Nurse practitioner Carol Biocic treats a Marine Corps veteran at a podiatry clinic for veterans in 2023 in Chicago. New professional student loan caps might make it more difficult for people to pursue advanced nursing degrees. (Photo by Scott Olson/Getty Images)

Zoe Clarke became a hospital registered nurse two and a half years ago, following in the footsteps of her mother and grandmother.

Clarke, an ICU nurse in Asheville, North Carolina, wants to get her master’s degree to become a nurse practitioner or a certified registered nurse anesthetist — occupations in high demand — and eventually work toward a doctoral degree.

But new borrowing limits on federal student loans may hinder her from reaching that goal.

A provision in the federal One Big Beautiful Bill Act, the tax and spending law enacted this summer, overhauls the federal student loan program for graduate students in an effort to simplify the loan process and discourage colleges from raising tuition.

To comply with the new law, the U.S. Department of Education recently issued a draft rule that would impose limits on how much graduate students can borrow — up to $20,500 per year and $100,000 in total for most students, but up to $50,000 a year and $200,000 in total for students in a new “professional” category. The category includes people studying to be medical doctors, dentists, veterinarians, pharmacists and lawyers.

Students pursuing advanced nursing degrees, however, are not included in the professional category.

Advanced practice nurses, hospital associations and other health groups say the rule will make it unaffordable for many nurses to advance their careers — disproportionately affecting communities, especially rural ones, that rely on them amid physician shortages.

Advanced nurses can provide primary care, deliver babies as nurse midwives and anesthetize surgery patients where there aren’t enough physicians to go around. They can also write some prescriptions. Advanced practice nurses also serve as college faculty in community colleges and nursing schools.

The U.S. Bureau of Labor Statistics estimates the nation will employ an additional 134,000 nurse practitioners, nurse midwives and nurse anesthetists in the next decade, 35% more than there are now. In high demand, nurse practitioners are one of the fastest-growing occupations in the nation, the bureau says.

“We depend heavily on nurse practitioners,” said Sandy Reding, a president of the California Nurses Association and vice president of National Nurses United. “But if they don’t have access to getting further education, we’re not going to see additional nurse practitioners come into the field.”

Tuition, combined with living expenses, can far exceed $50,000 a year for many post-bachelor’s nursing programs.

“Potentially, this could devastate a whole generation of nurses getting their advanced practice degrees,” Clarke said.

Some education advocates fear that losing a pipeline of advanced nursing practitioners to serve as college faculty also could lead to fewer registered and advanced nurses and other caregivers with two- and four-year degrees, because there would be fewer people to teach them.

Many advanced-degree nursing faculty are retiring. Nursing schools reported more than 2,100 full-time faculty vacancies in 2022, according to the American Nurses Association — leading to roughly 80,000 students being turned away.

States are already grappling with workforce shortfalls caused by exhausting work conditions that have led many nurses to burn out and leave the field, or leave bedside care to teach, nurses told Stateline.

In response to an uproar from nursing associations and others in health care, the Department of Education released a rebuttal last week defending its proposal, saying it is not a “value judgement about the importance of programs.”

It also said it may make changes in response to public comments. The new limits would take effect July 1, 2026.

Rural and underserved communities

Advanced practice registered nurses, known as APRNs, fill gaps in rural communities where there aren’t enough clinicians. For example, nurses needed for surgeries — nurse anesthetists, or CRNAs — make up 80% of anesthesia providers in rural counties. About a fifth of APRNs nationwide worked in rural areas in 2022, according to one survey of more than 18,800 APRNs.

“The nurse practitioners, APRNs, are a needed lifeline to help fill those gaps,” said Heidi Lucas, executive director of the Missouri Rural Health Association and former director of the state’s nurses association. “Putting barriers in the way to keep [nurses] from getting degrees — that’s just going to exacerbate the problems that we already have.”

She said Missouri will be short about 2,000 physicians next year.

The new rule cutting options for federal student loans would only worsen staffing shortages amid tenuous rural hospital budgets, said state-level observers. Hospitals already are grappling with millions of dollars in looming Medicaid cuts over the next 10 years, said Rich Rasmussen, president of the Oklahoma Hospital Association.

