shortage of nurses seems to have solidifed the commu- nity college system’s role in training the nursing workforce with associate degrees. As the labor market continues to demand higher education levels among nurses, the state may need to consider additional pathways to bachelor’s degrees in nursing. 18 At private, for-proft institutions, most students earn associate degrees and certifcates for health care support occupations. Te majority of certifcates awarded by public institutions—both community colleges and adult voca - tional education programs—are in allied technical support felds. Figure 7. The number of associate and postsecondary degrees conferred by private, for-profts has grown considerably over the past decade SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics. NOTES: Associate degrees at public institutions are all completed at community colleges. Certifcates at public institutions are completed at community colleges (80%) and vocational education programs (20%). Private institutions include both for-proft and nonproft private institutions, although nonproft private institutions make up a very small proportion of sub-baccalaureate health degrees. About 3% of associate degrees and 1% of certifcates completed at private institutions are at nonprofts; the remainder are completed at private, for-proft institutions. 0 10,000 20,000 30,000 40,000 50,000 60,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of completed health degrees Associate degree, public Associate degree, private Certifcate, public Certifcate, private Figure 8. There are large diferences in the level and type of degrees conferred by private and public institutions SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTES: Private, nonproft institutions are not shown in the fgure, because they produce a very small share of sub-baccalaureate health degrees relative to public and private, for-proft institutions. The categories are based on groupings of Classifcation of Program (CIP) codes; for more information on the specifc groupings, refer to the technical appendix. The “Other” category includes medical administration, premedical preparatory programs, massage therapy, and other bodywork/alternative medicine programs. Other Support Technical Nursing50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Total completed health degrees Public, associate degrees Private, for-proft, associate degrees Public, certifcates Private, for-proft, certifcates The majority of certifcates awarded by public institutions—both community colleges and adult vocational education programs— are in allied technical support felds. 13 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Tere also appear to be diferences in the programs being completed at public and for-proft institutions (Table 2). For instance, more than 90 percent of emergency medical technicians are certifed by public schools, while private schools award large shares of licensed vocational nurse and pharmacy technician credentials. Private, for-proft institu- tions also confer an overwhelming majority of certifcates in health care support felds. Nearly four in ten certifcates in health programs completed at private, for-proft institu- tions are awarded to medical assistants—one of relatively few occupations in the health workforce with projected surpluses over the next several years. To look more closely at degree production in the context of labor market demands and opportunities, we examined data on wages earned in these occupations. Te fnal column of Table 2 presents wage information for occupations related to select health degree programs. In general, workers with associate degrees in allied health technical support occupa - tions earn more than those with less-than-two-year degrees. But there is a substantial amount of variation in earnings across occupations. Tis may refect labor market demand, worker characteristics, hours worked, or a variety of other factors unrelated to training program alignment (or mis - alignment). However, it is worth noting that more than half Table 2. The degrees awarded most frequently by private, for-profit schools are in occupations with the lowest wages Type of health degrees A ssociate degree Public Private, For-Proft Median Wage, 2012 Nursing 5,668475$70,000 Technical support 2,8494,684 Licensed vocational nurse 367788$42,000 Dental hygienist 298206$50,000 Respiratory therapist 488747$61, 242 Imaging technology 5751, 030$63,283 Health care support 5893,244 Medical assistant 2712,753$2 5 , 517 Dental assistant 13 0308$ 2 7, 8 5 2 Total associate degrees 9,8849,769 Certifcate (less-than-2-year awards) Technical support 4,80712,969 Emergency medical technician 1, 8 81162$33,500 Licensed vocational nurse 8064,0 01$39,807 Pharmacy technician 3363, 516$33,010 Health care support 2 ,14 923,530 Medical assistant 92017, 314 $2 5 , 517 Dental assistant 5214,284 $25,789 Nursing assistant/home health aide 5581, 357$19,500 Total certifcates 7, 7 9 646,805 SOURCES: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. Wage information is from the ACS 2010–2012 3-year PUMS. NOTES: Only select degrees are shown for each category, and they do not sum to total for the group. Total associate degrees and total certifcates include all degrees conferred, including those not categorized in technical or health care support, such as medical administration degrees, massage therapy, and premedical preparatory degrees. Median wages are calculated from ACS 2010–2012 3-year PUMS that matches the health training program (based on CIP codes) and to occupational codes (based on SOC codes). Median wages presented are restricted to the California adult sample with the same education level of the degree program; in the case of certifcates, reported education level