Training for Health Care Jobs in California: Opportunities for Workers without a Four-Year Degree

To be clear, just because there are programs available does not mean everyone can access them. In the case of selective programs like registered nursing or dental hygienist, prerequisite requirements may be a deterrent or obstacle.

Moreover, in the last several years, waiting lists at many community colleges also curtailed access. Our interviewees shed light on this issue:

They’ll apply to the nursing program here after finishing their two years of prereqs. They don’t get into the program. So they’ll just take a year off, and then that turns into two years, three years… then they have kids, and all these other responsibilities come up where they can’t get into the program. I can’t tell you how many people I have come in to reapply with the same story. Oh, yeah, I finished all my prerequisites for the program; I didn’t get admitted. And then life happened. It’s super hard for a student to come back full time to school once you take that gap. – Community college career counselor

A student tells me, I want to be a nurse, but I’m place bound. It has to be this college. I want to do my ADN program here. And it’s a lottery-based system, you know, and that’s just so tough for students, because they can’t even plan knowing which semester they’re going to be admitted into the nursing program. – Community college career counselor

The impaction of our nursing programs really limits student access and what happens is they turn to private institutions that have much higher costs and create more financial burden to get that nursing degree. – Community college career counselor

Lack of faculty and securing clinical placements for students are key challenges to expanding available training slots in nursing programs. A recent survey of registered nursing programs in California found that among those enrolling fewer students, about a quarter reported a lack of faculty as the most important reason and about 15 percent difficulties securing clinical placements (California Bureau of Registered Nursing 2024).

Challenges to Completing Community College Programs

Although completion rates in community college health programs are higher compared to other career education fields, many students still do not finish programs they start by earning a credential or degree (Bohn et al. 2016a; McConville et al. 2021). Completion varies considerably across health programs. Associate degree health programs included in this report boast very high completion rates, between 80 and 95 percent. On the other extreme, emergency medicine technicians have the lowest completion rates (around 40%) and only about half of students in other short-term programs like nursing assisting and pharmacy tech complete a credential (Bohn et al. 2016a).

We found that full-time enrollment is the strongest contributing factor to completing programs even after controlling for differences across gender, age, race/ethnicity, socioeconomic status, financial aid, and other factors (McConville et al. 2021). Still, some student groups fall off completion trajectories within the first few semesters of starting a program of study. This is especially true for Black students, suggesting that targeting intensive supports when people enter programs could be necessary to improve overall completion. In comparison, Latino students pursuing health pathways tend to have completion rates of their white counterparts, but it takes them much longer. In comparison, Asian students have the highest completion rates for community college career education programs though this may mask differences across Asian subgroups (McConville et al. 2021).

The length of time it takes to finish health awards at community colleges could be a factor in low completion rates. On average, it takes health students about two to three years to complete short- or long-term certificates. Additionally, community college health students often complete a significant number of units not necessarily related to their field of study, including in health training programs (McConville et al. 2021). This could reflect students’ need to maintain eligibility for financial aid by enrolling in general courses even if health courses are not available, their desire to work towards transfer, or being undecided about their specific pathway.

Our past work has shown students who receive financial aid—including Pell Grants, an indicator of students from lower-income families—are more likely to complete community college health programs and stackable credentials compared to those who do not. We also found that targeted support programs for student parents who received CalWORKs cash assistance increased the likelihood that students enrolled full time, successfully completed courses, and persisted to the next term (McConville et al. 2020).

Future Job Opportunities and Local Labor Markets

The regional distribution of health training programs is driven, at least in part, by local labor market demand. Even though they may also recruit from outside the local area, the presence of large employers like hospitals can create job opportunities—and training needs—for individuals in the region. Additionally, regional needs for health services driven by population growth and composition (e.g., aging) or policy (e.g., insurance expansion or contraction) also factor into job opportunities for prospective health workers.

The most recent state-level job projections suggest several of the health occupations we study here are projected to grow at rates above the state average (8.8%) by 2033, though there are some exceptions. Projected growth for LVN and CNA jobs is slightly lower than the state overall (8.3% and 8.4%, respectively) as are growth rates for dental assistants and dental hygienists (7.7% and 8.3%, respectively). Growth rates range from 10–20 percent across the other health occupations considered in this study. In addition to growing as a share of the workforce, job openings will also become available because of retiring workers or due to the turnover of workers in some occupations. Job openings are projected to be greatest for registered nurses (20,800 per year through 2033), but after that are expected to be more numerous in lower-wage occupations like nursing and medical assistants (between 15,600 and 17,000 per year) (Technical Appendix Table A6).

