Health Care Opportunity Occupations and Workforce Strategies in U.S. and Eighth District Hospitals

Background

Educational and medical intuitions, or “eds and meds,” are often two of the biggest employers in large and small U.S. communities alike. For instance, in 2019, 13.9% of the St. Louis area’s employment came from such entities. The number of people that they employ in the region had grown 41.1% since 2004, outpacing population growth, which was 2.9%. In rural southeast Missouri, 5.2% of employment came from eds and meds. However, the bulk of that share was from hospitals, which employed 6,700 people in 2019 and generated $422.1 million in employment income.

For communities of all sizes, eds and meds are important employers that serve as anchors, fueling regional economic development and stability. While anchor institutions, like hospitals, may offer a fair number of jobs through direct employment, they also support jobs indirectly through the goods and services they purchase within their geography. Furthermore, an anchor institution’s employees spend money within the local economy, helping to create jobs at places like grocery stores, retail outlets, entertainment venues and restaurants. Finally, it is important to note that anchor institutions also contribute to the local economy by attracting and retaining residents and business investment.

While many of the positions for which eds and meds hire require extensive higher education, many others do not—especially in a hospital setting—and still offer a living wage and benefits like health insurance coverage and a pension. One such group of jobs is called opportunity occupations (PDF). Opportunity occupations are careers that do not require a four-year college degree but tend to pay above the national median wage. (The annual median wage was $49,500 in 2024, according to the U.S. Bureau of Labor Statistics.) Examples of opportunity occupations in health care include work as a licensed practical nurse, registered nurse, laboratory technician, pharmacy technician, radiology technician or respiratory therapist. While earnings in nonmetro areas are typically lower than earnings in metro areas, opportunity occupations offer an avenue for recent high school graduates from rural communities to pursue a stable career in their hometowns or for older workers to reskill and enter a new field. Not all opportunity occupations offer benefits like health insurance or a 401(k), but those in a hospital setting often do.

This report seeks to understand how health care institutions consider the future of their workforce through internal (e.g., talent development, leadership succession) and external (e.g., partnerships with educational institutions to create a pipeline of workers) workforce planning strategies. Data are disaggregated nationally, for Eighth Federal Reserve District states (Arkansas, Illinois, Indiana, Kentucky, Mississippi, Missouri and Tennessee) together and individually, and by metro proximity (metro, metro-adjacent and not-metro-adjacent). The primary goal of this report is to reveal potential opportunities and discuss approaches for workforce development organizations, hospitals and schools to strengthen the health care workforce.

Why Are There Opportunity Occupations in Health Care?

The health care sector is facing skill shortages, especially in opportunity occupations, for a variety of reasons. Three that cross specialties are: (1) an aging workforce, (2) reduced program offerings, and (3) work environment. In one illustration of an aging workforce, a 2021 report found the average registered nurse was 50 or older (PDF), with 1 in 3 nurses eligible for retirement over the following decade. In an example of reduced program offerings, institutions cut pharmacy technician training courses during the COVID-19 pandemic due to a lack of enrollment and scaled-back funding. And between 1984 and 2005, the number of licensed practical nurses in short-term care settings fell almost 50% (PDF), which led to fewer programs. The work environment in health care is complex and can include dynamics like higher workloads with less staff, violence from patients and poor management. COVID-19 exacerbated these issues, leading to further burnout, people exiting the workforce and, in turn, a greater need for workers in these occupations.

Simply filling the positions open today would not be enough to reverse this skill shortage long term; rather, the health care needs of an aging U.S. population will most likely require ongoing growth in the number of people training in these occupations. The U.S. Census Bureau projects that, by 2035, the population 65 or older will reach 87 million, or about 1 in 4 Americans. The effects of an aging population are especially pronounced in rural communities, which have seen many working-age adults move away amid overall population declines (PDF). The rural population ages 15 to 64 fell from more than 30 million to roughly 28 million between 2010 and 2023 (PDF), according to a 2024 U.S. Department of Agriculture report. At the same time, research predicts a national shortage of hospital beds by 2035, meaning there may not be sufficient staffed beds to meet patient needs. Together, the issues confronting the health care workforce suggest that, without change, the sector is not on a sustainable path.

