Nursing Workforce Programs in Title VIII of the Public Health Service Act

Nursing Workforce Programs in Title VIII of the Public Health Service Act

Order Code RL32805
CRS Report for Congress
Received through the CRS Web
Nursing Workforce Programs in Title VIII
of the Public Health Service Act
March 10, 2005
-name redacted-
Analyst in Life Sciences
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

Nursing Workforce Programs in Title VIII
of the Public Health Service Act
Summary
Responding to concerns about existing or impending shortages of nurses,
Congress passed the Nurse Training Act of 1964 (P.L. 88-581). It established in Title
VIII of the Public Health Service Act (PHSA) the first comprehensive federal support
for programs to develop the nursing workforce. Through subsequent authorizations,
these programs have been amended to increase opportunities in nurse education and
training for individuals and institutions. Currently, Title VIII authorizes grants to
institutions, and scholarships and loans to individuals, for basic and advanced levels
of nursing education and training. Programs and authorities in Title VIII are
administered by the Bureau of Health Professions (BHPr) in the Health Resources
and Services Administration (HRSA) of the Department of Health and Human
Services (HHS).
Congress passed the Health Professions Education Partnerships Act of 1998
(P.L. 105-392) and the Nurse Reinvestment Act of 2002 (P.L. 107-205). Under Title
VIII, programs for Basic Nurse Education and Practice, Advanced Education
Nursing, Nurse Education Practice and Retention and Nursing Workforce Diversity
have received continuous support since 1998. The 2002 law reauthorized some of
these programs and created new ones, including the programs for Nurse Faculty
Loans and Comprehensive Geriatric Education. Still, a number of programs in Title
VIII are due for reauthorization.
In 2002, the HHS reported on the supply of, demand for, and shortage of
registered nurses in the United States and projected that shortages are likely to
increase through 2020. In 2000, 2002, and 2003, the National Advisory Committee
on Nursing Education and Practice (NACNEP), a federal advisory committee, made
recommendations to the Secretary and Congress. According to NACNEP, the first
priority in alleviating the anticipated nursing shortage should be to ensure that an
adequate number of qualified faculty are available to teach prospective nurses.
This report examines the legislative, programmatic, and funding aspects of Title
VIII. It describes the registered nurse workforce, and requirements for education and
licensing in the nurse workforce, as these relate to Title VIII. In the 108th Congress,
legislation to reauthorize or amend Title VIII was introduced but did not become law.
The 109th Congress may see similar proposals introduced to reauthorize or support
Title VIII. A list of relevant legislation is provided.
This report will be updated as events warrant.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Legislative History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Title VIII Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Other Federal Nursing Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Funding for Title VIII Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Description of Nurse Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Basic Nurse Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Advanced Nurse Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Registered Nurse Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Demand and Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Advanced Practice Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
National Advisory Council on Nurse Education and Practice
(NACNEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Institute of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Legislation in the 109th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Legislation in the 108th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
List of Figures
Figure 1. Title VIII Funding: Distribution by Program, FY2005-FY2006 . . . . 10
Figure 2. National Supply and Demand Projections for Full-Time
Equivalent Registered Nurses, 2000-2020 . . . . . . . . . . . . . . . . . . . . . . . . . 14
List of Tables
Table 1. Authorizations and Expiration Dates in Title VIII of the PHSA . . . . . . 4
Table 2. Appropriations for Title VIII Authorizations, FY1998-FY2005 (est.) . . 9
Table 3. Title VIII: Grants to Institutions and Special Projects, FY2003 . . . . . 11
Table 4. Title VIII: Loan Repayment and Scholarship Awards
to Individuals, FY2003-FY2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 5. National Supply and Demand Projections for Full-Time Equivalent
(FTE) Registered Nurses, Selected Years, 2000-2020 . . . . . . . . . . . . . . . . . 21

Nursing Workforce Programs in Title VIII
of the Public Health Service Act
Introduction
In 1964, responding to concerns about existing or impending shortages of
nurses, Congress passed the Nurse Training Act (P.L. 88-581). It established in Title
VIII of the Public Health Service Act (PHSA) the first comprehensive federal support
of programs to develop the nursing workforce. The Nurse Training Act consolidated
in Title VIII existing nursing programs with newly established authorities, creating
construction grants to nursing schools, a student loan program, education grants, and
traineeships for advanced nursing practice.
Through subsequent authorizations, these programs have been amended to
increase opportunities in nursing education and training programs for individuals and
institutions. Currently, Title VIII authorizes grants to institutions for activities at
basic and advanced levels of nursing education as well as scholarships and loans to
individuals at all levels of nursing. Programs in Title VIII are administered by the
Bureau of Health Professions in the Health Resources and Services Administration
(HRSA) of the Department of Health and Human Services (HHS).
Congress created the National Advisory Council on Nurse Education and
Practice (NACNEP) in the Health Professions Education Partnerships Act of 1998
(P.L. 105-392) to advise the federal government on policy for Title VIII. NACNEP
recommends that the first priority in alleviating the anticipated nursing shortage
should be to ensure that an adequate number of qualified faculty are available to
teach prospective nurses. Shortages of nursing school faculty; slow growth in
enrollments in nursing schools; fewer new nurses entering the profession; slow
growth rate in the total population of registered nurses (RNs); job burnout and
dissatisfaction among practicing nurses; and high nurse turnover and vacancy rates
are among the many challenges confronting the nursing profession, according to the
American Association of Colleges of Nursing (AACN).
This report examines the legislative, programmatic, and funding aspects of
nursing workforce programs in Title VIII. In the 108th Congress, legislation to
reauthorize or amend Title VIII was introduced but did not become law. Since some
authorizations are expired but funded, the 109th Congress may see similar proposals
introduced to reauthorize or amend Title VIII. In previous years, programs in Title
VIII have been reauthorized simultaneously with programs in Title VII of the PHSA.
Title VII authorizes support for all other health professions except for nursing.
Several programs in Title VII are overdue for authorization. A list of relevant
legislation is provided. This report will be updated as events warrant.

