Proceedings of a Workshop Series—in Brief

Convened February 28, March 25, April 1, and April 23–24, 2025

Affordability of Health Professional Education
Proceedings of a Workshop Series—in Brief

The Global Forum on Innovation in Health Professional Education of the National Academies of Sciences, Engineering, and Medicine convened a workshop series in early 2025 to explore the issue of affordability of health professional education (HPE). A committee planned the series according to a Statement of Task. This expert committee selected speakers and panelists to discuss educational and financial models of HPE programs, drawing from examples in the United States and around the globe. The workshop was divided into four parts, with virtual sessions held in February, March, and April and a culminating hybrid event on April 23 and 24, 2025. Participants in virtual sessions looked at specific topics within the broader issue of affordability: cost as a barrier to HPE, payment models for HPE, and cost as a barrier to entering primary care and working in rural settings. Information gathered from these sessions was used to inform the April workshop, which focused on the value proposition of HPE. This Proceedings of a Workshop Series—in Brief presents a summary of the presentations and discussions at the workshop sessions in chronological order.

COST AS A BARRIER TO HPE¹

The first session, held February 28, 2025, was designed to examine whether the cost of education is a barrier to pursuing a career in the health professions and identify cost barriers that limit entry into HPE. Zohray Talib, California University of Science and Medicine and cochair of the Global Forum on Innovation and Health Professions Education, welcomed participants to the session and introduced Bianca Frogner, University of Washington, and Mark Merrick, University of Toledo, the planning committee cochairs. Merrick explained that the question of whether cost is a barrier is an important one to ask for several reasons. First, applications to many HPE programs are declining, resulting in a growing misalignment with high employment demand. Second, requirements in the health professions for higher levels of education have cost implications for students along with debt-related stress and anxiety for both practitioners and students. Third, high levels of postgraduate student debt can add to clinician distress and burnout, further reducing the already limited number of clinical preceptors. Merrick underscored the importance of understanding how students perceive the value of higher education and whether this calculation influences early decisions on pursuing a career in the health professions.

The health professions have potentially multiple pathways (Figure 1), with different roles needing different educational requirements and associated costs, said Merrick. For most, the bachelor’s degree is just one step

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of the journey toward obtaining a health professional degree. Merrick underscored that graduate-level training is now the “norm” for health professionals, with cost implications for each level of degree requirement.

Is Cost a Barrier to Entering HPE?

Given the importance of a robust health workforce, said Richard Shields, University of Iowa, it is critical to understand the role that educational cost plays in the decisions that individuals make about their education and career. One way of determining the economic value—or return on investment (ROI)—of an HPE program is to look at the starting salary, annual salary growth, and duration of career. Shields and his colleague conducted this economic analysis for several careers, assessing educational debt and assumptions about future economic conditions. It allows for comparing the present value of various degrees; obstetrics/gynecology and surgery have the highest value at over $2 million,² and chiropractic and bachelor’s degrees are at the lower end with a value under $1 million (Shields et al., 2023). Shields used physical therapy (PT) as an example to demonstrate how the value of a degree and career can be modeled. The average PT entry-level salary is $77,750, with a growth rate of 1.51 percent. The average educational debt is $99,592. The question, said Shields, is whether an individual can manage the repayment of this debt. Federal guidelines recommend that debt payments not exceed 15 percent of discretionary income; Shields calculated that given entry-level salaries, a debt of over $150,000 would be unmanageable. Shields emphasized that debt highly influences decisions about career selection and job satisfaction. Shields’ work found that debt influenced the career decisions for 62 percent of students, and the data suggest a correlation between debt and career regret. Creating a robust health care workforce, said Shields, requires examining educational debt and how it may cause downstream effects, like exhaustion, career regret, and workforce attrition.

Cost of Moving Up the Career Ladder

Nathan Sick, Urban Institute, said that entry-level health care training programs tend to be relatively affordable and accessible. For example, certified nursing assistant

