health care

Nursing Shortages Will Put California's Plans for Universal Healthcare on Hold

Specifics remain sparse, but universal healthcare will surely increase demand for medical services, and California's already low on nurses.


Based on his inaugural promises, early administrative appointments and first budget, California Gov. Gavin Newsom is preparing to make some type of universal healthcare coverage the centerpiece of his administration. It is unclear if he will take the single-payer route or focus mainly on expanding access for the state's residents to various state and federal healthcare programs, including Medicare.

Whatever one thinks about the wisdom of expanding medical care in this manner, it's clear that demand will increase for medical services. That is the economic reality whenever a highly sought-after service is subsidized, and therefore offered to more people at a discounted price. That means more pressure on the existing system of medical care and a growing need for the services of people who work in the healthcare field.

In particular, Newsom's proposals—whatever their final details—will exacerbate a long-running problem that California policy makers have thus far failed to address: The state's growing shortage of nurses. A 2017 report by the National Center for Health Workforce Analysis, a project of the U.S. Department of Health and Human Services, predicted the need for registered nurses to grow by 28 percent by 2030 largely because of an aging population and an aging workforce. Many states are on track to keep up with the demand, but not California.

"If the current level of health care is maintained, seven states are projected to have a shortage of RNs in 2030, with four of these states having a deficit of 10,000 or more FTEs, including California (44,500 FTEs), Texas (15,900 FTEs), New Jersey (11,400 FTEs) and South Carolina (10,400 FTEs)," according to the report. (FTE stands for "full time equivalents.")

The report notes that nursing staff levels tend to be cyclical, with some periods of surplus. However, the overall trend, especially in California, is for a continued shortfall, especially as employers and legislatures move to require that all nurses eventually receive a four-year bachelor's of science in nursing (BSN) degree rather than a two-year associate's degree in nursing . [Both degrees make you an RN.] That will further limit the supply of nurses given the additional time and cost involved in receiving a more rigorous nursing degree.

A 2016 report by the University of California San Francisco found that "many Chief Nursing Officers are experiencing difficulty recruiting RNs for specialized positions and that more than 90 percent of hospitals reported demand for RNs being greater than the available supply. Hospital vacancy rates have been rising since 2013, reaching 5.9 percent in 2016. There also has been growth in the share of newly graduated RNs reporting they are employed within 12 months of licensure, rising from 59 percent in 2013 to 84 percent in 2016." The bottom line: despite occasional temporary surpluses, the trajectory is clearly toward more severe shortages.

Another way to measure the demand for nursing is to look at the nurse-to-population ratio. California "has ranked a dismal 48th in the nation for the past 10 years," according to the trade journal, Working Nurse. "In 2013, California had an estimated 657 RNs for every 100,000 population, well below the national average of 874 RNs per 100,000. The Nurse Workforce Report Card gave California's RN supply a 'D' grade and projects that by 2030 we will be more than 193,000 nurses short of our nursing needs." Those poor ratios come after the state mandated lower ratios 10 years ago. The publication termed it "wishful thinking" that such a law would "somehow resolve our nursing shortage."

The problem is not salary. California has the second-highest nursing salaries in the nation (more than $100,000 annually), second only to Hawaii. So even with attractive salaries and benefits, the state is falling behind in its efforts to meet the demand. The governor has spoken of the need to control healthcare costs. One way to do that, of course, is to assure that there are enough nurses to fill existing slots so that pay levels won't have to soar even higher to attract new candidates.

Despite the obvious shortage, the California Board of Registered Nursing(BRN), which is the state's nursing-related regulatory agency, appears to have imposed caps on student enrollment in some private nursing programs. That's not only counter-productive, it may be beyond its authority: There is nothing in the BRN's mandate that allows it to determine the number of nursing graduates.

The board has echoed concern "from public schools that some private schools with more resources are providing monetary support to the hospitals and/or paying preceptors, and public schools do not have the resources to do this." This is called "clinical displacement." This is bureaucratic nonsense. The state should assure that there is an adequate number of properly trained nurses—not worry about whether those nurses graduate from public or private programs. The state's public system cannot accommodate the number of applicants.

California's nursing education system has long had too few slots for the number of qualified nursing candidates, a situation going back more than a decade. In 2007, the Legislative Analyst's Office explained, "the number of applicants to nursing schools in California far exceeds the number of available slots," with 28,400 eligible applicants for 11,000 first-year slots. The space shortage was so severe that many public schools use a lottery system to select students, which has left qualified applicants searching for an education among various private and trade schools—or sometimes leaving California altogether.

Some people who advocate for limiting the supply of nurses propose further increasing wages to fill the gap rather than in moving many new nurses through the pipeline. They sometimes argue that the shortage mainly is in experienced nurses or in certain regions of the state. The result would be to restrict the supply of qualified nurses, which makes it tougher for the state to meet its healthcare goals.

It is a strange conundrum. The nation is facing nursing shortages. There is an abundance of qualified students to fill the gap, but the state is imposing barriers to accommodate them. If the Newsom administration is serious about expanding access to healthcare coverage for all California residents, then it needs immediately to address a problem that has been lingering for many years.

This column was first published by the Orange County Register.