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Legislative History
Title VIII of the PHSA authorizes funding for federal programs and activities
in nursing education to develop the nursing workforce. Nurses aides, licensed
practical nurses and registered nurses constitute this workforce. Although a
smattering of federal initiatives for nursing education and training were in place prior
to the 1960s, the first comprehensive federal legislation to consolidate such programs
was enacted in the Nurse Training Act of 1964 (P.L. 88-581). This Act was a
response to a 1963 report of the Surgeon General’s Consultant Group on Nursing.
The report, Toward Quality in Nursing, Needs and Goals, anticipated a shortage of
nurses and recommended that the supply of nurses be increased from a total of
550,000 professional nurses in practice, to a total of 850,000 by 1970.1 The Act
consolidated in Title VIII previously established programs supporting grants and
traineeships for basic and advanced nurse education. Also, the Act added to Title
VIII newly created programs for construction grants to nursing schools; a student
loan program; education grants; and traineeships for advanced nursing practice.
Subsequently, Title VIII was amended or reauthorized in 1965 (P.L. 89-290);
1966 (P.L. 89-751); 1968 (P.L. 90-490); 1970 (P.L. 92-52); 1971 (P.L. 92-158); 1975
(P.L. 94-63); 1976 (P.L. 94-484); 1979 (P.L. 96-76); 1981(P.L. 97-35); 1985 (P.L.
99-92);1988 (P.L. 100-607); 1992 (P.L. 102-408); 1998 (P.L. 105-392); and 2002
(P.L. 107-205). During the period from mid-1960s through the mid-1970s, Title VIII
provided for construction grants to nursing education, capitation grants (grants to
schools based on the number of students enrolled), and support in the form of loans
and scholarships to all types of nurse education settings, including diploma schools
of nursing.
In 1979, Congress expressed concerns about the role of the federal government
in supporting nurse education programs. Should the federal government provide
institutional support? Was there actually a shortage of nurses? Should students bear
the entire cost of their nursing education? How should legislators address increasing
nursing specialization and unequal geographic distribution of nurses? According to
a congressional report, these questions and the “insufficient and contradictory”
information about the supply and distribution of nurses led to reauthorization of Title
VIII for only one year. In P.L. 96-76, Congress directed the Institute of Medicine
(IOM) to study the maldistribution of nurses in medically underserved areas and the
reasons why nurses leave the profession.2 In its report to Congress, Nursing and
Nursing Education: Policies and Private Actions, the IOM found that federal support
to increase the overall supply of nurses was not needed, but that generalist education
programs should continue to help sustain the nursing supply. The IOM further
recommended that federal, state, and private actions were needed to alleviate certain
shortages and the maldistribution of nurses.3
1 U.S. Department of Health, Education, and Welfare, “Toward Quality in Nursing, Needs
and Goals,” Report of the Surgeon General’s Consultant Group on Nursing, Feb. 1963.
2 U.S. Code Congressional, and Administrative News, Legislative History of Nurse Training
Amendments of 1979, P.L. 96-76, pp. 1264-1265.
3 U.S. Institute of Medicine (IOM), Nursing and Nursing Education: Public Policies and
(continued...)

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In the Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35), Congress
authorized and extended to 1984 some programs for nurse education and training,
while it repealed others. Repeals of programs for nursing education continued under
the Nurse Education Amendments of 1985 (P.L. 99-92). The 1985 law repealed
construction grants; loan guarantees for construction grants; capitation grants (to
schools based on the number of students enrolled); financial distress grants (to
prevent nursing school closures); and scholarships at schools of nursing. By the end
of the 1980s, several Title VIII authorities that were established in the 1960s and
1970s had been repealed.

Amid continued concerns about the shortage of registered nurses, Congress set
new priorities for Title VIII in the Health Omnibus Program Extension of 1988 (P.L.
100-607).4 Funding priorities placed greater emphasis on innovative practice models
in home health care and nursing homes, long-term care nursing demonstrations and
traineeships for advanced nurse education. These replaced the earlier institutional
models for institutional support, such as grants for construction and capitation. Also,
in 1988, Congress created the National Advisory Council on Nurse Education
(NACNE) directing the group to evaluate the effectiveness of projects supported
through Title VIII. Existing programs for advanced nurse education (including nurse
practitioners, midwives, and anesthetists) were revised and extended. In 1992, the
Nurse Education and Practice Improvement Amendments (P.L. 102-408)
reauthorized Title VIII adding requirements for special projects to establish career
ladders for nursing assistants and other pre-professional nurses, and extending other
authorities to increase opportunities for professionals in pursuing leadership roles in
advanced nurse education.5
The 1998 reauthorization of Title VIII, the Health Professions Education
Partnerships Act of (P.L. 105-392), increased support of activities for basic and
advanced nursing education through scholarship and grants programs. In addition,
institutions received funding preferences for projects offering “substantial benefit”
to meet public health nursing needs to medically underserved populations.6 Also, the
1998 reauthorization created the National Advisory Council on Nursing Education
and Practice (NACNEP) which supersedes the former National Advisory Council on
Nurse Education. Today, NACNEP is a body of nursing professionals representing
academic and non-academic entities. NACNEP’s key function is to provide advice
and recommendations to the Secretary of HHS and Congress about federal policy for
3 (...continued)
Private Actions, 1983, at [http://books.nap.edu/books/0309033462/html/2.html#pagetop].
4 U.S. Congress, Senate Committee on Labor and Human Resources, Nurse Education
Reauthorization Act of 1988, “Health Omnibus Programs Extension of 1988” (P.L. 100-
607), 100th Cong., 2nd sess., S.Rept. 100-476 (Washington: GPO, 1988), p. 9.
5 U.S. Congress, House Committee on Energy and Commerce, Health Professions Education
Extension Amendments of 1992, 102nd Cong., 2nd sess., H.Rept. 102-925 (Washington: GPO,
1992), pp. 1426-1429.
6 U.S. Congress, Senate Committee on Labor and Human Resources, Health Professions
Education Partnerships Act of 1998, 105th Cong., 2nd sess., S.Rept. 105-22, (Washington:
GPO, 1998), p. 9.