What Are the Consequences If These Positions Are Not Filled?

Worker shortages are expected to persist for some health care opportunity occupations. For instance, there were enough licensed practical nurses nationally in 2025 to meet only an estimated 84% of the need for people in this occupation. By 2035, that figure is projected to drop to 67%. The stresses of the COVID-19 pandemic spotlighted the consequences of such shortages, in some cases causing providers to limit services. Outside of the pandemic, shortages, particularly around nurses, have led hospitals to reduce staffed beds. Studies point to higher patient-to-nurse ratios leading to staff burnout, readmission and higher patient mortality.

The situation is more pronounced in rural communities, where more than 60% of health care professional shortage areas (PDF) are located. This may lead to a reduction in services like obstetrics and chemotherapy and in patient care. For instance, between 2014 and 2023, 51% of rural hospitals in Mississippi and 40% of rural hospitals in Tennessee stopped offering chemotherapy. The result can be health care desserts, potentially causing patients to travel longer distances to get treatment, delay treatment or miss treatment altogether.

A better understanding of the recent trends in health care opportunity occupations can help identify which fields and geographies have the biggest gaps. The following analysis uses microdata from the American Hospital Association’s 2019-23 annual surveys to describe the supply of and the demand for full-time workers in opportunity occupations. The 2019-23 period captures health care employment and labor needs prior to the pandemic through the most recent data available, as well as at similar stages of the business cycle as measured by unemployment rate trends. Employment and vacancy metrics for part-time positions are outside the scope of this analysis, although the value of part-time positions is briefly discussed at the end of the report.

Trends in Opportunity Occupation Employment and Vacancies

This report delves into the evolving landscape of employment and vacancies within six opportunity occupations in the health care sector. The description of occupational roles is from the American Hospital Association. Education requirements, median salary and expected employment growth are from the U.S. Bureau of Labor Statistics Occupational Outlook Handbook. Some occupations may have a bachelor’s degree listed as an education requirement to match the salary reflected in the Occupational Outlook Handbook. These occupations are still included in the report because job postings requiring less than a four-year degree exist for them. Finally, the adequacy percentage is from workforce projections produced by the Health Resources and Services Administration. Only opportunity occupations with both employment and vacancies data were included in the analysis. This section is structured to provide a comprehensive understanding of each listed occupation, encompassing the following elements:

1. Description: A detailed overview of each role and its responsibilities
2. Education requirements: The necessary educational qualifications and certifications
3. Median salary: The middle point of wages for professionals in these roles (see Table 1)
4. Expected growth (2024-34): Projected employment trend over 10 years
5. Percent adequacy (2025-35): The relationship between the expected future supply and expected future demand for workers
6. Analysis of employment trends: An examination of the proportion of hospitals with at least one full-time position and one full-time vacancy from 2019 to 2023

The occupations examined in this section are licensed practical nurse, registered nurse, laboratory technician, pharmacy technician, radiology technician and respiratory therapist. The analysis begins with nursing positions, then takes up the other positions in alphabetical order. The 50th percentile of the median wage for nearly each career in this list is above the U.S. median (again, $49,500 in 2024), an important factor for being considered an opportunity occupation here. However, jobs in these fields will not universally pay above the median rate, as some of the lower-percentile wages in Table 1 demonstrate.

In addition to parsing data at the national and Eighth District state levels, the analysis examines geographical differences in opportunity occupations by metropolitan counties (metro), nonmetro counties that are adjacent to metro areas (metro-adjacent), and nonmetro counties that are not adjacent to metro areas (not-metro-adjacent). Metro-adjacent areas serve as a proxy for rural areas, while not-metro-adjacent areas proxy rural communities that are more isolated.

Licensed Practical Nurses (LPNs)

• Role: LPNs are nurses who graduated from an approved school of practical (vocational) nursing and work under the supervision of registered nurses and/or physicians.
• Education: Requirements generally include having a high school diploma or GED, completing a vocational training course and passing an examination. Programs take approximately 12 months to complete.

