Occupational licensing laws make it illegal for aspiring workers to begin working before meeting minimum entry requirements and define what services they can provide. Economic research has consistently shown that occupational licensing results in higher wages for licensed professionals and higher prices for consumers. More recent research finds that occupational licensing results in reductions in employment and significant deadweight losses. Evidence is much more ambiguous with respect to the effects of occupational licensing and the quality of service received. In fact, a recent study finds that consumers in an online marketplace for contracting services are much more interested in reviews from peers than the provider’s licensing status. With this evidence in mind, several states have taken steps to reform occupational licensing to make sure that regulations are serving the best interest of consumers. To provide some assistance with this effort, we have organized this symposium on occupational licensing reform in Utah.
By Kihwan Bae
Knee Center for the Study of Occupational Regulation (CSOR) and Saint Francis University
Occupational licensing typically requires professional service providers to satisfy a list of licensing requirements. Among them, one of the most common licensing requirements is the requirement on the minimum level of education though professional schools. Some of these requirements are familiar: nurses are required to have a certificate or degree from a nursing school, and doctors a professional degree from a medical school, according to the CSOR database. But some might be surprising. For example, Utah asks cosmetologists to obtain 1,600 hours of education in a cosmetology school, which is more than ten times as long as the coursework required to become an Emergency Medical Technician (EMT). On top of that, occupational licensing usually requires aspiring workers to pass exams on the professional knowledge or skills relevant to the profession. The intent of these licensing requirements is to improve the proficiency of service providers and protect consumers from unscrupulous practices.
However, education requirements for occupational licensing are likely to be a barrier to entry into the profession and many do not improve the service quality of licensed professionals, and thus raise prices and reduce access for consumers, and impose wasteful costs on professionals themselves.
As Milton Friedman documented in his bestseller Capitalism and Freedom, professional associations like the American Medical Association usually set the education and training requirement for individuals and also accredit professional schools or training institutions. Under these circumstances, professional associations may have a perverse incentive to heighten the education requirement to benefit existing professionals at the expense of aspiring workers and consumers. Indeed, a recent study showed that an increase in the minimum credit hours for certified public accounts (CPA), from 120 to 150 hours, reduced the number of new CPAs, raised wages for members of the profession, but did not improve the quality of accounting service.
Occupational licensing also puts additional burdens on aspiring workers by driving them to obtain a costly college education, which is often financed by student loans. About a half of licensed jobs require college education, and about two-third of recent college graduates financed their college education with student loans. Moreover, my recent study demonstrated that college graduates with occupational licenses are about 10 percentage points more likely to have borrowed for their college education than those without licenses, and have borrowed about $12,000 (38.5 percent) more than those who are unlicensed. The difference between the licensed and unlicensed graduates is mostly driven by licensed workers who have borrowed for postgraduate education. Furthermore, occupational licensing also contributes to the student loan accumulation of non-college graduates in low-income occupations. Two undergraduate certificate programs, cosmetology and health and medical assistance, are among the top ten programs with the most student loan borrowers, and they together generate more student loan borrowers than bachelor’s degree program in nursing.
Often, the educational requirements seem arbitrary and not commensurate with the likelihood that the requirements fulfill their purpose of protecting consumers or improving proficiency. For example, education requirements for the same occupation often differ across states. The cross-state variations are particularly pronounced among low income occupations. For example, the minimum level of education for cosmetologists ranges from 1,000 hours in New York to 2,100 hours in Iowa. Similar differences also exist for other occupations such as barbers, manicurists, skin care specialists, massage therapists, and EMTs. Sometimes, requiring a high school diploma restricts entry into a profession. One specific case is barbers in Tennessee—state policy makers added a requirement for barbers to complete high school in 2015. The state’s Chancery court recently ruled this requirement to be unconstitutional. The seemingly arbitrary variations in education requirements also signify the necessity and plausibility of licensing reforms to relax extra burdens on certain professionals in certain states.
The occupational licensing of Utah influences a larger fraction of workers than that of other states. 23.8% of workers are licensed in Utah while 21.7% are in the United States. Utah ranks 18th for the number of low income licensed occupations among all states. Utah’s education requirements for occupational licensing are broadly similar to or somewhat less strict than those of other states. For example, cosmetologists, barbers, skin care specialists, massage therapists, manicurists, and EMTs, respectively, are required to obtain no more than the median of hours of education of all states. Nevertheless, because of the broad coverage of low income occupations, Utah’s occupational licensing is likely to impose disproportionately large burdens on aspiring workers in low income occupations.
While the student loan crisis is less severe in Utah—thanks, in large part, to well-funded educational institutions and a high proportion of students that elect not to borrow—many students borrow to pursue a postsecondary degree. 36% of recent college graduates financed their college education with student loans in Utah whereas 65% did in the United States, and the average debt was $19,728 in Utah compared to $29,200 in the United States. According to the College Scorecard data, federal student loan default rates of those who recently entered into repayment are about 6% in Utah, which is much lower than the national average of about 10%. Despite the good news here for Utah residents, the education requirements for low income licensed occupations in Utah force aspiring workers to obtain costly education in for-profit schools and bear student loan debts. For instance, according to the College Scorecard, students pursuing the required 1,600 hours of training at Salt Lake City’s Paul Mitchell the School pay about $16,182, and 77 percent of students borrow about $10,555 each.
Given the costs of occupational licensing, particularly those due to education requirements, I propose three policy measures to the state of Utah. First, the state should delicense low-income occupations to set aspiring workers free from costly education for insufficient returns. For example, Alabama did not license barbers in 1983-2013. As an indirect, partial delicensing method, Utah and several other states recently exempted hair stylists or braiders from obtaining cosmetology licenses. The state of Utah could extend this movement by fully delicensing cosmetologists and barbers.
Next, the state should implement a review of education requirements for occupational licensing. It could be a part of the sunset review on existing licenses or sunrise review on new licenses. In particular, the review should carefully scrutinize the need for postgraduate education requirements, which are the most prohibitive and costly of all education requirements. In this vein, many states have recently relaxed the CPA exam sitting rule from 150 to 120 credit hours so that the candidates can take the exam without a master’s degree or additional college credits. The state of Utah could follow this practice or even return the CPA licensing rule to 120 credit hours. More generally, the state could review the number of hours of initial and annual training required in each field.
