Strengthening the Public Health and Healthcare Workforce

November 27, 2024

Introduction

Public health leaders face significant challenges recruiting and retaining a workforce that can provide foundational services to their communities. A 2023 study found that state and local public health agencies lost nearly half of their employees between 2017 and 2021, citing issues such as low pay, limited career advancement opportunities, job-related stress, and burnout. The study also suggests that state health agencies nationwide could lose more than half of the current workforce if the attrition rate continues, draining these agencies of critical institutional knowledge and experience. In addition, the healthcare workforce continues to face significant challenges with national shortages projected for primary care providers, physicians, nurses, and behavioral health professionals. A 2024 study also showed a persistent turnover of healthcare workers post pandemic, including substantial loss of Black employees and many professionals leaving the healthcare profession entirely.

To address these issues, policymakers are taking action to recruit and retain a workforce that can provide crucial public health services in their communities. The federal government is providing funding to 107 jurisdictions, including state, county, city, and territorial health departments, through the CDC Public Health Infrastructure Grant for recruitment, training, and retention.

Legislative Trends

Training the Next Generation of Healthcare Workers

In recent years, state legislatures have used pipeline or pathway programs as a way for students and current healthcare professionals to begin or advance their careers. These programs can successfully address workforce shortages and increase the number of underrepresented healthcare providers and leaders, resulting in a more diverse healthcare workforce—a key factor in reducing health disparities.

In 2024, at least five states enacted legislation that would create, support, or expand programs in several healthcare professions. Arizona enacted SB 1163, which creates a pathway for acupuncturists, physical therapists, naturopaths, chiropractors, and people trained in emergency care by the U.S. Armed Forces to become licensed homeopathic physicians. Hawaii provided funding for the Healthcare Workforce Initiative glidepath program through HB 1827, which allows certified nurse aides to study and become a Licensed Practical Nurse while maintaining their full-time jobs. In addition, the bill provides funding for the state’s high school healthcare workforce certification program, which allows high school graduates who complete the program to obtain entry-level positions in the healthcare workforce.

Maryland enacted SB 718, establishing a pilot program to support students in Licensed Practical Nursing programs who intend to practice in the state or continue in their education to become a Registered Nurse. The program would provide financial support (e.g., loan repayment, tuition assistance) as well as wraparound services such as assistance with childcare, elder care, and transportation. West Virginia established a program through HB 5347 that makes emergency medical technicians eligible for state assistance to become certified paramedics after three years of service.

In addition, states also enacted legislation to promote coordination between state agencies, schools, and universities to bring more students into the health care field through career and technical education (CTE). Colorado enacted SB 24-104, which requires the Department of Labor and Employment to coordinate with the Career and Technical Education Division of the Colorado Community College System to align CTE and registered apprenticeship systems for healthcare programs, among others. Washington enacted HB 2236, which expands the state’s CTE program to include a program for students pursuing nondegree credentials that would lead to careers in healthcare and/or a two- or four-year degree.

Recruiting and Retaining Public Health and Healthcare Workers

Along with advancing current healthcare workforce skills, state legislatures have embraced providing financial incentives for healthcare professionals that currently work or agree to work in rural or underserved communities, such as loan repayment and tax credits. At least four states enacted legislation in 2024 that expands current loan forgiveness programs to include additional healthcare professions. Georgia (HB 872) includes dental students, Oklahoma (HB 1696) includes certified nurse practitioners and general surgeons, and Washington (HB 1946) expanded their loan repayment program for behavioral health professionals to include a scholarship program.

Florida’s SB 7016 expands eligibility for their dental student loan repayment program to include dental hygienists, as well as expands eligibility for reimbursement assistance to include advanced nurse practitioners, licensed practical nurses, registered nurses, and mental health professionals. In addition, Georgia enacted HB 82 which establishes a five-year tax credit for dentists and certain physicians (e.g., pediatricians and OB/GYNs) who live and practice in a rural county.

At least three states also provided incentives to current healthcare professionals and teaching hospitals who train new professionals. Florida enacted SB 330, which designated four hospitals as behavioral health teaching hospitals, and provides each one with funding for up to 10 new residency slots and maintaining integrated workforce development programs. Oklahoma (HB 3351) created a nonrefundable income tax credit for tax years 2025-2034 for faculty preceptors who conduct a preceptorship rotation. Washington (SB 6286) directs the state’s board of nursing to develop and maintain a grant program that provides incentives for certified registered nurse anesthetists to precept residents in healthcare settings.

Sustained Public Health Funding

State and territorial health agencies rely heavily on federal funding for a robust workforce to carry out core public health services, such as infectious disease control and chronic disease prevention. Although ASTHO continues to advocate for sustainable and flexible federal public health funding, state health departments have used innovative strategies such as braiding and layering existing funding to maximize the impact on public health. In addition, several states are investing in their public health system.

The Wyoming legislature (HB 1) increased the public health division’s budget by approximately $8 million, directing the division to provide grants to county public health staff. Additionally, Wyoming enacted HB 74, which directs the Department of Health to increase compensation for counties that provide public health nursing services whenever there is an increase in compensation for public health nursing employees.

Other instances of funded public health initiatives this year include Kentucky (HB 6) providing a $10 million increase over two years for the Kentucky Healthcare Workforce Investment Fund, Maryland (SB 360) providing additional funding to support the state’s loan repayment programs for nurses and nursing staff as well as for school nurses, Michigan (SB 747) increasing funding to expand the state’s Certified Community Behavioral Health Clinic program, and Virginia (HB 6001) fully funding community health workers in local health departments and expanding their Behavioral Health Loan Repayment Program.

Looking Ahead

During the 2025 state legislative sessions, ASTHO anticipates that legislatures will continue efforts to support the public health and healthcare workforces, including:

• Exploring state funding to sustain prior federal investments in public health workers.
• Modifying professional licensing requirements to retain and expand the healthcare workforce.
• Streamlining state hiring processes and modernizing employment policies.
• Investing in workforce pathway and pipeline programs, especially those supporting underserved and under-resourced communities.
• Considering using artificial intelligence for certain tasks that allows health agency staff to focus on other priorities.