Between 2019 and 2023, about 1 in 10 hospitals both nationally and in the Eighth District did not employ a full-time LPN (Figure 1; Appendix A). These hospitals were more commonly located in metro or metro-adjacent areas. For instance, in 2023, when comparing metro, metro-adjacent and not-metro-adjacent hospitals in Illinois (17.5%, 13.9% and 0% without a full-time LPN, respectively) and Indiana (9.9%, 22.0% and 0% without a full-time LPN, respectively), these trends are especially evident (Appendix B). Some organizations have spent years phasing out LPN programs (PDF), which has led to fewer people being trained. LPN programs, which train workers quickly, may be one way to help alleviate the current nursing shortage. Among states in the Eighth District, the absence of full-time LPNs was more prevalent in Illinois and Indiana hospitals, with fewer instances in Kentucky and Tennessee hospitals.

Regarding vacancies, there was a notable increase in the share of hospitals with at least one full-time LPN opening from 2019 to 2023. During this period, the proportion of hospitals with a vacancy for an LPN rose 44.4% nationally and 37.0% across Eighth District states (Appendix C). The largest percentage growth occurred in Kentucky (186.5%) and Tennessee (82.4%), with the exception of these states’ not-metro-adjacent areas (Appendix D).

Registered Nurses (RNs)

• Role: RNs are nurses who both graduated from an approved school of nursing and are registered by states.
• Education: Requirements generally include a bachelor's degree and state licensure. An associate degree in nursing and state licensure may also be accepted for some postings, which is why the role is included in this report as an opportunity occupation. The median salary below is based on having a bachelor’s degree.

From 2019 to 2023, nearly all hospitals employed at least one RN (Figure 2; Appendix A), but most also had vacancies (Appendix B). In 2023, 84.3% of hospitals nationally and 78.9% of those in the Eighth District had at least one vacancy, with little yearly variation. However, the share of hospitals with vacancies varied for individual Eighth District states: During this period, Missouri and Tennessee saw increases of 13.9% and 13.6%, respectively, while Mississippi saw a 31.7% decrease (Appendix C). Full-time vacancies did not consistently differ among metro, metro-adjacent and not-metro-adjacent hospitals in Eighth District states, indicating that employment opportunities for RNs are available across geographies (Appendix D).

Laboratory Technicians

• Role: Laboratory technicians fill professional and technical positions in all areas of the medical laboratory, including, but not limited to, histology, phlebotomy, microbiology, pathology and chemistry.
• Education: Requirements generally include a bachelor's degree. An associate degree may also be accepted for some postings, which is why the role is included in this report as an opportunity occupation. The median salary below is based on having a bachelor’s degree.

From 2019 to 2023, Eighth District hospitals consistently showed a higher percentage of facilities without a laboratory technician—typically not considered an opportunity occupation—compared with the national average. In 2023, 24.3% of hospitals in Eighth District states lacked a laboratory technician versus 18.8% nationally (Figure 3; Appendix A). State-level variations were sizeable, with Illinois having the highest proportion of hospitals with a laboratory technician and Indiana and Missouri having the lowest. Metro hospitals and often metro-adjacent hospitals were more likely to lack a laboratory technician than not-metro-adjacent hospitals (Appendix B).

During this period, the share of hospitals with a vacancy for laboratory technicians increased both nationally (19.6%) and across Eighth District states (21.0%). Individually, Illinois (29.7%), Indiana (62.2%) and Kentucky (103.2%) experienced the largest increases, while Mississippi (-56.5%) and Missouri (-55.6%) saw declines (Appendix C). There was high demand for laboratory technicians across all Eighth District geography types, except in Missouri, where it was low in metro, metro-adjacent and not-metro adjacent areas alike (Appendix D).

Pharmacy Technicians

• Role: Pharmacy technicians assist pharmacists with activities such as reviews for drug incompatibility, typing labels and prescription packaging, handling purchase records and inventory control.
• Education: Requirements in most states generally include passing an examination or completing a formal program. Some jobs may require postsecondary education in pharmacy technology.