in the ACS is “Some College.” California’s Health Workforce Needs: Training Allied Workers 14 www.ppic.org of the degrees awarded by private, for-proft schools in 2012 are certifcates for health care support—occupations with the lowest median wages. It is also important to consider how well these pro- grams are meeting the needs of those who enroll, particu- larly among underrepresented students. We now turn to an examination of students completing associate and certif- cate degrees in health programs with a focus on the racial/ ethnic distribution of students across programs and insti- tutions. Given the growing need for diversity in the health care sector, ensuring training opportunities for California’s diverse population is particularly important. Relative to California’s college-age (18 to 34) population— which is 44 percent Latino, 33 percent white, 13 percent Asian, and 6 percent black—Latino, Asian, and black stu- dents are well represented in health program completions for associate degrees and postsecondary certifcates, while white students are underrepresented (Figure 9). When we look beyond these aggregate groupings, we fnd large diferences in the level of degree and type of institutions. Nearly three-quarters of all degrees below the bachelor level earned by black and Latino students are certifcates from for-proft institutions (Figure 10). Only 7 percent are associate degrees from community colleges— as compared to about 20 percent among white students and 25 percent among Asian students. Moreover, white and Asian students receive more certifcates from public institutions than do black and Latino students. Te diferences between public and for-proft institu- tions in the type of degrees completed and the students completing them point to an important aspect of training opportunities for the allied health workforce: the growing role of private, for-proft institutions. The Rise of Health Degrees from For-Profit Institutions For-proft institutions focus on health degrees: one-quarter of all associate degrees and certifcates conferred by private, Figure 9. Nonwhite students are well represented in health associate degree and postsecondary certifcate completions relative to California’s college-age population SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTE: The “Other” racial/ethnic category includes American Indians, Alaskan Natives, Pacifc Islanders, multirace categories, and a nonresident alien category. White 25% Black 9%Asian 12% Latino43% Unknown 6% Other 5% Figure 10. A large share of black and Latino students complete health certifcate degrees from private for-profts SOURCE: IPEDS, U.S. Department of Education, National Center for Education Statistics, 2012. NOTE: The “Other” racial/ethnic category includes American Indians, Alaskan Natives, Pacifc Islanders, multirace categories, and a nonresident alien category. 100 90 80 70 60 50 40 30 20 100 Percentage of completed health degreesWhite Latino Black Asian Other Unknown Certifcate, private, for-proft Certifcate, publicAssociate degree, private, for-proft Associate degree, public Latino, Asian, and black students are well represented in health program completions for associate degrees and postsecondary certifcates, while white students are underrepresented. 15 California’s Health Workforce Needs: Training Allied Workers www.ppic.org for-proft institutions in California are for health-related programs. As public institutions have grappled with budget cuts and funding constraints, for-proft schools have met some of the excess demand for associate education (Deming, Goldin, and Katz 2013). In California in particular, there is strong evidence that budgetary constraints in community colleges have led to an increase in for-proft colleges enter - ing the market (Cellini 2009). But the poorer labor market outcomes among gradu- ates of for-proft institutions are cause for concern. Nation- wide studies have found that, among students completing health programs, those at for-proft institutions are more than twice as likely as community college graduates to be unemployed, and the earnings of those who are employed are about 12 percent lower (Deming, Goldin, and Katz 2013). For-proft institutions are more likely to ofer cer- tifcate programs in health care support felds that tend to have lower wages. Related research suggests that fnancial returns on postsecondary certifcates in health degree pro- grams may be lower relative to associate degrees in related felds (Lang and Weinstein 2012). It should be noted that the student population at private, for-proft institutions appears to be more disadvantaged than the population at community colleges—there are fewer high school gradu- ates and more single parents and lower-income students (Deming, Goldin, and Katz 2013). Tis raises the pos- sibility that students who complete programs at for-proft schools are better of than they would be without any postsecondary schooling. However, we also need to consider the high cost of attending these schools. Health degree programs in private, for-proft schools are generally more expensive than com- munity college programs. We do not have comprehensive cost data, but information available through the College Navigator run by the National Center for Education Statistics suggests a wide gap in costs for health programs between for-proft and community colleges in California. For example, the tuition and fees for a licensed vocational nurse certifcate program at a group of for-proft institu- tions ranged from $20,000 to $35,000. By contrast, tuition costs for the same program at community colleges are about $2,500 and total program costs (including books and other fees) are about $4,500. Most fnancial aid comes from federal loans that students must repay rather than grants or other institutional support. More than half of California students in default in 2011 attended a private, for-proft college (Johnson et al. 2013). To regulate for-proft postsecondary institutions, fed- eral and state governments have relied mainly on control- ling the availability of fnancial aid. At the federal level, “gainful employment” regulations have been proposed to provide enhanced oversight of vocational programs beyond the existing requirement that for-proft schools obtain at least 10 percent of their revenues from sources other than federal student aid (this is ofen referred to as the 90/10 rule). 