Just as occupational groups campaign within states, they also campaign across states. Over 40% of the 208 occupations in our dataset underwent review in more than one state. As shown in Table 12, the most reviewed occupations were acupuncturists (eight states),athletic trainers (eight states), genetic counselors (seven states) and massage therapists (seven states). ¹

Multi-state reviews often appear to stem from coordinated campaigns by affiliated industry groups seeking some benefit for their occupations. From the mid- 1980s through the early 2000s, the Arizona, Colorado, Nebraska and Washington state nutrition and dietetic associations, all state affiliates of the national Academy of Nutrition and Dietetics, pursued licensure of dietitians in their states—including five times in Colorado and twice in Nebraska. ² The Colorado and Nebraska associations’ proposals also included regulation of nutritionists. Hawaii considered nutritionist licensing as well. And while the state’s sunrise report does not name the group that proposed regulation, there is a Hawaii nutrition and dietetics association, ³ and the report notes that “regulation is likely to benefit the profession more than consumers.” ⁴

Similarly, genetic counselors, who assess patient risk for inherited conditions and provide related counseling, undertook a national lobbying campaign for licensure in the mid-2000s, and the occupation underwent review nine times across seven states. ⁵ Vermont’s 2006 sunrise report noted that the licensure proposal was “part of a multi-state effort by genetic counselors to promote the practice of genetic counseling. They are currently seeking licensure in approximately 15 other states.” ⁶ Interestingly, genetic counselors’ main justification for licensing was not the need to protect the public. Instead, it was to “raise the [occupation’s] visibility,” thereby increasing the popularity of and access to genetic counseling services and allowing providers to bill their services to insurers. ⁷

In the 2010s, music therapists likewise campaigned for licensure, with at least five sunrise reviews spanning five states and six years. State music therapy task forces were behind proposals for licensure in Washington, Arizona, Utah and West Virginia and one for title protection in Colorado. These task forces are affiliated with the American Music Therapy Association and the national Certification Board for Music Therapists. These groups collaborate on a project called the State Recognition Operational Plan, which advises state groups seeking regulation. The project’s goal is to persuade states to require CBMT certification before aspiring music therapists can legally work. ⁸ As with genetic counselors, health and safety does not appear to be a motivating factor. Instead, the SROP indicates the push for licensure is intended to elevate recognition and esteem for the occupation and expand its reach within health care. ⁹

This is not unusual in the history of occupational licensing. Previous research has documented nationwide campaigns for licensure motivated by a desire to enhance an occupation’s prestige rather than solely to protect the public. ¹⁰ Beginning in the late 19th century, for example, the National Funeral Directors Association pursued licensure of funeral directors and embalmers from coast to coast out of a desire to “professionalize” their industry. ¹¹ The association eventually won licensure of funeral directors across all 50 states and the District of Columbia. ¹²

Table 12: Occupations with the Most Sunrise Reviews Across States

Occupation	States	Reviews	Total reviews across states
Acupuncturists	8	AZ (1997), CO (1986, 1988), GA (1991), HI (1985), KS (2012), NE (2000), VA (1989), WA (1993)	9
Addiction Counselors	6	AZ (2002), GA (1999), NE (2004), VT (1999), WA (1995), WV (1999)	6
Art Therapists	4	AZ (2017), CO (1988, 1989, 2016), VT (2015, 2017), VA (1995)	7
Athletic Trainers	8	AZ (2000), CO (1987, 1990, 1995, 2005), FL (1994), HI (2010), VT (2002), VA (1999), WA (1993, 2002), WV (2004, 2007)	13
Audiologists	4	CO (1991, 1994), MN (2002), VT (1999), WA (1995)	5
Behavior Analysts	5	AZ (2007), NE (2011), VE (2015), WA (2014), WV (2012)	5
Community Association Managers	4	CO (2012), HI (2005), UT (2015), WA (1996)	4
Dialysis Technicians	5	AZ (2000), CO (1992, 1994, 1995, 2006), NE (2016), WA (1999), WV (2005)	8
Dietitians	5	AZ (1986), CO (1985, 1989, 1990, 1993, 2001), NE (1987, 1994), VA (1987), WA (1993)	10
Electrologists	5	CO (1994), GA (1989, 1991, 1995), SC (1994), VT (1999, 2004), VA (1999, 2002)	9
Genetic Counselors	7	CO (2004, 2013, 2017), GA (2017), HI (2006), NE (2011), VT (2006), VA (2011), WA (2006)	9
Home Inspectors	5	CO (2001, 2014), FL (1994), GA (1999, 2008), VT (2013), VA (1994)	7
HVAC Technicians	5	CO (1995), HI (1994), ME (2010), SC (1989), WV (2013)	5
Interior Designers	6	CO (1989, 2000, 2008), GA (1989), SC (1991), UT (2015), VA (1988), WA (2005)	8
Laboratory Technicians	4	MN (2009), NE (1987), VT (2009), VA (2012)	4
Marriage and Family Therapists	6	AZ (2002), CO (1985), HI (1995), NE (1988), VA (1994), WV (2006)	6
Massage Therapists	7	AZ (2002), CO (1989, 1990, 2007), GA (1997, 2002), KS (2011), MN (2002, 2009), VT (2010, 2016), VA (1995)	12
Midwives	6	CO (1992, 1985, 1991), HI (1999, 2017), ME (2008), NE (1994, 2006), VT (1999), WV (2008)	10
Music Therapists	5	AZ (2013), CO (2014), UT (2013), WA (2012), WV (2017)	5
Nutritionists	4	CO (1989), HI (1995), NE (1987, 1994), VA (1987)	5
Professional Counselors	4	AZ (2002), CO (1985), HI (1988, 1992, 1999), NE (1986)	6
Radiologist Assistants	4	AZ (2007), CO (2014), WA (2005), WV (2006)	4
Respiratory Therapists	6	AZ (1986, 1989), CO (1986, 1987, 1995, 1999), HI (1986, 1995), VT (1999, 2003), VA (1995), WA (1994)	12
Speech Language Pathologists	4	CO (1991), MN (2002), VT (1999), WA (1995)	4
Surgical Assistants	5	AZ (1995, 2000, 2007), CO (2004), GA (2004), NE (2015), VA (2010)	7
Surgical Technologists	4	CO (2010), NE (2015, 2016), VA (2010), WA (1996, 2012)	6
Tattooists	5	CO (1999), MN (2009), SC (1996), VA (1994), WA (1993)	5

