U.S. nurse conservation fact of the day

In the period 2010–17 the number of NPs in the US more than doubled from approximately 91,000 to 190,000. This growth occurred in every US region and was driven by the rapid expansion of education programs that attracted nurses in the Millennial generation. Employment was concentrated in hospitals, physician offices, and outpatient care centers, and inflation-adjusted earnings grew by 5.5 percent over this period. The pronounced growth in the number of NPs has reduced the size of the registered nurse (RN) workforce by up to 80,000 nationwide.

Here is the underlying research, via the excellent Kevin Lewis.  Given the growth of the health care sector, should not the number of nurses, broadly construed, be rising at a higher rate?

Via the excellent Kevin Lewis.


The easiest way to raise nurses in the USA is to open borders with the Philippines, where all girls are nurses (and all boys are policemen).

Right now, it takes about two years of paperwork to come to the USA legally, and it's almost impossible to leave the Philippines legally as a tourist to visit the USA (some sort of not-widely-published or informal agreement between the PH and US governments has been reached). I've had numerous Filipino friends turned away at the airport even when they have paperwork to work outside PH (for one thing, the PH government wants you to register with them before you take a job outside the country, and that takes a lot of time and effort). I myself had to jump through all kinds of hoops and almost was turned away at the airport just to take my girl out of the country for a vacation.

Bonus trivia: the Schengen visa in the EU, at least in Greece, is NOT an easy process, when it should be. Unreal. Even after hitting up my contacts (I have contacts all over the world, heck going all the way up to the presidential / prime minister level actually, one of the privileges of being in the 1%)

Ooooh, Ray, you are so boss.

I love the Filipino nurses, but they should stay in the Philippines. People on the islands need healthcare, and US nurses need to make money.

I have been vicariously considering farming in the Philippine Highlands, where the weather is nice. But I think I'm stuck in Thailand, hot and humid, due to family obligations.

I am here right now. The weather is a bit better than Manila and other areas, but still wouldn't call it "nice". And this is the dry season. Beautiful views though.

The overseas demand for nurses led to more Filipinos studying nursing but it doesn’t appear to have decreased the number of nurses practicing in the Philippines at all.

> Using a new administrative dataset combining the universe of permanent migrant departures from the Philippines with the universe of institution-level post-secondary enrollment and graduation, we show that enrollment and graduation in nursing programs increased in response to demand from abroad for nurses. For each new nurse that moved abroad, approximately two more individuals with nursing degrees graduated. The supply of nursing programs increased to accommodate this. New nurses appear to have switched from other degree types. Nurse migration had no impact on either infant or maternal mortality.


@Barry - thanks for the link. @Ben Cole - you mean farm in Bagio, PH? That's like carrying coals to Newcastle, too much competition. I right now am gentleman farming in Greece, where land is cheap (if you know how to navigate). Don't expect to make a profit until about 10 years; you can make more money investing in the stock market, I'm just doing it for fun. And I might raise cattle too (for personal use).

Bonus trivia: beef bovine don't even need a stable. They pretty much sleep outside standing up. Pace dairy cows, sheep, goats. And there's both bear and jackals in the mountains of GR, and they eat livestock. That's where your 00-buckshot / slugs come in handy.

@ any real farmer reading this-- of course we are using sheepdogs here to guard our herd. The buckshot reference was for city slickers and animal advocates, lol. A good sheepdog will ward off a bear, usually, and absolutely destroy any jackal they run across.

"That's like carrying coals to Newcastle"


Obamacare increased the returns to being a NP versus being a RN (also Physician's Assistants got something good). *AND* it increased the returns to being a CNA, who an NP can supervise, but a RN cannot supervise without a NP or a PA.

So I think more of the work has shifted from doctor to NP and PA, and from RN to CNA. Which has reduced the returns for becoming an RN

......and increased the returns for becoming a physician. NPs and PAs are often used as physician extenders. They free up specialists from performing routine care allowing them to concentrate on more complex and remunerative care. This trend is particularly pronounced in Dermatology and Orthopedics.

They free up physicians to perform procedures, which makes them money. I'm not so sure that's a great thing; all of that cognitive ability and training wasted on performing technical things. In an ideal world, a mid-level would perform the procedures, and a doctor would do the thinking (and would be paid well for this).