Lastly, the state could provide the minimum level of education for low-income occupations through community colleges. For-profit colleges now have a big role in vocational education, for example, for cosmetologists, beauticians, health and medical assistants, cooks, mechanics, and technicians. Attending a for-profit college may be too costly for those who end up with low-paying jobs, however. Expanding the role of community colleges in vocational education with additional federal or state funding will be a plausible way to protect aspiring workers from spending too many resources for low income service occupations.
By Michael Bednarczuk, PhD
Senior Research Analyst
Institute for Justice
AFL-CIO Chair Professor of Labor Policy University Of Minnesota, Twin Cities
One of the largest and fastest growing labor market institutions in the U.S. and in Utah is occupational licensing. The institution requires workers to obtain permission from government in order perform certain tasks. The process creates barriers to entry both as workers shift from other occupations and from nonwork to the workforce (Kleiner and Xu, 2020). In addition, licensing regulations reduce interstate migration of licensed workers (Johnson and Kleiner, 2020). All these regulations impair the functioning of labor markets, and Utah is no exception. Estimates show that occupational licensing cost Utah almost 20,000 jobs in 2015 and reduced economic output by at least $90,000,000. While high, these costs were still much less than in many surrounding states (Kleiner and Vorotnikov, 2018). As has been shown, these types of regulations have the potential to create barriers to more efficient labor markets and reduce economic development.
One of the key elements driving the growth of licensing-related economic burdens has been the increasing role of national associations that represent licensed occupations and help develop licensing standards. One illustration of the role of national associations involves the state of Nevada and their regulation of dietitians. Initially, from 1995 – 2012, dietitians were certified which means that only persons who met certain requirements could use the official title of the occupation (right to title) in Nevada (Occupational Licensing Statute and Regulatory Law Research Project (ORLP) at the University of Minnesota, 2020). In other words, practitioners had to be registered with the Commission on Dietetic Registration (CDR), the national professional association, in order to use the title “dietitian” when providing any nutritional advice to patients.
In 2012, Nevada required individuals to obtain an occupational license to provide dietitian services for pay. To acquire a license, individuals dispensing nutritional advice had to pass an exam. The exam was administered by the CDR, and to take the exam, individuals had to fulfill the eligibility requirements determined by the professional organization (rather than requirements determined by the state). Consequently, the CDR effectively controlled entrance into the occupation in Nevada (and other states with similar regulations). The CDR has announced plans to require a Master’s degree to be eligible to take the exam as of January 1, 2024, according the association. Therefore, even if states do not raise their individual degree requirements from a bachelor’s degree to a master’s degree by January 1, 2024, a Master’s degree will effectively be the minimum degree requirement in states that require applicants to complete the CDR for licensure. And it is not just dietitians. As another example, physical therapists have often used the recommended standards of the professional association as a boilerplate standard to whipsaw states into developing similar procedures (Cai and Kleiner, 2020). These requirements suggest that the professional licensing bodies rather than the states will often determine entry into occupations in the state.
The data from the OLRP for Utah shows that dietitians are certified in the state, which means they have a right to title for the position. However, Utah (like Nevada) uses the national standards developed by the professional organization for certifying the occupation. One consequence is that the national professional organization, rather than the Utah state legislature, determines the standard for certification in the state.
In addition, these policies can have two potentially negative outcomes, one legal and the other economic. First, if the board is only following the professional association’s procedures, they may be in violation of the Supreme Court decision in the North Carolina state Dental Association versus the FTC (North Carolina State Board of Dental Examiners v. Federal Trade Commission, 2015). In this case the Court ruled that regulatory board decisions must have oversight by the sovereign and that Board members could be sued for triple damages, if individuals could show that there were economic losses to individuals or groups because the government dd not provide appropriate oversight.
Second, if the state adopts the boilerplate requirements from a national association, it fails to consider the economic and labor market conditions in a state. As a result, the state would not be incentivized to look after the best interests of its citizens. For both reasons, the use of national templates promoted and required by national associations whose interests are the economic well-being of its members, may be a net loss to the consumers of the service in a state.
To address these issues arising from undue deference to national professional bodies, state policymakers could adopt two major interrelated proposals. First, in a federalist system, states, not national organizations, are the preferred appropriate entities to license occupations. States are better able to adjust regulations to the specifics of the local labor market allowing for greater flexibility for the state’s labor force. Under the federalist system, states determine the efficacy of licensing for their citizens.
Second, states should use cost-benefit analysis to evaluate whether certification, licensing, or lesser forms of regulation should apply. Other states, like Colorado, have established a Department of Regulatory Agencies (DORA) which conducts cost-benefit analysis of occupations that are seeking regulation and periodically evaluates occupations to examine if they should be regulated. The agency is guided by evidence gathered and evaluated by analysts at DORA. For example, Funeral Directors moved from full licensing in Colorado to voluntary certification, in part due to the periodic reviews available through DORA.
My proposal for Utah is that when an occupational group seeks new licensing or a change in licensing requirements, or when a regulatory commission conducts a review of existing licenses, the governing state body should conduct a rigorous analysis to determine whether licensing (or additional licensing) is justified. The main criteria for regulation should be the health and safety of consumers and labor force issues. The inputs into that analysis could come from existing studies—if they exist and are deemed to be rigorous—or from new analyses. Representatives of Utah should consider the consumer and labor market conditions in the state along with guidelines for evaluating fundamental answers to questions on licensing. National guild-mandated guidelines for entering an occupation should be viewed with skepticism given the incentives for occupational associations is mainly concerned with the interests of the purveyors of the service and less with public concerns.
References
Cai, Jing and Morris M. Kleiner. 2020. The Labor Market Consequences of Regulating Similar Occupations: the Licensing of Occupational and Physical Therapists. Journal of Labor Research, 41, 352–381. https://doi.org/10.1007/s12122-020-09309-0
Johnson, Janna E., and Morris M. Kleiner. 2020. “Is occupational licensing a barrier to interstate migration?” American Economic Journal: Economic Policy 12.3: 347-73.
Kleiner, Morris M., and Ming Xu. 2020. Occupational Licensing and Labor Market Fluidity. No. w27568. National Bureau of Economic Research.
Kleiner, Morris M. and Evgeny S. Vorotnikov, 2018. At What Cost?: State and National Estimates of the Economic Costs of Occupational Licensing, Institute for Justice, Arlington, Va. Pp. 1-64.
Occupational Licensing Statute and Regulatory Law Research Project (OLRP). 2020. Minneapolis, MN: Minnesota Population Center, University of Minnesota.