19 In California, Cal Grants are the primary source of state aid; they are available to students enrolled at qualifed insti - tutions, with a special category for vocational and techni - cal programs. Te 2011–2012 state budget included major changes to the Cal Grant program: institutional eligibility is now based on student outcomes (graduation rates and fnancial aid default rates), and the California State Com - mission on Student Assistance develops lists of ineligible institutions for each school year. Institutions are deemed ineligible if their graduation rates are below 30 percent or their federal student loan cohort default rates are above 15.5 percent. 20 More than 60 percent of health care certif - cates and associate degrees conferred by private, for-proft schools are conferred by institutions that have not been eli - gible for Cal Grants at least one year since these rules took efect. 21 Tis means that students attending many private, for-proft institutions are not eligible for Cal Grant fnancial aid, which does not need to be repaid. Health degree programs in private, for-proft schools are generally more expensive than community college programs. California’s Health Workforce Needs: Training Allied Workers 16 www.ppic.org Te distribution of degrees across training programs and institutional sectors suggests mismatches in training capacity and employment demands. Te large diferences in the racial and ethnic distribution of students across institutions and programs also suggest that there is room for improvement. Tere may be avenues for state institu- tions, in particular the community college system, to better address both health workforce and student needs. The Importance of Community Colleges California’s community college system is poised to play a major role in training the nearly 200,000 workers needed by 2020 to fll occupations in the health care sector likely to require some college education below a bachelor’s degree. California’s is the largest public higher education system in the country, educating more than 2 million students in 112 community colleges across the state. Te success of the Nurse Education Initiative in increasing training opportunities and associate degrees in nursing over the past decade suggests that the system can expand programs and produce more workers in high-demand occupations. 22 Between 2005—when the state, facing a dramatic shortage of nurses, launched the initiative—and the end of 2009, the number of students enrolled in nursing programs increased by more than 75 percent, and 35 new nursing programs were established (California Nurse Education Initiative 2010). Tough other factors—including the labor force dynamics of the recent recession and wage increases—also played a role in addressing the shortage, it is clear that strong state action, including fnancial investment, can help improve health workforce supply over a relatively short period of time. Tere has been concern about relatively low levels of student success in the community colleges (California Community Colleges Chancellor’s Ofce 2012a), but suc- cess rates are higher in allied health programs (82%) and registered nursing (91%) than in other courses (70%). 23 Tese successful outcomes are probably driven by a num- ber of factors, including the selectivity of health care pro- grams, 24 student ability, and program or teaching quality. While these higher rates of student success suggest that state policy can increase health workforce skills, access may not be broad enough to meet future workforce demands. Bohn, Reyes, and Johnson (2013) estimate that constric - tions during the Great Recession brought the enrollment rate for college-age Californians close to a two-decade low. While community colleges ostensibly shielded high-priority courses from severe cuts, most areas were afected—including health programs. During the most severe years of the state budget crisis, 26 percent of health care courses were cut— a higher share than in other programs (see technical appen - dix Table B1). Some areas of health care training were more deeply afected than others—for example, the relatively small dental hygienist and respiratory therapist programs actually expanded, while fewer registered nursing courses were ofered. It is worth noting there may have been some consolidation into larger courses and therefore no decline in prerequisite course availability. And because most community college students are not required to declare or apply for a particular program of study, excess demand for programs or courses is difcult to measure. A full under - standing of whether access to health care programs was— and continues to be—constricted would require additional research. Community colleges are intended to be an open entry point to higher education for all Californians, with low fees and high use of need-based aid. Participation rates are substantially higher among historically underrepresented minority groups, such as African American and Latino students, relative to whites (California Community Colleges Chancellor’s Ofce 2012b, 2013). Tis positions the com- munity college system to