Texas lawmakers eye sharing health care workers with other states to address provider shortages

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A coalition of health industry leaders are backing a policy they say would help stop the statewide hemorrhaging of health care workers — allowing certain out-of-state professionals to practice in Texas.

The plan would allow Texas to join existing interstate compacts for nine professions: audiology and speech pathology, cosmetology, occupational therapy, physician’s assistants, counseling, dentistry, dietetics, respiratory care and social work. If a state agrees to join a compact, eligible professionals could obtain a multistate license similar to a driver's license that allows them to practice outside of their state. Texas workers would be able to work elsewhere and out-of-state workers can work in Texas.

Currently, bills to create compacts for cosmetology, counseling, and dentistry have been filed.

“It is too early to say what these compacts could add to the workforce as there needs to be studies done, but what it does is make it easier for folks to practice in multiple states,” said Bryan Mares, government relations director for the Texas chapter of the National Association of Social Workers.

Almost a dozen professional groups, including the Texas Academy of Physician Assistants and Texas Counseling Association, have formed the Interstate Compact Coalition to advocate for these agreements that they say will solve the insufficient number of workers that affect nearly all corners of the health care industry in the state. The compacts would expand the workforce pool and save traveling professionals — often those who are military spouses — time and money from having to obtain multiple state licenses. But skeptics fear the compact will end up only shipping off more Texas workers than it receives, all while watering down rigorous standards of Texas’ licensing boards.

“We have really good, robust licensing through the state board, and we want to maintain those standards, too, which sometimes with compacts, we’re not 100% sure can be guaranteed,” said Matt Roberts, a chair member of the Texas Dental Association.

Health care workforce shortages plague almost every state, but the problems in rapidly growing and diverse Texas are particularly acute.

Texas ranks at the bottom in the country in the number of dental hygienists per capita, at 37 per 100,000 people. It is also projected to have the third highest social worker shortage by 2030, with an estimated deficit of 33,825 jobs.

A Texas Hospital Association survey found that 64% of hospitals operate with fewer beds and reduced services because of nurse staffing shortages. There is a shortage of obstetricians in rural East Texas, and jails are holding inmates who must wait months for treatment because of a lack of psychiatric hospital staff.

The shortages particularly affect counties along the Texas-Mexico border. The lack of medical personnel can lead to long trips and delayed checkups for many Texans.

Why interstate compacts?

The U.S. Department of Defense has partnered with The Council of State Governments to fund the development of these interstate work licensing agreements because families of military personnel move around the country so often that getting certified to work in different states is time-consuming and costly.

“Military families can be very transitory, so the Department of Defense has funded this project to get some legislation for these states to enact,” Mares said.

Recruiting Texas would be a boon to these compacts because it has 15 active-duty military installations.

From an administrative and efficiency standpoint, licensing compacts can offer significant benefits, according to compact supporters.

Mares said for social workers and other licensed professionals, these interstate compacts are the best way for the state to build a sustainable workforce model by allowing incoming licensed and trained professionals to get to work sooner. They allow states to skip the vetting process of other compact members with comparable licensing standards.

“This eliminates duplicative efforts, saving time and resources while ensuring that qualified professionals are available to serve the public,” Darrel Spinks, the executive director of the Texas Behavioral Health Executive Council, the state’s mental health licensing authority, said.

For example, even if they’ve already met these requirements out of state, a licensed social worker interested in working in Texas must submit an application and other material, including a jurisprudence exam certificate, clinical supervision verification, fingerprinting, an Association of Social Work Boards exam, and more.

Moreover, the compact not only benefits these professionals but also the Texans they would serve, said Betsy Cauble, a long-time social worker on the board of directors at Preferra, an insurance company for more than 100,000 behavioral professionals, including many in Texas. She said since Texas borders so many states, residents living near state lines would particularly benefit from interstate providers.

“Oftentimes students, for example, at the University of Texas would be seeing a clinician, and then when they go home for vacations or the summer, they can’t see that therapist anymore because they aren’t licensed in the state they live in,” she said. “The compact eliminates many of these problems for people.”

Texas also lacks a diverse workforce, so Cauble said the compacts could help create more multilingual providers for residents here.

“When you are dealing with difficulties in your personal life, trying to express yourself in a second language can be pretty hard,” Cauble said. “Luckily, there are Spanish-speaking specialists nationwide who can help.”

Cauble said she expects some pushback to interstate compacts because in part, application fees that state licensing boards collect and rely on in their budgets could be affected.

Compacts don’t get you more chairs

John Bielamowicz, the presiding member of the Texas psychologists’ licensing board, questions billing interstate compacts as the solution to so many of Texas’ health care workforce problems.

“I would liken it to rearranging the deck chairs on a sinking ship,” he said. “Compacts don’t necessarily get you any more chairs.”

The social worker compact, for example, has 22 states and Texas would be the biggest contributor.

The projected shortage of social workers and other professionals is most prevalent in the state's rural areas, an issue that interstate compacts aren’t designed to address, said Roberts with the dental association.

“This is happening in every profession — optometrists, dental hygienists, social workers — all these folks are having trouble recruiting in rural areas, and the people who come from out of state with an interstate compact aren’t going to move to the rural areas over Houston or Dallas or Austin,” said Roberts, who lives in Crockett.

Other recruitment and retention methods such as loan repayment programs, increasing Medicaid payments to providers, and encouraging schools to send students to rural areas are better options than interstate compacts, Roberts said. However, compacts are a relatively cheap solution for the state, and the options Roberts suggests would require consistent government funding.

“We actually have a dental education repayment program on the books. It just hasn’t been funded,” Roberts said. “We have had the same problem as most when it comes to getting funding through the state Legislature that doesn’t want to go for recurring item issues, but man, it’s a rounding error for them.”

Bielamowicz said he recognizes a workforce issue in Texas, but a compact removes the state’s autonomy. Licensing boards would lose power at the expense of what a national board believes is best, he warns.

“You have a national organization that calls the shots and is effectively the gatekeeper of these compacts,” Bielamowicz said. “You have an organization who is not accountable to Texas, not responsible to the Legislature, not responsible to the governor or a state board. They have the power. It’s their ball; they can decide who gets to play.”

Mares insists these licensing compacts will preserve each member state's authority to control and enforce its rules. He said states whose rules are different than the norm for licensing, like New York and California, will most likely not be a part of these compacts.

A person can lose their license in Texas for numerous reasons, including sexual misconduct, violations of state or federal law, or physical harm. Texas also bars felons from obtaining social worker licenses. Not every state follows these exact rules.

The state currently uses agencies such as the Texas Behavioral Health Executive Council to regulate the licenses of certain skilled professions and pass down sanctions or revocations of licenses. By joining an interstate compact, the future of these umbrella agencies becomes uncertain, and what they can enforce will have to be negotiated with other states.

Bielamowicz said one of the primary downsides for Texans is that compacts remove local control in health care.

“When people have problems, they can come to us and yell or propose ideas,” Bielamowicz said. “When you have a compact, it’s usually an unelected board or commission made up of primarily industry participants that might meet a few times a year far away.”

Disclosure: Texas Dental Association and Texas Hospital Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.