North Carolina State Board of Dental Examiners v. Federal Trade Commission, 135 S. Ct. 1101. 2015. http://www.supremecourt.gov/opinions/14pdf/13-534_19
By Conor Norris
Knee Center for the Study of Occupational Regulation
In most markets, the adoption of technological innovations has reduced information asymmetry between buyers and sellers, making it easier to engage in transactions. However, these advancements have been slow to impact the housing market, which has remained surprisingly static. A lack of competition in local markets and the need to cooperate with other agents has kept commissions persistently high, even as the number of real estate agents has grown substantially. The total value of homes is over $33.3 trillion in the U.S. and over 5.3 million existing homes were sold in 2019, so persistently high commissions represent a substantial economic cost. Even when new entrants try to innovate and offer low prices, legacy practices maintained by cooperation between agents make competition difficult. Policymakers in Utah should consider reforms that would encourage price competition on commissions and make the market more efficient.
Agents are licensed by states, which set the standards to enter the profession. Like most other professions, these requirements for real estate agents vary widely between states. For instance, the minimum required education to obtain a real estate agent’s license ranges from 30 hours in Wyoming to 180 hours in Texas, with a median of 68 hours. Research has consistently found that licensing reduces the supply of workers in a profession and the same is true for real estate agents. Ingram and Yelowitz find a positive relationship between housing prices and the number of real estate agents, but fewer agents are able to enter the market in states with higher barriers to entry.
Because the agent commission rate is generally fixed, when home prices increase, more real estate agents enter the market. The number of agents changing in response to price changes, suggests that competition is dynamic. Membership in the National Association of Realtors (NAR) has doubled since 2000, while the number of houses sold has remained constant. However, looking at prices would suggest that the market is not competitive. In Utah, the rate of commission has remained stable at around 5.36 percent, which has resulted in the average commission being paid to increase from $11,404 in 1996 to $13,132 in 2020, adjusted for inflation. Similarly, the number of real estate agents in Utah has increased from 15,260 in 2002 to 26,407 in 2021 without impacting commissions. In other countries, like the UK, sellers typically pay just 2 percent in commissions, and they have fewer agents than the U.S.
In a competitive market, new real estate agents would not have to rely on top brokerages or be forced to sell under broker dealers. The commission rate would vary between homes. Properties that were more likely to sell quickly and with less effort would command lower commissions, while harder to sell properties would command a premium. Likewise, we would see real estate agents with more experience earning a higher commission. An increase in real estate agents, like Utah has experienced since 2002, would result in lower commissions as they compete for business.
The first code of ethics adopted by the National Association of Real Estate Exchanges stipulated that real estate agents should charge the commission rate prescribed by their local board, rather than attempt to compete on price by undercutting other members. They also encouraged the agent representing the seller to split the commission with the agent representing the buying evenly. To this day, typically the seller’s agent charges a commission from their client and splits the commission evenly with the buyer’s agent.
Local real estate markets are dominated by top brokerage firms, which have much higher concentration ratios than the market at the national level. Additionally, the top agents are critical for success in a local market. The top 10 percent of agents in terms of sales represented either the buyer or the seller in 81 percent of transactions. To be successful, real estate agents must cooperate with top brokerages and agents, limiting new entrant’s ability to compete on price. Any attempt to undercut commissions or charge a different type of fee that would reduce the top agents’ incomes would result in a refusal to cooperate, driving them from the market.
This has not occurred in the real estate market, because of the cooperation between agents necessary to make a sale. According to the Federal Trade Commission, the practice of steering makes price competition an unsuccessful strategy, resulting in persistently high commissions. Agents for buyers look for properties on the Multiple Listing Service (MLS) that meet their client’s needs. But the listing agent also includes the commission rate in the MLS, so the buyer’s agent knows which properties will pay them the highest commission. The buying agent, who is often with a top broker or a top agent, will first consider properties offering a higher commission. Berwick and Wang find evidence that in Massachusetts, properties offering lower commissions are less likely to sell, and when they do sell, they spend more time on the market. Listing agent’s success is measured by the time it takes to sell a property, so steering prevents them from undercutting other agent’s commission.
In Utah, a real estate agent cannot participate in the market without an affiliation with a principal broker. This additional regulation requires more cooperation between agents and gives the principal broker some authority over new entrants to set commission rates.
Policymakers have several alternatives to encourage competition in the real estate market. A simple solution would be to untie the commission payments, which is the norm in other similar markets. The buyer would pay a commission to their agent, and the seller to theirs. This would reduce the threat of steering and encourage buyers to consider commission when selecting an agent. Another possibility would be to encourage rebates from agents, like we see for some consumer goods. Rebates would encourage price competition, but leave current industry practices in place, so it’s a simpler reform.
Utah could combine one of the first two options with reforms that increase competition. For instance, they can remove the requirement for new real estate agents to practice with an affiliation with a principal broker, giving new entrants more ability Another means of increasing competition is to reduce the occupational licensing requirements for real estate agents. Currently, Utah require 120 hours of education, one of the highest in the nation and almost double the median. Reducing education requirements to 60 hours would save aspiring agents an estimated $1000. A final reform could take the shape of requiring greater transparency for agents, especially the buyer’s agent. Requiring them to disclose their commission rate and its effect on the price the buyer will pay will add transparency and encourage buyers to shop based on price. These reforms would encourage competition and reduce the inefficiencies currently present in the real estate market.
By Ryan Nunn, PhD
Assistant Vice President, Community Development and Engagement, Federal Reserve Bank of Minneapolis
and Gabriel Scheffler
Associate Professor of Law, University of Miami School of Law
During the COVID-19 pandemic, many states, including Utah, took emergency actions to temporarily modify or suspend specific occupational licensing restrictions for health care providers.[1] These reforms had two general objectives: first, they aimed to maximize the overall supply of health care providers for COVID-19 patients, thereby reducing the chances that the health care system would be overwhelmed by an influx of patients. Second, they aimed to remove barriers to the flexible redeployment of health care providers, thereby enabling them to work in the areas (and at the times) of greatest need.
Although there is as yet little direct evidence on the impacts of these reforms, earlier research suggests that many of these measures likely increased access to health care without reducing the quality of care being provided. Which raises the question—why not make these changes permanent?
Background on Licensing of Health care Professionals
Occupational licensing requirements are typically justified on the grounds that they protect the public from dangerous or incompetent practitioners. This justification is especially compelling in the context of health care, where it is often difficult for patients to evaluate practitioners’ competence, and where provider errors can have devastating consequences (Arrow 1963).
