High nursing school debt, proposed education loan caps threaten US health care access

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Nearly a third of registered nurses and advanced practice nurses in Michigan carry sizable student loan debt that is influencing their decision to leave the profession, according to a new study from the University of Michigan.
 
The research appears in Health Affairs Scholar, and comes as the U.S. Department of Education prepares to finalize new student loan rules that exclude graduate nursing programs from higher-tier loan limits, a move the study authors say could narrow the pathway for advanced clinicians and nursing faculty. 
 
After the Trump administration proposed the loan limits, researchers from the U-M School of Nursing wanted to know what impact debt had on nurses' career decision-making. To that end, the team analyzed data from the Michigan Nurses' Study,  a survey of 13,687 nurses with valid Michigan licenses that launched in March 2022.  
 
Michigan ranks eighth in the nation in number of registered nurses, making these data relevant to the national conversation, said study principal investigator Christopher Friese, the Elizabeth Tone Hosmer Professor of Nursing and professor of health management and policy. The study measured current loan balances (adjusted to 2025 USD), economic/household concerns and career intentions. Results were analyzed separately for RNs and APNs. 
 
Key findings (9,570 respondents):

• Approximately 28% of RNs and 33% of APNs hold active student loans.
• The median loan balance for APNs is $66,420, with nearly 29% of those debt-holders owing more than $100,000—the threshold of the government's proposed lifetime aggregate cap.
• Nurses with student debt cite family finances as a top concern more often compared to their debt-free peers (74% vs. 39%).
  Among nurses who had recently left or were planning to leave their positions, 51% of those with debt cited inadequate pay and benefits as the reason, compared to only 10% of those without debt.

"These findings suggest a large proportion of Michigan nurses hold student loan debt," Friese said. "Nearly a third of advanced practice nurses had loan balances that exceeded the proposed lifetime cap. Placing this cap would likely limit the entry of current nurses into APN programs, threatening the ability to deliver primary care, obstetrical care, specialty care and having enough faculty to teach nursing students in the future." 
 
The study highlights that loan relief and flexible borrowing are incentives for clinicians to work in underserved areas, and by curtailing these, the health care system risks losing the APNs and nurse midwives who provide essential primary and specialty care in underserved areas. 
 
Friese and colleagues argue that expanding the APN workforce is critical for U.S. health care access, yet the high debt carried by RNs, which are the primary pipeline for advanced roles, creates a significant financial barrier, as RNs will likely need loans to further their education. High debt levels also discourage nurses from entering lower-paying academia jobs, which further restricts the supply of new nurses by limiting school capacity.
 
To bolster the RN and APN workforce, health systems could partner with nursing schools to provide tuition discounts and long-term financial support as recruitment and retention tools, the researchers said.
 
The Department of Education concludes its rulemaking in July, and the exclusion of graduate nursing programs from higher loan thresholds runs counter to the goal of providing safe, accessible health care, the study concludes. The authors argue that capping loans for advanced degrees will discourage RNs from becoming NPs or educators, further exhausting an already strained system.