Add registered nurses to the list of people getting headaches from Obamacare.
The new law is accelerating a push toward requiring them to have higher-level education. Many nurses find that it isn't easy to get a job without a four-year degree, which traditionally they haven't needed.
"You do have hospitals increasingly expecting that nurses have at least a [bachelor's] degree," said Diana Mason, former president of the American Academy of Nursing. "The Affordable Care Act is raising the bar."
Nursing has traditionally been a good career path for people from low-income backgrounds partly because it didn't require the cost of financing a full college education. But nurses with just a two-year degree now face more competition and are increasingly finding that they'll need a four-year degree just to be competitive in the job market — something that many may not be able to afford.
Meanwhile, more nurses are staying in the profession longer since the recession caused many to postpone retirement. Those factors are creating a potential problem no one foresaw: an excess of nurses.
A decade ago the concern was over an expected shortage. Hospitals now have their pick of who to hire. A study last year by the Health Resources Services Administration predicted that the workforce could have a surplus of 300,000 nurses by 2025.
Mason, who is a professor at New York's Hunter College, has said she has heard from some students who are looking for jobs six months after graduating. In New York City, where she lives, it is so competitive at academic medical centers that nurses need a bachelor's degree and a 3.5 grade point average.
The hospitals are being picky because Obamacare provides them bonuses through its Magnet Recognition Program. The incentives are meant to improve both quality of care and cost control by eliminating wasteful, unnecessary procedures.
The Affordable Care Act does not specify educational levels for hospital nurses. That's up to the administrators. But it is hard for the facilities to reach the performance goals without nurses with at least a bachelor's degree.
"The main change I've seen is hospitals rarely hiring LPNs (licensed practical nurses, usually a nine-month program) or even ADN (two year associate's degree) nurses. They are really only hiring BSNs (Bachelor's degree, typically four years). Magnet hospitals cannot hire less than a BSN," a critical care nurse in Kansas City, Mo., who requested that her name not be used, wrote in an email.
The Obamacare ratings depend a lot on patient satisfaction scores, the nurse noted when speaking with the Washington Examiner. Nurses spend the most time with patients, so much of the pressure to get a hospital's ratings higher is put on them. That has forced them to take on more tasks, which in turn requires more medical knowledge.
The trend toward higher education was underway before Obamacare, Mason argues. Bachelor's degree programs accounted for 62 percent of nursing programs in 2012, up from 55 percent a decade ago. The number of associate degree programs shrank from 45 percent of all programs to 38 percent over the same period.
The number of nurses with a bachelor's degree rose from 45 percent of all undergraduates in 2002 to 53 percent in 2012, according to the journal Nursing Economics. Over the same period, the number graduating with two-year degrees fell from 55 percent to 45 percent.
It is not clear exactly how many people with degrees in nursing are out of work since the Labor Department does not track that figure. But other evidence suggests that a substantial number must be not be able to find work.
A study in the October issue of journal Medical Care estimated that 620,000 nurses entered the workforce between 2007 and 2013. Over the same period, 850,000 people took the test for a nurse's license for the first time.
"The gap between first time … test-takers and actual entry is likely due to a sizable number of younger RNs not working on a full-time basis," the study's authors concluded.
"Young nurses up until very recently have had it more difficult finding jobs than have other nurses with more experience," said Peter Buerhaus, a public health professor at Vanderbilt University and a co-author of the Nursing Economics and Medical Care studies.
The profession isn't growing as fast as many predicted, partly because increasing hospital efficiency has had the effect of blunting the need for more nurses. The Labor Department estimated in 2006 that 2.4 million registered nurses were in the workforce, a figure that grew to 2.7 million when Obamacare was signed in 2010. Four years later, the workforce remains 2.7 million.
Mason is optimistic that the situation will begin to sort itself out once the older nurses who delayed retirement begin to drop out. She argues that there is bound to be a greater need for nurses at all levels as the baby boomers age. The profession is also taking steps to make it easier for nurses to receive higher educations by offering combined bachelor's and associate degree programs.
"I've taught in these programs in the past and sometimes the hoops we put these people through were ridiculous. We are now looking at how do we streamline this," Mason said.