Healthcare Licensing Hellscape

Last week, Yahlin and I celebrated our 20th anniversary. On the way back from dinner, we talked about the importance of choosing a partner. “It’s the most important decision you can make,” Yahlin said. I nodded and responded:

Ryan: You made a good decision.
Yahlin: No, you made a good decision!
Ryan: You made a better decision than I did.
Yahlin [silence, anger]
Ryan: What? I’m complimenting you on your decision-making.

Marriage is a lengthy adventure. But on the whole, it seems like we’ve made reasonable decisions. For example, refraining from naming a child Q, as a friend of ours did. She’s based in Berkeley and as liberal as that locale suggests. So the emergence of QAnon has been her own Personal Pan Pizzagate. And so far we’ve been successful in keeping our kids away from bad influences, although a recent conversation with our 11-year-old went something like this:

Yahlin: Have you heard of peer pressure?
Zev: No. But it sounds fun. I want to do it.

Good marriages generally lead to happiness. Conversely, bad marriages go the other way. And outside Donald Trump + the Republican party, the most unholy marriage I know is the marriage of colleges + state occupational licensing boards.

Back in the 1950s, only 5% of American jobs required licensure. Now nearly 25% do. In the name of consumer protection, licensure has been delegated by states to professional associations (in the form of state professional licensing boards dominated by practitioners), which then decide how high a fence to erect around the profession. Given that licensure results in double-digit percentage increases in income, the usual answer is pretty high. As one commentator recognized, the way states run occupational licensure is “roughly akin to requiring the Commodity Futures Trading Commission to be run by active options traders.”

When I last lambasted licensure, I focused on ridiculous requirements for hair braiders and interior designers, leaving healthcare alone. Which idiot is going to argue that doctors and nurses shouldn’t be licensed? (Not this idiot, I thought.) But given that nearly 70% of healthcare jobs now require licensure, it’s time for another look. Because by adding friction to career entry in the largest sector of our economy, occupational licensure has become a major driver of American inequality.


Where we depart dramatically from other developed countries is licensure of entry-level healthcare workers as well as jobs delivering care that is objectively low-risk. In Europe, healthcare support roles called assistant or aide aren’t licensed and are therefore an accessible point of entry to health professions. The same is true of many therapeutic jobs.

Physical therapy assistant is a prime example of American licensing lunacy. While state PT boards established by statute and comprising a majority of practicing PTs have long mandated licensure of PTAs, physical therapy assistants are actually prohibited from designing or prescribing therapeutic exercises. That’s the province of physical therapists. So here’s what PTAs are actually permitted to do:

Meanwhile, in order to be licensed, all states require PTAs to have an associate’s degree accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE – a fitting acronym for a profession subject to regulatory capture). These degrees are five semesters and include courses in anatomy, physiology, exercise physiology, biomechanics, kinesiology, neuroscience, clinical pathology, and behavioral science. While there are clinical components, 75% of PTA programs are delivered in a classroom.

While there’s no question this coursework should be required for PTs (who, thanks to credential inflation mandated by state PT boards, must now obtain doctoral degrees), I can find no supporting evidence from CAPTE or state PT boards on why five semesters of coursework in anatomy, physiology, and neuroscience should be required in order to help patients do exercises designed by licensed PTs, particularly when PTAs can only work under their direct supervision. There don’t seem to be any studies demonstrating that PTAs with associate degrees perform better or provide better consumer/patient protection than PTAs without, or why relevant experience (say, as an athlete or personal trainer) might not be equivalent to sitting in a classroom for five semesters. Laughably (and tragically, as we shall see), the issue at hand for PTAs is not whether to eliminate the associate degree requirement, but rather whether to inflate to bachelor’s (perhaps because the gap from associate-PTA to doctoral-PT, involving a transfer credit transit, is so wide as to be fanciful). As an informed observer recently said to me, it certainly seems that colleges are in cahoots with licensing boards to create credential inflation.

