In America today, almost 25% of jobs require a permit. In the name of consumer protection, states have delegated professional licensing to professional associations, which then decide the height of a fence to erect around the profession. Since licensure is overseen by practitioners and results in double-digit increases in income, the usual answer is quite high. As one commentator acknowledged, the way states handle professional licensing is “much like requiring the Commodity Futures Trading Commission to be run by active options traders.”

The last time I castigated licensure, I focused on ridiculous requirements for hair braiders and interior designers, leaving health care alone. But since almost 70% of jobs in the health field now require a license to practice, it is time to reconsider the situation. By adding friction to getting jobs in the largest sector of our economy, professional licensing has become a major driver of American inequality — and a telling symptom of a larger problem.

The United States deviates significantly from other developed nations in licensing entry-level healthcare workers, as well as jobs providing objectively low-risk care. In Europe, healthcare support roles known as ‘assistant’ or ‘aide’ are unaccredited and provide an accessible entry point for healthcare professions.

But to be certified as a physical therapy assistant (PTA) in the United States, all states require an associate degree accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE, an apt acronym for a profession subject to regulatory capture). These degrees require five semesters of study and include coursework in anatomy, physiology, exercise physiology, biomechanics, kinesiology, neuroscience, clinical pathology, and behavioral science. In the meantime, here’s what PTAs are actually allowed to do:

  • Assisting patients with exercise and stretching, but not particularly for “procedures…such as mobilization of the spine and peripheral joints…and wound management”;
  • Observe exercises and record progress; and
  • Perform office tasks.

While there is no doubt that this course should be required for physical therapists themselves – who, thanks to credential inflation mandated by PT state boards, must now earn a doctorate – I find no supporting evidence from CAPTE or PT state guidance as to why five semesters of anatomy, physiology, and neuroscience courses should be required to help patients do exercises designed by licensed physical therapists, especially when assistants can only work under their direct supervision. There also doesn’t appear to be any studies showing that APTs with an associate’s degree perform better or provide better consumer/patient protection than those without, or why relevant experience – per example, as an athlete or personal trainer – might not be the equivalent of sitting in a classroom for five semesters.

Professional licensing is another example of failed US state capacity. As Ezra Klein recently noted in The New York Times — citing a 2021 article by Brink Lindsey, the director of the Open Society Project at the Niskanen Center — our government’s effectiveness has been swept away by two forces coming from directions very different: the knee-jerk anti-statism of the right; and on the left, a fetish for process at the expense of results.

The first is evident from the rise of Ronald Reagan. The latter, Klein explains – now quoting Nicholas Bagley of the University of Michigan – arose because the Democratic Party is “dominated by lawyers. [Joe] Biden and Kamala Harris hold law degrees, as did Barack Obama and John Kerry and Bill and Hillary Clinton before them. And that filters through the party. “Lawyers, not managers, have taken primary responsibility for shaping administrative law in the United States,” Bagley writes. “And if you only have one attorney, it all looks like a procedural issue.” the ability or employability of university graduates.

Let me tell you that there are a fair amount of procedures involved in getting a PTA license. In addition to earning an associate’s degree, PTAs must complete applications that require notarized documents, criminal background checks, character references, in-person interviews, and passing a licensing exam. As for the degree itself, CAPTE’s accreditation requirements span 34 pages, eight standards, and over 100 items, including maintaining accurate information regarding accreditation status on the program’s website. With so many procedures, it must be good, right?

In fact, the negative externalities are legion. Requiring licensure and a degree for entry-level positions in low-risk health professions increases the cost of health care without any demonstrable improvement in quality – and may in fact result in poorer outcomes due to lower availability of care. And it can exacerbate inequality by benefiting those who have established themselves in the profession while deterring aspiring PTAs, who may then be channeled into lower-paying positions that don’t require a license.

State authorization also severely restricts interstate mobility, which makes little sense in the age of telemedicine. Last but not least, it further erodes the legitimacy of the government – ​​already under constant barrage from the right. As Klein puts it (quoting Bagley), “legitimacy is not solely, not even primarily, a product of the procedures followed by agencies. … Legitimacy stems more generally from the perception that government is capable, informed, quick, responsive and fair. Multiply the PTA’s license and degree requirements on dozens of low-risk, entry-level healthcare jobs that should be easy stepping stones to economic advancement and it’s clear why dozens of million potential voters have verified.

States more interested in the well-being of their citizens than in the persistence of an ideological discourse on government inefficiency have two options. They can withdraw their approval delegation from captive professional associations. Given the certain backsliding of this option, an easier step for low-risk entry-level professions could be legislation requiring licensing boards to offer alternative routes to licensing – routes that compel applicants to demonstrate relevant experience or proficiency in relevant skills (i.e. helping patients stretch, not passing an anatomy course).

Tuition-dependent colleges will scream and howl, especially against the backdrop of the secular decline in enrollment. But let’s hope most are mission- and civic-minded enough to recognize the many problems with getting a state license, coupled with unnecessary degree requirements.

Ryan Craig is Managing Director of Reach partners, a New York-based private equity firm that invests in companies operating in technology, healthcare and business services. He is the author of “College disrupted” and “A New U: Faster and Cheaper Alternatives to University.” Follow him on Twitter @ryancraigap.