Yet while there is a strong case to require health care providers to be licensed, that does not mean that the current licensure system is well-designed (Nunn and Scheffler 2019). To the contrary, there are four specific aspects of the health care provider licensure system that stand out as impeding access to health care, while only providing minimal health and safety benefits (Scheffler 2019):
- Limited scope of practice for non-physician health care providers
- Lack of recognition of providers with non-U.S. credentials
- Lack of recognition of providers licensed in other states
- Limits on telehealth
The best-studied of these areas is non-physician scope of practice, where restrictive policies have not been found to raise quality—though they do raise prices and limit availability (Adams and Markowitz 2018). Similarly, lack of recognition for out-of-state physicians (whether practicing in-person or remotely) are difficult to justify from a public safety perspective since education and training requirements are set nationally (Kocher et al. 2014). Finally, state licensing laws likely deter many qualified and experienced foreign-trained providers from practicing in the United States by declining to recognize their overseas training and experience (Gross 2014).
How states responded to COVID-19
As COVID-19 prevalence increased and then declined at different times in different places in 2020, health care supply was often poorly matched to demand. In some places—like New York City in March and April 2020—health care provider shortages were dire.
To address these problems, several states relaxed scope of practice restrictions for health care practitioners: for instance, California temporarily allowed nurse practitioners to provide a broader range of care and Michigan did the same for licensed practical nurses and registered nurses. Utah expanded scope of practice for licensed practical nurses.
One common regulatory reform was to recognize the licensure of providers from other states on a temporary basis. For example, a March 2020 executive action in Florida allowed health care professionals licensed in other states to treat COVID-19 in Florida, under certain conditions. Executive action in Delaware allowed out-of-state providers to work in Delaware and permitted those who had recently retired to re-enter practice. New Jersey looked abroad, temporarily permitting physicians licensed in other countries to practice.
Notably, Utah has legislation authorizing the suspension of various licensure requirements for out-of-state medical professionals, as well as the suspension of scope of practice requirements for certain types of providers, upon the declaration of a national, state, or local emergency, or a public health emergency. During the pandemic, Utah also permitted formerly licensed individuals (if the license was in good standing when it expired) to practice in a volunteer capacity.
Several states and the U.S. Department of Health and Human Services also relaxed limits on telehealth. As with many sectors of the U.S. economy, remote work became even more valuable during the COVID-19 pandemic, enabling providers to reach patients who were reluctant or unable to receive services in-person. Alaska, Florida, and Hawaii are notable examples of states that made telehealth more accessible; Hawaii took the especially important step of allowing telehealth even when a provider did not have an existing relationship (and prior in-person consultation) with a patient.
What should policymakers consider in 2021?
The reforms described above are good examples of how states can continue to support the availability of high-quality health care for patients during a time of unprecedented stress on the health care system. However, many of these reforms were only enacted on a temporary, emergency basis. As the COVID-19 pandemic subsides, policymakers will be faced with important choices regarding which of these reforms to make permanent.
Like every state that relaxed health care licensure restrictions during the pandemic, Utah has an opportunity to both build on its own emergency measures and look for new ideas. For instance, Utah could both a) make permanent the recognition of out-of-state licenses it currently provides and b) recognize high-quality licenses granted in other countries. These two steps would make it easier for highly trained health care providers from other states and countries to practice in Utah, thereby further expanding the supply of qualified providers and increasing patient access. Another possibility is to make permanent the expanded scope of practice for non-physicians that state regulators can implement during a state of emergency.
In weighing these decisions, it is vital that policymakers consider the full range of costs and benefits of these changes. In order for a restriction to be justified, there must be evidence of health and safety benefits that exceed costs arising from reduced employment and access to health care. While health care licensure clearly has substantial health and safety benefits in many instances, this does not mean that every aspect of states’ licensure rules passes a cost-benefit test, or that it optimally accommodates the evolving needs of patients in a world of pandemics and remote practice. Policymakers should give special attention to the possibility of expanding scope of practice, recognizing out-of-state and foreign credentials, and maximizing the allowable use of telehealth.
By Robert Orr
Policy Analyst at Niskanen Center
Utah has made tremendous strides in easing excessive licensure-related barriers to health care professions. The next step for Utah should be the reduction of the administrative burdens imposed on practitioners by licensing. This should involve the lengthening of current licenses’ duration as well as the creation of a telemedicine registry for out-of-state providers.
The benefits and perils of health practitioner licensing
The purpose of licensing regulations is to ensure a minimum standard of quality, protecting consumers from charlatans and quacks. And, indeed, there is evidence that licensure has been successful in doing so with regard to health practitioners. The establishment of licensure of physicians and midwives in the late 19th and early 20th centuries has been linked to meaningful quality improvements, including lowered mortality.
However, the restrictions and administrative headaches imposed by contemporary state-licensing regimes often go beyond what can be defended based on the evidence. There are three areas where state licensing regulations tend to run amok. The first is needlessly difficult licensure requirements, such as more difficult licensing exams. Evidence is lacking that filtering out applicants beyond basic education credentials and the like results in improved quality. To illustrate, states with more stringent licensing of dentists appear to have simply charged more without delivering better quality. The second area where licensing regulations tend to fail is providing insufficiently flexible “scope of practice,” which defines what health care services a given licensed practitioner is authorized to do. For instance, easing restrictions on practice scope for highly-trained non-physician practitioners such as nurse practitioners and physician assistants has been repeatedly shown to improve access without sacrificing quality, reducing emergency care utilization as well as costs for insurers and consumers. The third way in which licensing regulations can be poorly designed is by imposing excessive barriers to cross-state practice. Given that licensing is administered by states, incompatible licensing requirements or onerous administrative processes can often delay or outright prevent practitioners’ ability to work in a state they’ve moved to or to offer cross-state telemedicine services.
Utah leads in terms of licensing reform, but room for improvement remains
Utah has placed itself largely at the forefront of evidence-driven regulatory reform for health practitioners in recent years. Licenses for health professions in Utah uniformly avoid the needlessly onerous requirements found in some other states. Legislation enacted earlier this year expanded practice scope for physician assistants and nurse practitioners, granting them the flexibility and autonomy necessary to better serve Utahans’ health care needs. Additionally, Utah has signed onto more interstate licensure compacts for health professions than any other state. Compacts are agreements between states that ameliorate cross-state licensing barriers, including the Interstate Medical Licensure Compact and Nurse Licensure Compact, which ease migration for physicians and nurses, respectively. Utah has also similarly signed onto compacts for physical therapists, psychologists, and emergency medical technicians. Additionally, health professions not covered by compacts benefit from Utah’s 2020 law stipulating that professions licensed in other states are generally eligible for licensure in Utah without undergoing additional training or credentialing.
