Federal policy makers are taking much-needed steps to bolster the nation’s health care workforce. This segment of the healthcare system was largely left out of the last major effort at health care reform marked by enactment of the Affordable Care Act. At that time, in 2010, policymakers indicated that they would soon tackle the many workforce challenges. In 2021, largely in response to the COVID-19 pandemic, Congress advanced several major pieces of legislation intended to strengthen the nursing workforce, improve health care access and advance health equity. These actions would provide the largest infusion of federal funding to grow and strengthen the nursing workforce in recent history; they would advance the work of theFuture of Nursing: Campaign for Action and speed implementation of the National Academy of Medicine’s Future of Nursing 2030 report recommendations. And Congress is still considering major additional steps that if enacted, would substantially advance health equity through nursing.

This document reviews the nursing provisions of legislation enacted in 2021 (and currently being implemented) as well as those that have passed the U.S. House of Representatives and are still under consideration by the U.S. Senate.

Nursing Workforce and Nursing-Related Provisions in the American Rescue Plan

On March 12, 2021, President Biden signed into law the major COVID relief package passed by Congress. This bill included record investments in the nursing workforce. Key provisions aligned with the Campaign’s goals:

• $1.1 billion to increase the number of primary and other health care providers in medically underserved areas and communities.

• $800 million increases scholarships and loan repayments to nurse practitioners, nurse midwives, physicians, dentists and other health professionals in return for two to three years of service as a primary care provider, through the National Health Service Corps (NHSC). Currently, 17 million people receive care from more than 16,000 clinicians serving at NHSC-approved sites in urban, rural and tribal communities.

• $100 million for state-run loan repayment programs which repay loans of registered nurses (RNs), advanced practice registered nurses (APRNs), physicians and other health professionals who agree to work for a set period of years in health professional shortage areas. 

• $200 million is to expand the Nurse Corps. This program provides scholarships and repays student loans for RNs and APRNs who work for two to three years in a primary or mental health professional shortage facility or area; or as nursing faculty in schools of nursing. This would more than double the current funding level of $88 million for this important program, a significant boost for nursing education at all levels.
• $7.6 billion is for the U.S. Department of Health and Human Services (HHS) to increase the national, state and local public health workforce by 100,000 workers. These workforce positions would include public health nurses, contact tracers, social support specialists, community health workers, epidemiologists, lab personnel, disease intervention specialists, and communications personnel. Funds would also support necessary technology and supplies, such as personal protective equipment (PPE), for use by the public health workforce. This would represent the largest increase in decades (if ever) for the public health workforce.

• $140 Million through several different programs administered by Health Resources and Services Administration (HRSA) aimed at addressing health professional (including nurses and through schools of nursing) burnout, mental health and substance abuse challenges.
• $100 Million to support expansion of the Medical Reserve Corps (MRC) to increase the number of nurses, physicians and other health professionals who volunteer through local organizations. This is likely to be used to help staff mass vaccination sites. The MRC is a national network of volunteers, organized locally to improve the health and safety of their communities. The MRC network comprises approximately 200,000 volunteers in roughly 800 community-based units located throughout the United States and its territories. MRC volunteers include medical and public health professionals, as well as other community members without healthcare backgrounds. MRC units engage these volunteers to strengthen public health, improve emergency response capabilities, and build community resiliency. 
• $150 million to expand the nurse-led model of care known as the Home Visiting Program to address the additional emergency needs of families related to the COVID pandemic.

Implementation of the American Rescue Plan

The Administration has been busy implementing the major provisions listed above.      

Highlights include:

• In line with the Campaign’s goal (and that of the NAM Future of Nursing report) of diversifying the nursing workforce, the White House announced that “All awardees of this American Rescue Plan funding will be asked to prioritize recruiting individuals from the communities they will serve and from backgrounds underrepresented in critical public health professions.”
• HRSA has announced multiple rounds of funding allocating the $800 million increase in the NHSC and the $200 million increase in the Nurse Corps. There will be additional rounds of funding announced as the monies are available until fully spent. The American Rescue Plan supplemental funding allowed HRSA to award almost 1,200 scholarships – a four-fold increase – in the NHSC and nearly doubled the number of Nurse Corps scholarship awards to 544. In addition, new awards to 136 nurse faculty are supporting training for the future nursing workforce. This year’s scholarship recipients join 2,500 current NHSC medical, dental, and health professions students and residents and approximately 900 current Nurse Corps scholars preparing to serve in high-need communities across the country.
• The White House announced that nearly $240 million of the Act’s funding will go to a new program focused on education and on-the-job training to build the pipeline of public health workers in the most underserved communities. This effort will support apprenticeship programs at over 500 health care and public health sites nationally, including emergency departments, health centers, state and local public health departments, community health centers, mobile health clinics, shelters, housing programs, faith-based organizations, and other locations where high-risk populations access care and receive services. 
• On May 13, the White House announced more detailed plans for spending the $7.6 billion provided in the law to expand the public health workforce, including at least $500 million dedicated to hiring school nurses.
• The White House has announced that the Indian Health Service (IHS) is investing $92 million to hire school nurses who can provide critical testing, contact tracing, case management, vaccination, and overall school health support to Bureau of Indian Education (BIE) K-12 schools; $67 million to enhance public health capacity and build better emergency preparedness for IHS and Tribal Nations; and, $45 million to expand loan repayment and support IHS’s ability to recruit and retain highly-skilled health care professionals including nurses in IHS, Tribal, and urban Indian health programs.
• The White House also announced that the Centers for Disease Control and Prevention (CDC) will use $3 billion from the American Rescue Plan to create a new grant program that will facilitate federal investment in the people and expertise needed at the state and local levels to expand, train, and modernize the public health workforce for the future. In the months ahead, CDC will work with leaders from across the public health community to design this new grant program.
• Not directly related to the American Rescue Plan, the U.S. Department of Education announced on October 6, 2021 that it was forgiving $1.74 billion in loans to over 550,000 nurses, teachers, first responders and other public service workers as part of the Public Service Loan Forgiveness Program. 
• The National Coalition of Ethnic and Minority Nursing Associations, whose memberships are actively engaged with CCNA and the Campaign, have called on HHS to use these funds as a means of diversifying the nursing workforce.

Nursing Workforce and Nursing-Related Provisions in the Build Back Better Act as Passed by the House of Representatives (11/19/21)

The House-passed Build Back Better Act, President Biden’s major social and economic legislation, would, if passed by the Senate, make historic investments — approximately $5 billion over the next 10 years — in the nursing workforce and nursing care. Many of these initiatives closely align with the recommendations in the NAM Future of Nursing 2030 report. The bill is now under consideration by the U.S. Senate. While it is expected that many aspects of the House-passed legislation will need to be cut or scaled-back, it is unclear at this time how these nursing provisions will be impacted.

The U.S. House included the following:

$500 million for Health Resources and Services Administration (HRSA) grants to enhance and modernize nursing education programs and increase the number of faculty and students at such schools.

In making grant awards to schools of nursing, Congress has directed HRSA to take into consideration equitable distribution of awards among the geographical regions and the capacity of a school of nursing to provide care in underserved areas.

The purpose of the HRSA grants include:

• Enhancing enrollment and retention of students at nursing schools, with a priority on students from disadvantaged backgrounds (including racial or ethnic groups underrepresented in the nursing workforce), individuals from rural and underserved areas, low-income individuals, and first-generation college students.
• Creating, supporting, or modernizing educational programs and curricula at nursing schools.
• Retaining current faculty and hiring new faculty, with an emphasis on faculty members from racial or ethnic groups that are underrepresented in the nursing workforce.

$500 million to expand the Nurse Corps Program

This program provides scholarships and repays student loans for RNs and APRNs who work for two to three years in a facility or area with a shortage of primary or mental health professionals; or as nursing faculty in schools of nursing. The American Rescue Plan provided an additional $200 million to expand the program. To give a sense of the magnitude of these increases, the 2020 funding level for Nurse Corps was $88 million.

$2 billion over five years for Health Profession Opportunity Grants.

The  Health Profession Opportunity Grants (HPOG) program is administered by the Administration for Children and Families at HHS. Funds are to be used to make competitive grants to at least two grantees in every state and at least 10 tribal or Indian health programs with the purpose of providing education, training and needed social supports to help move participants in the Temporary Assistance for Needy Families (TANF) program and other low-income individuals into occupations in the health care field that pay well and for which shortages are expected, or demand will be high.

The careers identified in this legislation include: nursing assistants, registered nurse, advanced practice nurse, and other professions considered part of a health care career pathway model.  Funding can be used for a host of activities to enable career advancement, including assistance with GEDs, tuition, fees, child care, mentoring, transportation and case management.

$170 million to grow and diversify the perinatal nursing workforce as a means of improving maternal health outcomes and develop curricula on bias/racism.