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nursing education and practice as these affect the nursing workforce, particularly
programs and activities established in Title VIII. (See section on NACNEP).
In 2002, the Nurse Reinvestment Act (P.L. 107-205) amended Title VIII, adding
three new authorities: National Nurse Service Corps; Comprehensive Geriatric
Education; and, Public Service Announcements. The Act extended and revised
authority for the Basic Nurse Education and Practice Grants and Loan Repayment
programs. Also, the 2002 law revised funding priorities for Nurse Education,
Practice and Retention Grants. Other provisions in the law support institutions to
train individuals for masters and doctoral degrees, combined registered
nurse(RN)/master’s degrees, post-nursing master’s certificates, and nurse-midwife
certificates (see, Title VIII Programs).
Title VIII authorities that were reauthorized in the 1998 law expired in 2002.
Some were revised and extended in the 2002 law. Some were not, but still receive
appropriations. A list of Title VIII authorities, current and expired, are listed in
Table 1.
Table 1. Authorizations and Expiration Dates in
Title VIII of the PHSA
Authorization
Expiration
Grants for Health Disparities and Cultural Competency (P.L. 105-392)
2002
Advanced Education Nursing Grants (P.L. 105-392)
2002
Workforce Diversity Grants (P.L. 105-392)
2002
Basic Nurse Education and Practice Grants (extended in P.L. 107-205)
2007
National Advisory Council on Nurse Education and Practice
(P.L. 105-392)
Indefinite
Nurse Faculty Loans Programs (as amended in P.L. 107-205)
2007
National Nurse Service Corps (established in P.L. 107-205)
2007
Public Service Announcements (established in P.L. 107-205)
2007
Comprehensive Geriatric Education (established in P.L. 107-205)
2007
Title VIII Programs
Programs for nursing education are administered by the Bureau of Health
Professions (BHPr) of the Health Resource and Services Administration (HRSA) of
the Department of Health and Human Services (HHS). The programs are codified
under Title VIII of the PHSA. A brief description of each program follows.
Part A — General Provisions. (Sections 801-810) This part defines terms
used under this title, requirements to be included in applications, and the general use
of funds. Eligible entities are schools of nursing, nursing centers, academic health
centers, state or local governments, and other public or private nonprofit entities

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determined appropriate by the Secretary of HHS. Preference is given to applicants
with projects that will substantially benefit rural or underserved populations, or that
help meet public health nursing needs in state or local health departments. Grants are
awarded on a competitive basis to carry out innovative demonstration projects or to
provide for strategic workforce supplementation activities.
Under Section 807, the Secretary is authorized to award grants for research and
demonstration projects for continuing training and education for the reduction of
disparities in health care outcomes and the provision of culturally competent health
care. This program has not been funded. HRSA’s Office of Minority Health has
established a Cultural Competence Initiative to promote and incorporate cultural
competence in all HRSA policies and programs.
Part B — Nurse Practitioners, Nurse Midwives, Nurse Anesthetists, and
Other Advanced Education Nurses. (Sections 811-815) This part authorizes
support to institutions in three programs: (1) the advanced education nursing grant
program; (2) the nurse anesthetist traineeship program; and (3) the advanced
education nursing traineeship program.
Under the advanced education nursing grant program, grants are awarded to
institutions for master’s and doctoral programs, combined RN/master’s degree
programs, and post- master’s certificate programs. Grants may also be awarded for
certificate programs for nurse practitioners, clinical nurse specialists, nurse-
midwives, nurse anesthetists, nurse educators, nurse administrators, public health
nurses, or in other nurse specialities that require advanced education. Funds may be
used for personnel salaries, consultant fees, supplies and equipment, travel expenses
and other project-related costs. Indirect costs are allowed for administrative costs of
the project, limited to 8% of direct costs.
The nurse anesthetist traineeship program awards grants to eligible institutions
to provide direct financial support to licensed registered nurses enrolled as full-time
students beyond the 12th month of study in a master’s nurse anesthesia program.
These funds may be used to pay all or part of the costs of tuition, books, fees, and
reasonable living expenses. Traineeship recipients are selected by the participating
institution. Indirect costs and trainee travel are not allowed.
The advanced education nursing traineeship program provides grants to
institutions for registered nurses enrolled in advanced education nursing programs
to prepare nurse practitioners, clinical nurse specialists, nurse midwives, nurse
anesthetists, nurse administrators, nurse educators, public health nurses, and nurses
in other specialties determined by the Secretary to require advanced education. Grant
funds can only be used to pay the costs of tuition, books, fees, and reasonable living
expenses. Not more than 10% of traineeship funds may be used for nurses in
doctoral degree programs. Indirect costs and trainee travel are not allowed. Graduate
students are limited to 36 months of support. Support is provided to nurse anesthetist
students only during their first year.
Part C — Increasing Nursing Workforce Diversity. (Section 821) Grants
are awarded to eligible entities for special projects to increase nursing education
opportunities for individuals from disadvantaged backgrounds by providing student

