HAP Resource Center

Advocacy Correspondence: PA House of Representatives, HAP Opposition to House Bill 106, Nurse Ratios

June 14, 2023

Honorable Members
Pennsylvania House of Representatives
Main Capitol Building
Harrisburg, PA  17120-2023

Dear Representatives:

On behalf of 235 hospitals statewide, The Hospital and Healthsystem Association of Pennsylvania (HAP) strongly opposes House Bill 106, which, among other provisions, seeks to establish government-mandated registered nurse (RN)-to-patient ratios across all hospital units. We understand that the bill may soon be considered by the full chamber. We respectfully—and in the strongest possible terms—urge you to vote no.

House Bill 106 is not a solution. Ratio mandates do not solve the core problem straining Pennsylvania’s caregivers: There simply are not enough nurses. Government-mandated ratios will not create more nurses. Instead, they will effectively force Pennsylvania hospitals to close beds or reduce services to comply with state law, and, in many communities, put hospitals at risk.

We appreciate the intention of this legislation and share a deep and fundamental belief in the value of the commonwealth’s nurses. They are exhausted and need help, but government-mandated ratios do not provide the help our nurses need. Mandates offer an overly simplistic response to an extremely complex issue and are not universally supported by the nursing community.

The Pennsylvania Organization of Nurse Leaders is “adamantly opposed” to legislation that mandates RN-to-patient ratios. The American Organization for Nursing Leadership asserts that mandated nurse staffing ratios are a static and ineffective tool that cannot guarantee safe health care environments and increase stress on a system already facing a shortage of educated nurses.

There are solutions that do support nurses. To meaningfully help practicing nurses, we must develop and incentivize more nurses to care for Pennsylvanians at the bedside. The commonwealth has more than 1,700 health care training programs and 400 nursing programs. Many maintain waiting lists and indicate that they would serve more students if they could add instructors and increase clinical opportunities.

Pennsylvania can increase its capacity to educate nurses by supporting nurses who seek the advanced degrees necessary to teach; reducing disparities between higher bedside pay versus lower nurse educator pay; incentivizing preceptorship; assessing clinical experience as a viable pathway to credentialing nurse educators; authorizing additional locations as suitable for clinical education experience; and advancing apprenticeship programs.

Pennsylvania can target financial incentives—scholarships, tuition discounts, student loan relief, tax incentives—toward current and future nurse educators as well as toward nurses who commit to remaining in Pennsylvania and working by the bedside.

Pennsylvania can finish the work necessary to operationalize interstate licensing compacts and to reform the licensing and credentialing processes. The commonwealth’s hospitals—particularly those near other states’ borders—report routinely losing qualified candidates during the hiring process because job seekers find it easier and faster to become licensed and start work elsewhere.

There are not enough nurses. There is a well-documented, nationwide health care workforce crisis and Pennsylvania hospitals are working aggressively to recruit and retain nurses. Despite significant sign-on bonuses—often more than $30,000—increased wages, higher shift differentials, more flexible scheduling options, substantial education support, and other incentives, average vacancy rates for direct care RNs exceed 30 percent across the state.

Eighty-four percent of hospitals report that “finding qualified professionals” is the top barrier to hiring more nurses. Even without House Bill 106, Pennsylvania’s RN gap is projected to be among worst in the nation, with a shortfall of 20,345 nurses within the next three years. The assertion that a government mandate will immediately shift the employment patterns of tens of thousands of professionals—across a complex mix of specialties and geographic areas—is simply not plausible.

Many hospitals are fundamentally changing the way they organize care to better support bedside RNs. This includes examining nursing work, redistributing tasks that can be safely accomplished by others, increasing the number of positions that support RNs, and deploying virtual and team-based approaches. These approaches ensure that staffing meets patients’ and the community’s needs and also empower RNs to practice at the top of their abilities and training. These decisions, made with nurses’ input, perspective and experience, provide patients with the right care at the right time. House Bill 106 would insert a government mandate and supersede clinicians’ judgement.

Government-mandated ratios are not a panacea. Most states have rejected ratios; only California has mandated such requirements across all hospital units. Their experience reveals that government-mandated ratios:

  • Do not end workforce shortages: CA’s shortfall is projected to be 44,500 nurses by 2030
  • Do not solve nurses’ short-staffing concerns: CA nurses continue to experience challenges
  • Do not improve the quality of care: CA ranks lower in overall care quality than PA
  • Do not increase access to care: CA ranks 46th in beds-per-capita, PA ranks 18th
  • Do not reduce cost of care: A day of a nonprofit hospital care in CA is $4.6k, PA is $2.9k

Unintended consequences will jeopardize access to care. Pennsylvania hospitals already take exceptional care to meet the needs of patients despite staffing constraints. You have heard from frustrated constituents that hospitals are increasingly working through extensive wait times, delaying procedures (when safe), closing beds, reducing services, transferring patients, and putting their emergency departments on “divert” status to incoming patients. Such measures are due, in large part, to assure high-quality care delivery with the staff available to provide it.

Given the well-documented, nationwide shortage of bedside nurses, if passed, this bill will put Pennsylvania hospitals in the impossible position of having to choose between reducing their capacity to care for patients or breaking the law at the risk of losing their licenses. Already stressed emergency department providers will operate at the intersection of federal law, which mandates that they care for every person who presents for treatment, and state law, which will sanction them for doing so when the government-required staffing level is unachievable.

Our rural hospitals—more than half of which have 100 beds or fewer—will find it particularly difficult to maintain services in the face of a state mandate they cannot meet.

As government leaders, you work closely with your local hospitals. You are well aware that many are navigating profound financial strain and some are just barely keeping their doors open. With historically high staffing, pharmaceutical, and supply costs and exceptionally low public reimbursement rates that do not even cover the cost of care, hospitals are operating in an unsustainable fiscal environment. Especially compared to before the pandemic, increases in care-related expenses are outpacing revenue, even when federal pandemic relief is included. Nationally, more than half of all hospitals lost money on care last year.

To the best of our knowledge, there has been no study of the potential—and far-reaching—fiscal impact of this bill. We urge you to ensure that you understand what a “yes” vote on House Bill 106 may mean for the cost of hospital-based health care for Pennsylvanians, availability of behavioral health care, first responder agencies, other service providers that rely on RNs, employers who provide insurance coverage, the insurance industry, government medical assistance programs, and the commonwealth’s state-owned psychiatric hospitals.

For these and other reasons, Pennsylvania’s hospital community strongly urges you learn more about the real-world implications of House Bill 106 and to vote no if it comes to the floor for consideration.

If you have any questions, comments, or concerns—or if you would like the citations for any of the facts asserted in this letter—please reach out to me at acarter@haponline.org or (717) 561-5314; or Heather Tyler, HAP’s vice president of state legislative advocacy, at htyler@haponline.org or (717) 561-5350.

Thank you for your time and consideration.


Andy Carter
President and Chief Executive Officer




Topics: Access to Care, State Advocacy, Workforce

Revision Date: 6/14/2023

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