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The COVID-19 pandemic has disrupted the US health care workforce owing to changes in the use and finances of health care clinician offices and institutions, increased health risks, burnout from increased patient burdens, and child care disruptions.^1-4 While federal programs have provided financial assistance to hospitals and institutions,¹ the net effect of these forces on health care employment levels and wages has not been examined. Understanding trends in employment levels by health care settings and locations is critical for planning and responding to public health crises.

We used industry- and county-level data from the US Bureau of Labor Statistics Quarterly Census of Employment and Wages (QCEW, which covers more than 95% of US jobs).⁵ We conducted 2 analyses to quantify changes in employment and average wages of employees of 6 key health care organizations (offices of physicians, offices of dentists, home health care services, hospitals, skilled nursing facilities [SNFs], and combined other facilities) during 2020 and the first 6 months of 2021. First, we examined quarterly national trends in health care employment and average wages between March 31, 2020 (2020-Q1), and June 30, 2021 (2021-Q2), relative to 2019 (pre-COVID levels). Second, we examined associations between the 12-month changes in employment levels during 2019 to 2021, COVID-19 burden, and pre-COVID physician-to-population ratio. Multivariable linear regression models were conducted with Stata, version 17.0. The study was granted Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00207016).

Health care employment levels declined suddenly, from 22.2 million in 2019 to 21.1 million, in 2020-Q2—a 5.2% decline (vs a 9.0% decline in all industries), and considerably rebounded to 21.8 million in 2021-Q2. Average wages within the health care sector increased at a lower rate relative to all industries’ changes (2020: 5.0% vs 6.7%; and 2021-Q2: 1.5% vs 6.9%).

Employment declines varied by types of health care organizations (Figure), with the largest declines in 2020-Q2 among offices of dentists (10.0%) and SNFs (8.4%). The smallest declines were among hospitals (2.5%) and offices of physicians (4.6%). While the employment level of most health care sectors rebounded to the pre-COVID levels in 2021-Q2, there were more declines in employment among SNFs (13.6% decline compared with 2019). Employees in SNFs exhibited the largest wage increases in 2020 (9.5%) and 2021 (6.3%), compared with 2019.

The Table highlights a statistically significant and positive association between the COVID-19 burden and 12-month percent change in employment levels among SNFs: the adjusted 2020 employment level in SNFs relative to 2019 was 105.2% among counties with the lowest quintile of COVID-19 cases and only 90.4% among counties with the top 20% burden (P = .008). Compared with the top 20%, counties with the lowest physician-to-population ratios tended to have higher adjusted employment levels in offices of physicians (107.8% vs 97.9%, P = .04) and among offices of dentists (110.1% vs 98.4%, P = .02). These associations were not statistically significant among other types of institutions.

Protecting the health care sector has been a priority in the pandemic.⁶ We documented changes in health care employment levels and wages during 2020 and 2021. We found substantial employment declines among SNFs, which were more severe in counties with high COVID-19 burden. The 2020 declines in employment among offices of physicians and offices of dentists were relatively smaller in counties with lower pre-pandemic physician-to-population ratios.

Limitations include the exclusion of certain counties with censored data and our inability to examine mechanisms for workforce changes. Future research is needed to understand if organizations are demanding fewer workers or fewer workers are willing to work at health care positions. Overall, our results imply that intensified early efforts are needed to protect the health care workforce in future pandemics.

Accepted for Publication: December 19, 2021.

Published: February 25, 2022. doi:10.1001/jamahealthforum.2021.5217

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Cantor J et al. JAMA Health Forum.

Corresponding Author: Thuy Nguyen, PhD, Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, M3234 SPH II, Ann Arbor, MI 48109-2029 (thuydn@umich.edu).

Author Contributions: Dr Nguyen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cantor, Whaley, Nguyen.

Administrative, technical, or material support: All authors.

Supervision: Whaley, Simon.

Conflict of Interest Disclosures: Dr Whaley reported grants from National Institute on Aging during the conduct of the study, and personal fees from Doximity outside the submitted work. Dr Simon reported grants from the National Institutes of Health outside the submitted work. Dr Nguyen reported grants from the Agency for Healthcare Research and Quality outside the submitted work. No other disclosures were reported.

Funding/Support: National Institute on Aging (K01 AG061274, Whaley).

Role of the Funder/Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: All information and materials in this article are original and do not represent the views of the National Institute on Aging.

Data Sharing Statement: Data are publicly available at . The analytic code will be made available to others via Dr Nguyen’s GitHub ().