March 2, 2026
Re: Docket ID ED-2025-OPE-0944 for “Reimagining and Improving Student Education”
The National Center for Health Research (NCHR) appreciates the opportunity to comment on the proposed rule entitled “Reimagining and Improving Student Education,” which would revise Title IV federal student loan regulations, including annual and aggregate loan limits for graduate and professional students and the elimination of the Graduate PLUS program.
NCHR is a nonprofit, nonpartisan think tank that evaluates health policies and regulatory decisions to ensure they are supported by strong scientific evidence and advance public health and equity. For 27 years, our experts have analyzed the impact of federal legislation, laws, regulatory proposals, and policies on patients and communities across the United States. NCHR frequently submits comments to federal agencies, testifies before advisory committees, and publishes evidence-based analyses regarding policies that influence healthcare access, workforce capacity, and patient outcomes.
Our expertise regarding healthcare in the U.S. provides a unique perspective on the implications of revising federal student loan limits. Whether you call them graduate degrees or professional degrees, reducing educational loans for post-baccalaureate degrees in health fields will harm the health and well-being of millions of Americans by limiting their access to effective treatment, adding to shortages of advanced practice registered nurses (APRNs), clinical psychologists, physical therapists, occupational therapists, clinical social workers, and other clinicians essential to rural healthcare delivery, primary care, mental health services, maternal health, rehabilitation, independent living, and other life-saving healthcare services.
Student loan policy directly influences who can begin and complete graduate professional training and patients’ access to appropriate diagnosis, treatment, and preventive care, especially in rural areas and less populated States. We therefore provide the following comments regarding the proposed amendments to 34 CFR part 685 and related provisions governing annual and aggregate borrowing limits for graduate and professional students.
We provide these comments on the proposed amendments to:
- §685.102 (definitions)
- §685.200 (Direct PLUS Loan eligibility)
- §685.201 (limited PLUS eligibility)
- §685.203 (loan limits and borrowing structure)
1. Concerns
The United States faces documented and persistent shortages in its health care workforce. HRSA projects a shortfall of approximately 23,640 full-time equivalent primary care physicians by 2025, even under current training assumptions.1 Many states report fewer than 60 primary care physicians per 100,000 population, reflecting significant geographic disparities in access.2 At the same time, demand for nurse practitioners is projected to rise to approximately 68,040 FTEs by 2025, up from about 57,330 FTEs, underscoring expanding reliance on advanced practice clinicians to meet care needs.¹ These shortages are compounded by clinician retirements, uneven distribution of providers, and increasing demand driven by an aging population.
In addition to shortages in primary care and nursing, HRSA states that more than 122 million Americans currently live in federally designated Mental Health Professional Shortage Areas, and the agency’s projections indicate that by 2037 the United States could face shortages of approximately 88,000 mental health counselors and 114,000 addiction counselors.3 These figures reflect substantial unmet behavioral health needs nationwide, which is one of the reasons so many teens and adults of all ages are relying on the sometimes fatal counseling available from ChatBot and other unregulated AI products.4
Graduate programs training for clinical psychologists, licensed mental health counselors, and
other behavioral health professionals are therefore essential to addressing documented workforce deficits. Moreover, the cognitive behavioral therapy that these therapists can provide has repeatedly been proven more effective for depression, insomnia, ADHD, and many other behavioral problems compared to the psychotropic drugs that the U.S. Department of Health and Human Services is currently investigating.
Similarly, a national shortfall of 12,070 full-time equivalent physical therapists in 2022 (a 5.2% deficit), is projected to reach 8.2% by 2027.5 Demand for physical therapy services is projected to grow 14.7% by 2037, nearly double projected population growth of 8%.5 Occupational therapy workforce analyses similarly document regional shortages and rising demand driven by an aging population and disability-related care needs.6 These shortages directly affect access to psychotherapy, substance use treatment, diagnostic testing, and crisis intervention services.
- 685.102- Definitions
The proposed definitions in §685.102, including “professional student,” “expected time to credential,” and “program length,” appear to exclude graduate nursing programs, and graduate/professional degrees in clinical psychology, clinical social work, physical therapy, occupational therapy, and related fields from professional status.
The American Nurses Association (ANA) states that the Department’s proposed professional degree definition continues to exclude nursing despite the advanced clinical education, licensure, and supervised care required by these programs.7,8 Clinical graduate nursing programs prepare nurses for roles such as nurse practitioner, nurse anesthetist, nurse midwife, and clinical nurse specialist. These roles are clinically demanding and require national certification or state licensure. They significantly reduce the need for physicians in rural communities and other areas with physician shortages.
Peer-reviewed evidence supports that nurse practitioners provide high-quality care with outcomes comparable to physicians in many primary care settings.9-13 Excluding graduate nursing from the professional category does not reflect workforce realities documented in clinical research and national workforce data. Moreover, HRSA’s 2025 workforce projections show continued unmet need for clinicians across multiple disciplines, including primary care and advanced practice roles.
