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Kenneth Botelho, founding director of the doctor of medical science (DMSc) program at The College of St. Scholastica and a physician assistant, discusses his article “Federal graduate-loan caps threaten rural health care access.” Kenneth explains how impending borrowing limits for physician assistant and nurse practitioner programs create an insurmountable barrier for students from the very communities that need providers most. He illustrates the paradox where government grants aim to stabilize rural health care while loan policies simultaneously cut off the supply of future clinicians. The conversation highlights the urgent need to align financial aid with public health goals to prevent a rise in mortality rates in underserved areas. Join us to understand why financial barriers to education are becoming a matter of life and death for rural America.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kenneth Botelho. He is the founding director of the Doctor of Medical Science Program at the College of St. Scholastica and a physician assistant. Today’s KevinMD article is “Federal graduate loan caps threaten rural health care access.” Kenneth, welcome back to the show.

Kenneth Botelho: Thank you so much for having me again, Kevin. I am happy to be here.

Kevin Pho: All right, tell us what your latest article is about.

Kenneth Botelho: Our latest article takes two different aspects of the more recent “big, beautiful bill” that was passed and talks about a paradox that exists within that. I would be happy to go into more depth. This really started as I have been involved in rural health and access to care in those places. I am very familiar with the Rural Health Transformation Plan that is within the bill. What I was not as familiar with until more recently was some of the federal student loan caps that are existing also within the same exact bill.

This really came into fruition when I had discussions with prospective PA students and then also PAs themselves. They take this bill and the loan cap, and they see themselves not being able to complete their education if those loan caps existed for them at this time. That includes me personally.

The prospective students are concerned because they are worried that they will not be able to pursue the career that they would like. Also, folks like myself that have already completed their education and are practicing clinicians would not be able to do so in this type of an environment. That is where this came into play.

Kevin Pho: Now for those who are not familiar with the student loan cap and the “One Big Beautiful Bill Act,” tell us exactly what kind of numbers we are talking about.

Kenneth Botelho: That is a great point. For physicians, they are within what is considered a professional loan cap, which I believe is $200,000 lifetime in terms of student loan borrowing through the federal government. PAs and nurse practitioners, which is where the article does most of its centralizing, are capped at $100,000 or less.

If we zoom out, how much does it cost to go to PA school? It is about $100,000. That is not with housing. That is not with food because almost every PA student is not working because of the intensity of the programs. That also takes into account that $100,000 includes undergraduate education. So if you take that, the math just simply does not work. If we look specifically at the student loan component of things, that immediately sends a red flag up for me that there are going to be fewer folks going into these professions.

Now, wearing the rural health hat, it effectively turns the water supply off of a brand new fire truck that we are funding in the bill. That is where the paradox comes into play. I think a lot of your listeners are likely to be aware of where I am going with this. If we do not have a supply or have a reduced supply in an area that is already hurting, we are not going to be able to fight the fire in the way we think we are going to be able to fight it.

Kevin Pho: So you are saying that applicants or students who come from rural areas tend to go back and practice in rural areas as well after they finish. So if their loans are capped, like you said, it threatens that supply.

Kenneth Botelho: Absolutely, it threatens that supply. This is looking at it before the July deadline when it would be enacted. I wanted to ensure that this article raises red flags for the fact that it does a great job of putting more money into the rural health pipeline. However, it actually reduces the supply of what we would quote, unquote use to fight the fire, which would be the clinicians.

Kevin Pho: You mentioned that you talk finances with prospective applicants, of course without any identifying information. Tell us about some of those conversations, especially in light of these loan caps. What are these conversations like? What are some of the questions that applicants are asking you?

Kenneth Botelho: There are two portions to that. I would say a lot of it is fear. First of which is fear that they may be less likely to pursue the career that they are interested in, which in this case would be a PA or a physician assistant. Secondly, if there are fewer PAs pursuing careers or fewer nurse practitioners being pursued, who is going to take care of those communities that they are already a part of?

Of course, the answer is physicians, and that is absolutely the answer. However, we also know that there is a declining supply in those particular areas to begin with. So as a country, what do we do in these circumstances when we have a paradox? What does the clinician or the prospective clinician do in these circumstances? That is really where the meat of the discussion that I have had with these prospective students has been. It has been a bit difficult because I do not have all the answers to these things.