Nurse practitioners often serve as primary care providers, writing prescriptions and managing patient care. About 80% of them see Medicaid and Medicare patients, according to the American Association of Nurse Practitioners, citing federal data from the Centers for Medicare and Medicaid Services.

The proposal to deny advanced practice nurse practitioners the more generous loan options ignores the nation’s needs, said nurse practitioner Valerie Fuller, president of the association.

“At a time when America needs more health care providers, we can’t afford to put more obstacles in place for nurse practitioner students who want to go on and further their education and take care of the patients that need care,” said Fuller, former president of the Maine Nurse Practitioner Association. “We know it’s going to harm our workforce.”

‘Clipping the wings’

Rasmussen, of the Oklahoma Hospital Association, said he is concerned about the effect the rule will have on the pipeline for certified nurse midwives and the state’s already dwindling rural maternal health care options.

“We are clipping the wings of rural [obstetrics] to be able to blossom in our state if we’re going to put these types of restrictions on the borrowing capability of nurses who want to pursue obstetrical services in nursing as well,” he said. He added that the rules will force nurses to seek private sector loans — which don’t qualify for federal loan forgiveness programs that encourage clinicians to come work in rural areas.

Teshieka Curtis-Pugh, executive director of the South Carolina Nurses Association, is also concerned about nurse midwives. South Carolina is expected to see a shortage of 3,200 physicians by 2030.

“We also live in a state that has very poor maternal outcomes, especially for women of color. So think about, how does that impact them?” she said. “That means we don’t get the certified nurse midwives who are masters prepared, some of them are doctorally prepared, who are able to fill that gap for birth in that area.”

Diversity and opportunity for students from marginalized groups could also take a hit, said Curtis-Pugh, a registered nurse with a master’s of science in nursing. And for those going back to school while juggling parenting, federal loan dollars can help beyond tuition, she noted.

“They help that mom be able to supplement child care for their child, so that they can have child care while they go to school,” she said. “There’s tuition, there’s books, there’s keeping the lights on. They’re feeding the family they’re getting to and from.”

The exclusion from the higher, “professional” category of student loan options is especially galling after nurses’ work during the COVID-19 pandemic, said Reding, of National Nurses United.

“We were all heroes in 2020. Now, what are we?” Reding asked. “It’s a slap in the face to the nurses that go to work every day doing our very best to care for our patients, even under very adverse conditions and even facing deadly viruses.”

Clarke, the registered nurse considering a post-bachelor’s degree, said nurses’ pandemic-era devotion influenced her own career path.

“When I saw the nurses and the health care workers really working hard for their communities and sacrificing a lot, I was really inspired by that,” Clarke said. “And that’s why I went to school.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

 

Children are pictured at an Autism Speaks Light it Up Blue Autism Awareness Celebration at Chicago Children's Museum in April 2017. State Medicaid agencies are struggling to pay for applied behavior analysis, an intensive therapy for children with autism. (Photo by Daniel Boczarski/Getty Images for Autism Speaks)

State Medicaid agencies are struggling to pay for an intensive therapy for children with autism — and looming federal Medicaid cuts are likely to make the problem worse.

Parents of children and young adults who receive applied behavior analysis, or ABA, worry states’ cost-saving measures will make it harder for them to get vital services. About 5% of children ages 3 to 17 on public insurance have autism spectrum disorder, compared with 2% who have private insurance, according to a CDC survey.

Many families and autism therapists say ABA can help improve communication and social skills, sharpen memory and focus, and replace challenging behaviors with positive ones. ABA therapy can range from 10 to 40 hours per week in different settings, including home and school. That makes it expensive.

In 2014, the federal Centers for Medicare & Medicaid Services mandated that all state Medicaid programs cover comprehensive autism services for children. It did not explicitly require coverage of ABA, but by 2022, every state Medicaid program covered ABA.

In addition, more kids are getting diagnosed with autism as screenings increase. As a result, state spending on the service has skyrocketed. In Indiana, for example, Medicaid spending on ABA therapy grew from $21 million in 2017 to $611 million in 2023. The sharp increase has prompted Indiana, and other states, to take steps to control costs.