become a key player in closing gaps in educational achievement—and ultimately fostering Strong state action, including fnancial investments, can help improve health workforce supply over a relatively short period of time. 17 California’s Health Workforce Needs: Training Allied Workers www.ppic.org employment opportunity—in California. Te system may also be able to diversify the state’s health workforce, a long- standing goal that is becoming increasingly important as older Californians become more and more diverse. How- ever, our examination of recent health degree completions suggests that black and Latino students are not utilizing the community college system for health training opportu- nities at the same levels as other groups. Moving Forward California may not be on track to meet future health work- force needs for occupations requiring only some college training. Tis workforce skills gap could constrain the delivery and quality of health care services, particularly to California’s growing elderly population. At the same time, many Californians will miss opportunities for employment in a fast-growing sector. How can the state address these workforce needs, and how can it monitor the progress of state and private institutions in training and serving the needs of students? Data Coordination and Planning To ensure that California can meet health workforce needs and train an adequate number of workers, state and regional policymakers require good data. Te state has infrastructure devoted to monitoring health workforce needs and supporting training opportunities across dif - ferent education levels. Te Ofce of Statewide Health Planning and Development’s Healthcare Workforce Devel - opment Division coordinates state planning related to the health workforce. It also administers several programs that provide fnancial assistance and in-kind support to institu - tions and individuals in a wide variety of training areas. 25 In addition, legislation passed in 2007 tasked the agency with assembling licensing, employment, and education data on the health workforce. Te resulting Healthcare Work - force Clearinghouse has done an admirable job pulling together data from a variety of sources, but it is limited by the availability and type of information collected. Information about workforce training has been further limited by the decommissioning of the California Post- secondary Education Commission in 2011—formerly a clearinghouse for comprehensive higher education train- ing information. But individual public systems—including the California Community College Chancellor’s Ofce (already a leader in making data publicly available), the California State University system, and the University of California system—could coordinate information on health workforce training within their institutions. Link - ages to employment information via the state Employment Development Department would be an important next step. Legislative action could improve the accessibility and consistency of workforce training, employment, and wage information across the many occupational groups that make up the health workforce. Oversight of For-Profit Institutions As part of its efort to meet workforce needs, the state must monitor the quality of existing health programs. As we have shown, for-proft colleges are playing a large and growing role in training health care workers with less than a college degree, but they may not be ofering the best opportunities for students, particularly those from disadvantaged back - grounds. Tese schools typically have higher costs, and many have been cited recently for misleading practices, low graduation rates, and high loan-default rates among their graduates. In October 2013, California’s attorney general fled a suit against Corinthian Colleges, Inc., and its sub - sidiaries, which operate many colleges around the state and nation, accusing them of false and predatory advertising and making intentional misrepresentations to students, among To ensure that California can meet health workforce needs and train an adequate number of workers, state and regional policymakers require good data. California’s Health Workforce Needs: Training Allied Workers 18 www.ppic.org other violations (Ofce of the Attorney General 2013). Federal sanctions against Corinthian Colleges, including withholding of federal fnancial aid funding, led Corinthian Colleges to recently announce the sale and closure of many of its campuses, including several in California.Te agency responsible for overseeing the state’s for- proft higher education institutions is the Bureau of Private Postsecondary Education, housed within the Department of Consumer Afairs. In a March 2014 report, the Califor- nia State Auditor concluded that the bureau “consistently failed to meet its responsibility to protect the public’s interests” and recommended shutting it down. Te report found that the bureau had failed to respond to numerous student complaints regarding practices at private, for-proft schools, failed to regulate the information the schools provided to students on expected graduation rates and salaries, and mismanaged the Student Tuition Recovery Fund (California State Auditor 2014). Te lawsuit and auditor’s report indicate a need for improved state oversight and monitoring of private, for- proft institutions and the educational opportunities they can ofer to students. As discussed earlier, one state strat- egy has been to tie state fnancial aid for students through the Cal Grant program to school performance. Te Cali- fornia Student Aid Commission maintains a list of schools that are ineligible to participate in the Cal Grant program because they do not meet minimum criteria for student graduation rates and fnancial aid default rates. Many Community colleges could play a key role in preparing Californians to enter the fast-growing health care sector. D ON BA RTLET T I / LOS A N G ELES TIMES /CO PYRIG HT C 2012. LOS A N G ELES TIMES. RE PRINTED W ITH PE R M I SSION. 