I work with many aspiring clinicians from rural communities, and their stories tend to follow the same pattern: deep commitment, strong community roots, and a determination to return home and practice primary care. These are the students who keep rural towns alive.

Lately, many are telling me something I have never heard at this scale: “I don’t think I’ll be able to afford to become a clinician.”

This isn’t about unrealistic expectations. It is about the 2026 federal graduate-loan caps, which will significantly limit how much students can borrow for programs that train physician assistants (PAs) and nurse practitioners (NPs). For rural students, these caps don’t just make the path harder; they risk closing it entirely.

A composite story that reflects a growing reality

A student from a rural Upper Midwest community recently walked me through her financial projections. She grew up in a county with only one primary-care clinician, who is nearing retirement. Her goal has always been to return home and serve that community.

When she added up tuition, housing, childcare, transportation, and the realities of not being able to work full-time during training, the math was blunt: If the loan caps were already in place, she could not enroll.

She told me, “I want to go back home. They need me. But I couldn’t do this unless I could borrow enough to get through the program.”

I have now heard versions of this same sentence from multiple students across rural Minnesota, Wisconsin, and North Dakota. These are the students who are most likely to return to underserved areas and the most sensitive to borrowing restrictions.

A policy paradox with real human consequences

Federal and state governments are simultaneously investing in rural-health stabilization through loan repayment programs, rural training tracks, community-based clinical education, and grants to expand the primary-care workforce. These initiatives recognize what rural communities already know: Shortages are no longer temporary; they are structural.

But loan repayment does not solve shortages if students cannot afford to enter training in the first place.

This is not only an access issue; it is a mortality issue. Primary-care density is strongly associated with life expectancy. When primary-care access erodes, mortality rises. The regions already experiencing the steepest shortages are also the regions most vulnerable to worsening outcomes.

The only growing component of the primary-care workforce is at risk

Workforce data show a consistent trend:

• The number of primary-care physicians is shrinking.
• Retirements are accelerating.
• Training output is not keeping pace with demand.
• PAs and NPs are the only expanding segment of the primary-care workforce.

In many rural counties, they are the sole ongoing source of care.

Policies that restrict PA/NP training pipelines have predictable consequences: reduced access, longer wait times, more preventable complications, increased emergency-department use, and greater financial strain on rural hospitals. These outcomes are not theoretical; they are well documented in health-services research.

Aligning loan reform with public-health needs

Loan reform and rural-health stabilization do not need to be in conflict. Several approaches could maintain fiscal responsibility while protecting access:

• Align borrowing limits with the actual cost of programs that reliably supply rural or primary-care clinicians.
• Create loan-eligibility tiers tied to primary-care service commitments, especially in shortage areas.
• Ensure rural-health workforce initiatives are paired with financing models that do not restrict entry into training.
• Evaluate loan caps alongside hospital closures, demographic trends, and clinician-retirement projections.

A narrowing pipeline at the moment we can least afford it

The United States is approaching the same primary-care deficit that originally led to the creation of the PA profession in the 1960s, but under far more challenging conditions: an aging population, rising chronic disease, and widespread rural-hospital instability.

The composite student described above may still find a path forward. But her warning is clear: When financial barriers prevent rural students from becoming clinicians, it is not only their futures at risk; it is the health of entire communities.

Loan policy cannot be separated from patient outcomes. And right now, the primary-care pipeline is narrowing at the very moment we need it to grow.

Kenneth Botelho is the founding director of the doctor of medical science (DMSc) program at The College of St. Scholastica and a practicing clinician affiliated with Essentia Health. A nationally recognized leader in physician associate (PA) education and workforce innovation, Kenneth is also the founder of Paving Practices, an initiative that tackles the primary care shortage through structured postgraduate training for advanced practice providers. He brings over a decade of clinical experience and deep expertise in value-based care.

Kenneth has developed interprofessional curricula and forged academic-practice partnerships in Rhode Island and beyond. He has contributed to national policy as a delegate to the American Academy of PAs (AAPA) and currently serves as president-elect of the Society of PAs in Family Medicine. His recent thought leadership includes publications in Medical Teacher and the Duluth News Tribune. Connect with him on LinkedIn.