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scholarships, stipends, pre-entry preparation, and retention activities. Such
individuals include racial and ethnic minorities underrepresented among registered
nurses.
Nursing workforce diversity grants may be used for personnel salaries,
consultant fees, supplies and equipment, essential travel expenses, and student
stipends or scholarships. Indirect costs are allowed for administrative costs of the
project, limited to 8% of direct costs exclusive of equipment, tuition, and fees.
Stipends are $250 per month for full-time students, and scholarships are limited to
$7,000 per student per year for upper-division nursing students. Funds are not to be
used for a dependent’s allowance.
Part D — Strengthening Capacity for Basic Nurse Education and Practice.
(Section 831) This part establishes three priority areas in which grants may be
awarded to entities to respond to the nursing shortage and increase the number of
registered nurses. Those areas are education, practice, and retention.
An eligible entity under this part is a school of nursing, health care facility, or
a partnership of such school or facility. Under the education priority area, grants are
awarded to eligible entities to: (1) expand enrollment in baccalaureate nursing
programs; (2) develop and implement internship and residency programs to
encourage mentoring and the development of specialities; or (3) provide education
in new technologies, including distance-learning methodologies.
Grants are awarded under the practice priority area to: (1) establish or expand
nursing practice arrangements (nurse managed centers) in noninstitutional settings
to demonstrate methods to improve access to primary health in medically
underserved communities; (2) provide education and training for nursing care to such
groups as: underserved populations and other high-risk groups including the elderly,
HIV/AIDS patients, substance abusers, homeless, and domestic violence victims; (3)
provide managed care, quality improvement, and other skills needed to practice in
organized health care systems; or (4) develop cultural competencies among nurses.
The retention priority area grants are awarded to eligible entities to carry out
career ladder programs and to enhance patient care delivery systems. The career
ladder program promotes nurse advancement in a variety of training settings and
assists individuals in obtaining education and training required to enter and advance
within the nursing profession. The program to enhance patient care delivery systems
seeks to improve the retention of nurses that is directly related to nursing activities
through collaboration and communication among nurses and other health care
professionals, and by promoting nurse involvement in the organizational and clinical
decision-making processes of a health care facility.
Funds under this part may be used for personnel salaries, consultant fees,
supplies and equipment, essential travel expenses, and other related expenses.
Indirect costs are allowed for administrative costs of the project, limited to 8% of
direct costs exclusive of equipment, tuition, and fees.
Part E — Student Loans. (Sections 835-846A) This part authorizes nursing
student loans and loan repayment and scholarship programs to individuals and

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institutions. The nursing student loan program provides long-term, low-interest rate
loans to financially needy students pursuing studies leading to a diploma, associate,
baccalaureate or graduate degree in nursing. Participating schools select loan
recipients and determine the amount of loan assistance. Loans have a maximum of
$2,500 for an academic year, $4,000 for each of the final two years, or the amount
of the student’s financial need, whichever is less.
Under the nursing education loan repayment program, payments are made on
the principal and interest of education loans of registered nurses who agree to serve
at a health care facility with a critical shortage of nurses. Repayments may not
exceed 85% of the loan over a three-year period.
The nurse scholarship program provides scholarships to nursing students in
return for their agreement to work for at least two years at a health care facility with
a critical shortage of nurses.
The nurse faculty loan program establishes a student loan fund in participating
nursing schools to assist registered nurses to become nursing faculty. Maximum loan
amounts cannot exceed $30,000 for an academic year. The program has a provision
in which 85% of the loan may be cancelled over four years in return for service as
full-time faculty in a nursing school.
Part F — Funding. (Section 841) Appropriations are authorized to carry out
Parts B, C, and D. The Secretary is required to determine a methodology for
allocating funds using specified factors.
Part G — National Advisory Council on Nurse Education and Practice.
(Section 845) The National Advisory Council on Nurse Education and Practice
(NACNEP) is established to provide advice and recommendations to the Secretary
and the Congress relating to policy matters under this title. While NACNEP is
established in Title VIII, responsibilities and requirements for federal advisory
committees are established in Title X of the PHSA.
Part H — Public Service Announcements. (Sections 851-852) The Secretary
is required to issue public service announcements that advertise and promote the
nursing profession. The Secretary may award grants to state and local entities for the
same purpose. This program has not been funded, but HRSA officials report that
they work closely with private organizations to fulfill this need.
Part I — Comprehensive Geriatric Education. (Section 855) Under the
comprehensive geriatric education program, grants are made to eligible entities to
train individuals in providing geriatric care for the elderly. This program is
coordinated with programs under Section 753 (education and training relating to
geriatrics). Eligible entities include schools of nursing, health care facilities,
programs leading to certification as certified nurse assistants, or partnerships of
schools and facilities, or programs and facilities. Indirect costs are allowed for
administrative costs of the project, limited to 8% of direct costs. Trainee expenses
are not allowed.

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Other Federal Nursing Programs
In addition to Title VIII, other authorities are established in the PHSA to support
nursing education and training. HHS oversees the administration of these programs.
! National Health Service Corps (NHSC), Scholarship and Loan
Repayment Programs (Title III), which seek to improve the
distribution of nurses in health professional-shortage areas. The
NHSC is administered by HRSA;
! Extramural Loan Repayment for Individuals from Disadvantaged
Backgrounds, which encourages the recruitment and retention of
qualified nurses and other health professionals from disadvantaged
backgrounds to conduct clinical research (Title IV). This program
is administered by the National Institutes of Health (NIH); and,
! Nursing Research (Title IV), which supports comprehensive research
training programs to prepare nursing professionals to conduct
nursing research. This program is administered by NIH.
In addition, Section 1886(l) of Medicare law in the Social Security Act,
authorizes Medicare payments to hospitals for nursing education. For FY2004, the
Medicare program will make payments of approximately $270 million to hospitals,
and for FY2005, about $290 million, for nurse education activities.7
Funding for Title VIII Programs
In FY2005, six programs receive appropriated funds. Two programs, Advanced
Education Nursing and Nursing Workforce Diversity, are expired but receive
appropriations. An expired authorization, “Grants for Health Disparities and Cultural
Competency,” was never funded, and funds were never appropriated to the currently
authorized “Public Service Announcements.” NACNEP is an advisory group bound
by requirements established by the Federal Advisory Committee Act (FACA). It has
no direct appropriation. Instead, the Secretary is authorized to allocate funds from
Title VIII to support NACNEP’s activities for nurse education and training.8 (See
Appropriations, Table 2, below).
7 Telephone communication with Heath Westcott, Policy Analyst, Division of Acute Care,
Center for Medicare and Medicaid Services, Feb. 2005. The line item for this payment is
“Nursing and Allied Health Professional Education.”
8 42 U.S.C. § 297t.