19 California’s Health Workforce Needs: Training Allied Workers www.ppic.org private, for-proft colleges have been deemed ineligible for Cal Grants, so students attending these schools cannot receive these state grants, which do not need to be repaid. Te higher costs and poorer labor market outcomes of for-proft institutions indicate that the state’s community college system could play a larger role in providing train- ing opportunities for students in health programs. Expanded Access to Community Colleges California’s community colleges serve a number of mis- sions, including preparing students to meet workforce needs. As part of its mission to bridge workforce needs, the Chancellor’s Ofce Division of Workforce and Eco- nomic Development coordinates the eforts of employers, labor organizations, government training programs, and individual college districts within regions. Supported by an overarching Health Workforce Initiative, the ofce has made the health sector a planning and investment priority in each region of the state.To increase the number of allied health care workers, community colleges could expand access to high-demand and high-return programs and improve student outcomes. 26 As noted previously, the recent recession spurred cuts that limited the availability of courses and ultimately lowered col - lege attendance in the state. Because technical courses (and many other health care courses) are among the most expen - sive to administer (Shulock, Moore, and Ofenstein 2011; Shulock, Lewis, and Tan 2013), it may be more difcult to increase their availability to pre-recession levels and beyond than to restore access to less technical or low-infrastructure courses. 27 For example, in 2011–2012, respiratory care therapy courses nationwide cost $265 per student hour, and allied health and medical assisting courses cost $131 per stu - dent hour, compared with only $52 per hour in the humani - ties and $73 per hour in engineering (Shulock, Lewis, and Tan 2013). In addition to high costs, budget fuctuations from year to year and categorical funding streams may impede the ability of colleges to plan for workforce training needs. Another important step toward meeting the state’s health workforce needs is to improve access to train- ing programs among underrepresented student groups. Strengthening outreach and mentoring to minority students is important, as many would be frst-time college- goers. Te relatively small increase over the past decade in the number of Latino nurses, despite the state’s largely successful expansion of nursing training opportunities, indicates that there is room for improvement in engag- ing and supporting underrepresented students in health programs. A number of state health foundations and local initiatives ofer grants and targeted programs to diversify the pipeline of students in health degree training. Closer collaboration and coordination with these programs could help community colleges expand their outreach to under- represented students. But diversifying and broadening access to training programs is unlikely to meet broad workforce needs unless steps are taken to foster student success rates within those programs. Community college health courses have rela - tively high success rates, in part because, unlike many other courses of study, a number of them have admission require - ments. But most community college students struggle to complete degrees or certifcates within a reasonable amount of time. Te Student Success Task Force and a number of research studies have identifed ways for the community college system to improve student outcomes (California Community College Chancellor’s Ofce 2012a). Several recommendations have been or will soon be implemented, and it will be important to measure their impact on student success. In the feld of health care, requiring admission procedures similar to those in nursing programs for allied health training may incentivize student success, or at least ensure that training slots are allocated efciently. In fact, it To increase the number of allied health care workers, community colleges could expand access to high-demand and high-return programs and improve student outcomes. California’s Health Workforce Needs: Training Allied Workers 20 www.ppic.org would be useful to develop a better understanding of student intentions upon entering a community college, so that pit- falls could be identifed and addressed. Of course, the system must balance its eforts to improve outcomes with its open- access mission and its goal of diversifying the student body. In general, a more comprehensive analysis is needed of the role played by student- and institutional-level charac - teristics in the success of students in health care programs and the labor market outcomes of those working in health care professions. Tis analysis could inform the extent to which health care workers are able to climb a career lad - der with skills accumulated on the job or via successive educational credentials. For example, some schools have programs that are structured to provide a training pipe - line in nursing, from certifed nursing assistant to licensed vocational nurse to registered nurse. 28 Tese kinds of pathways are ofen cited in discussions about career devel - opment options for economically disadvantaged Califor - nians. 