Meanwhile, federal auditors have begun examining states’ coverage of ABA services to ferret out fraud and abuse.

Mariel Fernandez, vice president of government affairs at the Council of Autism Service Providers, a nonprofit trade association, acknowledged that states are facing difficult choices.

“For such a costly and intensive service, the states need to explore how to best reimburse this benefit so that it’s sustainable and promotes quality,” said Fernandez, who is also a board-certified behavioral analyst. “Is [the rate] going to bankrupt Medicaid? Is it going to ensure that people are actually receiving the service?”

The Medicaid changes included in the One Big Beautiful Bill Act that President Donald Trump signed in July will increase the pressure: The law includes more than $900 billion in federal spending cuts over the next decade. Medicaid is funded jointly by the federal government and the states.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. has described autism as a rapidly growing “epidemic” in the U.S. and has made it a major focus of his tenure. Kennedy has promoted the debunked theory that there’s a link between childhood vaccines and autism.

Curbing costs

Several states this year have considered curbing ABA costs by capping therapy hours, tightening provider enrollment rules, reducing reimbursement rates or changing patient eligibility rules. A bill in New York, for example, would establish a 680-hour annual cap on ABA services.

But nowhere has the issue been more prominent than in Indiana, where Medicaid has covered ABA therapy since 2016.

Governor’s group recommends ABA usage cap, rate changes as Medicaid costs rise

Historically, Indiana Medicaid has reimbursed ABA providers for most services at a rate of 40%, regardless of what they charged.

That “created some very strange incentives for a small portion of the provider network,” said Jason McManus, president of Indiana Providers of Effective Autism Treatment (InPEAT), which represents smaller ABA providers in Indiana and larger providers that operate in Indiana and elsewhere. “You had folks who were charging exorbitant amounts for the service.”

Beginning in 2024, Indiana lowered its reimbursement rate to about $68 per hour — and received plenty of pushback.

“That did have an impact on the provider community,” McManus said. “You had a lot of folks, smaller shops, who ended up closing their doors or consolidating with other organizations. So that was disruptive.”

And that year, the HHS inspector general issued a report which found that Indiana’s Medicaid program made at least $56 million in “improper” payments to ABA therapy providers in 2019 and 2020.

The state’s rapidly rising ABA costs and the federal audit prompted Republican Gov. Mike Braun to issue an executive order earlier this year creating a working group to examine ways to cut costs without compromising quality.

The group crafted recommendations to correct the problems identified in the federal audit and put ABA coverage on a financially sustainable path. Without changes in the state’s reimbursement policies, the group concluded, Indiana’s Medicaid spending on ABA therapy would reach a projected $825 million by 2029.

This month, Braun unveiled the group’s recommendations, which include the creation of a new ABA office to increase oversight and lower reimbursement rates, which the state has not yet detailed.

ABA allows people with autism “to obtain the highest level of independence that’s possible for them,” said McManus, who served on the working group.

“But from a state perspective, I can see how, if you’re purely just looking at the cost, you would say, ‘Wow, this is a cost that has grown over time, and if absent all other contexts, this is something we need to pay attention to, because it’s unsustainable.’”

Nebraska rate cut

In Nebraska, state officials also have been looking for ways to control spiraling ABA costs: Last year, Nebraska Medicaid paid out more than $85 million for ABA therapy, a surge from $4.6 million in 2020.

In July, the state announced that it would cut its Medicaid reimbursement rates for ABA, including a 48% cut to reimbursement for direct therapy provided by a behavior technician. That brought the rate to $74.80 per hour, down from about $144 per hour. Rates for therapy by physicians or other board-certified professionals also were reduced by about 37%.

Many providers saw the cuts coming, as the state has had the highest hourly reimbursement rate in the nation.

“It would be fiscally irresponsible of the state to maintain that,” said Leila Allen, vice president of external affairs at Lighthouse Autism Center, which has ABA therapy centers in Nebraska as well as in Illinois, Indiana, Iowa, Michigan and North Carolina.

Sam Wallach, president of Attain, an ABA therapy provider that operates in Nebraska and a dozen other states and Washington, D.C., said the service is “life-changing for children and families.” He views the ABA reduction as a “correction” that will make it feasible for Nebraska Medicaid to continue to cover it.