Steven Greenhut is a contributing editor for the California Policy Center. He is Western region director for the R Street Institute. Write to him at


NEXT: Movie Reviews: Lords of Chaos and The Man Who Killed Hitler and Then the Bigfoot

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

  1. “The state’s growing shortage of nurses. ”

    You mean nurses aren’t flooding across our open borders as fast as people in need of medical care?

    How odd.

    1. Maybe maybe not, the state is artificially restricting the labor market because public nursing schools can’t compete with private ones. Restricting labor markets does tend to have all sorts of seen and unseen consequences. How odd.

      1. Now now, you know the drill. It’s always the immigrants’ fault, no matter what. It’s probably those rascally Guatemalans who instituted onerous licensure requirements for nurses and health care workers, thereby driving down supply. Damn Guatemalans!

        1. Now now. It is never the immigrants fault. Ignore the costs of care to illegal immigrants. Ignore the 90% of trauma 1 centers shut down near the border from uncikpensated care. Illegal immigrants inject trillions of dollars into the economy, they never cause problems.

      2. Maybe some truth to this. Maybe not.

        Typically, Nursing Boards do this to crack down on diploma mills (as well as inflating testing standards). It’s not like California is restricted to only hiring nurses trained in CA (although I note CA isn’t a compact state. Back when, you could get an agency position where they would fly you into CA for the weekend, put you up in a decent hotel, and pay you up to $125/hr for your troubles to work a burnout position. I have no idea how it works now).

        Nor are any of the concerns raised unique to California (most places are making 4 year degrees mandatory, several have at least informal staff to patient ratios, most states are projected to have nursing shortages by 2030, etc.), although the universal healthcare bit is likely to exacerbate them.

        I also note none of the sources cited really convey this and is rather specific in the picture painted.

        This is shit journalism. Shame on you Reason.

    2. Perhaps we should send the elderly to Mexico where all the nurses are. We could rewrite social security law so that retirees born between 1945 and 1965 need to live in Mexico to collect social security retirement benefits.

      1. Medical tourism is a big business in Mexico. The private facilities are reportedly excellent and far cheaper. People also buy prescription drugs there at a much lower cost.

  2. Well, since manicurists have thousands of hours of education, and are familiar with using cutting tools, the answer is obvious.

  3. Homeless crisis and a nursing shortage… Just throw a couple hundred million at a hobos-to-HMOs jobs training program. Technocrating’s easy.

    1. There are 4000 recently unemployed journos we could train.

      1. “Learn to clean bedpans.” [They been slinging shit for years, now it’s time to clean it up.]

      2. “We see you are using an ad blocker. Please whitelist your nurse if you want your bedpan dumped.”

  4. Central planners couldn’t run a lemonade stand, and some people want them in charge of health care?

    1. Central planners are fully capable of running a lemonade stand.
      First you nationalize all lemon trees, this allows for free lemons.
      Then you nationalize all lumber mills, this allows for free lumber to build the stand,
      Then you create a national training program for lemonade mixers, this provides the workforce.
      Then you mandate lemonade stands every four blocks in cities and every 5 miles in rural areas, this provides the market.
      Then you fix the price of a glass (no disposable items) of lemonade at $1.00, this makes it affordable for everyone. As an additional benefit, anyone who could not be trained as a lemonade mixer can become a dishwasher.
      Then you require everyone to drink at least one glass of lemonade a day, for hydration, to preserve public health.
      Then you raise taxes on the rich to pay for it.

      1. You forgot to outlaw water so there is no competition.

        1. Not exactly forgot; the government will need water to make the lemonade. I just figured it was cheap enough now that it would not need to be nationalized.

  5. I should have become a nurse. I could have gotten a nursing degree, but when I was young, I was worried about accidentally killing someone if I became a healthcare professional. Now that I’m older and wiser, the possibility of accidentally killing someone doesn’t worry me at all.

    1. Not the right career for everyone. Lot of stress and burnout as well.

  6. Don’t worry the New Green Deal will fix this.

  7. the possibility of accidentally killing someone

    Feature, not a bug.

  8. But, Muh Rights….

  9. Hey, it’s like “houses for everyone–housing is a human right,” and then the left makes it completely unprofitable and a migraine-inducing hassle to actually build enough housing for everyone.


  10. Start working at home with Google. It’s the most-financially rewarding I’ve ever done. On tuesday I got a gorgeous BMW after having earned $8699 this last month. I actually started five months/ago and practically straight away was bringin in at least $96, per-hour….??…..HEAR>>

  11. I am creating an honest wage from home 2500 Dollars/week , that is wonderful, below a year agone i used to be unemployed during a atrocious economy. I convey God on a daily basis i used to be endowed these directions and currently it’s my duty to pay it forward and share it with everybody, Here is I started…..

  12. Twenty years ago there was a serious shortage of pharmacists, and the big chains were paying through the nose.

    So they got together, and their solution was to fund a bunch of new pharmacy schools all over the country. Then they advertised the crap out of those super great starting salaries a degree promised, and the schools priced tuition to match. All that ‘free’ student loan money took care of the rest.

    Now there is a glut of recent graduates with exorbitant levels of student loans, and salaries either stagnant or trending down. Most would have been better served financially, if not professionally getting a two year RN, and working while turning that into a BSRN.

Please to post comments

Comments are closed.