From 2019 to 2023, the percentage of Eighth District hospitals that lacked a full-time pharmacy technician was about equal the national average. In 2023, 12.4% of the hospitals in Eighth District states did not employ a pharmacy technician compared with 13.0% nationally (Figure 4; Appendix A). This was more commonly the case in Arkansas and Indiana and least common in Kentucky and Illinois; however, there were no clear trends based on metro proximity (Appendix B).

During this period, the share of hospitals with a vacancy for pharmacy technicians increased both nationally (22.6%) and in the Eighth District (10.5%) (Appendix C). The Eighth District states with the largest growth in hospitals posting a pharmacy technician vacancy were Illinois (30.7%), Kentucky (32.4%), Mississippi (95.3%) and Tennessee (51.7%). Missouri had the smallest share of hospitals with a pharmacy technician vacancy, at 8.9%, in 2023, which was an 18.3% decline from 2019. A large need for pharmacy technicians was observed across all geography types, except in rural areas of Missouri (Appendix D).

Radiology Technicians

• Role: Radiology technicians are part of the imaging field and operate technologies like X-ray, MRI and CT machines to help providers diagnose and treat patients.
• Education: Requirements generally include an associate degree.

In 2023, the share of hospitals that did not employ a radiology technician was greater in the Eighth District (25.6%) than nationally (17.3%) (Figure 5; Appendix A). This pattern, and these levels, were stable over the 2019-23 period. However, among the Eighth District states, Missouri saw the lowest share of hospitals that employed at least one full-time radiology technician (31.7% in 2023). This trend at the state level was consistent over the period and regardless of a hospital’s location in a metro, metro-adjacent or not-metro-adjacent community (Appendix B).

Between 2019 and 2023, the share of hospitals with a vacancy for a radiology technician increased 29.3% nationally and 22.4% among Eighth District states (Appendix C). In 2023, 56.5% of hospitals nationwide and 40.5% of hospitals across Eighth District states as a whole reported having at least one vacancy for this role. Demand for radiology technicians varied widely on a state-by-state basis. No hospitals in Missouri reported a radiology technician vacancy in 2023, and only 1.6% reported a vacancy in 2022. Except in Mississippi, where the proportion of hospitals with a vacancy decreased 23.9% from 2019 to 2023, Eighth District states demonstrated a larger and growing need for radiology technicians. The share of hospitals with at least one full-time vacancy increased in Illinois (41.7%), Indiana (40.1%), Kentucky (76.0%) and Tennessee (23.4%). When comparing vacancy rates across metro, metro-adjacent and not-metro-adjacent areas, metro hospitals generally had a higher share of openings (Appendix D). This pattern was observed nationally and in Eighth District states, although there were very few vacancies in Missouri geographies.

Respiratory Therapists

• Role: Respiratory therapists collect and evaluate patient data to determine an appropriate care plan, select and assemble equipment, conduct therapeutic procedures and modify prescribed treatment plans.
• Education: Requirements generally include an associate degree plus state licensure, but some positions may require a bachelor’s degree.

In 2023, a comparable share of hospitals in the Eighth District (15.2%) and nationwide (16.2%) did not employ a respiratory therapist on a full-time basis (Figure 6; Appendix A). These levels remained consistent over the 2019-23 period and in the Eighth District were more commonly found in metro and metro-adjacent hospitals than in not-metro-adjacent hospitals (Appendix B).

However, from 2019 to 2023, the share of hospitals that had at least one full-time respiratory therapist vacancy grew nationally (124.1%) and across Eighth District states (134.9%) (Appendix C). Growth in the share of hospitals with vacancies can also be observed in individual Eighth District states: Arkansas (115.0%), Illinois (79.2%), Indiana (39.1%), Kentucky (47.7%), Missouri (400.6%), Mississippi (366.5%) and Tennessee (144.4%). Patterns were largely consistent across states when considering differences among metro, metro-adjacent and not-metro-adjacent hospitals, with not-metro-adjacent geographies having higher rates of hospitals with a respiratory therapist vacancy, depending on the state (Appendix D). Of the opportunity occupations examined, respiratory therapist had the most growth in the proportion of hospitals with a vacancy.