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Table 2. Appropriations for Title VIII Authorizations, FY1998-FY2005 (est.)
(dollars in thousands)
FY2006b
Program
FY1998
FY1999
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005a
est.
Health Disparities and Cultural Competencyb (Section 807)
0
0
0
0
0
0
0
0
0
Advanced Education Nursing (Section 811)
48,693
50,581
50,587
59,045
60,018
50,174
58,636
58,636
42,806
Nursing Workforce Diversity (Section 821)
3,860
4,009
4,009
4,673
6,172
9,935
16,402
16,402
21,244
Nurse Education Practice and Retention (Section 831)
10,549
10,965
10,966
12,790
16,283
26,825
31,769
36,765
46,325
Loan Repayment and Scholarship Program
(Section 846(a))c
2,199
2,278
2,279
7,279
10,235
19,870
26,736
31,738
31,369
Nursing Faculty Loan Program (Section 846A)d
0
0
0
0
0
2,980
4,870
4,870
4,821
Public Service Announcements (Section 851)e
0
0
0
0
0
0
0
0
0
State and Local Public Service Announcements (Section 852)e
0
0
0
0
0
0
0
0
0
Comprehensive Geriatric Education (Section 855)e
0
0
0
0
0
2,980
3,478
3,478
3,426
Total appropriations
65,301
67,833
67,841
83,787
92,708
112,764
141,891
151,889
149,991
Source: Justifications of Estimates for Appropriations Committees, FY2000 thru FY2005, except where noted.
a. Conference Report on the Consolidated Appropriations Act, 2005 (H.R. 4818, H.Rept. 108-792, P.L. 108-447). Reflects FY2005 Conference Report levels prior to any rescissions
mandated in P.L. 108-447.
b. HHS. HRSA. FY2006 Justification of Estimates for Appropriations Committees, pp. 166-182.
c. Authorized in P.L. 105-392; remains unfunded.
d. Includes Loan Repayment Program authorized in P.L. 105-392 and National Nurse Service Corps created in P.L. 107-205.
e. Authorized in P.L. 105-392.
f. Authorized in P.L. 107-205.

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Almost two-thirds of FY2005 appropriations are distributed to two programs:
Advanced Nurse Education (39%) and Loan Repayment and Scholarship (21%)
(Figure 1). The FY2006 President’s budget proposes to target the largest share of
funding to Nurse Education and Practice (31%) and Loan Repayment and
Scholarship programs (21%) (refer to Appropriations, Table 2).
Figure 1. Title VIII Funding: Distribution by Program,
FY2005-FY2006
Source: HHS, HRSA FY2006 Justification of Estimates for Appropriations
Committees.
Note: The total appropriation for FY2005 is $151.8 million; the FY2006 request
is $149.9 million. Elements may not total 100% due to rounding.
Title VIII appropriations support the education and training of individuals at all
levels of professional nursing. Table 3 provides a complete list of FY2003 (most
recent information available) grants to institutions and special projects awarded under
Title VIII. Table 4 lists the awards made to individuals from FY2003 and estimates
for FY2004 and FY2005.

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Table 3. Title VIII: Grants to Institutions and
Special Projects, FY2003
New
Continuation
Total
awards
awards
awards
Advanced education nursing
36
97
133
Nursing workforce diversity
20
25
45
Basic nurse education and practicea
14
43
57
Nurse education, practice, and retentionb
40
0
40
Comprehensive geriatric education
17
0
17
Total
127
165
292
Source: HHS, FY2003 Awards Summary for Program Grants, the most recently available at
[http://bhpr.hrsa.gov/nursing/AACN/aacn32004_files/frame.htm#SLIDE0170.HTM].
a. Authorized in P.L. 105-392.
b. Authorized in P.L. 107-205.
Table 4. Title VIII: Loan Repayment and Scholarship Awards to
Individuals, FY2003-FY2005
FY2003
FY2004 (est.)
FY2005 (est.)
Number of loan repayment awards
602
863
807a
Number of scholarship awards
81
118
275
Source: FY2005 HHS, HRSA, Justification of Estimates for Appropriations Committees.
a. Increased administrative costs reduced the number of contract awards for FY2005, according to
HHS.
Description of Nurse Education
A registered nurse is an individual who has successfully completed a qualified
program in nursing education and has passed the licensing exam for nurses. An
individual may pursue one of three educational paths to entry-level professional
nursing: a nursing diploma, an associate’s degree or a baccalaureate degree. After
obtaining basic educational qualification, an individual may pursue an advanced
degree or professional certification. Title VIII supports all of these levels of nursing
education and training.

CRS-12
Basic Nurse Education
Diploma programs, administered in hospitals, take about three years to
complete. Associate degrees in nursing, offered by community and junior colleges,
take about two to three years to complete. A bachelor of science in nursing (BSN)
degree takes about four years to complete. Nursing education includes classroom
instruction and supervised clinical experience in hospitals and other health care
facilities. The typical supervised clinical experience is provided in hospital
departments such as pediatrics, psychiatry, maternity, and surgery. After completing
academic and experience requirements, an individual is qualified to sit for the
professional licensing exam to become a registered nurse. The National Council
Licensure Examination (NCLEX-RN) is the national licensing exam for registered
nurses. The exam is administered by the National Council of State Boards of
Nursing (NCSBN), a not-for-profit organization whose membership comprises the
boards of nursing in the 50 states, the District of Columbia, and five United States
territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the
Virgin Islands).
Accelerated BSN programs are available for individuals who have a bachelor’s
or higher degree in another field and who are interested in moving into nursing.
Accelerated BSN programs last 12 to 18 months and provide the fastest route to a
BSN for individuals who already hold a degree. Accelerated master’s degree
programs in nursing also are available and take about three years to complete. In
2004, more than 170 accelerated programs were available in the United States.9
Advanced Nurse Education
For professional nurses who are interested in obtaining an advanced degree, a
master’s degree in nursing prepares the professional to be an advanced practice nurse.
An advanced nurse may provide care as a nurse practitioner, clinical nurse specialist
(cardiology or oncology), certified nurse midwife, or nurse anesthetist.
Nurses may obtain doctoral degrees to work in higher education or research.
Advanced practice nurses prepare for the doctoral degree by fulfilling educational
and research requirements established by the university.
Registered Nurse Workforce
Registered nurses comprise the largest health care occupation, occupying a little
more than 2 million (full-time equivalent) positions in 2004, according to the
Department of Labor.10 Almost three out of five registered nurses work in hospitals.
Others are employed in physicians’ offices, nursing care facilities, home health care
9 Personal communication with Debbie Campbell, Director of Government Affairs, AACN,
Jan. 3, 2005.
10 U.S. Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook,
“Registered Nurses,” at [http://stats.bls.gov/oco/ocos083.htm].