You have top line training for doing procedures because that is when you need to be able manage things in the moment if they go wrong. Joint injections, for instance, can go very sideways very quickly if you hit a variant artery. Colonoscopies become extremely dangerous the moment something perforates. Even simple things, like cerumen deimpaction under microscopy can be troublesome if you encounter suppurative mastoiditis.

95% of the time you are not paying a physician for what they are doing. You are paying for their expertise should things go horridly wrong.

The real waste is not having somebody capable of handling all the complications while minimizing morbidity and mortality doing the procedures, it is forcing the physicians to train for so long in extraneous areas. Well over half of medical school and at least a quarter of residency is learning things that are useless to a physician's eventual practice (e.g. we recently reduced the EM residency by 25% because we found a lot of fat to trim). Becoming a board certified physician should not take over a decade from high school graduation.

Now sure, some procedures might make sense for a mid-level to be uptrained to handle all the complications. Sometimes the complications are such that you can get by with less training due to the scenario (e.g. nurse anesthetists have a lot leeway because their patients are already in the OR where you can intubate easily, are regularly monitored, and have surgeon in the room who can manage anything medical until help arrives). But in the main, procedures need to have a lot more skill present than will typically be used.

Interesting comment. Less training probably makes sense, but so does just paying specialty physicians less. They may become a tiny bit less talented on the margins, but there are a lot of very qualified, smart people who are passed over for medical school.

Could you be a bit more specific. How did Obamacare increase the returns of being an NP versus an RN? Remember only like 10% of the population ever got Obamacare policies. Did the law specifically mandate rewards for NP's?

Isn't it more the case that since insurance companies can pay less for a NP, they would rather cut costs by increasing NP visits instead of cutting doctor pay? Put that together with breaking some of the political logjams that kept NP tied to doctors and you've explained why NPs can grow as fast or faster than healthcare overall and at the expense of RNs.

You see "urgent care" clinics all over america. Those often have no doctor in them, or just one doctor supervising. Those aren't part of the Obamacare medicare extension or whatever, but their existence was a part of the ACA law, which included a TON of stuff that didn't have to do with insurance directly.

This is partly attributable to education inflation, the NP's (PAs, etc) replacing the RNs, in many cases performing the same function; but unlike the RNs, much of the work done by NPs is separately billable. Ray mentions CNAs (called CRNAs in my state - certified registered nurse anesthetist). In most states (including mine), CRNAs cannot work alone but must be supervised by a physician. No, not necessarily by an anesthesiologist, but a physician, which in many outpatient surgery centers, means the surgeon. It's not best practices (does a patient want the surgeon to be focused on both the surgery and the anesthesia?), but it's the most profitable. In other words, education inflation in health care is partly (mostly?) about capturing additional revenues. Of course, it's always about the money.

Anesthesia will probably move more and more toward a supervision modern, where one anesthesiologist supervises 2 to 4 anesthesia assistants or CRNAs. Really, I think this makes the most sense.

That model has been in existence for years. What I am describing is a model with no anesthesiologist supervising the CRNAs.

CNAs and CNRAs are very different. CNA stands for Certified Nursing Assintant: they work under RNs doing a lot of the grunt work of taking care of patients. They're also often in long-term care facilities. They have a lot lower credentialing requirements than RNs. It sounds like CNRAs are a step up from RNs.

Yeah, it's scope of practice defense. Docs groups will fight tooth and nail to keep mid-level practitioners to be permitted to perform even the most mundane task if it's currently restricted to docs. They're as bad as the damn dentists.

My impression is a lot of young women like to become physical therapists; it is quite the plum down here to be accepted into a well-regarded PT program. I have no experience of it so am neutral on whether PT deserves its now-obligatory place in the regimen of things a doctor prescribes (a close friend with sort of annually recurring back pain now skips the doctor and the referral if it is not severe, and goes straight to the PT, paying privately to have exercises given her) but perhaps it doesn't much matter what the nice young person is doing, exactly, from a therapy and getting-your-money standpoint. But separately billable, as rayward indicated; and easier, more flexible hours than nursing.

RNs can make good money with only a bachelors degree, but for some reason few young people are choosing it as a profession. I blame stubborn gender stereotyping, which discourages the male half of the population from nursing careers, even as women make inroads in previously male-dominated professions.