Summary of the Outlook for Opportunity Occupations

Of the six opportunity occupations reviewed, respiratory therapist has the highest projected 2024-34 employment growth—12%—at an organizational level. Since the onset of the COVID-19 pandemic, demand from hospitals for a full-time employee in this position has surged, regardless of the Eighth District state or geography relative to a metro area. Even at the 10th percentile, wages in this occupation exceed the U.S. median wage. The next highest-paying and most in-demand occupations are RN (5% projected employment growth, $93,600 median pay) and radiology technician (5% projected employment growth, $78,980 median pay).

According to the Health Resources and Services Administration, the projected supply of labor in the respiratory therapy field will meet only 93% of demand by 2035. Unmet need will also be large for LPNs (67%) and RNs (93%). In contrast, there may be an oversupply of pharmacy technicians by 18%. Consequently, data suggest there is both a need for RNs, LPNs and respiratory therapists and the potential for employment growth in these fields over the next 10 years. This may also extend to radiology technicians and laboratory technicians, but less data are available to model that need.

Opportunity occupations not in the American Hospital Association dataset, and thus not addressed in this report, but that are counted among the top 20 fastest-growing occupations by the U.S. Bureau of Labor Statistics include physical therapist assistant, which is projected to grow 22% by 2034 and has 2024 median pay of $65,510, and occupational therapy assistant, which is projected to grow 19% by 2034 and offers 2024 median pay of $68,340.

Workforce Planning Strategies

Having examined the landscape around employment and vacancies among opportunity occupations in the health care sector, it is important next to consider proactive measures hospitals are adopting to sustain and expand their workforce. These activities may encompass internal strategies, such as leadership succession and talent development, and external strategies, such as partnerships aimed at growing the workforce. Data on these items, first collected in the American Hospital Association’s 2021 survey, provide a contemporary snapshot, though they do not offer a pre- and post-COVID-19 comparison. For a comprehensive view, refer to Appendix E, which presents the full dataset.

Hospitals were surveyed using a checklist to identify which of five strategic activities they actively engaged in during the survey year for purposes of broad workforce planning. Hospitals could select from leadership succession, recruitment and retention, talent development, partnerships with elementary and secondary schools, and partnerships with community colleges and vocational schools. The following analysis highlights the most-recent data, which are from 2023.

Leadership Succession

Roughly 3 out of 4 hospitals both nationally and across the Eighth District had a plan for leadership succession (Appendix E). This strategy work generally was performed more in metro hospitals and decreased with rurality, both nationally and across the Eighth District. Within individual Eighth District states, Tennessee hospitals were most likely to have such strategies in place, regardless of metro proximity (metro, 82.1%; metro-adjacent, 94.4%; and not-metro-adjacent, 100%) (Appendix F). Arkansas hospitals were least likely to have a succession plan (metro, 53.7%; metro-adjacent, 52.2%; and not-metro-adjacent, 44.4%).

Recruitment and Retention

Of the five workforce planning strategies, recruitment and retention was that endorsed the most. On average, 9 out of 10 hospitals engaged in it (Appendix E). The Eighth District state that reported the lowest share of hospitals pursuing such strategies was Arkansas (78.0%); the remaining Eighth District states had shares above 90%. Generally, large proportions of hospitals reported doing this type of planning regardless of geography (Appendix F).

Talent Development

About 7 of 10 hospitals had a talent development strategy, both nationally and across the Eighth District (Appendix E). Eighth District states that had the highest proportion of hospitals with plans for developing talent were Kentucky (89.7%) and Tennessee (86.0%), while Arkansas had the lowest share at 43.9%. In terms of geographical differences, not-metro-adjacent hospitals, except for those in Kentucky, tended to have fewer strategies in place (Appendix F).

