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Nurse licensure compacts before, during, and after COVID

The COVID-19 pandemic highlighted major issues in the ways the health care workforce in the United States withstands shocks. Staffing issues put nurses…



By Lauren Bauer, Aidan Creeron, Joy Dada, Luiza Macedo

The COVID-19 pandemic highlighted major issues in the ways the health care workforce in the United States withstands shocks. Staffing issues put nurses in the headlines. In reaction to the public health emergency, all governors issued executive orders to allow nurses to work across state lines more freely. This action was a nationalization of an existing compact between many states. Those emergency orders have since expired, leaving room for policy interventions that can make labor markets more flexible and benefit workers.

In this post, we summarize changes to licensing requirements for nurses from before and during the pandemic, focusing on the Nurse Licensure Compact (NLC) and its reforms to interstate licensing. We provide evidence on both the benefits and consequences of licensing changes and outline the current debate surrounding these reforms. We also provide an overview of the current landscape of nurse licensing in the United States and conclude by considering the future of these reforms in four states that do not currently belong to the NLC.

The Introduction and Expansion of the Nurse Licensure Compact

The Nurse Licensure Compact (NLC) has grown since its inception in 1999. The compact increases the mobility of nurses nationwide by minimizing barriers to interstate practice. Prior to its implementation, nurses had to be licensed to work state-by-state, creating barriers to geographic mobility and interstate work. In the late 1990s, the National Council of State Boards of Nursing (NCSBN) explored a “mutual recognition model” between participating states for licensing of registered nurses (RNs) and practical/vocational nurses (LPN/VNs). This would allow in-person and virtual practice in participating states and would allow nurses to relocate to participating states without relicensing.

In 1997 the NCSBN unanimously endorsed a new model for nursing regulation, laying the foundation for the NLC to be ratified in 1999. Compact membership required Boards of Nursing to report to the newly formed Interstate Commission of Nurse Licensure Compact Administrators (ICNLCA), cease collecting licensing fees from nurses in other compact states, and pay a $6,000 annual membership fee.

Figure 1 shows the timing of the Nurse Licensing Compact adoption across states. The bulk of adoption took place in the first two years of the compact: 2000-2001. This amounted to 14 states. In the next 15 years, by comparison, Some attribute this plateau in new membership to the compact’s insufficient criminal background check requirements. On January 19, 2018, the Enhanced Nursing Licensure Compact (eNLC) was formed to address these concerns through 11 new uniform licensing requirements, aiming to encourage its national adoption. In the following two years, 9 more states joined the eNLC, and all previous member states were grandfathered into the new compact. One exception, Rhode Island, joined the NLC in 2008 but opted not to join the eNLC in 2018. After the incidence of the national pandemic which introduced the State of Emergency quasi-national compact discussed below, 3 more states joined the eNLC, the most recent of which is Ohio, joining the compact on January 1, 2023.

Evidence of the Effects of the Nurse Licensing Compact

Just prior to the pandemic, interstate nursing practice was becoming more common in eNLC states. Multi-state licensure take-up has been steadily increasing from 1.6% of NLC nurses working in a compact state in 2008, to almost a quarter of all RNs holding an interstate license (24%) by 2020. Thirty-three percent of nurses cite using their interstate license for travel nursing, with 16% for telehealth and 8% for distance education, yet only 4% cite travel nursing as their main motivation for obtaining this license.

The literature largely corroborates the causal impact of compact membership on greater mobility among nurses. Shakya, Ghosh, and Norris exploit the diversity in states’ timing of NLC adoption, calculating that compact nurses are 11% more likely to move and work in other compact states. Ghani finds that the single-state licensing system causes more rigidity in the labor market, whereas the NLC boosts interstate migration and might divert flows toward non-compact states. Moreover, Johnson and Kleiners’ report on labor migration patterns shows that the NLC both boosts job outflows within the health and social assistance industry by 11% and dampens the number of health workers moving from compact to non-compact states. Conversely, DePasquale and Stange’s research on commuting found no causal effects on labor supply or mobility; nurses living in a metropolitan statistical area that spans multiple states experience only a 1.2% increase in likelihood of interstate work after their state joins the NLC. research on commuting found no causal effects on labor supply or mobility; nurses living in a metropolitan statistical area that spans multiple states experience only a 1.2% increase in likelihood of interstate work after their state joins the NLC.