The definitions of “expected time to credential” and “program length” may also disadvantage students in extended clinical training programs. Many clinically intensive programs cannot shorten clinical hours or meet licensure requirements without harming educational quality.
Clinical psychologists and clinical social workers are trained and licensed to provide mental health testing, therapy, and other services that psychiatrists have been trained to provide; however, for a range of reasons, most psychiatrists focus on providing prescriptions and managing facilities, with limited time spent providing individual or group therapy.
Physical therapists are trained and licensed to provide patient care that can delay or replace surgical interventions requiring physicians, and physical therapists and occupational therapists are trained and licensed to provide rehabilitative services needed after accidents, stroke, brain injuries, surgery, arthritis, and other medical conditions.
Because of advanced training and licensing requirements, nurses, mental health professionals, physical therapists, and occupational are trained professionals who can reduce physician hours by supplementing and in certain contexts, substituting care provided by physicians and can also reduce the cost of treatment for individual patients as well as reducing the cost of health insurance, Medicare, Medicaid, and VA Health Care. They are all currently in short supply in many communities across the country, especially but not limited to rural, underserved, and less populated areas of the country. Federal student loan policy that limits access to graduate training in these fields therefore would be expected to have devastating implications for healthcare services for millions of Americans, reducing national health system capacity and undermining efforts to control increasing costs.
- §685.200 and 685.201- Direct PLUS Loan Eligibility
- §685.203- Annual, Aggregate, and Lifetime Loan Limits
The proposed rule includes Direct PLUS Loan eligibility for graduate and professional students (§685.200), but §685.201 would limit eligibility based on student classification.
While PLUS Loan eligibility is a necessary component of financing graduate education but will not be meaningful when aggregate borrowing limits (§685.203) are much too low to enable students to complete the degree and training. The proposed loan limits for graduate students are much too low for the careers we have focused on in our comment, and many similar health-related fields.
The proposed rule (§685.203) establishes separate borrowing tiers:
- Professional students: $50,000 annual / $200,000 lifetime
- Other graduate students: $20,500 annual / $100,000 lifetime
A doctorate in clinical psychology usually requires at least 4 years of graduate school and training (comparable in annual costs of other graduate and professional school programs), as well as a year of predoctoral clinical experience and often a year of post-doctoral clinical experience as well. This can easily exceed $150,000. Degrees in clinical social work, counseling, physical therapy (DPT), and occupational therapy (OTD or MOT) programs frequently require 2–3 years of advanced clinical training and commonly exceed $80,000-$120,000 in tuition and associated expenses, particularly in private institutions. The restrictive aggregate borrowing caps that have been proposed will contribute to shortages of newly trained professionals in all these fields, in addition to nursing.
If students exhaust their borrowing capacity before completing programs, PLUS eligibility alone will not solve financing gaps. National nursing advocacy groups have pointed out that limiting borrowing for advanced nursing education could worsen workforce shortages and inevitably reduce access to care,7,8
and the therapy careers we’ve listed face similar reductions if the proposed loan limits are finalized. Limiting PLUS eligibility for students in high-need training programs may unintentionally reduce the pipeline of clinicians entering primary care, behavioral health, rehabilitation services, and other essential clinical fields.1-3
The proposed lifetime aggregate cap also raises even greater concerns for students who:
- Change careers (due to AI, government cuts, and other workforce changes) and enter healthcare later in life
- Have prior undergraduate borrowing
- Pursue sequential advanced credentials
Reducing annual loan limits for less-than-full-time enrollment may further disadvantage students during clinical rotations when tuition and associated costs remain high despite changes in course load.
Allowing institutions to impose additional borrowing limits without standardized criteria may result in uneven access across schools and states, particularly affecting students in high-cost or high-need fields.
In addition to documented healthcare professionals’ shortages, recent evidence highlights financial vulnerability within the health care workforce itself. A 2025 study published in JAMA found that many U.S. healthcare workers experience poverty, food insecurity, and housing instability, underscoring that economic strain is present even among those delivering care.14 These findings indicate that workforce challenges are not limited to supply shortages but also include financial sustainability and retention concerns. Policies that increase financial barriers to professional education, such as restrictive graduate loan caps further exacerbate economic strain in essential health professions and deter entry into high-need fields.
2. Recommendations
- Revise the Definition of “Professional Student” (§685.102)
The definition of “professional student” should include programs that:
- Require advanced clinical training and licensure
- Include direct independent and/or supervised patient care
- Prepare graduates for licensed clinical roles involving diagnosis, treatment, or direct patient care.
This change would better align loan policy with training and licensure requirements as well as documented evidence of the work that these positions entail.
- Align PLUS Eligibility (§§685.200 and 685.201) With Workforce Criteria
- Students enrolled in programs that meet the revised professional definition should receive full access to Direct PLUS Loans, regardless of how those programs have traditionally been categorized in federal regulations.
