[00:00:00] Welcome to the Health Policy Podcast. I'm Brian Hyde. Today my guest is Dr. Valerie Fuller, president of the American Association of Nurse Practitioners. That's the largest organization representing nurse practitioners in the United States. Dr. Full. Thank you so much for joining us today. Thanks for having me. It's great to be here. We have a really important, uh, topic to discuss, but before we delve into it, could you tell us just a little bit about yourself, about who you are and what you do? Sure. So my name is Dr. Valerie Fuller. I am, I have dual certifications as a nurse practitioner. I'm. What we call a family nurse practitioner, which is a primary care nurse practitioner, and I'm also an acute care nurse practitioner, which is acute and critical care. I hold a DNP in nursing, which is a clinical doctorate in nursing, and I also hold a PhD, a re research degree in nursing, and I've worked for the last 20. Oh my goodness, 27 years as a nurse practitioner and about [00:01:00] 32 as an rn. There is a health policy proposal, which has recently come out that could have some very significant implications, uh, for, for patients as well as the healthcare workforce. For those who are not familiar with this proposed rule, could you fill us in? Absolutely. So when HR one, the one big beautiful Bill Act passed with it came some new guidelines or recommendations around federal loans for students, specifically graduate students. So historically there had been several options for students. There had been something called grad plus loans. Those have completely gone away for all students. Those funds could be used for things like lab fees and the excess tuition that perhaps your federal loans didn't cover. Cost of living expenses, transportation, et cetera. Those have gone away for, for everyone. And then what they did with the rest of it is they decided to make two categories of graduate students. One category is called professional student [00:02:00] and one category is called graduate student. The difference being that the professional student has a federal loan limit of $50,000 annually with a $200,000 cap lifetime cap. For the graduate student, it's a hundred thousand dollars cap, 20,500 annually, so significantly lower amount for those that fall in the graduate category, and you can probably anticipate what I'm gonna say next. Nursing was not included in the professional category. Let me get some clarification too, because I want to understand nurse practitioner. Can you kind of help us understand what, what a nurse practitioner is and what a nurse practitioner can do compared to say a, uh, you know, physician or a a, a nurse? Sure. So we are graduate prepared, advanced practice nurses, meaning we have either a master's, which is the minimum, but more and more students have moved towards a doctorate. In nursing. We can diagnose, we can prescribe, we can treat, we can order, we can order, uh, and interpret diagnostic tests. And [00:03:00] we see patients across the lifespan, meaning we have. Pediatric nurse practitioners that focus on pediatrics. We have family that kind of sees everyone across the lifespan crib, decrypt, as they like to say. We have psych mental health nurse practitioners, which have just been a godsend for, for the mental health crisis that we have in this nation. And we have neonatal nurse practitioners. They deal with neonates, so we really run the gamut. We provide. Last year alone, we provided more than a billion patient care visits, and we are a cost effective healthcare provider, but we're also highly liked, we get very high patient satisfaction ratings, which is always great to see. So let's talk about, uh, some of the practical concerns associated with this proposed rule change. Let's start with the, those who are studying to become nurse practitioners. How would they be affected by this? Sure. So if the proposed rule, and I wanna be clear that this is proposed, we're still in an open comment period with the Department of Education, but if it were to go through starting on July 1st, 2026, [00:04:00] your loan amount would be capped at 20,500 a year with a hundred thousand dollars cap. That's not gonna cover. The cost of education for all advanced practice nurses or all graduate nurses, because there are advanced practice nurses, like nurse practitioners, like nurse anesthetists, like nurse midwives, and like clinical nurse specialists, as well as people who are getting a master's in say, nursing education. The loan amounts won't directly affect undergraduates, but here's where the undergraduate will be affected. So in all 50 states. A master's in nursing is required to teach nursing. So last year alone, we, the American Association of Colleges of Nurses actually say in their data that they collected from 2024 to 2025, more than 80,000 qualified nursing students were turned away from nursing programs because of a lack of faculty. We already have a shortage of faculty, but add to that. Now they're gonna have lower amounts available to them to go back to get [00:05:00] graduate education. The nursing faculty shortage will get worse. It will directly affect anyone seeking a graduate and degree, degree in nursing, meaning master's or doctorate, and it's very concerning, particularly for all APRNs for, I'll speak for nurse practitioners. We have a number of nurse practitioners across the country who are reaching retirement age, and it's really important that one, that they be allowed to retire and that we have a robust pipeline of nurse practitioners ready to step into their shoes. We, last year, as I said, we did a billion in patient care visits according to Medicare. Nurse practitioners and PAs care for about 66% of the rural Medicare population. So we really are a rural, we're the backbone of rural healthcare. So without