Short-sighted new student loan caps elevate chiropractic care over critical health care professions

STAT News – Tuesday, June 30, 2026
By David Shapiro

In May, the Department of Education finalized its framework under the “Reimagining and Improving Student Education” (RISE) rules and made a technical distinction that carries life-or-death stakes for the American health care system. By capping annual federal borrowing for standard graduate students at $20,500 while preserving a $50,000 threshold for an exclusive list of 11 “professional” degrees, the administration attempted to use a balanced ledger to codify a dangerous misunderstanding of modern medicine. The new caps go into effect Wednesday.

A lawsuit filed by the American Nurses Association (ANA) and nine other national nursing organizations highlights a glaring absurdity: Under the new framework, an aspiring chiropractor qualifies for maximum federal borrowing, while advanced practice nurse practitioners (NP) and physician assistants (PA), both key to fulfilling existing and anticipated shortages in primary care and rural health nationwide, are locked out. Further, growing fields like cardiovascular perfusionists, more and more involved in ICU care, field resuscitation, organ preservation, and other support roles, remain unrecognized.

While the DOE says this is not a “value judgment,” the new rules drastically overlook important needs in American health care — not so great, insufficiently healthy, and definitely not beautiful.

The arbitrary classification defies public health knowledge and ignores decades of rigorous health services literature. If the federal government is truly committed to reining in predatory graduate debt, it mustn’t do so by choking the pipeline of the very clinicians keeping America’s health care system afloat. The vast majority of professional students, even those in fields not recognized by the new DOE list, rely on federal loans, and only 5%-10% on private student loans. Can you smell what private lenders are cooking?

The Education Department’s primary rational seems to be rooted in legal formalism and a plan to protect taxpayers. While this may insulate the federal government, and therefore the taxpayer, from absorbing massive amounts of non-repayable student debt, this is apparently only achievable by imposing federal caps and dismissing the need for health care workers in already fragile fields.

Officials argue that graduate debt accounts for more than one-third of the federal student loan portfolio, making tightening limits a necessary fiscal corrective. In its rulemaking, the department even acknowledged that advanced nursing degrees satisfy the three-part legal test for professional degrees. They were excluded because they apparently failed the contextual requirements of traditional, independent professions. Some states still require physician supervision for nurse practitioners, while 27 states and the District of Columbia allow for NPs to practice independently, and more are anticipated. Further, nurse practitioners, who are heavily engaged in rural access and primary care, are also involved in the delivery of women’s health as certified nurse midwives (CNM) and anesthesia care as certified registered nurse anesthetists (CRNA).

Chiropractic programs, which operate outside mainstream hospital systems, have limited oversight and do not require collaborative agreements. Evidence for chiropractic care is limited to the symptomatic relief of musculoskeletal conditions, primarily low back and neck pain. Moderate evidence shows that chiropractic care has effects similar to that of physical therapists, another group not on the list. Spinal manipulative therapy may offer a cost-effective or cost-neutral alternative, but the evidence base has substantial limitations and results are inconsistent. Further, there is no biological plausibility or clinical evidence supporting a life-prolonging effect of chiropractic care, especially for systemic disease as claimed by some in the field.

By contrast, the literature on health care workforce utilization consistently demonstrates that APRNs — including nurse practitioners, certified registered nurse anesthetists, and certified nurse midwives — are the primary drivers of health care access, particularly in historically underserved areas. NPs provide care that is identical in quality and clinical outcomes to that of physicians in particular fields, but at a fraction of the cost. Medicare beneficiaries attributed to primary care NPs had 21%-34% lower average costs than those attributed to physicians. NPs and PAs significantly reduced total costs, direct costs, and hospitalization costs compared with other health professionals.

This administrative logic is hopelessly out of touch with the empirical reality of American health care.

Furthermore, the American health system is currently facing a catastrophic workforce shortage. The U.S. will need hundreds of thousands of additional nurses over the next decade to cope with an aging baby boomer population and a rising tide of chronic illness survivors. Further, the physician shortage will limit specialists and primary care alike. CRNAs already provide the vast majority of anesthesia care in rural counties.

While chiropractic care has its place in musculoskeletal wellness, it is not a frontline necessity for keeping emergency departments open, managing complex disease, or delivering premature infants in health care deserts. Elevating chiropractic education to a privileged federal funding tier while artificially capping advanced nursing is a severe misallocation of public resources. The large and growing physicians shortage is projected to reach between 13,500 and 86,000 physicians by 2036; some estimates are higher.

The economic barrier of the RISE rule is profoundly inequitable. Becoming a clinician is capital-intensive. These programs require thousands of hours of clinical rotations, making full-time employment next to impossible during schooling. Under the new $20,500 annual cap, a student pursuing certification as a NP faces a staggering financial shortfall, as modern tuition and cost-of-living expenses regularly exceed $40,000 per year.

When federal loan availability drops, it does not result in lower tuition overnight. Instead, it pushes students toward high-interest private loans with predatory repayment terms, or it deters them from pursuing higher education entirely.

The burden of this rule will fall heaviest on first-generation and nontraditional students — the exact demographic necessary to build a culturally competent health care workforce. This policy also directly threatens the faculty pipeline for future educators of all professional types.

By choosing a rigid, historical list of professions over a data-driven, needs-based model, Washington has signaled that it values archaic professional titles over measurable public health outcomes.

The lawsuit brought forth by the ANA and its allies is more than a technical dispute over the Administrative Procedure Act; it is a battle for the future of American clinical care, and for the welfare of all those who seek care.

David S. Shapiro, M.D., M.P.H., is a board-certified surgeon, surgical intensivist, and physician executive. He writes on various advocacy topics including injury prevention, patient advocacy, and team-based health care. His social media is focused on TikTok as @onetwoicu, where he teaches evidence-based medicine and debunks myths of unproven care.

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