Grants would go to schools of nursing for scholarships for those studying to be an APRN with a focus on maternal/perinatal health. Priority would be given to those who plan to practice or currently practice in a health professional shortage area and to those from racial and ethnic groups underrepresented in the health professions. Funds are also to be used to develop curriculum for students seeking to enter careers focused on maternal and perinatal health that includes training programs on bias, racism, discrimination, providing culturally competent care, or trauma-informed care.

$2 billion to expand the National Health Service Corps (NHSC)

This program provides scholarships and loan repayment in return for two years or more of service in a health professional shortage area. It would have a major impact on nursing in that a new report to Congress found that nurse practitioners account for 26 percent of all health professionals participating in the NHSC.  

$50 million to schools of nursing, medicine and other health professional schools to develop, disseminate, review, research, and evaluate training for health professionals and all staff who interact with patients to reduce discrimination and bias in the provision of health care, with a focus on maternal health care.

$50 million for minority-serving institutions to study maternal mortality, severe maternal morbidity, and maternal health outcomes.

This funding is targeted to Historically Black Colleges and Universities (HBCUs) and other minority-serving institutions and could serve as a boost to research infrastructure in the nursing schools in these institutions.

$20 million for nursing schools and others training sites to train nurse aides to provide interprofessional team-based palliative care in hospitals and long-term care settings. Funds can also be used to develop curricula and train faculty. 

Increased nursing home nurse staffing levels.

The bill would require that nursing homes participating in the Medicare and Medicaid programs provide at least the services of a registered professional nurse for a minimum of eight consecutive hours a day, seven days per week until October 1, 2024, and 24 hours a day, seven days a week beginning after that date.

Improved Medicaid funding for Home and Community-Based Services (HCBS).

The bill makes historic investments to allow more seniors and individuals with disabilities to receive the services they need to remain in their homes, alongside their friends and family. The legislation invests $150 billion to expand access to quality home-based services and care for millions of older adults and people with disabilities. Much of this major funding increase would come in the form of a permanent six percentage point increase to the federal medical assistance percentage (FMAP) if the state implements an HCBS improvement program to strengthen and expand HCBS. It provides an enhanced FMAP of 80 percent for administrative costs associated with improving HCBS. In order to receive increased federal matching rates for improved HCBS, states must provide detailed reports on the numbers and pay-rates of the direct care workforce, including RNs, LPNs, NPs CNSs and CNAs. The reports should also include an assessment of the relationship between payment rates and workforce shortages and average wait times for HCBS.

$60 million for costs associated with permanent extension of the nurse-led Independence at Home demonstration. 

The Independence at Home (IAH) demonstration is a Congressionally mandated test of whether a payment incentive for providing home-based primary care reduces health care expenditures and improves quality of care for eligible fee-for-service Medicare beneficiaries. To be eligible for enrollment in the demonstration, beneficiaries must have had at least two chronic conditions; required help from another person with at least two activities of daily living; have been admitted to a hospital in the last 12 months; and have used acute or subacute rehabilitation services in the last 12 months. Participating home-based primary care practices can earn incentive payments if (1) their patients’ Medicare expenditures are less than a given expenditure’s target and (2) they meet the standards for selected quality measures. Results to date show cost savings and quality improvements.

Nursing-related items in House and Senate Appropriations Committees fiscal year 2022 funding legislation

Both the U.S. House and Senate included provisions in their fiscal year 2022 appropriations legislation that would increase investments in the nursing workforce and advance health equity.  House and Senate leaders are negotiating on overall government funding levels in the hopes of finishing work on a compromise by February 2022.

Here are some substantial House and Senate provisions:

Nursing Education/Training

Title VIII Nursing Workforce Funding: The House provides a $50 million increase while the Senate provides an increase of $16 million for these programs.

National Health Service Corps: The Senate bill would provide $150 million for the NHSC, an increase of $30 million above the fiscal year 2021 enacted level, to continue improving access to quality opioid and substance use disorder [SUD] treatment in rural and underserved areas nationwide. This increase would be over and above the increased funding provided in the American Rescue Plan Act earlier in 2021.

Medicare Funding for Nursing Education (Graduate Nursing Education): The Senate billnotes that nursing shortages during the COVID–19 pandemic have significantly strained healthcare delivery. It requests CMS to provide an update on the role of Medicare funding in supporting the training of nurses and allied health professionals in the fiscal year 2023 Congressional Justification.

