Persistent workforce shortages continue to define the post-pandemic healthcare landscape. Hospitals, health systems, and long-term care providers report enduring deficits in nursing, primary care, and behavioral health staffing, with projections indicating that these shortfalls are likely to persist through the next decade.[1] At both the federal and state levels, policymakers are advancing a range of... Continue Reading
Persistent workforce shortages continue to define the post-pandemic healthcare landscape. Hospitals, health systems, and long-term care providers report enduring deficits in nursing, primary care, and behavioral health staffing, with projections indicating that these shortfalls are likely to persist through the next decade.[1]
At both the federal and state levels, policymakers are advancing a range of measures intended to adapt workforce rules to current operational realities. These efforts include expanding the responsibilities of non-physician clinicians and redefining supervision and collaboration requirements. This post highlights recent state and federal developments in workforce and licensure policy addressing ongoing staffing pressures.
Scope of Practice and Workforce Integration
As discussed in our post earlier this year, California remains at the forefront of scope-of-practice reform. Assembly Bill 890, enacted in 2020 and now in its second implementation phase, creates two new categories of nurse practitioner certification. The “103 NP” may practice independently within defined healthcare settings such as hospitals or clinics, while the “104 NP” will be permitted to practice fully independently outside those settings after at least three years of 103-level experience. The Board of Registered Nursing began issuing 103 NP certifications in 2023 and expects to open 104 NP applications in 2026.
Senate Bill 1451, effective January 2025, streamlines this framework by simplifying transition-to-practice documentation, recognizing doctoral-level clinical hours, and clarifying disclosure obligations. Participation in the new certification pathways remains voluntary, and nurse practitioners who do not opt in continue to practice under existing rules. Early implementation has been measured, as hospitals and clinics work through the operational implications for privileging, supervision, and liability coverage. Questions also remain regarding how payers will treat services furnished by independently practicing nurse practitioners.
In addition, as discussed in our recent post on Assembly Bill 1501, California has enacted new legislation modernizing the state’s physician assistant (“PA”) practice framework. Signed by Governor Newsom on October 1, 2025, and effective January 1, 2026, AB 1501 increases the permissible physician-to-PA supervision ratio from 1:4 to 1:8 across all settings and directs the Physician Assistant Board to undertake a comprehensive review of practice agreement structures in collaboration with the California legislature and other stakeholders, such as the California Academy of Physician Assistants and California Podiatric Medical Association. The law also extends the Board’s authority through 2030 and updates licensing, fee, and renewal procedures.
Other states are moving in a similar direction. New York, for example, extended in 2025 its NP autonomy model. Under the Nurse Practitioner Modernization Act, NPs with at least 3,600 hours of qualifying practice are exempt from the requirement to maintain a written collaborative agreement with a physician. The 2025 State Budget extension continues that exemption through July 2026.[2] States are generally pursuing comparable reforms for nurse practitioners, physician assistants, and behavioral health clinicians to address persistent access gaps, particularly in rural and underserved regions.
For providers, these developments may warrant a review of credentialing, privileging, and supervisory frameworks. Expanded practice authority affects team composition and referral pathways, which highlights the need to update policies on clinical oversight, delegation, and communication. Stakeholders should confirm that supervision and documentation practices remain clear and revisit liability coverage and reimbursement arrangements to ensure alignment with evolving licensure and payer requirements. Providers should also plan for operational integration, including adjusting staffing models and transition-to-practice programs as needed, and continue to monitor utilization, quality, and outcome data to demonstrate compliance and effectiveness.
Federal Standards and the CMS Staffing Rule
In April 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule establishing minimum nurse staffing standards for Medicare- and Medicaid-certified nursing facilities. The rule set an average of 3.48 total nursing hours per resident day, including 0.55 hours of registered nurse (“RN”) time and 2.45 hours of nurse-aide time and required continuous 24-hour on-site RN coverage.[3] However, in April 2025, a federal district court vacated the 24-hour RN and hours-per-resident-day requirements, holding that CMS exceeded its statutory authority under the Social Security Act.[4] While CMS appealed, Congress enacted a ten-year moratorium on enforcement through the July 2025 budget package,[5] and the Office of Management and Budget initiated a regulatory review process to revise or rescind the contested provisions.[6]
Although the federal standards are not currently in effect, state-level staffing laws remain fully enforceable. California, for example, prescribes nurse-to-patient ratios by hospital unit and requires hospitals to maintain written staffing plans and patient classification systems to support compliance.[7] Massachusetts similarly limits intensive-care nurses to one patient at a time, subject to limited exceptions.[8] Providers should continue to comply with applicable state ratios and facility-level documentation obligations pending further federal rulemaking.
Looking Ahead
Regulatory policy at both the state and federal levels is expected to continue addressing the persistent gap between workforce supply and patient demand. Providers should closely monitor federal and state rulemaking, assess potential operational impacts, and ensure that internal governance structures remain aligned with evolving licensure and staffing requirements. Proactive review of credentialing processes, supervision policies, and facility-level staffing plans will help organizations adapt to these changes.
FOOTNOTES
[1] See U.S. Bureau of Labor Statistics, Employment Projections — 2023-33 Summary, Industry and occupational employment projections overview and highlights, 2023–33 : Monthly Labor Review : U.S. Bureau of Labor Statistics; Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections From 2021 to 2036, Physician Workforce Projections | AAMC.
[2] NY State Senate Bill 2025-S2360
[3] Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS 3442-F) | CMS
[4] Health Care Association, et al v. Kennedy, Nos. 2:24-CV-114-Z-BR and 2:24-CV-171-Z (consolidated) (Amended Complaint) (N.D. Texas, Jun. 18, 2024).
[5] Text – H.R.1 – 119th Congress (2025-2026): One Big Beautiful Bill Act | Congress.gov | Library of Congress
[6] Pending EO 12866 Regulatory Review
[7] CCR 22 § 70217 View Document – California Code of Regulations
[8] MGL 111 § 231General Law – Part I, Title XVI, Chapter 111, Section 231