COVID-19 and the Emergency Licensing Waiver: A Quasi-National Compact

The outbreak of COVID-19 prompted all states to declare a State of Emergency in 2020 and implement an emergency licensing waiver for health care professionals, initiating a functionally national compact to make labor markets more flexible. Nurses could effectively practice anywhere without applying for an additional license or paying additional fees, regardless of a state’s pre-pandemic membership in the compact. In analyzing the impact of COVID-19 on the active nursing population, Chan and collaborators claim that “at no other time in the history of the United States has the NLC been more critical for nurse licensure regulation than the COVID-19 pandemic.”

There was an estimated 35% growth of travel nursing in 2020 and an additional 40% growth in 2021. Wages for those willing to travel skyrocketed to an average of $154 an hour, not including other cash incentives. For nurses willing to relocate on a more permanent basis, signing bonuses reached as high as $13,000.

Figure illustrating Date of Exit from Quasi-National Compact

States began rescinding their states of emergency as early as April 2021, and the majority of states allowed their temporary emergency authorizations to expire by September 2022. Figure 2 shows the timing of exit from the quasi-national emergency compact. States in solid colors exited the national compact into the existing eNLC while states with horizontal lines reverted to nonparticipation in the eNLC. To be clear, however, the historically tight labor market during the recovery from the pandemic has likely been—and continues to be—more consequential to the nursing labor market than changes to licensing.

The Debate Surrounding the Nursing License Compact

Many states have reconsidered NLC membership following temporary measures implemented over the pandemic as possible solutions to labor shortages and turnover. The Massachusetts State Legislature has recently considered joining the eNLC. As of February 2023, Bill H.1284 sits with the Joint Committee on Health Care Financing, bolstered by support from the Massachusetts Health and Hospital Association. During the pandemic, the state’s declaration of emergency permitted out-of-state licensed health professionals to practice in Massachusetts through June 30, 2023. By May 2021, the Board of Registration in Nursing had issued 8,500 temporary licenses. Washington state is also considering joining the compact, with both House Bill 1417 and Senate Bill 5499 in committee as of February 2023. Illinois is reconsidering its licensing practices in the face of looming shortages as well. In response to the public health emergency in early 2020, Governor J. B. Pritzker signed multiple executive orders to allow temporary nursing assistants to perform the tasks typically completed by certified nursing assistants. Out-of-state nurses could also complete the Health Care Temporary Practice Application to receive a temporary Illinois permit. The ability to practice with a temporary permit expired in February 2023.

While participating in the common market may help to alleviate nursing shortages, for a variety of reasons some states pursue a more limited strategy. For example, California and Oregon have considered joining the compact several times. Opposition to NLC implementation from Boards of Nursing have cited concerns over falling nursing board revenues and work standards, a lack of disciplinary oversight, and a loss of sovereignty to the ICNLCA. Some nursing advocacy organizations and affiliated unions highlight worries over diminished bargaining power, as well as wage depression caused by an influx of traveling nurses. If, for example, the removal of licensing restrictions encourages nurses to travel to a state that enjoys elevated wages, then unionized nurses may suffer from declining wages, erasing the above-average wages that the state boasted before joining the compact.

In California, the state of emergency permitted out-of-state nurses to practice without a California-issued license, but authorization expires at the end of February 2023. Oregon has also considered joining the NLC in the past but abandoned this effort in 2016 after facing opposition from the Oregon Nurse’s Association. Temporary emergency licenses for out-of-state nurses were allowed under Governor Kate Brown’s March 2020 emergency declaration; those with such licenses could practice until mid-2023. Oregon’s Nursing Board reports over 11,000 emergency authorizations issued over the two years, and as of June 2022, about one-third of the 9,000 active authorizations had applied for and received an Oregon state license to practice after the state of emergency expired.