And why wouldn’t they be? At some private colleges, PTA programs generate over $100K in tuition revenue for jobs with a median salary of $49,180. Add this cost to a 2+ year time commitment (introducing a significant risk of life getting in the way – the overwhelming risk at community colleges, where PTA programs are generally affordable) and it’s pretty clear that, in the name of consumer protection, state boards are privileging incumbent workers and colleges at the expense of job seekers and economic mobility.


Requiring licensure for entry-level/low-risk healthcare professions and then adding a degree requirement is a Russian nested doll of bad decisions. I don’t blame the professions. The American Physical Therapy Association is going to act according to the parochial interests of its members (and apparently those of the schools they attended). I blame state governments for empowering professional associations. Other developed countries avoid these issues by retaining licensure as a government function.

Occupational licensure is another example of failure of American state capacity. As Ezra Klein noted last month in the New York Times, government effectiveness has been sideswiped by two forces coming from very different directions: knee-jerk anti-statism from the right; and from the left, a fetish for process at the expense of outcomes. The former has been obvious since the rise of Reagan and believes delegating decision-making to industry is a damn fine idea. The latter, Klein explains, citing University of Michigan’s Nicholas Bagley, has arisen because the Democratic Party is “dominated by lawyers. Biden and Kamala Harris hold law degrees, as did Barack Obama and John Kerry and Bill and Hillary Clinton before them. And this filters down through the party. ‘Lawyers, not managers, have assumed primary responsibility for shaping administrative law in the United States,’ Bagley writes. ‘And if all you’ve got is a lawyer, everything looks like a procedural problem.’” And if you’ve got a solution with enough procedure, no need to worry about outcomes (like, say, supply of housing, refining capacity or employability of college grads).

Let me tell you, there’s a healthy amount of procedure involved in PTA licensure. In addition to earning an associate’s degree, PTAs must complete applications requiring:

As for the PTA degree itself, CAPTE’s accreditation requirements span 34 pages, 8 standards, and over 100 elements including maintaining accurate information regarding CAPTE accreditation status on the program website. With so much procedure, it’s got to be good, right?

In fact, the negative externalities are legion. Requiring licensure and a degree for entry-level positions in low-risk health professions raises healthcare costs without any demonstrable improvement in quality (and may actually result in worse outcomes due to less availability of care). We may really be paying more for less (just like Netflix!). Worse, it exacerbates inequality by benefiting those who have already established themselves in the profession while deterring aspiring PTAs, who are then steered into lower-paying positions that don’t require a license, like retail, food service, or Amazon warehouses: jobs with fewer career prospects. State licensure – referenced by some commentators as “federalism gone wild” — also severely restricts interstate mobility, which makes little sense in an era of telemedicine. Last but not least, it further erodes government legitimacy – already under constant barrage from the right. As Klein says (quoting Bagley), “Legitimacy is not solely, not even primarily, a product of the procedures that agencies follow… Legitimacy arises more generally from the perception that government is capable, informed, prompt, responsive and fair.” Multiply PTA licensure + degree requirement across dozens of entry-level, low-risk healthcare jobs that should be easy stepping stones to economic advancement, and it’s clear why tens of millions of potential voters have checked out and don’t plan to check back in anytime soon (making it nearly impossible to address our most intractable problems like immigration and climate change).

States more interested in the welfare of their citizens than continuing to make an ideological point about government ineffectiveness – i.e., blue and purple states, hopefully a few red states – have two options. They can withdraw delegation of licensure to captive professional associations. But given certain pushback, an easier step for entry-level, low-risk professions is legislation requiring that licensing boards provide alternative pathways to licensure that only require candidates to demonstrate relevant experience or mastery of relevant competencies (i.e., helping patients stretch, not passing an anatomy class). Tuition-dependent colleges will yell and scream, especially in the early innings of secular enrollment decline. But let’s hope most are still sufficiently mission- (and civic-) minded to recognize the many problems spawned by their terrible, horrible, no good, very bad marriage with state licensing boards.