Kevin Pho: What kind of options do these students have if they still want to pursue PA school but their federal loans are capped? What options do they have?

Kenneth Botelho: That is a great question. You still have $100,000 in federal student loans that, at least according to the bill, will still be available. With that said, we know that at least in the PA profession, that number is well beyond the $100,000. There are always private options that are available, and they are somewhat diverse and also somewhat variable. Then there are also grants that are available nationally for folks that come from rural areas. Those can also be quite helpful.

I question as I am talking to you, Kevin, about this if the Rural Health Transformation Bill itself would be helpful with this, but I do not particularly have an answer. That is certainly something that I think a lot of states will likely want to pursue and consider as the money starts to go into these states as they have applied for the Rural Health Transformation Program and bill. So, private loans are still available and there are still federal student loans, but they are capped. The clinicians or clinicians-to-be would need to do a lot of legwork to figure out how to make up that deficit.

Kevin Pho: In terms of the difference between government versus private loans, is it simply the interest rates? What other financial considerations does one need to make when considering one versus the other?

Kenneth Botelho: I think a lot of it has got to do with interest rates and the differentiation there. It is also availability. To some folks that are out in rural areas, if they tend to have lower income, they may not be as formidable of an applicant to some private loans. So there are also concerns there.

There are a lot of different things that need to be ironed out as we start to approach next summer when this would otherwise come into play. My hopes are that this is a discussion that starts to gain steam within the policy and government community because I know there are always good intentions with a lot of these things. We need to also be aware of the ramifications. We do not want our future clinicians to be overburdened with what they would need to do in order to pursue their education.

Kevin Pho: So what are you doing as an organization? And certainly you don’t have to talk specifically about St. Scholastica, but in general for other people in your position, what are schools in general doing to address this issue and the fact that it may choke off a potential source of rural applicants?

Kenneth Botelho: That is a great question. A lot of folks are realizing that they need to become creative in outreach to state organizations and maybe other federal organizations. When I say folks, I am generalizing to the higher academic community. If they are academic communities that help with providing a vital service to the communities that they serve, then there needs to be some consideration to make sure we are able to sustain taking care of our own population. I do not know of specifics that I can attest to on the podcast, but I know there are ongoing discussions with local private sector loan companies and also with state organizations that may be of help.

Kevin Pho: So why do we extrapolate a situation? Just tell us the worst case scenario. If the applicants tend to be more financially homogenous that don’t need loans or this issue doesn’t affect them, how does that affect the workforce going forward? And what kind of implications are we going to have when it comes to our health care workforce?

Kenneth Botelho: This is where the thought of the creation of this article has come from. If we shut off the water supply to a fire truck that is fighting a fire, that fire gets worse. That is the point of ensuring we have this discussion today because it is absolutely vital to the future of rural health and really the future of primary care. We need to be able to sustain a workforce. By these loan caps, they effectively shut off the water pressure.

Kevin Pho: Do you have any insight in terms of some of the motivations behind setting these loan caps, especially as it relates to PAs and NPs in the first place? Are you allowed to speculate?

Kenneth Botelho: That is a great question. I will speculate to a degree because this is a nonpartisan discussion. I have no political leanings other than for the patients of the United States. The Rural Health Transformation Program is a fantastic step in the right direction for those communities. It is just the paradox of putting loan caps creates this environment where it almost becomes a moot point.

To speak directly to the PAs and NPs in these circumstances, I would suspect that there is not a full understanding that by capping both of those professions, that could actually have a very negative effect on public health. So to answer your question directly, I believe there is less likely or there is less understanding of those professions and the circumstances of how they affect rural health patients.

Kevin Pho: We are talking to Kenneth Botelho. He is the director of the Doctor of Medical Science Program at the College of St. Scholastica and a physician assistant. Today’s KevinMD article is “Federal graduate loan caps threaten rural health care access.” Kenneth, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kenneth Botelho: A fire truck without water cannot put out a fire. A rural health system without a training pipeline cannot survive. If you find this conversation to be beneficial or eye-opening, my recommendation would be to get involved and use our voices. A lot of the times the folks that see these types of things are the folks that deliver direct care. We see those faces every day. Some of those folks have fear in their eyes. We have the opportunity to make sure our voices are heard and that we can help continue to supply appropriate high-level care to our patients.

Kevin Pho: Thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Kenneth Botelho: Really appreciate it. Thank you so much, Kevin.