States participating in a compact enjoy higher mobility and more interstate practice, with some uncertainty over the magnitude of these impacts. Supporters of the NLC have long envisioned a scaling up of those benefits through a standardized national framework for licensure reciprocity.

The pandemic and concurrent changes to occupational licensing highlighted the need for policy interventions that can benefit workers. Working conditions and burnout have worsened, perhaps exacerbated by significant workforce changes as more nurses temporarily moved across state lines. In addition, turnover and the impending wave of retirements may change post-pandemic workforce projections for nursing. While the current compact focuses on the standardization of state nursing licenses for in-person medical care, the rise of remote medical services before and during the pandemic presents a new challenge to individual state systems, where barriers remain to offering interstate telehealth services.

The flexibility provided to nurses during the pandemic, both in the model of the NLC allowing nurses to move to places of high demand, as well as the easing of requirements around remote medical care, represent possible reforms. In light of changing demographics and geographic disparities in health care access, the need is evident for more flexibility in the structure of medical licensing and provision of care alongside policies that improve working conditions.

The Brookings Institution is financed through the support of a diverse array of foundations, corporations, governments, individuals, as well as an endowment. A list of donors can be found in our annual reports published online here. The findings, interpretations, and conclusions in this report are solely those of its author(s) and are not influenced by any donation.

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Fighting the Surveillance State Begins with the Individual

It’s a well-known fact at this point that in the United States and most of the so-called free countries that there is a robust surveillance state in…



It’s a well-known fact at this point that in the United States and most of the so-called free countries that there is a robust surveillance state in place, collecting data on the entire populace. This has been proven beyond a shadow of a doubt by people like Edward Snowden, a National Security Agency (NSA) whistleblower who exposed that the NSA was conducting mass surveillance on US citizens and the world as a whole. The NSA used applications like those from Prism Systems to piggyback on corporations and the data collection their users had agreed to in the terms of service. Google would scan all emails sent to a Gmail address to use for personalized advertising. The government then went to these companies and demanded the data, and this is what makes the surveillance state so interesting. Neo-Marxists like Shoshana Zuboff have dubbed this “surveillance capitalism.” In China, the mass surveillance is conducted at a loss. Setting up closed-circuit television cameras and hiring government workers to be a mandatory editorial staff for blogs and social media can get quite expensive. But if you parasitically leech off a profitable business practice it means that the surveillance state will turn a profit, which is a great asset and an even greater weakness for the system. You see, when that is what your surveillance state is predicated on you’ve effectively given your subjects an opt-out button. They stop using services that spy on them. There is software and online services that are called “open source,” which refers to software whose code is publicly available and can be viewed by anyone so that you can see exactly what that software does. The opposite of this, and what you’re likely already familiar with, is proprietary software. Open-source software generally markets itself as privacy respecting and doesn’t participate in data collection. Services like that can really undo the tricky situation we’ve found ourselves in. It’s a simple fact of life that when the government is given a power—whether that be to regulate, surveil, tax, or plunder—it is nigh impossible to wrestle it away from the state outside somehow disposing of the state entirely. This is why the issue of undoing mass surveillance is of the utmost importance. If the government has the power to spy on its populace, it will. There are people, like the creators of The Social Dilemma, who think that the solution to these privacy invasions isn’t less government but more government, arguing that data collection should be taxed to dissuade the practice or that regulation needs to be put into place to actively prevent abuses. This is silly to anyone who understands the effect regulations have and how the internet really works. You see, data collection is necessary. You can’t have email without some elements of data collection because it’s simply how the protocol functions. The issue is how that data is stored and used. A tax on data collection itself will simply become another cost of doing business. A large company like Google can afford to pay a tax. But a company like Proton Mail, a smaller, more privacy-respecting business, likely couldn’t. Proton Mail’s business model is based on paid subscriptions. If there were additional taxes imposed on them, it’s possible that they would not be able to afford the cost and would be forced out of the market. To reiterate, if one really cares about the destruction of the surveillance state, the first step is to personally make changes to how you interact with online services and to whom you choose to give your data.

