The Future Of The American Healthcare Workforce

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0:26The U.S. is facing a steep and growing health care worker shortage. A federal analysis last year projected that by 2038, 30 out of 35 physician specialties will have a shortage. Overall, it's expected the U.S. will be short over 140 ,000 physicians and short over 108 ,000 nurses. That stark projection comes as states and medical associations say new caps on student loans will make this shortage worse. Last week, 25 states plus the District of Columbia filed a lawsuit against the Department of Education over new federal student loan limits on graduate degrees, including health care degrees. Of particular concern, advanced nursing degrees.

1:08The president of the American Nurses Association said in a statement, quote, this rule will be felt in real communities, for example, in rural areas where nurse practitioners, midwives, and nurse anesthesiologists are often the only providers of core care services. But Education Secretary Linda McMahon says these worries are overblown and that these new rules aim to force colleges to lower tuition rates. Over 90 percent of the nursing graduate programs in our country can be achieved for less than$100 ,000. $100 ,000 under this bill is the cap for the graduate program as it is defined by Congress.

1:47And so, therefore, one of the goals, hopefully, is to help colleges see these incredible costs of colleges, that 10 % that's not doing it, and help bring college costs down. I'm Jen White. You're listening to the 1A Podcast. Today, what could these changes mean for the future of our health care workforce and care in the U.S.? We'll look into that and more after this short break. Stay with us.

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3:15Welcome back to the 1A Podcast. We're talking about the changes to student loan caps under the One Big Beautiful Bill Act and how they will affect the future of health care. Here in studio is Corey Turner, NPR's education correspondent. Corey, it's great to have you. It's great to be here, Jen. Also with us is Sarah Zanton, the dean of Johns Hopkins School of Nursing in Baltimore and a nurse practitioner. Dean Zanton, welcome. Thank you so much. And joining us from Michigan is Dr. Bobby McComla, the president of the American Medical Association and an ear, nose, and throat doctor. Dr. McComla, thanks for joining us.

3:50Great to be here. Thanks for having me. So, Corey, these caps were initiated in President Trump's big spending bill. Grad plus loans are being phased out. That's right. And we'll talk about the latest definitions that differentiate professional and standard degrees in a moment. But just kind of walk us through the initial changes and these loan limits. Yeah. So one of the biggest changes to come out of what Republicans called for most of the past year, the one big beautiful bill, is to cap graduate school loans. And this is a really big deal. Most people don't realize that the program known as Grad Plus has been around for about 20 years.

4:28And basically what that did for students who wanted to get a graduate degree is it said the federal government will essentially give you a blank check to cover the cost of the program. You could borrow up to the cost. So if the program cost$80 ,000, you could borrow up to$80 ,000. And what the one big beautiful bill does is say, no more of that. We're ending grad plus. We're capping graduate student loans, most what they call standard graduate student loans at$20 ,500 a year with a total aggregate cap of$100 ,000. Where we find ourselves in this lawsuit that you mentioned in the intro is there is one exemption to this cap, and that is what has forever in a day been known as a professional degree and what the education department has defined for years, a few decades at least, as something that requires at least, I think it's six years of post-secondary work.

5:34There are a few other pieces of the definition, but it's essentially, at least the department thinks of it as a sort of a doctorate and only within specific segments. And this is where things get complicated because the professional degree gets exempted from the$20 ,000 a year student loan cap. And they get a$50 ,000 a year student loan cap with an aggregate instead of$100 ,000 of$200 ,000. And so that's where we are right now. Now, these changes take place July 1st. This is coming up very quickly. What does it mean for students who are currently in programs? So there is a grandfathering clause for students who have already or who will have taken out loans, I believe it's by June 30th.

6:21Please check my math, everybody. But I believe it's by June 30th. If you've taken out a loan, you are enrolled in a program, then you are grandfathered in under the current rules. However, big exception here, you can't transfer without essentially resetting your stats. So be careful there. So if you're midway through a program, you can remain under the same loan amount as you were unless you switch schools. That is my understanding. Dr. McComala, these caps mean that if you're pursuing a professional degree, including becoming an MD, your loans are capped at$200 ,000. That sounds like a lot of money to me, but what does that limit mean for those wanting to pursue that bill?

7:03Well, the simple way to say it is it's not enough. You know, the average medical student debt is more than$250 ,000. And that's, you know, like if you and I were at University of Michigan, right? So that's what kind of qualifies for that. But if we went to a private medical school, then we're in the$300 ,000 range. So now the gap between the limit of$200 ,000 and what you might be paying in tuition, that's just for the medical school phase, including the undergrad phase even more, is something that's going to dissuade people from pursuing certain aspects of that career, right? So the first step is getting people to go to medical school.