“The previous rates were well above what most Medicaid programs pay nationally, and while that created short-term benefits, it wasn’t realistic or sustainable,” Wallach said.

But some providers are taking issue with the way Nebraska went about those cuts.

For example, the state provided only 30 days’ notice before making the change. “There were providers that within 30 days had to tell their staff, ‘We’re so sorry. We have to cut your salary by ‘x’ percent in 30 days,’” Allen said.

Nebraska also didn’t examine how much it costs to provide ABA in the state, she said. The new rate is closer to what neighboring states, such as Iowa, pay. But therapists are few and far between in sparsely populated Nebraska, and families there often have to travel long distances to reach ABA providers.

“There was no cost survey to determine what the cost should be,” said Allen. “They didn’t take into account that you do have to pay people a little bit more to be able to work as behavior analysts in Nebraska.”

Finding ABA therapists in Nebraska is particularly difficult for families with older kids. Angela Gleason, executive secretary on the board of autism advocacy organization Arc of Nebraska, has a 13-year-old son with autism. She said many companies only serve very young children, up to age 6.

“So for families like mine, it’s then hard to even find a company that will serve his age and will provide that kind of support,” she said. To be able to afford therapy, her son Teddy has Medicaid coverage as his secondary insurance. ABA therapy helps him with socializing and speaking with his speech delay.

“He needs a lot more help throughout his day than a normal 13-year-old without autism might need,” Gleason said.

North Carolina court case

In North Carolina, the cost of covering autism services, including ABA, will total an estimated $639 million in fiscal 2026, up 425% from 2022, according to the state’s Medicaid agency. About five autism providers made up roughly 41% of the state’s increase in spending in fiscal year 2023-2024, according to the state.

Effective on Oct. 1, North Carolina Medicaid cut reimbursement rates for all kinds of health care services, arguing that state legislators had not budgeted enough money to keep up with rising costs. The reductions, which ranged from 3% to 10%, included a 10% cut to the reimbursement rate for autism services, including ABA therapy.

But the families of 21 children immediately sued the state Department of Health and Human Services to halt the move, arguing that it was discriminatory because it targeted children with disabilities.

Earlier this month, the families won a preliminary injunction temporarily halting the rate cut.

But families across the state are on edge as children with autism often see multiple providers — psychologists and speech language pathologists, for example — whose rate cuts were not paused, according to Allen, of Lighthouse Autism Center.

David Laxton, director of communications for the Autism Society of North Carolina, which is also a provider, said many providers won’t be able to absorb the rate reductions and continue operating.

“At some point, the math is not going to math,” Laxton said.

“It’s very stressful for families, because right now, there’s not an end in sight,” Laxton said. “There’s agreement that this [service] is very important, but there’s not been action to bring an end to the cuts.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

A farmhouse sits along a gravel road near Elgin, Iowa. For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a new report. (Photo by Scott Olson/Getty Images)

For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a report released Monday.

The nonprofit Commonwealth Fund based its analysis on federal health workforce data. Its report comes just days after states applied for portions of a $50 billion rural health fund included in the broad tax and spending law President Donald Trump signed in July. Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one.

About 43 million people live in rural areas without enough primary care physicians, according to the report. Across the country, nearly all — 92% — of rural counties are considered primary care professional shortage areas, compared to 83% of nonrural counties. Forty-five percent of rural counties had five or fewer primary care doctors in 2023. Roughly 200 rural counties lacked one altogether.

Nationally, the report found there was an average of one physician per 2,881 rural residents. States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician.

Rural residents are less likely to use telehealth for primary care, largely because of limited broadband internet access. About 19% of rural respondents said they received health care from a primary care physician via telehealth over the past year, compared with the national average of 29%.

The report also took the pulse of states’ participation in national programs for rural areas, such as a federal loan repayment and scholarship program for physicians working in areas with a shortage of health care providers. In 2023, 40% of rural counties had at least one primary care clinician participating in the program — compared to 60% of nonrural counties.

While the demand for primary care physicians will surpass the supply, the study estimates that the supply of rural nurse practitioners will exceed demand over time, as nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the authors wrote.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.