Changing the bedpans of silent-generation men while they sexually harass you isn't actually that appealing to modern young women.

There's actually still big demand for RN educational programs, and the limiting factor is hospital internships. There's also a lot of burnout in the profession - if you have to work only nights for the first few years of your career, it's not very attractive.

Given the hot labor market, my guess would be that some number of people are foregoing the extra educational and certification requirements of the RN and taking jobs instead as LPNs, medical assistants, and home health aides, telling themselves they'll go back to school in a few years.

This is solving for the equilibrium in terms of how much healthcare revenue is available medium term. While nurses are very important, the most pressing need was to bring in more physician activity without having to allot substantially more government redistribution or other resources. In other words, very limited market growth to ensure that further healthcare inflation does not occur.

The increase in NPs and PAs does help ameliorate physician shortages, though mainly at the general practice level, not so much at the specialist level.

The real problem is a shortage of MDs. NPs and PAs are ways to backfill that shortage.

Not sure why Tyler thinks nurses should be raising at a higher rate--the whole scalability thing is important because your costs do not raise linearly with growth. Maybe implies healthcare isnt maximally inefficient. Without regulation requiting hospitals' nurse staff have a particular distribution of certification, im sure nurse growth would be lower. You need a college education to take temperatures, give IVs, and change bedpans? Really?

The article is behind pay-wall for me. But to Tyler's question, did they look at national RN graduation rates? Also, were they able to examine rates of dropout from RN profession? Assuming influx of new RN's has been stable (or increasing, but not enough) I think there are several issues. Regardless of the pay, typical RN job (especially in the hospital) is physically demanding and stressful (and can be gross depending on the person). Yes there are RN aides, but not enough, so moving, bathing, calming patients is their responsibility. This is combined with long shifts, night shift responsibilities, lack of control in decision making, and increasing RN:patient demands (not to mention patients are sicker now more than ever). Then, to state the obvious, they are not paid enough. I'm not sure what national averages are, but at my hospital, starting salary for junior RN is ~50-60K and increases are slow. NPs/PA/CRNA's can make over $100K depending on specialty. It's a no-brainer, especially when you have debt and are getting burned out.

"Without regulation requiting hospitals' nurse staff have a particular distribution of certification, im sure nurse growth would be lower. You need a college education to take temperatures, give IVs, and change bedpans? Really?"

You have a very outdated idea of what LPNs, RNs and NPs, respectively, do.

An NP is doing stuff like administering anesthesia in rural areas where specialist MDs to do that are unavailable.

I wonder how much of this is also being driven by word about the opportunities in nursing and adjacent fields being better than those in med school: https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school.

Anecdotally, a number of doctors I know have said that they wish they'd been NPs or physicians assistants.

Are those women doctors? No male MD of my acquaintance would say that.

As a male MD, I would

What's stopping you?

$200k in student loans for med school and a career. Why would I pay to go back to school for something im already trained to do? This comment was about MDs reflecting on whether they would make the same choice again. Many would not.

Those nurses paid for with oil exports.
First we hired thousands of frackers, then we tax them and hire a bunch of nurses. Kind of like Saudis do.

The U.S. remains a crude importer - The United States is a net importer of crude oil. In November 2019, the latest monthly data, it imported 5.8 million b/d of crude oil and exported 3.0 million b/d of crude oil.

That 2.8 mbpd crude net import is then refined and exported, contributing to a 3.6 mbpd net export of refined product. Thus total crude and refined products is a net export of about 0.8 mbpd.

The US refining capacity (not all oil, or all refineries, are the same) is value adding. I suppose we could close those refineries, fire those (mostly union) workers, and stop importing extra crude to refine for others, but it seems a bad idea.

Nope - you are confusing 'petroleum' with crude oil. For example, bio alcohol and condensates converted to liquid fuel are counted as petroleum.

Here is another, slightly older EIA information (2018 data, article from May 2019) explanation - "The United States produces a large share of the petroleum it consumes, but it still relies on imports to help meet demand

In 2018, the United States produced about 17.7 million barrels of petroleum per day (MMb/d), and it consumed about 20.5 MMb/d. Imports from other countries help to supply domestic demand for petroleum"

Nope. If you look at the EIA data, the US became a net exporter in September 2019, so you 2018 data is indeed old.