29 We lack empirical evidence on the efectiveness of this strategy, but it is clear that the capacity to adequately train nursing and allied technical and support workers is a policy goal, and that meeting this goal would beneft Californians who need health care services as well as the workers themselves. Technical appendices to this report are available on the PPIC website: www.ppic.org/content/pubs/other/914SMR_appendix.pdf 21 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Notes 1 Tese investments included large funding increases to the National Health Service Corps (NHSC), which ofers scholarships and loan repayment to health professionals who practice in feder - ally designated shortage areas; new grant programs aimed at allied health professionals and direct care workers; and changes to gradu - ate medical education to support primary care physician training. 2 For example, the National Health Care Workforce Commis - sion, a new federal entity to coordinate and inform national health workforce policy, has not received any congressional funding and thus has never become operational; the additional support for NHSC is now the sole program investment, and it is scheduled to sunset in 2015 (Redhead 2013). Tere are limited health workforce demonstration programs moving forward, including grant programs for states, higher education institu- tions, and workforce investment boards to assist low-income individuals with education and training in health care jobs that pay well and are in high demand, as well as much smaller state grant programs to develop core training competencies and certi- fcation programs for personal and home care aides. 3 Other studies have projected that changes in nursing and allied workforce needs resulting from the ACA represent a small share of projected employment growth (Spetz 2013; Spetz et al. 2014). While these and other projection models ofer a reason- able source of information on future workforce needs, most are limited to the extent that they base future trends on historical use patterns (Ricketts 2011; Dall 2013). 4 HRSA projections assume that all states will expand Medicaid under the ACA and have not been adjusted to account for the fact that several states have chosen not to expand the Medicaid program, suggesting that the increase in demand driven by the ACA nationwide will be smaller. 5 California Employment Development Department 2010–2020 occupational projections. Includes new jobs and job replacement. See Figure 5. 6 Based on authors’ calculations of California Department of Finance population projections. 7 Based on California Employment Development Department 2010–2020 occupational projections that count workers in wage and salary jobs as well as self-employed persons. Similar statistics based on industry projections suggest slightly stronger growth, but exclude self-employed persons, agricultural workers, and unpaid family workers. 8 Employment fgures for 2012 are estimates based on the ACS. In some analysis that follows, we use slightly older employ- ment data (2010) from the California Employment Development Department in order to obtain additional detail on types of jobs within the health care sector. Te total employment estimates range between 1.1 and 1.3 million over this time period. 9 Tere is not an ofcial set of occupations that constitute the allied health workforce. Some therapists are ofen considered part of the allied health workforce, as are other, more technical occupations. We have included most therapists with advanced training in a separate category, choosing to focus our examina- tion of the allied health workforce on those with lower educa- tional requirements. 10 Te BLS reports training and education requirements for entry into occupations for which the BLS produces employment projections. Te level of education and training assigned to occupations is based on quantitative and qualitative informa- tion, including review of available data, interviews with experts and workers in a given occupation, and examination of specifc job postings. Te education assignments are based on the typi- cal education needed to get an entry-level job in an occupation. (Richards and Terkanian 2013). For more information, refer to the BLS Employment Projections, Education and Training Data (www.bls.gov/emp/ep_education_training_system.htm). 11 Bohn (2014) estimates wage premiums for large occupational groups using ACS 2010–2012 data. Tese estimates compare regression-adjusted earnings between workers with some college education and workers in the same occupational category but with only a high school education. 12 Te education information collected in the ACS does not allow us to distinguish between certifcates or awards of less than two years and college coursework that does not result in a degree. 13 Reed (2008) estimates that the regression-adjusted premium to having a college degree (compared with a high school diploma) increased from 55 percent in 1990 to 75 percent in 2005–2006. Given simultaneous increases in the supply of workers, the exis- tence of an increasing wage premium signals increasing demand for skill in the registered nursing profession. 14 Studies suggest that patients prefer providers who are of their own race, are less likely to postpone care when they have a physician of their own race, and report higher levels of satis - faction with their medical care when they have a physician of their own race. California’s Health Workforce Needs: Training Allied Workers 22 www.ppic.org 22 15 For a more detailed discussion of racial/ethnic diversity among California’s nursing workforce, see Waneka and Spetz (2012). 16 Te most recent BLS occupational projections to 2022, released in December 2013, do account for some expected changes in health care industry employment as the result of the ACA, but those are not yet included in state-level estimates. 17 In 2012, about 5,500 of the nearly 12,000 nursing degrees con- ferred in the state were bachelor’s degrees. 