However, while Utah’s licensing regime for health practitioners is better than in much of the country, there is still room for improvement. Current rules still impose administrative headaches that go beyond what can be defended on the basis of quality, particularly with regard to out-of-state practitioners looking to serve Utahans via telemedicine.
The benefits of recognizing out-of-state licenses are generally limited by the fact that multi-state practitioners are still required to maintain licenses in multiple states. Recognition through licensure compacts or other means merely streamlines the licensing process while leaving intact the need to obtain multiple licenses in order to practice in multiple states. The notable exception here is the Nurse Licensure Compact, which comes close to creating a genuine free-trade zone in 30-plus states, allowing nurses licensed in, say, Colorado, to work in Utah or any other member state without additional hassle. Nurses in compact member states need only to apply for a new state’s license upon changing their location of permanent residence.
This status quo for physicians and other practitioners is costly not only for those looking to move to Utah, but often also for those practicing in communities near state borders. Multi-state licensure is particularly costly for practitioners looking to provide telemedicine services. To illustrate in the case of physicians, the Interstate Medical Licensure Compact merely grants an expedited licensing process, maintaining the need to become approved and pay additional fees for each state that they practice in. Currently, over 22 percent of physicians are licensed in at least two U.S. states and 7 percent of physicians maintain licenses in three or more states. But only 14 physicians in the entire country are licensed in all 50 states. Achieving physician licensure throughout the entire U.S. would cost well over $10,000 in renewal fees every couple of years. With Utahans making up less than 1 percent of the nation’s population, the paperwork and fees involved in obtaining a separate Utah license make the state a relatively unattractive market to expand telemedicine services.
Next Steps for Utah Health Practitioner Licensing
The Department of Veterans Affairs (VA) provides a useful model for reforming Utah’s licensing rules here. In order to work for VA facilities, physicians, nurses, and other health professionals need merely to be licensed in any one of the 50 states. And VA telemedicine providers require just a single state license to provide services anywhere in the country. This is because the VA utilizes its federal authority to bypass state-level restrictions that run contrary to ensuring patient access. A Government Accountability Office report found that imposing state-by-state licensing on the VA would likely result in tangible difficulties with hiring and telemedicine operations while producing no discernible benefit. Though no state has thus eased restriction on cross-border medical services as much as the VA on a permanent basis, Colorado has done as much temporarily in response to COVID-19. Given evidence suggesting health care practitioners such as nurses responded to the pandemic by moving to virus hot spots, it’s likely that licensure liberalizations of this sort were effective.
Utah could mimic the VA by allowing health care providers to practice in Utah on an out-of-state license, superseding the flexibility granted under existing compacts, at least within Utah. Under such a move, licenses from out of state would remain valid until expiry, at which point licensees would be required to obtain a Utah license if that was their place of residence. This would represent merely an expansion of an existing Utah practice. Under Utah’s current law, physicians licensed in other states with at least 10 years of professional experience may legally provide care without applying for a duplicative Utah license. The current catch, however, is that such care may be provided solely on a charitable basis. By expanding this exception to physicians in commercial settings, as well as to other practitioners, Utah law would provide unparalleled freedom from needless barriers to cross-state practice. Not only would this benefit practitioners moving into Utah and those residing near the state’s border, but it’d also provide Utahans with unparalleled access to innovative telemedicine services provided by licensed practitioners anywhere in the country.
A more limited path for reform would involve carving out an exception for telemedicine specifically. Currently, nine states, including neighboring New Mexico and Nevada, carve out an exception to state licensing laws for out-of-state practitioners engaged in telemedicine services. In Florida, for example, health practitioners licensed and residing outside the state may provide telemedicine services with no fees and minimum hassle by simply signing up through the state’s telemedicine registry.
Finally, Utah should consider at least doubling the duration of its licenses. Under current Utah law, licensed physicians must submit paperwork regularly to maintain practice rights while paying related fees that can add up to between $1000 and $1500 each decade. This need to file paperwork every couple of years provides zero discernable benefits to patients. In fact, licenses for providers in European countries such as Sweden never expire, barring disciplinary action. Doubling Utah license durations would cut such fees in half, effectively cutting taxes for all practitioners in the state. And truth be told, health care practitioners have enough paperwork to deal with as part of their job.
Utah is further along in easing unnecessary licensing burdens on health care practitioners than most states. But that doesn’t mean that its work is done. The next steps should involve easing restrictions on practice by out-of-state providers and increasing license durations in order to minimize unnecessary fees and paperwork. Doing so will provide Utahan with better access to care and make Utah a more attractive state for providers, particularly with regard to the rapidly developing field of telemedicine.
By Stephen Slivinski
Senior Research Fellow and Director of the Doing Business North America Project at the Center for the Study of Economic Liberty at Arizona State University
Current occupational licensing laws in most states restrict the ability of someone moving from another state to immediately begin to work in the licensed profession upon arriving without first getting an occupational license issued by the government of the new state of residence. Depending on the occupation, this “re-licensing” requirement can be costly and time-consuming – it can require fees and multiple hours of training and duplicative exams. The redundant training requirements in particular can be quite onerous, particularly for someone already experienced in their field.
These impediments to starting work upon arrival can be a disincentive to move somewhere in the first place. Economists Janna Johnson and Morris Kleiner of the University of Minnesota have estimated that someone knowing she’ll be faced with a required re-licensing in the destination state leads to a substantially depressed rate of interstate migration when compared to those occupations that have some form of license reciprocity, endorsement, or no state-specific licensing exam requirement.
The lack of a pathway for licensed individuals to easily move isn’t as significant for all workers. For instance, attorneys and many in the medical profession don’t experience the same lack of mobility since the recognition of the license often does not rely on a set of additional state-specific requirements beyond having proven competency on an exam administered or some kind of certification earned by a nationally-recognized third-party.
The “trailing spouses” of enlisted members of the military can be among the hardest hit by re-licensing requirements in many states. When required to move, licensing barriers often prohibit them from working upon the completion of their transfer.