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Stock Market Today: Stocks turn higher as Treasury yields retreat; big tech earnings up next

A pullback in Treasury yields has stocks moving higher Monday heading into a busy earnings week and a key 2-year bond auction later on Tuesday.



Updated at 11:52 am EDT U.S. stocks turned higher Monday, heading into the busiest earnings week of the year on Wall Street, amid a pullback in Treasury bond yields that followed the first breach of 5% for 10-year notes since 2007. Investors, however, continue to track developments in Israel's war with Hamas, which launched its deadly attack from Gaza three weeks ago, as leaders around the region, and the wider world, work to contain the fighting and broker at least a form of cease-fire. Humanitarian aid is also making its way into Gaza, through the territory's border with Egypt, as officials continue to work for the release of more than 200 Israelis taken hostage by Hamas during the October 7 attack. Those diplomatic efforts eased some of the market's concern in overnight trading, but the lingering risk that regional adversaries such as Iran, or even Saudi Arabia, could be drawn into the conflict continues to blunt risk appetite. Still, the U.S. dollar index, which tracks the greenback against a basket of six global currencies and acts as the safe-haven benchmark in times of market turmoil, fell 0.37% in early New York trading 105.773, suggesting some modest moves into riskier assets. The Japanese yen, however, eased past the 150 mark in overnight dealing, a level that has some traders awaiting intervention from the Bank of Japan and which may have triggered small amounts of dollar sales and yen purchases. In the bond market, benchmark 10-year note yields breached the 5% mark in overnight trading, after briefly surpassing that level late last week for the first time since 2007, but were last seen trading at 4.867% ahead of $141 billion in 2-year, 5-year and 7-year note auctions later this week. Global oil prices were also lower, following two consecutive weekly gains that has take Brent crude, the global pricing benchmark, firmly past $90 a barrel amid supply disruption concerns tied to the middle east conflict. Brent contracts for December delivery were last seen $1.06 lower on the session at $91.07 per barrel while WTI futures contract for the same month fell $1.36 to $86.72 per barrel. Market volatility gauges were also active, with the CBOE Group's VIX index hitting a fresh seven-month high of $23.08 before easing to $20.18 later in the session. That level suggests traders are expecting ranges on the S&P 500 of around 1.26%, or 53 points, over the next month. A busy earnings week also indicates the likelihood of elevated trading volatility, with 158 S&P 500 companies reporting third quarter earnings over the next five days, including mega cap tech names such as Google parent Alphabet  (GOOGL) - Get Free Report, Microsoft  (MSFT) - Get Free Report, retail and cloud computing giant Amazon  (AMZN) - Get Free Report and Facebook owner Meta Platforms  (META) - Get Free Report. "It’s shaping up to be a big week for the market and it comes as the S&P 500 is testing a key level—the four-month low it set earlier this month," said Chris Larkin, managing director for trading and investing at E*TRADE from Morgan Stanley. "How the market responds to that test may hinge on sentiment, which often plays a larger-than-average role around this time of year," he added. "And right now, concerns about rising interest rates and geopolitical turmoil have the potential to exacerbate the market’s swings." Heading into the middle of the trading day on Wall Street, the S&P 500, which is down 8% from its early July peak, the highest of the year, was up 10 points, or 0.25%. The Dow Jones Industrial Average, which slumped into negative territory for the year last week, was marked 10 points lower while the Nasdaq, which fell 4.31% last week, was up 66 points, or 0.51%. In overseas markets, Europe's Stoxx 600 was marked 0.11% lower by the close of Frankfurt trading, with markets largely tracking U.S. stocks as well as the broader conflict in Israel. In Asia, a  slump in China stocks took the benchmark CSI 300 to a fresh 2019 low and pulled the region-wide MSCI ex-Japan 0.72% lower into the close of trading.
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Forget Ron DeSantis: Walt Disney has a much bigger problem

The company’s political woes are a sideshow to the one key issue Bob Iger has to solve.