7:41And when they're looking at this debt and now sort of the private loans that they might have to get to fill this gap, they're going to have a decision to make about whether even to pursue becoming a physician as a career, let alone what kind of physician, right? So becoming a pediatrician versus a pediatric cardiologist, all of a sudden the entire loan repayment process looks very different. And that's what the American Medical Association is very concerned about. Well, Corey, that gets into this question of what's defined as a professional degree versus a standard degree. How is the department making the distinction?

8:14Well, they're using a fairly old definition. And rather than going through all of the clauses included in it, I'll just run through the list of 11 categories. And what the department did in its rulemaking fairly recently, and this is what triggered the lawsuit, is they really restricted the definition of a professional degree to these 11 categories. And they are pharmacy, dentistry, veterinary medicine, chiropractic, law, medicine, MD, optometry, osteopathic medicine, podiatry, theology, and they added clinical psychology. For our purpose, if we're talking about the nursing workforce, there are really two very different groups of aspiring nurses here who I think are going to be impacted.

9:09And that is, one, we know that roughly 80 % of the nursing workforce does not have an advanced degree. So maybe a BSN, more a Bachelor's of Science in Nursing. And the undergraduate student loan limits haven't changed at all. They're really not at issue here. What we know, though, is that about 20 % do have some kind of master's degree, and then there's like a 4 % to 5 % range who have a doctorate degree. They're the ones who are going to be impacted here because the doctorate-level folks have been excluded from the professional definition, as have the master's-level folks. That's, I guess, a little less surprising, but still.

9:48And the issue, especially for the master's level folks, is now they're somehow going to have to pay for their programs with the$20 ,000. I mean, so are the doctorate level folks. Well, Dean Zant, I want to bring you in here because what role can nurses fill when they hold these advanced degrees? Thank you so much. So with the advanced degrees, they can be nurse practitioners, nurse anesthetists, they can be faculty. And I want to just build on what Corey was saying, that the list of who's professional is several decades old, as he said, but it was based on a list from the 1950s. And in the 1950s, nursing schools gave up where they were diplomas from hospital training programs.

10:31It was an apprenticeship model. So to base education policy on a 70-year-old classification of professionals when we didn't have nurse practitioners and faculty to teach didn't need a master's degree just doesn't make sense when we're already in a healthcare crisis. And just to add on, your question was what roles? So nurse practitioners and physicians assistants see 25 % of all primary care visits. They see a billion primary care visits a year. So we're talking about a very serious issue. Now, as we noted, this won't affect people pursuing a BSN or a Bachelor of Science in Nursing. So, Dean Zanton, how concerned are you that this might affect the current nursing shortage?

11:18Sure. So you're right. It does not affect people who are getting a bachelor's. But to teach those students, you have to have an advanced degree. And many people don't know that the nursing shortage is in great extent a nursing faculty shortage. It's hard to get nurses to leave clinical practice and become faculty. They often earn less than they do in clinical practice. So to try to dissuade people from becoming faculty with another aspect of dissuading in terms of not being able to get loans will add to the health care crisis. Coming up, student loan debt in the U.S. now totals over$1.8 trillion.

12:00Could CAPS help students avoid taking on more than they can afford? We heard from Jay in Oklahoma, who emails, 50 years ago, my state paid half of my university's budget on the understanding that investing in an educated populace improved the state. After decades of budget cuts, my state now pays only 12 percent of that budget, and the university has raised tuition to compensate. Students, especially health care students, should not be taking out loans to get an education that benefits the entire community. We'll be right back.

12:33This week on Sources and Methods, every White House has an official counterterrorism plan, a strategy document basically. But President Trump's new 2026 plan shifts focus to left-wing extremism. We're unpacking what's in the document and who influenced it this week on Sources and Methods. You can listen on the NPR app or wherever you get your podcasts. Let's get back into the conversation. We're discussing how new limits on federal loans for graduate school could impact health care in the U.S. Corey, what are the key reasons we're hearing from the Department of Education about these changes, why they're making them?

13:11Well, as we heard from Education Secretary Linda McMahon in that top clip you played, Um, they're really making the argument here that the grad plus program, um, drove up college prices. And the only way to bring them back down is to, to limit how much the federal government is willing to put on the table. You know, I love this part of the story because it's pretty nerdy, but, um, it goes back to 1987, President Reagan's education secretary, Bill Bennett, argued pretty forcefully in a piece in the New York Times called Our Greedy Colleges. He argued that if the federal government puts more money into financial aid, colleges are just going to raise their prices.

14:04And so what the Trump administration is arguing now is essentially the inverse. If we pull aid out of the marketplace, colleges will have to lower their prices. And I've spent the last several weeks talking with economists about whether or not, like, is this true? And it's interesting. There have been a few studies that have arrived at various conclusions. There was a study in Texas that did find that with the Grad Plus program, colleges did raise tuition. But there have been a few other studies that got more mixed results. So it's kind of a gamble right now. I do think there is a lot of consensus.

