By definition, health care occupations have a tighter connection to health and safety than many occupations in other fields. And as discussed above some states review only health occupations, while others review health and non-health occupations using slightly different criteria. For these reasons, it is worth exploring whether health and non-health occupations fare differently in sunrise review processes. For this analysis, we categorized occupations as health-related or not using the North American Industry Classification System’s coding. 1
We then compared regulation requests, sunrise recommendations and legislative outcomes across health and non-health occupations for all states.
Table 13 shows that, all told, 54% of the 494 sunrise reviews in our dataset covered health occupations, encompassing 42% of 208 occupations. Health occupations included acupuncturists, dialysis technicians, genetic counselors, massage therapists and surgical technologists, while non-health occupations included martial arts instructors, pawnbrokers, taxidermists, home inspectors and seed sellers.
Table 13: Health and Non-Health Reviews in This Study
Note: * = does not regularly produce reports.
Regulation proponents sought licensure more often for non-health occupations (71% vs. 64% for health occupations; see Figure 11). However, proponents sought distinct licenses far more frequently for health occupations (14% vs. 2% for non-health). Often, these are so-called allied health occupations—that is, health occupations apart from doctor or nurse—which tend to be highly regulated and involve overlapping duties. For instance, reflexologists, who practice a form of alternative medicine that involves applying pressure to points on the feet, have sought their own licenses separate from massage therapists. Likewise, doctors of homeopathy and naturopathic physicians have sought separate licensure from traditional medical physicians. 2
Figure 11: Regulation Proponents Pursue Licensure More Often for Non-Health Occupations
Note: 265 health reviews, 229 non-health reviews.
Perhaps unsurprisingly given health occupations’ tighter connection to health and safety, reviewers recommended licensure more often for health occupations (21% vs. 14% for non-health; see Figure 12). They also recommended distinct licenses more often: While reviewers never recommended distinct licenses for non-health occupations, they recommended them for 3% of health ones. Reviewers were also less likely to recommend no new regulation for health occupations (49% vs. 59% for non-health). However, even for health occupations, reviews overwhel ingly declined to recommend new or distinct licenses (75%), and nearly half recommended no new regulation at all (49%).
Figure 12: Reviewers Reject Regulation More Often for Non-Health Occupations
Note: 265 health reviews, 229 non-health reviews.
Legislatures were also more likely to enact most forms of regulation for health occupations than for non-health (see Figure 13). This was especially true with licensure (48% for health vs. 31% for non-health). The one exception was registration, which legislatures were more likely to enact for non-health occupations (8% vs. 1% for health). They were also less likely to enact no new regulation of personal qualifications for health occupations (42% vs. 58% for non-health).
Figure 13: Legislatures Enact Licensure More Often for Health Occupations
Note: 208 health occupations, 190 non-health occupations. For occupations reviewed more than once in the same state, analysis counts the outcome only once. Outcomes of no new regulation mean no new regulation of personal qualifications. The legislature may have enacted other regulations. Broader credential means the legislature opted to sweep the occupation into broader licensure, certification or registration scheme.
That reviewers and legislatures embraced licensure and most other regulations more often for health occupations than for non-health ones may make some sense given that health occupations have a tighter connection to health and safety and may therefore pose a greater risk of harm. Nevertheless, that reviewers and legislatures so often rejected licensure even for health occupations is notable. It suggests that even for health occupations where some regulation may be warranted, reviewers—and sometimes legislatures—recognize licensure is not always the right fit.
Dialysis technicians, for example, have been reviewed by five states—and four concluded licensing was unwarranted. 3
Dialysis technicians’ work unquestionably implicates health and safety. They operate and monitor hemodialysis machines, which control blood pressure and remove waste from the blood, an essential procedure for end-stage renal disease patients. Such patients are a rare example of consumers advocating for regulation through sunrise review. 4
Yet reviewers have expressed skepticism that licensure or state certification is appropriate.
Indeed, in Colorado, the Office of Policy, Research and Regulatory Reform’s most recent review noted that patients’ support for regulation of dialysis technicians is “sometimes misplaced, as the patients often believe that the certification/licensure process is more meaningful and comprehensive then [sic] the actual reality of such programs.” 5
COPRRR also noted that complaints about the occupation generally fell under infection control and quality of care, which the department concluded did not relate directly to skills, education or training—personal qualifications, in other words. COPRRR wrote: “Although kidney failure and hemodialysis is a life threatening and life saving procedure, there is a lack of evidence to indicate that any risk associated with dialysis would be lessened or decreased by creating a certified training program, or requiring licensure, for hemodialysis technicians.” 6
Nevertheless, four states ultimately opted to license dialysis technicians after sunrise review. 7
For surgical assistants, by contrast, reviewers’ conclusions were mixed, 8
but in the end, no state licensed the occupation following sunrise review, opting instead for less restrictive regulations such as certification or registration, or existing market and regulatory checks. 9
Surgical assistants are members of a surgical team who perform tasks like making incisions, removing veins and arteries, and reconnecting internal and external tissue. While accepting that this work involves risk, Georgia observed there were no known complaints against surgical assistants, and Colorado’s report found “no evidence of harm being caused to Colorado citizens by the unregulated practice of surgical assistants.” 10
Both reports pointed to existing voluntary certifications and noted that surgical assistants “function in a highly structured environment” under the direct supervision of operating physicians and that hospitals use rigorous bylaws for surgical assistants and other allied health occupations. 11
At face value, health occupations may seem more dangerous than other occupations because of their tighter links to health and safety. And, indeed, even though health occupations tend to seek licensure less often than non-health occupations, reviewers and legislatures alike are more willing to countenance licensure for health occupations. At the same time, both reviewers and legislatures reject licensure for health occupations more often than they accept it, recognizing that even where seemingly risky, and even life-threatening, job duties are at issue, licensure may not be the answer.