Health Equity and Nursing

Substance Abuse and Mental Health Services Administration (SAMHSA) – School Nurses and Mental Health: The Senate budget includes $1 billion within the School Improvement account for a new School-Based Health Professionals program. The Senate bill directs HHS to use $800 million from the Safe Schools National Activities Program for new awards through the Mental Health Services Professional Demonstration Grant Program and the School Based Mental Health Services Grant Program. These programs were created to increase the number of qualified, well-trained mental health professionals in schools, including school counselors, social workers, psychologists, or other mental health professionals, and could also support similar activities for school nurses. The Senate Appropriations Committee requests a briefing within 45 days of enactment on implementation plans for carrying out the fiscal year 2022 Mental Health Services Professional Demonstration.  

Health and Human Services Office of Minority Health (OMH) – Center for Indigenous Innovation and Health Equity: Both the House and Senate bills recognize the importance of advancing indigenous solutions to achieve health equity and provide $3 million, an increase of $1 million, to the OMH to support the work of the Center for Indigenous Innovation and Health Equity. The Senate urges HHS to consider partnering with universities with a focus on indigenous health research and policy among American Indians and Alaska Natives, as well as universities with a focus on indigenous health policy and innovation among Native Hawaiians/Pacific Islanders.

Social Determinants of Health (SDOH): The House bill includes an increase of $150 million for SDOH to improve health equity, including funding grants to expand activities to address SDOH in state, local, tribal and territorial jurisdictions to improve outcomes among persons experiencing health disparities and inequalities, including, but not limited to:

• expanding and implementing Accelerator Plans,
• initiating a SDOH implementation program,
• providing technical assistance to communities and
• continuing to build the evidence base and advance data collection to better understand health disparities.

SDOH Accelerator Plans should include a description of the health and social outcome objective, identify populations that would benefit from implementation of the plan, including Medicaid eligible individuals; and identify non-governmental, private, or public health organizations and community organizations that would participate in the development of the plan.

Research on Health Equity: The House bill includes an increase of $3,000,000 for Agency for Healthcare Research and Quality (AHRQ) to support investigator-initiated research grants related to health equity and an additional $1,000,000 to support research supplements related to health equity, the same as the fiscal year 2022 budget request.

National Center on Antiracism and Health Equity: The House bill urges HHS to establish a National Center on Antiracism and Health Equity within the department to lead efforts to identify and understand the policies and practices that have a disparate impact on the health and well-being of communities of color, It directs the Secretary to submit a report, not later than 180 days after enactment of the Act, that provides detailed proposals to establish a such a center.

Public Health Pilot Program to Address Structural Racism in Public Health: The House bill directs the HHS Office of Minority Health (OMH) to establish a pilot program to advance these goals and includes $10,000,000 to fund 20 eligible applicants. It requires the OMH Director to submit a report to the House Appropriations Committee, no later than180 days of enactment of the Act, on the progress of this pilot program.

Mental and Substance Use Disorder Workforce Training Demonstration: The House bill provides $34 million to expand the Mental and Substance Use Disorder Workforce Training Demonstration program, to make grants to institutions to support training for medical residents and fellows in psychiatry and addiction medicine, as well as nurse practitioners, physician assistants, and others, to provide substance abuse treatment in underserved communities.

CDC: Public Health Infrastructure and Capacity: The Senate bill includes $600 million, $200 million more than the budget request, for CDC to rebuild a robust public health infrastructure (including workforce). 

Nursing earmarks

Both the House and Senate included “earmarks” that provide direct Congressional funding of over $13 million to local nursing workforce programs/innovations requested by home state Senators. This could be an idea for future state Action Coalition funding. Below are the Senate earmarks.

• Bradley University in IL, $850,000 for nurse education and equipment (Durbin)
• Visiting Nurse Association of Central Jersey, $500,000 for facilities and equipment (Booker)
• Yakima Valley College in WA, $1.75 million for nurse training initiative (Murray)
• VBR Research and Education Foundation in VT, $1.2 million to strengthen nursing career pipelines (Leahy)
• Colby-Sawyer College School of Nursing & Health Sciences in NH, $1.5 million for facilities and equipment (Shaheen)
• Genesee Intermediate School District in MI, $1 million for nursing workforce development and training (Peters)
• Marquette University College of Nursing in WI, $217,000 to support continuing education for clinicians. (Baldwin)
• University of Maryland, Baltimore School of Nursing, $1.25 million for facilities and equipment (Van Hollen)
• Oregon Center for Nursing, $459,000 to support the mental health and emotional well-being of nurses (Merkley)
• Helene Fuld College of Nursing in NY, $1 million