18 In fact, the legislature is considering SB 850, a pilot program that would involve community colleges awarding applied bachelor’s degrees in nursing (and other areas). Policies like this might help respond to employers’ demand for more nurses with bachelor’s degrees, but questions remain about training quality and other issues. 19 Gainful employment regulations require public and private college vocational programs to meet certain standards related to student debt loads and employment outcomes in order to remain eligible to receive federal fnancial aid. Te U.S. Depart- ment of Education released revised regulations in March 2014, afer previous attempts at developing federal rules were struck down by the courts in 2012. Te revised regulations establish standards for student loan default rates and debt-to-earnings ratios, whereby if institutions exceed a certain percentage, their students will not be eligible to receive federal fnancial aid. 20 Te minimum graduation and default rates eligibility standards apply only to qualifed institutions where at least 40 percent of the student population is receiving federal fnancial assistance. 21 Based on authors’ calculations of IPEDs data merged with information from California Student Aid Commission (CSAC) Cal Grant Eligible and Ineligible Institutions listing for school years 2011–2012, 2012–2013, and 2013–2014. Te CSAC provides listings of both ineligible and eligible institutions. Another one- third of sub-baccalaureate health degrees completed at for-proft institutions is at schools on neither the eligible nor the ineligible list, suggesting they do not participate in the Cal Grant pro- gram. 22 Te initiative provided state funding and additional public/ private investments to support the expansion of nurse train- ing programs across all California public higher education institutions, including $90 million over fve years to increase educational capacity at California community colleges through a competitive grants process. It also added capacity to bachelor’s, master’s, and doctoral levels of nurse training, created nurse faculty loan programs to incentivize teaching, and invested in clinical simulation laboratories to improve access for rural and medically underserved areas. For more information, refer to annual reports available from the California Labor and Work- force Development Agency. 23 California Community Colleges Student Success Task Force (2013), “Advancing Student Success in California Community Colleges.” 23 Authors’ calculation from California Community Colleges Chancellor’s Ofce Data Mart. See technical appendix Figure B1 for details and categorization of courses. Success rates are share of students with a passing grade (on a course-by-course level). 24 Student success measures, particularly high retention rates, may refect external incentives to stay in and successfully com- plete a course. Many health programs at community colleges are unusual in that they require admittance to a particular program of study, and thus are rationed. Tis rationing may increase stu- dent incentives to keep a course and to pass. Most community college courses are essentially open to all, and course seats are allocated based on student priority, determined by continuing status and other factors. Indeed, this enrollment priority system is one focus of statewide eforts to improve student success at the community colleges, and changes were adopted in 2012 intended to incentivize completion. Recent changes to the priority enroll- ment system may result in improvements to course success rates. 25 Te Health Professions Education Foundation, California State Loan Repayment Program, and National Health Services Corps support scholarship and loan repayment programs for health training in allied health professions, nursing programs, licensed vocational nursing, and others. Te Song-Brown Pro- gram provides fnancial support to accredited training programs for registered nursing—among others—with a goal of providing health care in medically underserved areas. 26 Te California Community Colleges Chancellor’s Ofce has received state funding in the past and distributed grants to col- leges to provide diagnostic and support service to reduce student attrition in nursing programs and promote retention (California Community Colleges Chancellor’s Ofce 2010). 27 Te funding formula for community colleges is set by Propo- sition 98 and is based on student enrollment, not the cost of providing various programs. Te fnancial incentives embedded in Proposition 98 thus discourage high-cost programs, since all funding is allocated at the same rate, regardless of program cost. Additional funding to support high-cost training programs, such as nursing, is sometimes available through various sources on mostly a competitive basis. 23 California’s Health Workforce Needs: Training Allied Workers www.ppic.org 28 Te pathway for nurses reaches beyond the community colleges. Te percentage of students pursuing a bachelor’s or master’s degree in nursing has grown signifcantly over the past 20 years. Califor- nia can encourage this pipeline to higher skills in a few ways. Te frst would be to increase capacity in the community college sys- tem, allowing qualifed students a gateway into the feld of health care. A further step would be to simplify the process of transfer- ring from a community college campus to a California State Uni- versity or University of California campus. Students would beneft from a guaranteed path to higher degrees. 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Shulock, Nancy, Colleen Moore, and Jeremy Ofenstein. 