14:47I will say this for the administration. There is a lot of consensus that graduate school costs especially are out of control. You look at the$1.7 trillion student loan debt right now, right? And we know that roughly half of the new debt being issued each year is going to grad students, even though they make up really only roughly one in five borrowers. It's a problem. The question is, what do we do about it? Well, we heard from an earlier listener who said, look, the school I went to received less investment from the state. So they pointed to that as a factor of why tuition has gone up. We can also talk about the way student loans are structured.

15:31You see so many stories from people who say, I've been paying on this loan for decades and I now owe more money than I did when I originally took the loan out. So it seems like there are multiple options. Why do you think the administration has landed on this? Well, and to bring us full circle to the subject at hand, which is nursing programs, I do think there's one really important factor here that Dean Zanton can also speak to, which is, you know, not all graduate programs are created equal insofar as what they actually cost the school, right? So a master's in social work or let's say a master's in anthropology is not – is arguably – or I assume is not going to cost as much as a program in nursing where there are lots of resources, expensive resources that have to be made available so that we are educating skilled nurses.

16:24Well, Dean Zanton, talk a little bit about the cost of a nursing degree, a master's or a Ph.D., and why it is so expensive. it. Sure. Thank you. And Corey's right that we have to have simulation labs and clinical experiences. You know, you can't learn how to put in a central line on a blackboard. You need actual experience and you need didactic experience in the classroom. I will say, I agree that there's too much graduate student debt in this country. And when I became dean, one thing we started to work on was to cut a whole semester off of our nursing program. We have a program where people are getting a master's and they're becoming a nurse.

17:03We've cut it down to four semesters, and that's starting this fall. And we started doing that before this bill came. And if you look at the$20 ,000 a year,$20 ,500, that's for living expenses and tuition. So even if tuition was$1 ,000, which no school could afford to do, people still would only have$19 ,000 to live on, which is just unsustainable. And the Secretary of Education made the point that a $100 ,000 cap is workable for many. I agree that that's workable for many, but the$20 ,000 a year is not, even if someone has almost no tuition to pay. Well, let's hear from more of you. Here's Teresa in Minneapolis.

17:46My son Jack is 28, and he made the decision a couple years ago to switch from a career in finance and real estate to a dream career in medicine. He spent the last couple years doing all of his prerequisites and taking the medical school entrance exam. He's a 4.0 student and would make a wonderful doctor. He got accepted into only one medical school, which was Creighton University, a wonderful program. But being a private institution, Jack is being confronted with the possibility of incurring over$600 ,000 in debt to get a medical degree at Creighton. The recent change in the Big Beautiful Bill is affecting his first year as a medical student because a limit of$200 ,000 is forcing him to rely mostly on private loans.

18:40And Jack is now starting to second guess his decision a couple years ago to go into medicine. Thanks for that message, Teresa. According to Stat News, rural areas are projected to face a 56 % shortage compared to 6 % in urban areas. And this is a physician shortage. Dr. McComla, when you hear a story like Teresa just shared, I'm curious to hear your perspective on this physician shortage, particularly for rural and underserved areas. You work in Flint. Tell us about your concerns. What Jack is going through, making a decision now about a career and where he's going to go relative to more than half a million dollars in loans, you can totally understand why looking at the math, and even though if Jack came from Flint, Michigan, or rural anywhere, underserved anywhere, his dedication may be to go back to his home community, to serve that community where he grew up.

19:38But now the math on that, the ability to do what he loves to do, do what he dreams of doing, but now relative to half a million dollars in debt, even what specialty, as I talked about, would pay off that debt sooner, it's going to change from what they love to what they have to do for financial reasons. And so that's something that the American Medical Association is very concerned about, right? Because of that physician shortage, 83 million people in the U.S. are not going to have sufficient access to a primary care physician, particularly in rural and underserved areas. And so we want to improve the health of our country by having patients have access to their physician.

20:19And now it's going to be worse because of people reconsidering going into that career, let alone what specialty within that career. Dean Zanton, I'm curious to hear how you think perhaps a loss of advanced nursing degrees might affect care, especially in rural and underserved areas. Absolutely. Nurse practitioners and physician's assistants provide a quarter of all primary care, And nurse practitioners were created specifically to serve people in rural areas and underserved areas. And we've been meeting that need since the 1960s. So the one billion visits, the primary care visits that nurse practitioners and physicians assistants offer, we all know, I'm sure everyone who's listening knows how hard it is to get an appointment with anyone these days.