CRS-13
services, employment services, government agencies, and outpatient care centers,
among other settings.
Demand and Supply
According to a 2002 survey by the National Center for Health Workforce
Analysis at HRSA, demand for registered nurses is expected to grow in all
employment settings, but demand in some settings could occur more rapidly than in
others. Consequently, the distribution of demand will change according to the setting
of practice. HRSA comments:
Hospitals have been and will continue to be the major source of demand for RNs
but while the total number of nurses in hospitals will continue to grow, the
hospital sector’s share of total RN employment will remain stable at about 62
percent. Employment settings closely associated with service to the elderly are
projected to increase their share of the total demand for RNs. For example, the
demand for RNs in nursing homes is projected to increase from 8 percent of total
demand in 2000 to 10 percent in 2020. Similarly, growth in the home health care
sector will result in an increase in demand for RNs from 6.5 percent to 9 percent
of total RN demand. These increases will naturally be offset by a corresponding
decline in the proportion of demand in ambulatory and other settings.11 [Other
settings include occupational nursing, nursing education, and school nurses.]
The National Center for Health Workforce Analysis projects that a total of 2.16
million nurses would be needed in 2005 compared to a projected supply of 2.01
million (on a full-time equivalent basis), indicating a shortfall of almost 150,000 FTE
registered nurses.12 Under current assumptions, the shortage of nurses is expected
to grow through 2020. Growth rates in demand for FTE registered nurses contrasted
with negative growth in supply results in a growing shortage of FTE registered nurses
beginning in 2014 through 2020 (see Figure 2). A data table for this figure is in the
Appendix.
11 HHS, HRSA, BHPr, National Center for Health Workforce Analysis, July 2002, at
[http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm#chart1].
12 Ibid.

CRS-14
Figure 2. National Supply and Demand Projections for Full-
Time Equivalent Registered Nurses, 2000-2020
Source: HHS, HRSA, Projected Supply, Demand, and Shortages of Registered
Nurses, 2000-2020.
Note: Vertical axis does not start at 0.
Advanced Practice Nursing
Title VIII programs support all types of education and training for advanced
practice nurses. Advanced practice nursing is an umbrella term appropriate for a
licensed registered nurse prepared at the graduate degree level as either a Nurse
Practitioner, Clinical Specialist, Nurse-Midwife, or Nurse Anesthetist. Advance
Practice Nurses (APNs) are professionals with specialized knowledge and skills that
are applied within a broad range of patient populations in a variety of practice
settings.13 The American Association of Colleges of Nursing (AACN) recommends
that all advanced practice nurses should hold a graduate degree in nursing and be
13 Unless otherwise noted, information for this section is taken from Advanced Practice
Nursing, Extending Primary Care’s Reach: Your Nursing Career, Look at the Facts, at
[http://www.aacn.nche.edu/Education/nurse_ed/career.htm]. The American Association of
Colleges of Nursing (AACN) represents 575 schools of nursing at public and private
universities and senior colleges nationwide.

CRS-15
certified in advanced practice nursing. The AACN argues that the quality of care
provided by advanced practice nurses is equal to, and at times better than,
comparable services by physicians, and often at lower costs.14 The AACN further
asserts that demand for advanced practice nurses is driven by the health system’s
increasing demand for front-line primary care, and the accelerating drive toward
managed care, prevention, and cost-efficiency.
Nurse practitioners diagnose and treat common illnesses and injuries in patients.
In all states and the District of Columbia, nurse practitioners may receive and/or
dispense drug samples based on authorized scope of practice, rules and regulations,
or statutes.15 In 38 states, nurse practitioners can prescribe (including controlled
substances) with some degree of physician involvement or delegation of prescription
writing.16 In 13 states and the District of Columbia, nurse practitioners can prescribe
(including controlled substances) independent of any required physician involvement
in prescriptive authority.17 They practice in clinics and hospitals in metropolitan
areas, and deliver care in rural sites, inner cities, and other locations where there are
shortages of health professionals. Many nurse practitioners work in pediatrics,
family health, women’s health, and other specialties, and some have private practices.
There are an estimated 103,000 nurse practitioners in the United States.
Clinical Nurse Specialists (CNSs) provide care in a range of specialty areas,
including cardiology, oncology, neonatology, and obstetrics/gynecology. They
provide acute care and mental health services, develop quality assurance procedures,
and serve as educators and consultants. They work in hospitals and other clinical
sites. An estimated 69,000 clinical nurse specialists are in practice nationwide.
Certified Nurse-Midwives (CNMs) provide prenatal and gynecological care to
normal healthy women. This includes delivering babies in hospitals, private homes,
and birthing centers, and follow-up postpartum care. There are approximately 9,200
CNMs nationwide.
Working in the oldest of the advanced nursing specialities, Certified Registered
Nurse Anesthetists ( CRNAs) administer anesthesia for all types of surgery in settings
ranging from operating rooms and dental offices to outpatient surgical centers.
CRNAs may practice independently of physician supervision in states where the
governor has opted an institution out of the federal requirement for physician
supervision.18 The American Association of Nurse Anesthetists (AANA) reports that
14 AACN, “Mounting studies show that the quality of APN care is equal to, and at times
better than, comparable services by physicians, and often at lower cost,”
[http://www.aacn.nche.edu/Education/nurse_ed/career.htm], Mar. 10, 2004.
15 Information on prescriptive authority taken from Seventeenth Annual Legislative Update,
The Nurse Practitioner, Jan. 2005, p. 17.
16 The states are: AR, CA, CO, CT DE, GA, HI, IL, IN, KS, LA, MA, MD, MI, MN, MS,
NC, ND, NE, NJ, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, VA, and WV.
17 The states are: AK, AZ, IA, ID, ME, MT, NH, NM, OR, UT, WA, WI, and WY.
18 In 2001, HHS issued a final rule authorizing states to waive the physician supervision
(continued...)

