Nurses carry substantial student loans: health care workforce implications

Introduction

Health systems face persistent workforce challenges that threaten their ability to ensure accessible, safe care delivery. Two concerns are the adequacy of the registered nurse (RN) and advanced practice nursing workforces. Nurses are essential clinicians across inpatient, ambulatory, long-term, and home care settings. Advanced practice nurses (APNs), including nurse practitioners, certified registered nurse anesthetists, nurse midwives, and clinical nurse specialists, deliver vital primary, procedural, and advanced specialty care.

Health care professional training is costly, often necessitating student loans at both undergraduate and graduate levels. Loan relief is a recognized strategy to incentivize clinicians to work in underserved communities.¹ Loan relief has heightened importance as higher education tuitions climb, especially for graduate programs.²

After enactment of HR 1 (119th Congress),³ the Department of Education established new annual and aggregate loan limits for professional degree programs. On November 7, 2025, a departmental committee concluded negotiated rulemaking and identified degree programs eligible for the highest level of unsubsidized loans: annual caps of $50 000 and lifetime aggregate caps of $200 000. Graduate nursing programs, including post-baccalaureate Master’s and Doctorate of Nurse Practice Degrees, were excluded and instead would be subject to a lifetime aggregate cap of $100 000. Final rulemaking is expected in early 2026. Our team examined the prevalence and amounts of nursing student loan debt and whether loan balances were associated with economic concerns and job plans.

Methods

The Michigan Nurses’ Study was launched in March, 2022, to answer timely policy questions. Nurses with a valid unrestricted Michigan RN license—including all advanced practice nurses—were invited to complete a survey via email invitation. The University of Michigan Institutional Review Board (IRB) determined the protocol to be exempt from review. In 2022, 13 687 nurses (8.3% response rate) completed the survey.⁴ Survey completers had similar demographics to nonresponders.

Nurses reported whether they held student loans. Those with any active student loan reported their current balance (converted to 2025 US dollars). We asked whether the economy or household finances were a top concern. Among nurses who had recently left practice, we asked how many cited pay and benefits as a primary concern. Among nurses who were planning to leave their position within 1 year, we asked how many were dissatisfied with pay or benefits. We defined an APN as either completing a master’s or doctoral degree or reporting an occupational title as nurse practitioner, nurse midwife, nurse anesthetist, or clinical nurse specialist. Analyses were stratified by holding an RN or an APN role.

Results

Among respondents who answered the loan status question (n = 9570), 2086 RNs and 692 APNs reported active loans, representing 28% and 33% of the respective subgroups. In 2025 dollars, the median (interquartile range) loan balance was $33 210 ($15 498–$55 350) for RNs and $66 420 ($33 210–$110 700) for APNs.

We estimated the number of nurses with loan amounts that exceed the proposed lifetime aggregate cap proposal of $100 000. Among those with loans, 116 (5.6%) of RNs and 200 (28.9%) of APNs reported nursing student loan balances that exceeded $100 000 (see Figure 1).

Figure 1.

Student loan balances among registered nurse and advanced practice nurses, Michigan 2022 (converted to 2025 dollars). n = 2778. Abbreviations: APRN, advanced practice registered nurse; RN, registered nurse; Source: authors’ analysis.

We examined whether loan balances were associated with economic or household financial concerns. RNs and APNs with student debt cited family finances more frequently as a top concern, compared with those without student debt (73.5% vs 38.8%, respectively).

Finally, we assessed the role of student loan balances among nurses who had either recently left practice (n = 2687) or were planning to depart within 1 year (n = 4029) and cited inadequate pay and benefits as the reason. Among nurses who had recently changed positions or anticipated changing positions within 1 year, those with student debt cited pay and benefits more frequently as the key factor, compared with those without student debt (51.0% vs 10.1%).

Discussion

Analyses from a large statewide survey suggest that nearly one-third of RNs and APNs hold substantial amounts of student loan debt; nearly one-third of APNs with debt had balances that exceed the currently proposed lifetime aggregate cap of $100 000. High debt levels held by APNs underscore the need for maximal flexibility in student loan programs to support these professionals. Moreover, capped aggregate loan levels for APN students are likely to curtail interest in advanced practice degrees and, subsequently, threaten health care delivery, especially in underserved communities.

This study is limited by its cross-sectional design and a low response rate (8.3%), which may introduce nonresponse bias; however, respondent demographics were similar to the licensed population.

Boosting the availability of APNs is essential to improving US health care access. Current RNs are future APNs. Given the high loan balances carried by RNs, RNs who plan to pursue advanced practice degrees will likely require loans to finance graduate school. Health systems that seek to bolster their RN and APN workforce could partner with nursing schools to offer discounted tuition or offer other supports as a retention tool across the lifespan of a nursing career.

Higher loan balances appear to be related to both heightened economic concerns and career decisions. Nurses with loan balances report more stressors in managing family finances, which may contribute to clinician burnout and hinder quality of care.⁵

Faculty shortages threaten the future supply of the RN workforce. APNs are a key source for nursing school faculty. However, faculty salaries routinely lag behind full-time clinical practice salaries, creating structural disincentives to teach. Policy strategies that reduce student loan eligibility and curtail loan repayment programs do not align with the policy goals of an adequate workforce of nurse clinicians and faculty.

Conclusion

As the Department of Education concludes rulemaking, exclusion of graduate nursing programs as professional programs that qualify for the highest threshold of student loans runs counter to the goals of safe and accessible health care services. To assure that the United States has an adequate nursing workforce, policymakers should reconsider the decision to curtail student loan thresholds for graduate nursing education. Expanded strategies to reduce out-of-pocket costs for nursing education, for both RNs and APNs, is likely to address the growing health care needs of the US population.¹

Supplementary material

Supplementary material is available at Health Affairs Scholar online.

Funding

The Michigan Nurses Study was funded in part by the Elizabeth Tone Hosmer Professorship funds available to C.R.F.

Disclaimer

The views expressed in this paper are solely those of the authors and do not necessarily represent the views of the institution and/or affiliated organizations.