21:08And if we had a billion fewer visits, if you take nurse practitioners and physicians assistants out of the equation, it'll be that much harder. Well, we got this from Kathy in Michigan who emails, I believe there is a cap on graduate social work degrees and we are a part of the healthcare profession. Despite there being a critical shortage of mental health workers, the profession is being penalized as well. And social workers are being categorized as standard degrees, which will receive that lower cap. And we also got this from many of you who are chiming in. Hubert emails, you keep emphasizing nurses, but please include physician assistants in your conversation.

21:44They are in the same boat. And Sandy in Michigan emails, physical therapists and occupational therapists were bachelor's level degrees in the 70s. Now physical therapy is a doctoral level degree and occupational therapy is a master's level degree. These changes are very misguided. Dr. McComala, the degrees that are deemed professional by the education department or not deemed professional, they're standard by the education department, so they'll be given these lower caps. They include nursing, physician assistants, physical therapists, speech language therapists, mental health practitioners, health administrations, and more.

22:19So when you look across the broader healthcare landscape, how do you think these caps may reshape the landscape we have, especially when you look down the road maybe five or ten years? It's worse. I mean, we function as a healthcare team. So I'm an otolaryngologist. There's a lot of the patients that I see in my office that need a speech therapist. And that's, they're part of the team, right? I have physicians assistants that help us, nurse practitioners that help us be part of that team. All of us are challenged now by this, you know, loans that capped at$100 ,000 for four years or$200 ,000 for four years.

22:59Any player on the team that gets affected is going to affect the outcome of that team. And who suffers? It's going to be the patients. if they don't have access. At the same time, Dr. McComla, as we've been hearing, there is too much student debt. Too many people are going into debt to pursue these degrees. So what are policy solutions you'd like to see put in place to address the physician shortage? Yeah, I mean, so there's things that are being considered now. There's a bipartisan resident education deferred interest, which would basically defer student loans for medical and dental residents in training.

23:33And there's also another one called the SPARC Act, which addresses the physician shortage in rural areas. So there are legislative solutions that the American Medical Association very much supports. And so, but both are components of potentially bad outcome, increasing the number of residency positions, increasing the loan amount to actually match what students have to sort of borrow to get the education they need to solve this shortage. So there's multiple ways to address this issue, none of which can be ignored. That's Dr. Bobby McComla. He's the president of the American Medical Association.

24:10He's also an ear, nose, and throat doctor. Dr. McComla, thanks for your time today. Thank you so much. Corey Turner, NPR's education correspondent, is sticking with us, as well as Sarah Zanton, the dean of Johns Hopkins School of Nursing. And now let's bring in Beth Akers. She's a senior fellow at the American Enterprise Institute. That's a conservative-leaning think tank where she focuses on the economics of higher education. She's also the author of Making College Pay, An Economist Explains How to Make a Smart Bet on Higher Education. Beth, welcome to the program. Thanks for having me. So you think this worry about worsening the nursing shortage with these new caps is overblown?

24:49Explain why. Well, I think these shortages and the direction we're going are seriously problematic. What I think that's maybe different from the rest of the panel is that I don't think giving students access to uncapped debt is the answer for addressing that shortage. And I really am sympathetic to the argument coming from the department, as well as what was inherent in the legislation, which is that this is being put in place as a consumer protection. And I think quite unfortunately, the language here is a bit problematic. I wish we were calling these standard and, you know, additional lending programs rather than standard and professional, Because I think when we categorize programs as not being professional, some people are interpreting that as some sort of slight against those professions, when in fact that's not at all what this is implying.

25:41I'm a PhD economist, and I could not borrow under the professional loan caps, and I'm not at all offended by that. I think that's great for any aspiring economist to not borrow that much. So I wish we could get past that bump in the road here and talk about this really more as a consumer protection. But then also think seriously about what are those crises that are coming that, you know, my co-panelists have been talking about and what are some other solutions that could address them. Well, Dean Zanton, the Department of Education states that 80 percent of nurses do not have an advanced degree.

26:14The education secretary says that this cap will not affect people who want to become a nurse. So what's your response to that argument? Right. So that is a true fact, but that other 20 % is who are teaching the nurses and who are the nurse practitioners, who are the nurse anesthetists, the psychiatric nurse practitioners in rural areas. That 20 % is a very important part of healthcare. There's more nurses. You can put together every single other healthcare profession, doctors, occupational therapists, physical therapists, all of them, and you don't get as many nurses as there are in this country.

26:48So 20 % of nursing is a very large amount. I would also say I would take issue with my co-panelist, Beth, about it being consumer protection because when people need to turn to private loans, many of them won't be able to get them if they don't have co-signers. And the for-profit universities often aggressively market to those who will be squeezed hardest by these caps, and they have lower pass rates for the nursing license. And so, you know, if what we're trying to do, I would love to join with Beth to protect consumers who are seeking a nursing degree. I don't see this as that solution. Beth, I want to give you a chance to reply, but Corey first.