To assess how projected workforce needs match up with available and newly trained workers, we draw on a variety of sources. According to the Health Care Resources and Services Administration (HRSA)—a federal agency within the US Department of Health and Human Services—EMTs and respiratory therapists already have more workers relative to available jobs in California and that mismatch is expected to continue over the next decade (Technical Appendix Table A6). Similarly, supply-demand projection models from the California Department of Health Care Access and Information (HCAI) indicate the state has an oversupply of LVNs now and in the near future.

Nursing occupations—especially registered nurses—are the most widely studied and available. In collaboration with UCSF researchers, California’s Board of Registered Nursing (BRN) provides detailed estimates of the supply and demand for nursing professions. Their most recent statewide forecasts suggest a small, current shortage of RNs that will likely abate over the next few years (Spetz 2024). This implies a more balanced supply and demand for registered nurses statewide than the HCAI estimates for RNs, which forecast a shortage over the next decade.

While state-level assessments of workforce needs are useful for high-level planning decisions, labor markets operate at a local level, so regional projections are more informative for training providers and students alike. Depending on the source, forecasts for registered nurses are either relatively balanced through 2035 or face some shortages, which are more acute in certain regions. In particular, the Bay Area, Central Valley, and Central Coast regions are expected to have lower ratios of registered nurses than other regions, and less than national benchmarks suggest (Spetz 2024).

In response to the over- or under-supply of workers in any given occupation, employers adjust wages. Prospects of job openings as well as higher wages for an occupation may incentivize residents to pursue that career. However, in the health sector wages may not be as flexible as in other industry sectors because of financing through government programs and minimum wage policy in some fields (such as medical assistants and CNAs in some health care settings). Nonetheless, there is variation in wage rates for health occupations across regions in California, which to some extent reflects the supply and demand of workers.

We find that there is some variation in earnings potential across regions, but the larger variation is across occupations—consistent with what we presented earlier in this report. For instance, the highest-return occupations like RNs and dental hygienists earn between 1.9 and 3 times the median hourly wage across all regions of the state (lowest in LA and Kern and highest in the North San Joaquin regions—see Technical Appendix Figure A4). Medium-return health occupations earn between 0.9 and 1.7 times the regional median hourly wage, with LVNs being at the top of that range across all regions, and the biggest advantage to psych techs in the San Joaquin regions. Most other occupations earn roughly on par with median workers in their regions, or some slightly behind par, like EMTs and nursing assistants who earn 80–90 percent of median wages in some regions.

Licensing Requirements

As previously mentioned, most of these health occupations require workers to have a state license; medical assistants and alcohol/drug counselors are exceptions. While licensing requirements ensure that workers in jobs have adequate training and skills, they can limit access to many occupations and impose costs (Nunn 2018). In order to get a license to work in these health care jobs in California, one must typically pass a licensing exam, pay a fee, and meet other requirements like criminal background checks.

Passage rates for the national registered nursing exam (NCLEX-RN) are generally high, averaging above 90 percent for many available RN programs. Still, for those students who complete a registered nursing program and are not able to pass the licensing exam, the time and costs of training will not translate into the expected economic gains. Rates of passage for other health occupations are also relatively high but vary across different programs and institutions. Some training providers offer innovative ways to support their students who need to take licensing exams:

We coordinate to get private testing dates for the CNA licensing exam. So they can go as a class if they want and most of them do. And if you want the support of your professional development instructor being there, we have set that up too. We’ve paid for it, and we’ll get you through it. – Nonprofit workforce provider

Though licensing for health occupations is billed as important to protect public health and safety, there have been calls to reexamine California licensing requirements to help improve access to jobs and economic mobility (Little Hoover Commission 2016). In addition, most licensing exams are only offered in English, which could also create barriers for some people. Industry organizations representing skilled nursing facilities have lobbied for changes and introduced legislation to offer exams in Spanish or provide other accommodations for students whose native language is not English.