CRS-16
CRNAs administer more than 65% of all anesthetics given to patients each year, and
are the sole anesthesia providers in two-thirds of all rural hospitals in the United
States.19
Perspectives
National Advisory Council on Nurse Education and Practice
(NACNEP)
Congress created NACNEP in the Health Professions Education Partnerships
Act of 1998 (P.L. 102-395). NACNEP supersedes the former National Advisory
Council on Nurse Education (NACNE). The law specifies that NACNEP is “a body
of 21-23 nursing professionals” representing academic and non-academic groups.
Congress charged NACNEP with the following responsibilities: (1) provide advice
and recommendations to the Secretary and Congress about policy related to the
administration of Title VIII; (2) provide advice to the Secretary about general
regulations related to programs and authorities in Title VIII; and (3) submit annual
reports to Congress on its activities along with findings and recommendations for
programs and authorities in Title VIII. NACNEP issued reports in 2000, 2002, and
2003.20
In its 2000 report, NACNEP analyzed the current role of registered nurses. The
advisory group found that registered nurses are practicing in a more complex
environment than in the past. Continuing changes in the way health care is delivered
(resulting from managed care); rapid advances in technology (drug therapy and
medical equipment); increasing numbers of older adults with chronic conditions
(Alzheimers disease); and the expanding diversity of the country’s residents are some
of the factors creating changes in the nursing environment. Consequently, registered
nurses need to be better educated to meet these changes. NACNEP recommends
federal actions to target federal funds to increase the overall number of baccalaureate
and higher-degree prepared nurses to constitute more than two-thirds of the nurse
workforce by 2010. Other recommendations include: (1) expanding funding and
federal programming for nursing education; (2) increasing the capacity of nursing
programs to ensure a diverse workforce that reflects the racial/ethnic composition of
society and provides culturally competent care; (3) addressing the need for federal
action to improve quality of work that nurses do; and, (4) and increasing the use of
18 (...continued)
requirements for nurse anesthetists. HHS, Centers for Medicare and Medicaid Services
(CMS), Medicare and Medicaid Programs; Hospital Conditions of Participation: Anesthesia
Services. 66 Federal Register 56762, Nov. 13, 2001. At least seven states have opted out
of requirements for physician supervision of nurse anesthetists. They are ID, IA, KS, MN,
NE, NH, and NM, according to Nursing Executive Watch, Apr. 2003, p. 8.
19 American Association of Nurse Anesthetists, Nurse Anesthetists at a Glance, at
[http://www.aana.com/crna/ataglance.asp].
20 HHS, HRSA, BHPr, Division of Nursing, National Advisory Council on Nurse Education
and Practice, Reports to the Secretary of Health and Human Services and the Congress.

CRS-17
advanced technologies, such as informatics and biotechnology, to improve quality of
nursing care. Also, this first report discussed joint activities with the Council on
Graduate Medical Education (COGME)21 that were published in Collaborative
Education to Ensure Patient Safety, a report to the Secretary of HHS and Congress.22
To promote patient safety, the joint report recommends education and practice of an
interdisciplinary nature for medical and nursing professionals.
The 2002 NACNEP report summarized interdisciplinary activities and discussed
projects supported by the nursing and medicine divisions of HRSA. The report also
concentrated on the need to address the nurse faculty shortage. In its 2002 report,
NACNEP notes that the “first priority in alleviating the anticipated future nursing
shortage” is to ensure that an adequate number of qualified faculty is available to
teach prospective nurses.23 The Nurse Reinvestment Act of 2002 (P.L. 107-205)
incorporated some of NACNEP’s key recommendations. These are focused
exclusively on the retention of nursing professionals through continued support for
programs in Title VIII and are as follows:
! Career ladders encourage nurses to train in a variety of settings and
across the range of nursing occupational categories. Career ladders
focus on both recruiting and retaining individuals already in the
nursing workforce preparing them to move up the professional
ladder. Programs are currently authorized in Section 831;
! The nurse education, practice, and retention grants are another tool
for retaining and encouraging collaboration and communication
among nurses and other health professionals to enhance the quality
of patient care. These are authorized in Section 831;
! Internships and residencies are retention tools that encourage
mentoring and the development of nursing specialties. An existing
program in Section 831 encourages individuals to participate in
programs containing both clinical and practical aspects of learning;
! Comprehensive geriatric education is focused on continuing
education with an emphasis on geriatric content in nursing
curricula. Section 855 provides support for geriatric programs in
which geriatric nursing leaders are encouraged to train individuals
to become licensed practical nurses and certified nursing assistants
who, later on, might consider a professional nursing career;
! Loans for nurse faculty aim to increase the pool of nurses prepared
to be faculty members in schools of nursing in Section 846A; and
! The Nurse Scholarship Program established in Section 846 provides
for scholarships for nursing students in exchange for a service
commitment at a health facility with a critical shortage of nurses.
21 COGME is an advisory group to the Secretary of HHS and Congress. COGME provides
ongoing assessments of physician workforce trends, training issues and financing policies.
It recommends federal and private sector efforts on these issues.
22 HHS, HRSA, BHPr, Division of Nursing and Division of Medicine and Dentistry, Sept.
2000.
23 HHS, HRSA, BHPr, National Advisory Council on Nurse Education and Practice, Second
Report to the Secretary of Health and Human Services and the Congress, Nov. 2002, p. 12.