the ability for nurses who are interested in furthering your education to become a nurse practitioner or other type of advanced practice nurses, we're gonna really kink the pipeline when at a time in our nation's history when we have a shortage of healthcare providers for people [00:06:00] who, who are in, you know, the medical profession, particularly those studying to become a nurse practitioner. I can see where this would be a concern. I can also see people saying, well, but I'm not going to school to become one. So really this doesn't affect me. But actually talk to me about what this means for patients and for, for communities. It does. It means that with fewer healthcare providers, you're gonna have longer wait times to see a primary care provider. I don't know if you've tried to find one recently. People are waiting months and months and months to find one. There'll be longer those, those wait times will get significantly longer. Patients will have less access to specialty care services. We have a lot of nurse practitioners working in both primary care, acute and specialty care, so longer wait times, less mental health. Services, which we desperately need in this country. We need more mental health, not less so, it will ultimately affect the patient. And that's, that's really where our main concerns lie, is that the patient isn't gonna get what they need. So let's talk about from, you know, the, the classification. Is it gonna do anything positive or is, [00:07:00] is it mainly concern? Obviously it was suggested for reasons that made sense to somebody, but what's the good and what's the bad of this proposal? I can't say a lot of good. I mean, they removed the grad plus loans. They created categories. The problems that we see is that if there's no federal loan available or there's a cap, there'll be several problems. The biggest one for us is if you can't get federal loans to cover the cost of your education, you're gonna turn to private loans, which tend to have a much higher interest rate. Aren't usually subject to the same repayment options. Um, often with federal loans, there's some grace period to allow you to finish your education before you have to start paying it back. We don't always see that with private loans. What changes might you recommend they make before they, they issue a final rule on this? Yeah, so we're asking everyone to write in. To the Department of Education and specifically ask the Department of Education to include post baccalaureate nursing programs and the definition of professional degree, I will [00:08:00] address. One thing that we'd heard a lot early when we first heard about this was that we were being called. Not professionals. I don't think that's what the intention of this is. It's a category of loan. It's not a character characterization of, of the care we provide. We provide excellent care as nurses and as advanced practice nurses. So it's not that, but certainly when, when we heard that we weren't included with the other professionals, it did sting. I'll be honest. Well, and as, as you and I were talking, this is for the sake of the listener before we went on the air, uh, Dr. Full and I were talking about my daughter spent, uh, most of the night in the emergency room here a couple nights ago. And it was a nurse practitioner who ultimately attended to her. And I'll tell you at that point, I was not gonna, well, just a nurse practitioner, are you a professional or are you a graduate? I was just grateful to have someone who was there, who knew what to do. And, and so absolutely, I'm, I'm very much on, on the side of, you know. Where, wherever they can help. That's, that's wonderful. How do those who, uh, [00:09:00] wanna make their voices heard in terms of this public comment period, how do they best go about, uh, making sure that, that they're reaching the people who need to hear it? Yeah, so I'm gonna give you a link to the American Association of Nurse Practitioners website, www.aamp.org. As soon as you open that page, you'll see a place that says, make comments here, or Take action here. There's a button right at the bottom. There are templates in there for students, for advocates, which, and you don't have to be a nurse practitioner to use this website. You can be a patient, you can be. Someone, a family member. You can be anyone. Anyone can use it. It will help you write a template. Again, we're asking people to personalize it with a story like your story from the emergency department, because we've heard that the Department of Education may try or maybe using AI to read some of these responses. There's been more than 25,000 responses so far, and there's more coming in. Comment period ends March 2nd, but we're asking people to try to get it in ahead of that, [00:10:00] in case they close it off. But yes, please write in, please specifically say you want post-baccalaureate nursing included in the definition of professional degree. I have to admit this, this is, uh, it, it kind of throws me for a little bit of a loop because it's the Department of Education that is actually making this proposed rule change. And, you know, I would've expected, you know, the FDA or USD, I don't know, you know something, you know that. That I would more, more likely associate with medicine. But to get these, uh, these individuals trained as nurse practitioners, I guess education is, is the way that it's done. Absolutely, and and the interesting thing is the federal government has a definition of what a professional degree is, and it's one that requires skill belong Beyond the levels of a bachelor's and often professional licensure is required. Nurse practitioners are required to obtain additional skills and education beyond the level of the bachelor's degree. So it's a master's or a doctorate. As I mentioned, we are, we have to