Luckily, this is not a problem that military couples moving to Utah need to worry about. Since 2018, those transferred to Utah can receive a license in their occupation upon arrival as long as the license in their chosen field is active in the prior state or residence. In fact, Utah’s law on this matter was among the first to be enacted in the U.S.
In 2020, this approach was broadened to all workers moving into Utah. Changes to the law stated that as long as a license is required for a particular occupation in Utah and the new resident has a license in good standing in their state of origin, Utah would issue that person a state license upon arrival.
Utah’s reforms were fortuitously timed. The state was a desirable destination for workers and companies even prior to 2020. The workforce changes that resulted from the Covid-19 pandemic that year only increased the potential to encourage more workers to choose Utah as a relocation destination. The seemingly permanent changes to workforce arrangements in the wake of the Covid-19 pandemic will likely continue to drive workers to migrate in larger numbers than before, particularly away from high-cost cities and into those with a more reasonable cost of living.
It also placed Utah in the vanguard of a handful of states — a total of at least 12 by the spring of 2021 – that have enacted some form of universal recognition. This type of reform – which is best described as “universal licensing recognition” for reasons that will become evident – was different than a particular type of reciprocity that has existed for many years: interstate compacts.
Interstate compacts are agreements between two or more states to allow occupational license portability between residents of member states. A license holder who moved from a state that is a member of the compact to another compact member-state can obtain a license by endorsement by actively applying for one. This only works when moving from one compact state to another.
These attributes make it a less flexible and effective solution for expanding opportunity
for new workers. A compact typically covers only one occupation and requires deliberation, negotiation, and legislative action over several years to be enacted. Increasing either the number of states in the compact, the number of occupations it covers, or (ideally) both, would take substantially more time. In addition, compacts have a tendency to require “harmonization” which may mean a state needs to increase their licensing burdens to meet the standards of the compact. This “ratcheting up” of licensing burdens is a natural by-product of a compact. Finally, compacts by design are necessarily are less flexible: to change the harmonized licensing requirements requires re-negotiating the compact with all the member states.
Universal licensing recognition, on the other hand and as the name implies, covers all licensed occupations. It does not require multilateral action and negotiations between states. It can cover more occupations and more workers more quickly. When properly crafted, it can also encourage healthy competition between states and can avoid the “ratcheting up” of licensing requirements that are characteristic of compacts.
Utah is off to a good start. State law since 2020 already includes a number of important attributes, including avoiding the “harmonization” of licensing requirements that comes when state law requires a “substantially equivalent” license standard in the awarding of a license to a new resident. But the state can be in an even better position to maximize the economic potential of those who have already chosen to relocate and those who may arrive in the future. It can do so by improving the reforms passed in 2020 in at least two ways:
–Extend the scope of experience that can provide a pathway for unlicensed workers. Applying for a license in a new state when you have a license in good standing from another state is fairly straightforward. But what if a new Utah resident arrives from another state that does not license the occupation in which they have substantial and reputable work experience? Universal recognition statutes can be reformed to acknowledge this disparity by expanding the realm of what is acceptable as a proxy for a “license in good standing.” Iowa, Kansas and Mississippi currently recognize three years of work experience as an adequate predicate to award a license in their state. Allowing a private certification (either from a national or state entity) to serve as a proxy for an occupational license is also worthy of inclusion in such a reform.
–Restrict the state regulator’s power to deny an application. A positive attribute of a well-constructed universal license recognition law is that it takes the opinion of licensing boards largely out of the equation of awarding a reciprocal license. That’s a feature because licensing boards – or executive-branch agencies tasked with the same functions – tend to be deferential to incumbent license holders which by definition tend to prefer keeping out new entrants. The incentives of licensing boards, on which incumbents typically hold the majority of seats, would be to find a way to deny the reciprocal license if they are given the power to do so. The current Utah law does give the Division of Occupational and Professional the power to deny if the Division has “reasonable cause to believe that the person is not qualified to receive a license in [the] state.” Changes to the Utah universal recognition law should be more explicit in what actually qualifies as grounds to deny a license.
Finally, policymakers should remember that universal license recognition is not a substitute for more fundamental reforms to reduce the overall burden of occupational licensing. The “licensure by endorsement” reforms outlined here mainly serve to get new residents into the workforce quickly. They do not make any specific headway in regard to lowering the existing licensing burdens in Utah. Whether an occupational should continue to be licensed and to what extent are still important policy questions. State policymakers are well-advised to continue looking for opportunities (perhaps though a sunset review process or a recurring evaluation of the actual need for a state-mandated license) to reduce over the long term the overall burden that licensing imposes on the state’s workers and entrepreneurs.
Director, Center for Ethics in Society at Saint Anselm College
Occupational licensing requirements have grown significantly over the past few decades, mostly as a result of state legislation. By a common estimate, the percentage of the U.S. workforce required to obtain a government license in order to practice their trade rose from 5 percent in the 1950s to almost 30 percent by the 2010s. While some licenses may have a consumer or environmental protection rationale, research consistently finds that they more often serve as a legal barrier to entry, raising prices and wages in licensed occupations without raising quality. Moreover, to the extent that any government involvement beyond the tort system is needed to protect consumers, a ready alternative to licensure is available: state certification, which provides a set of voluntary benchmarks that practitioners may choose to meet and prohibits practitioners from falsely claiming to have met those benchmarks or to be certified. If certification benefits consumers, then at least some consumers will be willing to pay more for the services of certified practitioners, and practitioners will have an incentive to seek certification.
So why is certification so rare, and licensure so common? If licensure requirements actually do not improve quality, then consumers are not willing to pay for them. The only way to get them into place is to mandate them. And once they are in place, practitioners can benefit from the reduced competition to raise their prices and incomes. Typically, new licensing laws grandfather existing practitioners, who do not have to meet the sometimes-stringent education and examination requirements. Practitioners’ interest in licensing is therefore obvious.
By why do state lawmakers listen to practitioners and adopt economically destructive policies? The usual answer is “concentrated benefit, dispersed cost.” Consumers lose from licensure more than practitioners gain, but each individual consumer loses only a little, while each individual practitioner gains a great deal. Therefore, practitioners have an incentive to lobby for restrictions, while consumers have no such incentive to oppose them. Very commonly, lawmakers hear only supportive testimony on licensing proposals and adverse testimony on proposals to reduce licensing requirements.