That's actually from his own link. At the very top. He literally cherry picked data lower down the page. What a troll.

"In November 2019, the United States exported 772,000 barrels per day (b/d) more petroleum (crude oil and petroleum products) than it imported, marking the third consecutive month in which the United States was a net petroleum exporter."

Perhaps linking to a non-EIA source will help. "But there is important context between these numbers. First, the 20.5 million BPD is a fairly accurate representation of U.S. consumption, but there is a large U.S. production number that isn't included in the crude oil production numbers.

There is a line item called Other Supply, which consists primarily of natural gas liquids (NGLs) and fuel ethanol. This category represents a significant input to refiners in addition to the 11.7 million BPD of production (and the 4.0 million BPD of net crude oil imports). Other Supply represented 6.9 million BPD of production, and it mostly ends up as feedstock for refiners or petrochemical production."

The article continues, referencing the Bloomberg article - "The headline said "oil." The U.S. is still a net importer of oil to the tune of 4.0 million BPD.

Further, total U.S. production of oil and other supply that is fed into refineries is 18.6 million BPD, while U.S. consumption is 20.5 million BPD. That still puts U.S. consumption at nearly 2.0 million BPD more than we produce. (It's actually a little worse than that, because not all NGLs end up as refinery feedstock).

So the bottom line is that we aren't net exporters of crude oil, and we aren't energy independent."

Back to current government figures of the sort of "petroleum" we export in reference to the Forbes article - fuel ethanol, to the tune of 1 million barrels a day.

And here is the same author writing in December, 2019 - "But what is the situation now with respect to crude oil imports? A year ago, in response to the Bloomberg article, I reported that the U.S. was still a net crude oil importer to the tune of about 4 million BPD. A year later, that number has fallen to about 3 million BPD, and sometimes falls even lower.

For all of 2018, the U.S. was still a net importer of crude oil to the tune of 5.7 million BPD. That number had fallen by 1.5 million BPD over the previous two years. Final numbers for 2019 aren’t yet available, but the average for the year so far is 4.0 million BPD.

That’s a remarkable year-over-year decline, but the U.S. is still very much a net importer of crude oil. Even if the current trends continue (particularly the robust growth of shale oil production), it looks unlikely that crude oil imports could turn into exports before about the middle of the next decade."

Seriously? The very source that you link to proves you wrong, so you go trolling in desperation for something else to prop up a bad argument.

Since there seems to be a length limit, here is what the original link says at the end - 'If these forecasts are realized, the United States would be a net petroleum exporter for the first time on an annual basis in EIA's data series that dates back to 1949. EIA forecasts that the United States will remain a net importer of crude oil in both years, importing a net 3.9 million b/d of crude oil in 2020 and 2.9 million b/d in 2021.'

After reading the Forbes information about how the EIA considers NGLs and fuel ethanol petroleum, maybe the simple statement at the end of the original EIA article makes more sense. Or possibly, you now have more context for this equally simple statement from Forbes - "Further, total U.S. production of oil and other supply that is fed into refineries is 18.6 million BPD, while U.S. consumption is 20.5 million BPD. That still puts U.S. consumption at nearly 2.0 million BPD more than we produce."

The numbers are not really up for discussion, nor is the fact that crude is not the same as petroleum. Yes, we export petroleum and yes, we import crude oil. As noted in the original EIA link, twice. We import roughly 10% of the liquid fuel that we use, a number likely to continue to shrink over the next half decade.

What's your point?

China, India and the EU are larger net oil importers. Is your point that the US is fourth?


...to take something the US is doing well and try to deny that it's happening.

+1, it seems to just be trolling.

Let's see if the 2019 Forbes link works here - https://www.forbes.com/sites/rrapier/2019/12/01/us-still-not-a-net-crude-oil-exporter/#454edd2025a8

America Is Not Yet A Net Crude Oil Exporter - and within that article is the link to the 2018 one.

Part of it could be the aftermath of the meltdown and Obamacare. I say this because I have a child in that age group and 4 of her peers decided to go into nursing. At this point, it looks like they’ll have a job most of their lives. That age bracket was living thru uncertainty and who knows what they absorbed from or experienced through their parents and friends’ parents.

The meltdown? Obamacare helped finance the existing market for affordable care that people needed but weren't previously receiving. But of course nursing has been a viable career path for a long time.

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