- Loan eligibility levels should consider workforce shortages in these licensed clinical professions, as reflected in current shortages as well as nationwide supply-demand projections in the coming decades.
- Adjust Loan Caps in §685.203 to Reflect Program Costs and Workforce Needs
Annual and aggregate loan limits should be increased to resemble those for physicians in order to:
- Reflect the documented cost structures of clinically intensive programs
- Permit completion of credentialing pathways in shortage professions
- Be informed by workforce projections and actual educational cost data
- Conduct a Workforce Impact Analysis Before Finalization
Before finalizing loan definitions and caps, the Department should evaluate:
- Whether affected programs prepare licensed professionals in fields currently experiencing shortages or projected shortages over the next decade
- Likely impact on primary care, nursing, and therapy supply and geographic distribution of clinicians
- Projected impact on access to training and essential healthcare professionals across states and institutions
Given documented shortages and geographic disparities in clinician supply, federal loan policy will determine a large percentage of who can afford to enter and complete training in these professions. A workforce impact assessment would help ensure that revised loan limits do not exacerbate existing supply gaps.
Conclusion
Federal student loan policy directly influences who can enter and complete training in several high-need healthcare professions. The proposed rule does not modernize graduate loan structures because it ignores: 1) current and future shortages in many essential professions, 2) the high cost of post-baccalaureate education and training, and 3) the impact fewer students would have on U.S. healthcare in the near future. Aligning loan definitions and borrowing limits with documented workforce projections and program cost realities will help ensure that federal student aid supports credential completion, strengthens clinician supply, and promotes access to care nationwide.
Respectfully submitted,
National Center for Health Research
References
1. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2016. National and Regional Projections of Supply and Demand for Primary Care Practitioners: 2013-2025. Rockville, Maryland. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/training/projections2025.pdf#page=9.54
2. Kaiser Family Foundation. Total Active Physicians, Primary Care Physicians Indicator. https://www.kff.org/state-health-policy-data/state-indicator/total-active-physicians/?currentTimeframe=0&selectedDistributions=primary-care-physicians&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
3. A Workforce Under Pressure: Preparing the Behavioral Health Workforce for Today and Tomorrow. https://www.thenationalcouncil.org/behavioral-health-workforce-under-pressure-preparing-today-tomorrow/
4. PTJ: New Workforce Forecast Projects PT Shortages Through 2037.https://www.apta.org/news/2025/03/04/workforce-forecast-2022-2037/
5. Giovanelli A, Roundfield KD. Adolescent Vulnerability to Consumer Chatbots—Artificial Agents and Genuine Risk. JAMA Netw Open. 2025;8(10):e2539028.
doi:10.1001/jamanetworkopen.2025.39028
6. U.S. Bureau of Labor Statistics. Occupational Therapists. Occupational Outlook Handbook –Employment of occupational therapists is projected to grow much faster than average, reflecting increasing demand driven by population aging and healthcare needs.https://www.bls.gov/ooh/healthcare/occupational-therapists.htm
7. American Nurses Association. Department of Education Proposal Still Excludes Nursing From Professional Degree Definition (2026). https://www.nursingworld.org/news/news-releases/2026-news-releases/department-of-education-proposal-still-excludes-nursing-from-professional-degree-definition/
8. American Nurses Association. ANA Comment Letter on RISE NPRM (Feb 26, 2026).https://www.nursingworld.org/globalassets/docs/ana/comment
letters/risenprm_anacommentletter_final022626.pdf
9. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Board on Health Care Services; Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care; Nass SJ, Amankwah FK, DeVoe JE, et al., editors. Health Care Service Delivery. Washington (DC): National Academies Press (US); 2024 Aug 23.
https://www.ncbi.nlm.nih.gov/books/NBK607582/
10. DesRoches, C. M., Clarke, S., Perloff, J., O’Reilly-Jacob, M., & Buerhaus, P. (2017). The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries. Nursing outlook, 65(6), 679–688. https://doi.org/10.1016/j.outlook.2017.06.007
11. Graves, J. A., Mishra, P., Dittus, R. S., Parikh, R., Perloff, J., & Buerhaus, P. I. (2016). Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce. Medical care, 54(1), 81–89. https://doi.org/10.1097/MLR.0000000000000454
12. Perloff, J., DesRoches, C. M., & Buerhaus, P. (2016). Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians. Health services research, 51(4), 1407–1423. https://doi.org/10.1111/1475-6773.12425
13. Barnes, H., Maier, C. B., Altares Sarik, D., Germack, H. D., Aiken, L. H., & McHugh, M. D.(2017). Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices. Medical care research and review: MCRR, 74(4), 431–451.https://doi.org/10.1177/1077558716649109
14. Zhong A, Gao C, Szlosek D, Nguyen D, Amat MJ, Phillips RS. Poverty, Food Insecurity, and Housing Instability Among US Health Care Workers. JAMA. 2026;335(1):86–88.doi:10.1001/jama.2025.17422