Some lawmakers have realized this problem and have sought to insulate licensing somewhat from typical legislative processes. Beginning in the 1970s, many states have adopted “sunrise” and “sunset” procedures for state bureaucracies, including licensing agencies. Sunrise procedures require review of legislative and administrative proposals for new rules, programs, or agencies before the normal process of enacting a statute or rule may proceed. Sunset procedures require rules, programs, or agencies to terminate after a certain period of years unless the legislature takes positive action to renew them. Typically, there is also a review process to determine whether the sunsetting program is meeting its objectives.
How well do sunrise and sunset procedures work? Researchers have found that there is no straightforward correlation between having sunrise or sunset legislation and overall regulatory burden, including the number or stringency of occupational license requirements. There have been some agency sunsets in the states, but some states that initially adopted sunset requirements have abandoned them due to the cost of conducting reviews and the absence of perceived benefits. Many states that have sunrise and sunset requirements on the books do not actually follow the requirements or conduct only pro forma reviews. In following state legislative sessions, I have frequently observed legislatures reauthorizing dozens of agencies in a single omnibus bill, or attaching reauthorization of core agencies, such as the state education department, to “must-pass” legislation.
Still, sunrise and sunset review can have benefits if states take them seriously. One study of public accountancy sunset review in Colorado found that as a result of review, the legislature decided not to change Colorado’s requirements (mostly in the direction of restrictiveness) in order to become “substantially equivalent” to other states.
When we look at the restrictiveness of licensing regimes across states, some states stand out. The Ruger and Sorens index of occupational freedom is probably the most comprehensive and externally validated measure of occupational regulation at the U.S. state level. It incorporates various measures of the extent and intensity of licensure, as well as breadth of health paraprofessional scope of practice and interstate reciprocity. Colorado, Idaho, and Vermont have the least regulation as of year-end 2016 by this index, while California, Texas, and Illinois have the most. Utah has lower-than-average occupational regulation, coming 15th-best in the country on occupational freedom.
Breaking down the occupational freedom category, we see that Utah is about average in the extent of occupational licensing, but scores better than average on health paraprofessionals’ scope of practice and interstate reciprocity. However, there is room for improvement here as well. Utah requires extra licensing and substantial, additional education for advanced practice registered nurses (APRNs) to be allowed to prescribe controlled drugs. It also does not allow dental hygienists general freedom to practice within their scope of training without dentist oversight, as Colorado and Maine permit. Some occupations that Utah licenses but at least some other states do not include (but are not limited to): property managers, environmental health scientists, sign language interpreters, dietitians (far-reaching certification judged to be equivalent to licensure), pharmacy technicians, athletic trainers, massage therapists, private detectives, security guards, funeral service interns, manicurists and pedicurists, construction contractors, well drillers, security and fire alarm contractors, and crane operators. Utah has sunset but not sunrise review.
We can look at how the occupational freedom index correlates with various measures of a state’s policy outlook and institutions in order to try to better understand why some states regulate occupations much more heavily than others. When we do this, we see that measures of special interest group influence and “legislative professionalism” seem to correlate most strongly, and negatively, with occupational freedom. Legislative professionalism largely refers to the careerist incentives of state legislators, as reflected in their pay and the length of the legislative session. Left-right ideology, as captured by presidential vote shares, does not correlate significantly with occupational freedom, nor do size of the legislature, the existence of the ballot initiative, urban population share, state age, or the existence of sunset reviews. States with sunrise reviews do have more occupational freedom, but the effect is small.
Still, the way sunrise review is used could have a big impact on occupational regulation. When controlling for legislative professionalism, the states that have the highest “unexpected” (i.e., residual) occupational freedom are, in order, Colorado, Rhode Island, Idaho, Vermont, and Alaska. Rhode Island, Idaho, and Alaska do not do sunrise review, but Colorado and Vermont take sunrise review quite seriously. Colorado has a well-funded office dedicated to sunrise and sunset review, called the Colorado Office of Policy, Research, and Regulatory Reform. It releases its reports on its website in a timely fashion. Vermont’s Office of Professional Regulation conducts rigorous regulatory reviews, which are also available to the public on an up-to-date website. By contrast, Virginia has a less wide-ranging sunrise review process limited to health professions. Outside the health professions, Washington’s sunrise review appears to be dormant (no information is available on the web), and among the health professions, Washington’s sunrise review also applies to attempts to increase a profession’s scope of practice, potentially locking in more restrictive licensing rules.
In the end, there is probably no institutional “quick fix” to excessive regulation of occupational entry, but sunrise review can be a useful tool provided the agency conducting it is well-equipped and the legislative committee responsible for licensing legislation takes their research seriously. In Colorado, the late Jerry Kopel, who as a legislator wrote the initial sunrise and sunset review legislation, maintained a website where he kept close watch on occupational licensing issues. Activist and legislator pressure can help translate independent reviews into intelligent legislative decision-making.
When considering sunrise review as a possible institutional fix to right-size occupational licensing, Utah should look to its neighbor Colorado for ideas. It should create a special policy research office within the Division of Occupational and Professional Licensing and require all new legislative proposals to regulate occupations and professions undergo an independent review by that office. (Note that not all occupational licenses in Utah are housed within that Division. For example, the Utah Division of Water Rights regulates well drillers.) Utah should require and provide permanent funding for the involvement of a professional economist in sunrise reviews, and it should stipulate that these reviews, like Colorado’s, should consider whether licensing is necessary to protect the public, or whether some less restrictive form of regulation, such as bonding, registration, or voluntary certification, is sufficient.
Alicia Plemmons, PhD
Assistant Professor, CAS Undergraduate Economics, Program Director in the Department of Economics & Finance at Southern Illinois University Edwardsville, and a Research Affiliate of the Knee Center for the Study of Occupational Regulation at Saint Francis University
Introduction
The United States is experiencing a primary healthcare shortage where there are not enough providers and specialists able to service everyone in need of medical care. Nationwide, there are 29.2 active physicians per 10,000 population, but in Utah there are only 21.6 per 10,000 residents. This discrepancy between the providers and consumers reduces access to safe and affordable healthcare. That discrepancy is particularly harmful for socioeconomically disadvantaged and rural communities. Reforming occupational licensing and scope of practice of within healthcare professions can improve the level of care and the availability of care for all Utahns.
