From Aron’s Desk

Friends, 

This week, I have to note the spread of measles in South Carolina. This latest outbreak is driven by people not vaccinated for measles, which is one of the most contagious diseases we face. Measles outbreaks are completely preventable with vaccination - we have known this for a long, long time. 

The federal Department of Education is planning to change the way students access federal loans. They have created rules to limit access to loans by clinical profession, which will change who can access important careers based on money and not merit. 

By playing with the definition of graduate and professional education, the department is changing who gets the chance to be a nurse anesthetist or physician assistant, both well-paid and important clinical fields. This can seem technical, because it is. But like lies, damn lies, and statistics, it’s the technical pieces that hide the goals of policy in the minutia of the federal register.

On January 30 the Department of Education published “Reimagining and Improving Student Education.” The proposed rule uses the terms “professional” and “graduate” to limit borrowing. Fields judged to have “professional” education allow double the borrowing of fields judged to have “graduate” education. In both cases the education comes after a traditional college degree. The department proposes “three-part test” defining a profession¹ on page 4262 of the January 30, 2026 federal register:

1. education must signify completion of the academic requirements for beginning practice,
2. education must be beyond a bachelor's degree, and
3. practice requires a professional license.

These three rules are supposed to define what makes a profession and allow larger amounts of borrowing. The whole premise starts as a muddle, because the medical degree (MD) violates rule one - you have to do a residency of three to seven years after medical school to do independent practice if you are an MD. There is a special carveout in the legislation to have medical students count as professional students, but the inconsistency of conclusions and rules makes it clear that the proposed rules are a pretense and not the real rules in the logical sense.

There has been considerable pushback on the proposals because nursing is not a profession under these rules. The administration has tried to claim they do not want to demean nurses - this is just about loan limits, but the proposed rule (p4265) clearly states “the department believes that nurse practitioners cannot be said to be part of a distinct profession…“ 

As their justification, they add a fourth rule just for the nurses: degrees are not “professional“ when the degree leads to employment, where the employee must be supervised by another professional, who has “more education, training and qualifications than the person being supervised.“ The doctors are professionals based on only two of the three rules, but the nurses are expected to clear four rules.

The Department frames the whole issue of graduate versus professional training not in terms of what our country needs from graduate or professional education, but rather, how much money the government wants to spend. The rules clearly point to a limiting borrowing in the hopes that it will decrease tuition costs. As somebody who has been around medical and health education for a long time, this rule won’t have that effect. Clinical education is expensive. Institutions will continue to accept applicants, but only those with access to financial support can actually pay tuition and matriculate. Simply, these rules will change who has the opportunity for this life-changing education from who has merit to who has money.

It appears the Department of Education does not think nursing is a profession, particularly the part of nursing that includes nurse practitioners, including certified nurse anesthetists. The same goes for the physician assistants, clinical counselors, and many other members of the healthcare team. Our country needs these professionals to provide access to care. (How many people do you know struggling to find a primary care provider, a counselor, or therapy?)

More existentially, our greatness has come from being the land of opportunity, and we should make sure people have the chance to enter these well-paid professions. Our rural communities need their first generation college students to have these educational options regardless of whether they come from means. We all should be creating opportunities based on merit rather than wealth.

Public comment on the rule closes March 2, 2026, and RFUMS will be one of the institutions providing comments. We will express our opposition to the rule changes in writing and during our conversations with legislators. Historically, the comment process has rarely led to rule changes, but the process of creating comments is how institutions and societies create and find allies. Our professional societies should be providing relevant comments, and I encourage you to participate in your professional society as an important part of advocating for the health of our patients.

Improving the wellness of all people with you,
Aron

Aron Sousa, MD FACP
President

¹The authors of the rule feel it necessary to reference Merriam Webster in their use of the word “signify” but not “professional” or “graduate”. One might refer them to the definition of "arbitrary."