Partnerships with Elementary/High Schools to Develop Interest in Health Care Careers

Turning to external workforce strategies, most hospitals that responded to the American Hospital Association survey had some kind of plan to form partnerships with schools to develop interest in health care careers, with a greater proportion of hospitals with strategies found at the Eighth District level (72.6%) than at the national one (67.3%) (Appendix E). The Eighth District state with the highest proportion of hospitals with partnerships was Tennessee (84.0%); the Eighth District states with the lowest were Mississippi (66.7%) and Arkansas (41.5%). Lower proportions of hospitals with elementary and high school educational partnership strategies were also generally observed in not-metro-adjacent hospitals, except in Mississippi (Appendix F).

Partnerships with Community Colleges and Vocational Training Programs

Forming partnerships with community colleges and vocational training programs was hospitals’ second-most-common workforce planning strategy after recruitment and retention. Activities of this type were adopted by 4 of 5 hospitals, both nationally and across the Eighth District (Appendix E). In the Eighth District, Arkansas reported the smallest share of hospitals with community college and vocational training program partnerships (62.2%). Over 90% of hospitals in Kentucky, Missouri and Mississippi indicated having some kind of partnership in place. Within each state, there were no consistent differences between metro, metro-adjacent and not-metro-adjacent communities (Appendix F).

The Future of Health Care Opportunity Occupations

Despite overall stability in the share of hospitals employing at least one person in each opportunity occupation, certain roles have seen substantial increases in vacancies since 2019. Jobs like LPN, pharmacy technician, radiology technician and respiratory therapist are now in higher demand. From 2019 to 2023, the share of hospitals with at least one vacancy for an LPN increased 44.4% nationally and 37.0% in Eighth District states. For laboratory technicians, the increase was 19.6% and 21.0%, respectively. Pharmacy technician vacancies grew 22.6% nationally and 10.5% in the Eighth District, while radiology technician vacancies rose 29.3% and 22.4%, respectively. Shares of hospitals reporting vacancies for respiratory therapist jobs saw the biggest increase during the period, growing 124.1% nationally and 134.9% in Eighth District states.

Future Directions in Full-Time, Part-Time and Contract Employment Differences

A substantial proportion of hospitals across the Eighth District operated without full-time personnel in some of these opportunity occupations. For instance, across Eighth District states, 28.5% of metro hospitals, 20.4% of metro-adjacent hospitals and 22.1% of not-metro-adjacent hospitals did not employ a radiology technician full time in 2023. This raises questions about whether hospitals are instead turning to part-time and contract workers or coordinating with nearby hospitals to fill positions.

Given the complexity of the health care workforce, particularly in rural communities, a better understanding of how employment needs are met could help paint a more complete picture of where gaps might be. In comparing median numbers of full-time and part-time employees per hospital between 2019 and 2023, it is clear that part-time workers account for a large portion of hospitals’ workforce (Figure 7). Looking at median numbers, about 1 in 4 hospital workers in the U.S. were part-time in 2019, which was still the case in 2023. Contract workers were integrated into the hospital workforce to a lesser extent.

Looking at urban and rural geographies across Eighth District states, in 2023 the median numbers of employees per metro hospital were 697.5 full time, 324.0 part time and 14.0 contract. In metro-adjacent hospitals, the median numbers of employees were 180.0 full time, 78.0 part time and 2.0 contract. In not-metro-adjacent hospitals, the median numbers of employees were 190.0 full time, 61.0 part time and 3.0 contract. This indicates a heavy reliance on part-time employees while contract workers make up only a small portion of the workforce.

Future analyses should consider whether hospitals’ reliance on part-time employees represents a shift in employment trends and, if so, what it means for individual occupations; a marked change toward part-time work in opportunity occupations could potentially diminish benefits that traditionally make such roles appealing.

Future of Opportunity Occupations with AI Adoption

An important workforce consideration on the horizon is the emergence of artificial intelligence (AI). AI is already used to some extent in more than 40% of metro hospitals and 18% of hospitals in the most-rural areas. AI tools may impact some of the opportunity occupations described in this report; for instance, AI is already being integrated into the fields of radiology, pharmacy (PDF) and nursing (PDF). Despite advancements in AI, it still has limitations that require human oversight. As young adults or those seeking new careers contemplate opportunity occupations in health care, it is important to understand how fields are leveraging AI, as well as its limitations, in an ever-changing environment.