take a national certifying exam. We were. Are [00:11:00] required to carry state licensure, both as an RN and as an advanced practice registered nurse. And so we meet the definition, so to not include us seems unjustifiable. And, and also to provide some context, just so people understand, uh, the, the, the type of education that is being taken on when one seeks to become a nurse practitioner. Talk to me a little bit about the timeframe involved and, and if you want to talk about what, what are the expenses of obtaining such an education? Absolutely. So for nurse, I'll speak for nurse practitioners, but I can also throw out some o other numbers that that we've been seeing since this came out. So to become a nurse practitioner, you have to have a bachelor's in nursing, so that's a four year degree in nursing. You have to graduate from that program and then you enroll into a nurse practitioner program. At a minimum, it's two years, some are two and a half years, depending on the type. For a master's degree, if you wanna go on for a doctorate, depending on what type of doctorate, whether it's a clinical doctorate or a research doctorate, it's at least two to four years, more, at least so [00:12:00] many years of education involved here. And we are trained like the other professionals that were included in the, in the proposed rule. And so it, it is frustrating and it's really hard to fathom in some way. Is that we weren't considered to be the same as the folks in that were included. And I don't know if you've seen the list, it was physicians, dentists, veterinarians, chiropractors, podiatrists. Theologians. Oh, and licensed clinical psychologists. I might be missing another one. But yeah, very similar trajectories. Um, and so. It's, it's con confounding for sure. It sounds like every one of the professions you've just described, we're not talking about, oh, you just work your way through college. You'll, you know, just pick up a part-time job. You'll be able to pay for it. I mean, this is, this is seriously e expensive, uh, training. But tell me this, not withstanding the, the time commitment, the, the effort that's required to, to master those, uh, those subjects and, and to pass. [00:13:00] Why do people choose to go into this particular line of work? So as opposed to our medicine colleagues, we are nurses at heart and nurses carry a very different perspective to care. We like to see the person as a whole being a whole entity, not just a disease or a condition that they might have. Nurse practitioners are also born educators. We like to educate. We spend a lot of time doing patient education, and you may have seen that even in your ED visit. Lots of education being given because we know that that will help people live their best lives. So it's often an, you've been a nurse, there's a desire to go back because you wanna do more. And that's exactly what it was for me. I was, uh, I had been working as a nurse in Boston. I was ready to take that next step. I knew that we could do better in certain areas, and so the nurse practitioner degree allowed me to do that. And, and once again, I'm gonna ask you for, for the sake of those who maybe grabbed a pencil and paper, wanting to write down the, the web address that you gave earlier, by which they can make their voices heard. What was that address? Once more. A [00:14:00] A np.org Okay. Yes. Is there anything else that, uh, that you would want people to, to better understand about, uh, what you do and why it's important that, that people make their voices heard on this subject? Sure. So by excluding nurse practitioner programs from the, from the definition of professional degree, the department's really outta step with modern healthcare. Like I mentioned, nurse practitioners are the backbone of healthcare in many communities, particularly in our rural communities. So to exclude them, again, is unjustifiable. There's no reason to exclude them, and we are asking the Department of Education to please include us in the definition of. Professional degree so that students that are interested in going back have those funds available to them. Because the last state I saw was we have a hundred million Americans who don't have access to primary healthcare services. Nurse practitioners are the answer to that problem. We can answer the call, but we need the educational funds to get us there. Is that primarily a challenge in rural communities or is [00:15:00] that a challenge that's seen regardless of, of, you know, the size of community? It's everywhere. So in rural communities, I think I mentioned that Medicare data, we see we're responsible for the primary care in medic rural areas. About 66% of patients who receive Medicare receive their care from a nurse practitioner or a pa. In non-rural areas, it's around 50 to 56%. So we're, we're doing a lot of primary healthcare in this country. As, as well as acute and specialty care. I've done surgery for the last 22 years of my career, which is really considered a specialty, but a lot of care is being provided by nurse practitioners and by other advanced practice nurses. And I will say that some of the data that I've seen, the average nurse practitioner program was somewhere between a hundred and a $129,000. Where students may also get caught up here though, is some nursing programs work on a trimester system, meaning they go. Spring, summer, fall 20,500 for a whole year isn't gonna get you through three semesters, [00:16:00] as you probably know. Well. So those students will also find themselves, you know, sometime during their academic year without funds. Again, we are talking with Dr. Valerie Fuller, president of the American Association of Nurse Practitioners. Thank you so much for being our guest today on the Health Policy Podcast. Thank you, Brian. It was great to be here.