Walt Disney has a massive, but solvable, problem.

The company's current skirmishes with Florida Gov. DeSantis get a lot of headlines, but they're not having a major impact on the company's bottom line.

Related: What the Bud Light boycott means for Disney, Target, and Starbucks

DeSantis has made Walt Disney (DIS) - Get Free Report a target in what he calls his war on woke, an effort to win right-wing support as he tries to secure the Republican Party nomination for president. 

That effort has generated plenty of press and multiple lawsuits tied to the governor's takeover of the former Reedy Creek Improvement District, Disney's legislated self-governance operation. But it has not hurt revenue at the company's massive Florida theme-park complex.  

Disney Chief Executive Bob Iger addressed the matter during the company's third-quarter-earnings call, without directly mentioning DeSantis.

"Walt Disney World is still performing well above precovid levels: 21% higher in revenue and 29% higher in operating income compared to fiscal 2019," he said. 

And "following a number of recent changes we've implemented, we continue to see positive guest-experience ratings in our theme parks, including Walt Disney World, and positive indicators for guests looking to book future visits."

The theme parks are not Disney's problem. The death of the movie business is, however, a hurdle that Iger has yet to show that the company has a plan to clear.

Boba Fett starred in a show on Disney+.

Image source: Walt Disney

Disney needs a plan to monetize content 

In 2019 Walt Disney drew in more $11 billion in global box office, or $13 billion when you add in the former Fox properties it also owns. In that year seven Mouse House films crossed the billion-dollar threshold in theaters, according to data from Box Office Mojo.

This year, the company will struggle to reach half that and it has no billion-dollar films, with "Guardians of the Galaxy Vol. 3" closing its theatrical run at $845 million globally. 

(That's actually good for third place this year, as only "Barbie" and "The Super Mario Bros. Movie" have broken the billion-dollar mark and they may be the only two films to do that this year.)

In the precovid world Disney could release two Pixar movies, three Marvel films, a live-action remake of an animated classic, and maybe one other film that each would be nearly guaranteed to earn $1 billion at the box office.

That's simply not how the movie business works anymore. While theaters may remain part of Disney's plan to monetize its content, the past isn't coming back. Theaters may remain a piece of the movie-release puzzle, but 2023 isn't an anomaly or a bad release schedule.

Consumers have big TVs at home and they're more than happy to watch most films on them.

Disney owns the IP but charges too little

People aren't less interested in Marvel and Star Wars; they're just getting their fix from Disney+ at an absurdly low price. 

Over the past couple of months through the next few weeks, I will have watched about seven hours of premium Star Wars content and five hours of top-tier Marvel content with "Ahsoka" and "Loki" respectively. 

Before the covid pandemic, I gladly would have paid theater prices for each movie in those respective universes. Now, I have consumed about six movies worth of premium content for less than the price of two movie tickets.

By making its premium content television shows available on a service that people can buy for $7.99 a month Disney has devalued its most valuable asset, its intellectual property. 

Consumers have shown that they will pay the $10 to $15 cost of a movie ticket to see what happens next in the Marvel Cinematic Universe or the Star Wars galaxy. But the company has offered top-tier content from those franchises at a lower price.

Iger needs to find a way to replace billions of dollars in lost box office, but charging less for the company's content makes no sense. 

Now, some fans likely won't pay triple the price for Disney+. But if it were to bundle a direct-to-consumer ESPN along with content that currently gets released to movie theaters, Disney might create a package that it can price in a way that reflects the value of its IP.

Consumers want Disney's content and they will likely pay more for it. Iger simply has to find a way to make that happen.

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