When multiple states reviewed the same occupations, they tended to agree about whether licensure was warranted, even if their specific recommendations differed. ¹³ And when reviewers agreed about licensure, they mostly recommended against it or made no recommendation at all. For example, four of the five states that reviewed dietitians, all five states that reviewed HVAC technicians, and all four states that reviewed surgical technologists recommended against licensure, though in a few cases reviewers recommended a less restrictive alternative. ¹⁴

Not only did different states’ reviewers often agree about whether licensure was warranted, but they often returned the same specific recommendations. ¹⁵ For 20 occupations, all reviewers agreed no new regulation at all was warranted. Among those occupations were crane operators (three states), nutritionists (four), physical therapist assistants (two) and recreation therapists (three). ¹⁶

For only two occupations were multiple reviewers united in favoring licensure: assisted living administrators (two states) and domestic violence counselors (two). ¹⁷ Overall, for occupations reviewed by multiple states, nearly half (49%) received recommendations for no new regulation, while only about a quarter received recommendations for licensure.

Legislatures also tended to agree about whether to create a new or distinct license for an occupation. ¹⁸ In several cases, they were unified against licensure. For example, none of the six states that reviewed interior designers enacted licensure. ¹⁹ The same went for dietitians (five states) and music therapists (five). ²⁰ In those occupations, a few states enacted a less restrictive regulation, but in others, legislatures in different states agreed no new regulation of personal qualifications was needed. These include community association managers (four), fire alarm installers (two), laboratory scientists (three), laboratory technicians (four) and soil scientists (three). ²¹

In other cases, however, different states’ legislatures united in favor of licensure, and they did so more often than reviewers. While, as noted above, only two occupations saw unanimous recommendations for licensure—and each involved just two states—15 occupations saw all legislatures agree on licensure. Moreover, most cases involved three or more states taking the same legislative action. For example, four states licensed speech language pathologists, six respiratory therapists and eight acupuncturists. ²² In keeping with our broader results, legislatures again appear more amenable to licensure than sunrise reviewers.

Indeed, as Figure 10 illustrates, once again, legislatures enacted new or distinct licenses for far more occupations than reviewers recommended it (45% vs. 26%). This includes new licenses enacted even though most sunrise reviewers found them unnecessary. For example, while all four states that reviewed nutritionists recommended against licensing the occupation, Hawaii licensed it anyway. ²³ Similarly, four states opted to license genetic counselors even though four of seven reviewers recommended against it. ²⁴ For athletic trainers the gap was even starker: All but one state enacted licenses, despite five out of eight reviewers recommending against it. ²⁵ The other state enacted certification. ²⁶

Figure 10: When Multiple States Reviewed Occupations, They Enacted Licensure More Often Than Recommended

Note: Analysis considers 275 reviews of 85 occupations reviewed in multiple states. For occupations reviewed more than once in the same state, analysis considers only the final recommendation and counts the outcome only once. Recommendations of no new regulation mean just that; outcomes of no new regulation mean no new regulation of personal qualifications. The legislature may have enacted other regulations, such as business regulations.

Different legislatures licensing the same occupations could be taken as evidence those licenses are truly necessary. On the other hand, sunrise reviews of these occupations usually recommended against licensure. An alternative explanation is that licensure in one state creates momentum, even urgency, for licensure in other states—no matter what sunrise reviews recommend. In its 1999 review of electrologists, the Virginia Board of Health Professions suggested as much. It wrote: “[T]he Board is concerned that there is pressure from national trade associations and surrounding states which currently have a regulatory program.” ²⁷ Coordinated multistate or national campaigns for licensure may not pan out everywhere, but sunrise data suggest they may create momentum once a first state gives in.