Can the US Attract Healthcare Workers Under New Loan Rules?

Recent federal loan changes cap borrowing at $200,000 and eliminate Grad PLUS, thereby pushing future clinicians toward private loans. Monique Nugent, MD, MPH, hospitalist at South Shore Health in Boston and author of Prescription for Admission, explores what these changes mean for the current and future healthcare workforce.

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Transcript:

How may recent changes in loan programs for medical training impact the future healthcare workforce?

Dr. Nugent: In order to recruit, train, and maintain a diverse healthcare staff—and diverse means a lot of things. But really, what it comes down to is a diverse type of life experience and what you bring from that life experience into your work. In order to be able to recruit, educate, and maintain that workforce takes a lot of, not just work, but a lot of money. Going to medical school is expensive, going to nursing school is expensive, going to dental school is expensive, as well as physical therapy, occupational therapy. All of the things that we need to care for our patients—[and] care for each other, really—we have decided come with really high price tags. How we structure the way people are able to access that money really will be reflecting how we are able to recruit a different set of people to participate in the education and therefore participate in the work.

Traditionally, you either had kind of money from mommy and daddy to pay for medical school, law school, nursing school, whatever it was, or if you were a student like myself, you sought loans. And those loans were high. A lot of us graduated from medical school with well over $200,000, $250,000 worth of debt. Why am I saying that specific number? The reason I’m giving that specific number is not just because medical school today in the United States costs more than that, but that’s the number that now is really limited. The amount of money you can take out for medical school, graduate school, healthcare school, dental school now has been limited by the One Big Beautiful Bill to $200,000. And yeah, that sounds like a lot of money—and it is a lot of money—but if that’s not what it takes to cover the funding necessary for school, then what you’re really saying is people who are not able to get past the $200,000 on their own are going to have to start seeking funding through private loans.

What’s the issue with that? Private loans tend to be higher rates for interest, but also a lot less flexible on repayment. Or people will have to start seeking money from family, friends, savings, and not everyone has the money to tap those monies to supplement that.

There was another program called the Grad PLUS program, and that was a federal loan program that was able to give you more money when you had tapped out the amount of money you were getting from other sources [such as] the federal government. And the One Big Beautiful Bill has eliminated that program. So yet another option for funding that is gone for people.

Now I’ve heard people say things like, some medical schools are free, and we’ve seen some really wonderful benefactors pick medical schools and say, “From here on out, I will pay for people’s medical school education,” or “We will find ways to make medical school education significantly more affordable here.” And yes, people can go to state schools, which may be a little bit lower [cost]. But overall, we’re starting to stymie the way that people are able to access funds to go to medical school, nursing school, dental school, all of these professions that are really necessary to, and I want to say it again, care for each other. It’s not just caring for patients. A lot of the times we say, oh, patients, patients. But we kind of forget that at some point, we become the patients. Our family becomes the patients. Our parents are the patients. And so how we are caring for each other, how we’re recruiting the staff, educating that staff, and maintaining that staff to care for each other is really vital in how we think about the workforce in American medicine.

How may these changes impact the current healthcare workforce?

Dr. Nugent: So there are a few programs that are already in place that, when I went on the different websites from the federal government [and] the Department of Education to really understand, they said they were not going to change. But they may change how people participate.

If you are already in income-driven payment programs—and there’s not just the income driven payment program, there’s a few other programs that live under that name—if you’re already participating in that, that program is not going to be taken away from you. New ways of limiting payment options, new ways of how you are taxed on your loan forgiveness will occur.

Under the previous [Biden] administration, people benefited from the public service loan forgiveness plan. And what is that plan? The public service loan forgiveness plan was a plan where you said, I will work in these given areas that the government says we need people to work for, [for] a certain amount of time, and then a certain amount of my loans will be forgiven in a reflection of the work that I’ve done. So the government currently claims that there will not be changes if you are in [the loan forgiveness program,] but going forward, public service loan forgiveness is no longer going to be available. Income-driven repayment program and the other ones that lived under that name, they’re not going away, but they’ll be changed a bit. And then the new version may not include options that were available to you in the past.

It’s not just that you go to school, you study really hard, and you get this big bill, and then you start working and you [think], oh, okay, now I can pay it back really easily. People often have a really difficult time paying these loans back for lots of different reasons. I myself put some of my loans on deferment while I had children, and I was on maternity leave. Being able to have some flexibility with that payment was a real big boon to me and my family. If we’re having these programs where people are not going to have a lot of these options [and] tools available to them, how they can structure repayment, how they’re going to be able to structure going forward in their life—that is going to make people think twice about going into the field. And then when they’re in the field, they’re going to start thinking twice about how they participate in that field, [such as working in specialties] that we really need to attract people to, like primary care, which tends to be a little bit lower paid than other types of medical specialties. Are we going to start seeing people looking away and saying, “I’m really not interested in that career because I’m going to take so much for me to be able to pay back this loan. I’m going to, therefore look towards another specialty where I can make money a little bit more easily, and I will be able to structure my payments and my life in a little bit more comfortable of a fashion.” We really have to think about what are we asking our students to do. Who are we asking them to become in healthcare? And how are we going to support them in that journey? If we as a nation say, we need more primary care, we need more nurses, we need more dentists in rural areas, we need more endocrinologists, specialties that we tend not to pay much or not be able to attract people to do that work—how can we make it more, not just attractive, but more livable? And it comes down to how we expect people to fund that education, both while they’re in school and after.

What are some potential opportunities to help increase the healthcare workforce capacity?

Dr. Nugent: When I think about the students that I want to attract into medicine, in so many different veins—and again, I don’t want to just say physicians, though I’m a physician. The people I want to attract to be our speech therapists and our physical therapists, the people who I want to attract into research—I think about wanting to attract people who are not only really dedicated to the work, but bring with them a different flavor, a different life experience, a different vision. And the only way we can really do that is to not just think about attracting and maintaining and educating students in professional schools. We have to bring it all the way back to how we teach our students in elementary school. What are we exposing younger students to at different ages? How are we getting more diverse students more interested in doing science? And then also not doing away with the arts—understanding how people who love the arts are also people who can do science, who can also bring that vision into the world of caring for someone else.

The thing that I’m always struck by when I have these conversations about education and funding is that we really focus on [a small amount of] time of a person’s education journey and professional life, when all the years before and all the years after are really the things that determine not only who comes into the profession, but how they come into the profession and how they stay in the profession. I really want us to think about reaching our younger students. Yeah, we think about high school—go back. How are we treating our elementary students when it comes to science? What are we exposing them to, and how can we make it more exciting to every student? Then, when we go forward in their career, how do we continue to support them to have excitement for the work that they’re doing at every stage of their life? Because life changes over time.