CRS-18
In the 2003 report, NACNEP expressed continuing concerns about the nursing
shortage, and recommended enhancements for the nursing profession in improving
the health care of the population. In defining those issues related to improving the
quality of nursing education, NACNEP acknowledged contributions of the Institute
of Medicine, Health Professions Education: A Bridge to Quality (2003).24 The IOM
report discusses reforms for health professions education. It emphasizes integrating
a core set of competencies for health professionals. The IOM recommends, among
other things, an outcomes-based approach to education that prepares clinicians to
meet the needs of patients in a rapidly changing health system.
Congress may wish to consider recommendations from NACNEP’s 2003 report,
which focus on next steps to build on the broader recommendations in its first two
reports to the Secretary of HHS and the Congress.25 NACNEP recommends the
following actions:
! Broaden the impact of the initiatives enacted in the Nurse
Reinvestment Act of 2002 by increasing appropriations consistent
with national demand for the nurse workforce;
! Expand resources available to develop models to effectively recruit
and graduate sufficient numbers of racially and ethnically diverse
students;
! Support continuing efforts toward fostering education and
interdisciplinary practice for the health professions by implementing
IOM recommendations (see next section on “Institute of Medicine”);
! Foster working conditions providing for nurse involvement in
operational and patient care decision-making within health care
facilities and programs incorporating a diverse workforce at all
levels of the organization;
! Support the development and evaluation of culturally competent
interventions through demonstration projects using cooperative
agreements; and,
! Develop survey mechanisms to create a database on the elements of
the nurse work environment through cooperative agreements with
professional hospital-affiliated organizations
In view of NACNEP recommendations, Congress may wish to consider the
following options for Title VIII:
! Revising and expanding authorities at all levels of nursing
education;
24 Institute of Medicine, Health Professions Education: A Bridge to Quality (Washington,
DC: National Academies Press, 2003).
25 HHS, HRSA, BHPr, Division of Nursing, National Advisory Council on Nurse Education
and Practice, Third Report to the Secretary of Health and Human Services and the
Congress, Nov. 2003. First and second reports by the same authors were issued in 2000 and
2002, respectively.

CRS-19
! Recruiting qualified students who do not complete physician training
and instead transfer to accelerated nursing programs;
! Amending Title VII and Title VIII education programs to provide
grant opportunities that would support the definition of a common
language across the health professions;
! Revising authorities to incorporate quality of care objectives within
Title VIII;
! Extending and appropriating funds to existing programs in Title
VIII, such as the previously authorized programs for Workforce
Diversity, and Health Disparities and Cultural Competence; and,
! Establishing new authority for Title VIII nursing workforce surveys,
or amending Title VII to include such a provision in the section on
Health Workforce Information and Analysis.
Institute of Medicine
In 2002, the IOM held a summit on health professions education at which 150
leaders in the health professions made recommendations to improve the quality of
health education. In Health Professions Education: A Bridge to Quality, the IOM
provides a plan with recommendations for such reforms. Recommendations address
all health professionals, including nurses. Broad recommendations call for: (1) a
common language and adoption of core competencies across the health professions;
(2) interdisciplinary training environments that incorporate the core competencies;
(3) better research and information about health care quality; and (4) sustained
educational leadership in achieving measurable changes in health professions
education.26
Legislation in the 109th Congress
Incoming Chair of the Senate Health Education Labor and Pensions Committee,
Senator Mike Enzi, announced on December 9, 2004 that he will work on strategies
to ensure an adequate supply and distribution of doctors, nurses, and other critical
health professionals. It is uncertain whether such legislation will include amendments
to Title VIII programs. Legislation that was introduced but not passed in the 108th
Congress may reappear in the 109th Congress. The next section lists some of those
proposals.
26 Institute of Medicine, Health Professions Education: A Bridge to Quality, chap. 6:
“Recommendations for Reform.”

CRS-20
Legislation in the 108th Congress
H.R. 920 (Baca)
To amend the Public Health Service Act to promote careers in nursing and diversity
in the nursing workforce.
Introduced February 26, 2003.
Referred to the House Committee on Energy and Commerce.
H.R. 2053 (Capuano)
To authorize the Secretary of Health and Human Services to award grants to
associate degree schools of nursing and professional nursing organizations to
improve nursing education, and for other purposes.
Introduced May 9, 2003.
Referred to the House Committee on Energy and Commerce.
H.R. 3512 (Otter)
To provide for the establishment of demonstration programs to address the shortages
of health care professionals in rural areas, and for other purposes.
Introduced November 18, 2003.
Referred to the House Committee on Energy and Commerce, Subcommittee on
Health.
H.R. 5324 (Lowey)
To amend the Public Health Service Act to authorize capitation grants to increase the
number of nursing faculty and students, and for other purposes.
Introduced October 8, 2004.
Referred to the Committee on Energy and Commerce.
S. 2091 (Frist)
A bill to improve the health of health disparity populations.
Introduced February 12, 2004.
Referred to the Senate Committee on Health, Labor and Pensions.
S. 2739 (Bingaman)
A bill to improve the training and retention of health professionals under titles VII
and VIII of the Public Health Service Act, and for other purposes.
Introduced August 22, 2004.
Referred to the Senate Committee on Health, Labor and Pensions.
S.Amdt. 1552 (Mikulski) (Amends H.R. 2660)
To increase funding for programs under the Nurse Reinvestment Act and other
nursing workforce development programs.
Amendment proposed by Senator Mikulski, September 3, 2003.
S.Amdt. 1552, as previously agreed to, was further modified by unanimous consent,
September 10, 2003.

CRS-21
Appendix
Table 5. National Supply and Demand Projections for Full-Time
Equivalent (FTE) Registered Nurses, Selected Years, 2000-2020
Supply
Demand
Excess or shortage
Percent
Year
(FTE)
(FTE)
(supply less demand)
shortagea
2000
1,889,243
1,999,950
-110,707
-6%
2002
1,937,336
2,062,556
-125,220
-6%
2004
1,989,329
2,128,142
-138,813
-7%
2006
2,028,548
2,196,904
-168,356
-8%
2008
2,047,729
2,270,890
-223,161
-10%
2010
2,069,369
2,344,584
-275,215 -12%
2012
2,075,218
2,426,741
-351,523
-14%
2014
2,061,348
2,516,827
-455,479
-18%
2016
2,049,318
2,609,081
-559,763
-21%
2018
2,032,230
2,708,241
-676,011
-25%
2020
2,001,998
2,810,414
-808,416
-29%
Source: HHS, Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020, July
2002, at [http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm].
a. The number by which demand exceeds supply divided by supply.
b. The number by which demand exceeds supply divided by supply.

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