Occupational licensing is the system established by the government for providing legal permission for an individual to work in specific jobs. Within healthcare, states have set both the requirements for obtaining an occupational license as well as the scope of duties and tasks a licensed practitioner may provide. The tasks and job duties a practitioner can provide is commonly referred to as “scope of practice” regulations. They determine which activities, like diagnosing patients, developing treatment plans, ordering imaging and laboratory testing, and prescribing medication, a practitioner may provide.
For example, in Utah, scope of practice determines the situations under which nurse practitioners can prescribe medication and the job duties they can legally perform, such as ordering tests and labs to confirm a diagnosis. Scope of practice affects dozens of occupations including: nursing, physician assistants, optometry, dentistry, pharmacy, specialized therapy, imaging and sonography, anesthesiology, surgery, midwifery, chiropractic, nutrition, and psychology. These healthcare fields provide important services to patients and represent a significant share of the Utah economy. Yet, many of these occupations are subject to burdensome rules and regulations that make it difficult or impossible to effectively service residents, reducing access to care or driving up costs. Sensible changes in expanding scope of practice for these occupations would improve access and affordability of healthcare for all residents, especially those in frontier and rural counties.
The rationale for empowering healthcare providers
States that relax scope of practice laws have experienced many measurable benefits. Physicians spend more time on complicated or specialized medical cases when routine care is provided by a licensed advanced registered practice nurse. This is because the specialized physicians can spend less time on paperwork and routine care, and instead focus on the unusual cases. In the language of economics, increasing the autonomy of nurses acts as a complementary good for other healthcare providers. By letting nurses do more, doctors can do more as well. That makes healthcare more accessible and efficient for residents.
Rural areas stand to gain the most from expanding scope of practice. Rural areas sometimes struggle to attract or retain physicians and dentists because there are not enough patients in the area. Practitioners can make more money by moving to a more populated area. Instead, if individuals such as nurse practitioners, certified nurse midwives, and dental hygienists can provide routine care and medication without direct on-site supervision, these rural areas will be more likely to have access to a healthcare provider where none was previously available.
Research bears this out. bordering states Colorado and Nevada that have expanded scope of practice experience a reduction in practitioners leaving the state, as well as an increase in new practitioners moving into the state, especially within disadvantaged or rural communities, as the job autonomy leads to increased provider and resident satisfaction. Both customers and professionals are better off because of expansions in scope of practice.
Scope of practice expansions also reflect the high training requirements within healthcare fields. In some cases, practitioners are trained for certain procedures but not allowed to perform them on the job. Research on scope of practice regulations has found that there can sometimes be an inefficient mismatch between occupation training and job duties. For example, nurse practitioner university education includes multiple courses on pharmacology and the handling of Schedule II drugs, yet in Utah they are unable to prescribe this medication without supervision or a collaborative agreement with a physician, even though completing these courses qualify the practitioners for independent prescriptive authority in all neighboring states. The question is if individuals who have undergone extensive education and training in a job skill can perform that job duty in a supervised or unsupervised manner. For example, in Idaho pharmacists may adjust prescriptions or change an individual’s current prescription in order to enhance their drug treatment. Currently, in Utah, these pharmacists may not perform these specific duties of their job even when they have received extensive training in pharmacy school and in continuing education programs approved by the Board of Pharmacy. Limitations to scope of practice such as these should be routinely analyzed to determine if the rules set by government are in accordance with education and training.
How to Expand Scope of Practice in Utah
Utah has made significant improvements in scope of practice during 2021. Here are a few of the highlights:
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- HB 287 developed a pathway for nurse practitioners to prescribe schedule II drugs without a consultation and referral agreement. It also paired down oversight requirements for new nurse practitioners in solo practice.
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- S 28 allowed physicians assistants to specialize in mental healthcare and outlines the rules and requirements for this specialization.
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- S 27 removed the requirement that physician assistants had to maintain a specific relationship with a physician or other provider and permitted physician assistants to respond during a healthcare emergency or disaster.
In the years prior, Utah also saw expansions in teledentistry for non-emergency dental care, expansions to dental hygienist scope of practice so that they can treat patients in certain settings with a written agreement, and removal of good moral character clauses in which people could be disallowed to participate in their field due to unrelated offenses many years prior. While Utah should be praised for the changes it has made towards removing barriers to opportunities, employment, and healthcare access for many Utah residents, there is still much work to be done.
There are many pathways in with Utah can continue to expand and ensure access to medical services for their most socioeconomically disadvantaged and rural communities. First, expanding the prescriptive authority of psychologists to provide psychiatric medication, such as selective serotonin reuptake inhibitors for major depressive disorder, can allow them to establish crucial and time-sensitive interventions for patients experiencing mental or behavioral health episodes. Psychologists are currently allowed to prescribe psychiatric medication in Idaho, Illinois, Iowa, Louisiana, and New Mexico which allows them to include both talk and psychiatric drug therapy as part of their treatment plan without waiting to visit with a psychiatrist. Utah would benefit from this prescriptive authority expansion because most counties do not have access to practicing child and adolescent psychiatrists and Utah’s rural areas have a substantial mental health care provider shortage.
Pharmacists are also an integral part of the healthcare system. Utah legislators should consider following bordering state Idaho and allowing pharmacists to utilize their training and experience to adjust or adapt medication orders in order to optimize the therapeutic outcome through renewal or changes. Additionally, Utah could allow pharmacists to prescribe certain medication on-demand such a tobacco cessation aids after consulting with patients, who can later follow up with their primary healthcare provider to continue services such as in the surrounding states of Arizona, Idaho, Colorado, and New Mexico.
Utah has dozens of professions subject to licensing within healthcare, yet there is no systematic review process for determining if these laws should be updated, suspended, or repealed to reflect current needs and understanding. Conducting a regular systematic review of healthcare licensing boards and the associated legislative documents would increase transparency and allow legislators to identify and address when a legal limit may be causing undue harm to residents and practitioners by restricting to scope of practice of healthcare occupations.
Reforming Scope of Practice Improves Access and Affordability
Utah’s policymakers can do more to improve healthcare access and affordability. Allowing some providers, such as nurse practitioners and physician assistants, to provide a wider range of treatment and services is one important step for addressing these issues. Improvements should not only be limited to primary care, but also to mental health, pharmaceutical, optometric, and dental care. The next few years will be crucial to update the legal structure of the healthcare field to ensure that Utah maintains and attracts top talent, provides employment opportunities and autonomy to residents working in the healthcare, and develops a system in which affordable healthcare options and access are available for as many markets as possible.
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