2011. “Te Road Less Traveled: Realizing the Potential of Career Technical Education in the California Community Colleges.” Institute for Higher Education Leadership and Policy report, California State University Sacramento. Spetz, Joanne. November 2011. Forecasts of the Registered Nurse Workforce in California. University of California, San Francisco. Available at www.rn.ca.gov/pdfs/forms/forecasts2011.pdf. Spetz, Joanne. 2013. Forecasts of the Registered Nurse Workforce in California . University of California, San Francisco. Available at www.rn.ca.gov/pdfs/forms/forecasts2013.pdf. Spetz, Joanne, Ken Jacobs, Bianca Frogner, Shelley Oberlin, Steve Parente, Dylan Roby, Nigel Lo, Greg Watson, and Jack Needleman. 2014. “Impact of the 2010 Afordable Care Act on the California Labor Force.” Webinar by Health Systems Innovation Network and SEIU UHW-West. Available at www.seiu-uhweduc.org/file /pdf-documents/ACA-Labor-Force-Impact-Webinar---1-24-14.pdf. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2013. “Projecting the Supply and Demand for Primary Care Practitioners Trough 2020.” Rock- ville, MD: U.S. Department of Health and Human Services. Waneka, Renae, and Joanne Spetz. 2012. Te Diversity of California’s Registered Nursing Workforce . University of Califor- nia, San Francisco. Available at www.rn.ca.gov/pdfs/schools /diversity.pdf. California’s Health Workforce Needs: Training Allied Workers 26 www.ppic.org 26 About the Authors Shannon McConville is a research associate at PPIC. Before joining PPIC, she was a research training fellow in the Health Services and Policy Analysis program at the University of California, Berkeley; a senior research associate at the Department of Health Research and Policy at Stanford University; and a project manager at the Lewis Center for Regional Policy Studies at the Uni- versity of California, Los Angeles. Her research interests include health care access, utilization, and outcomes among vulnerable populations. She holds an M.P.P. degree from the University of California, Los Angeles. Sarah Bohn is a research fellow at PPIC. A labor economist, she focuses on issues at the intersection of public policy and labor markets, with particu - lar attention to low-income and vulnerable populations. At PPIC, her work focuses on poverty, the economy, and higher education. She has published research on California’s community colleges, underground labor markets, and the labor market impact of immigration policy. She has also conducted research on income inequality, with a focus on the role of unemployment and educational attainment on family economic outcomes. Sarah holds a Ph.D. in economics from the University of Maryland, College Park. Laurel Beck is a research fellow at PPIC. She focuses on health policy, including program evaluation, insurance markets, and issues among aging populations. She has also researched the physical and mental health of working mothers. Before joining PPIC, she was a research associate at the Federal Reserve Board of Governors and participated in doctoral trainee programs with the National Institute of Mental Health and the National Institute on Aging. She holds a Ph.D. in economics from the University of Wisconsin–Madison. Acknowledgments Te authors thank Lupe Alonzo-Diaz, David Auerbach, Caroline Danielson, Hans Johnson, and Lynette Ubois for providing very helpful feedback on earlier drafs of this report and Mary Severance for editorial support. We also thank Moreen Lane, Rosielyn Pulmano, Javier Romero, and Joanne Spetz for insightful discussions during the early stages of project development. Any errors are our own. 27 California’s Health Workforce Needs: Training Allied Workers www.ppic.org Board of Directors DONNA LUCAS , CHAIRChief Executive Ofcer Lucas Public Afairs MAR K B ALDASSAREPresident and CEO Public Policy Institute of California RUBEN BARRALESPresident and CEO GROW Elect MAR Í A BLANCOVice President, Civic Engagement California Community Foundation BRIGITTE BRENAttorney WA LT E R B. HEWLETTMember, Board of Directors The William and Flora Hewlett Foundation PHIL ISENBERGVice Chair Delta Stewardship Council M AS MASUMOTOAuthor and Farmer STEVEN A. MERKSAMERSenior Partner Nielsen, Merksamer, Parrinello, Gross & Leoni, LLP KIM POLESEChairman ClearStreet, Inc. THOMAS C. SUT TONRetired Chairman and CEO Pacifc Life Insurance Company PPIC is a public charity. It does not take or support positions on any ballot measures or on any local, state, or federal legislation, nor does it endorse, support, or oppose any political parties or candidates for public ofce. PPIC was established in 1994 with an endowment from William R. Hewlett. Copyright © 2014 Public Policy Institute of California. All rights reserved. San Francisco, CA Mark Baldassare is President and Chief Executive Ofcer of PPIC. Donna Lucas is Chair of the Board of Directors. Short sections of text, not to exceed three paragraphs, may be quoted without written permission provided that full attribution is given to the source. Research publications refect the views of the authors and do not necessarily refect the views of the staf, ofcers, or Board of Directors of the Public Policy Institute of California. Library of Congress Cataloging-in-Publication Data are available for this publication. I S B N 978 -1-5 8213 -159 -7 PUBLIC POLIC Y INSTITUTE OF CALIFORNIA 500 Washington Street, Suite 600 San Francisco, California 94111 Telephone 415.291.4400 Fa x 415 . 2 91. 4 4 01 PPIC S ACRAMENTO CENTER Senator Ofce Building 1121 L Street, Suite 801 Sacramento, California 95814 Telephone 916.440.1120 Fax 916.440.1121 Additional resources related to health and human services and the economy are available at www.ppic.org. The Public Policy Institute of California is dedicated to informing and improving public policy in California through independent, objective, nonpartisan research." 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