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(CNA) training costs $500–2,000 and takes only a few months to complete. Those with lower incomes have several avenues to access this type of entry-level training, such as employer-subsidized training, Pell grants, and tuition assistance. However, the wages in these careers also tend to be low, and a family-sustaining wage may only be accessible with further education and training. Studies show that it is relatively rare for entry-level health professionals to complete a higher degree or credential; only 3–7 percent of CNAs advanced to a licensed practical nurse, licensed vocational nurse, or registered nurse (RN). These higher-level programs take substantially more time than entry-level programs and are far more expensive, said Sick. While eventual earnings are likely to be higher, many barriers exist to advancement for entry-level professionals. Students may not be able to work during the program, either requiring more savings or incurring more debt. They may need more support to attend class, such as childcare or transportation. Coursework is harder, and students may be balancing other responsibilities, such as working and/or parenting. If students can overcome these barriers, they will earn substantially more income at the higher-level credential, said Sick, but many do not end up completing these programs. Some students may instead opt to stack entry-level credentials—for example, CNA, phlebotomy, and EKG certificates—but no evidence shows that this will appreciably increase earnings. Despite many barriers that prevent completing higher-level education and training, said Sick, evidence shows that innovative approaches—such as co-location of training and employment, strong employer support, and flexible training hours—can address these and facilitate moves up the career ladder.

Australian Perspective

For a non-U.S. perspective on cost as a barrier to HPE, Jonathan Foo, Monash University, spoke about the structure for financing HPE in Australia. The federal government sets national tuition for all public undergraduate programs, said Foo. Students are expected to contribute a portion of this, and the government contributes another portion. Most students are eligible for this assistance, said Foo, with 90 percent of domestic medical students qualifying. As a result of this support, Foo said that most students do not pay any tuition until they graduate and begin working. Despite these supports, surveys of young people in Australia have shown that the cost of tuition and reluctance to take on loans are among the top barriers to attending university.

Student Perspective

Kashon Corley, Ubiquitous Counseling Services, and Breanne Jaqua, A.T. Still University, spoke about the student experience with the costs of HPE. Speaking from the perspective of a former student and now professor of osteopathic medicine, Jaqua said that HPE has many hidden costs. First, most students are unable to earn any significant income while attending school. For those with dependents, taking on debt for living expenses can be a “daunting prospect.” Second, licensing exams occur during school; these cost around $1,000, and many students also pay for preparatory courses and materials to improve their likelihood of success. Third, many students must relocate for their clinical rotations; some may end up paying double to retain their permanent housing while living in temporary housing. Fourth, enormous costs can be associated with travel during medical school. Students may need to travel for audition rotations and in-person interviews for residency programs. “A conservative 10 to 15 interviews” are often needed, and the costs quickly add up to thousands of dollars, she noted.

Corley spoke about her experience becoming a licensed mental health counselor. After getting an undergraduate degree in psychology, Corley realized she would need more education to obtain a job that could pay off her undergraduate debt. She chose mental health counseling and quickly learned about the costs involved with completing the required 3,000 hours of direct care with clients, including paying a licensed professional counselor to supervise her during these hours. She juggled that requirement with studying for her licensing exam and being a single mother. Corley said she was fortunate that she had a paid internship, family support, and family childcare, noting that some peers did not have these privileges and had to pay for daycare just to complete their internships. Corley also discussed experiencing mental and physical strain, admitting that if she had known the hidden costs of her program up front, she might have chosen a different one or looked for alternative ways of paying for her education. Ultimately, both Corley and Jaqua acknowledged a point of no return where each was so far invested that the financial risks of not

completing the programs far outweighed the burdens of earning the degree.

PAYMENT MODELS FOR HPE³

On March 25, 2025, the second part of the workshop series was held with a focus on looking at payment models for HPE. Frogner remarked that becoming a health professional can be expensive. Some health professions do not require an undergraduate degree, but they tend to be low paying. Obtaining a bachelor’s degree incurs significant costs already, and if an individual chooses to pursue a master’s or doctorate program, costs can be enormous. Some professions have changed their criteria for entry-level jobs, requiring higher levels of education and thus an ultimately higher financial cost. This session, she said, was designed to explore various payment and educational models that have applicability to HPE.

Repayment Plans for Loans

Many students rely on federal and private loans to pay for their education, said Betsy Mayotte, Institute of Student Loan Advisors. Student loan debt totals $1.6 trillion, with private debt accounting for $130 billion of this. About 70 percent of medical school students graduate with an average debt of $223,000, with half of all graduates owing more than $150,000 (Murphy, 2024). Student loan debt impacts more than recent graduates, said Mayotte, with over half of loan holders being over 35 years old and 20 percent over 50. “The fastest-growing population of student debt holders is those over 65, and the default rate increases with age,” she remarked.

The options for paying back loans differed depending on source and type of loan, Mayotte explained. Non-federal loans are generally repaid on a 10–20-year schedule, with limited forbearance options. If a private debt is unpaid, cosigners may be impacted, and debts may be sold and litigated. Federal loan repayment had a variety of options as of early 2025, including the 10-year standard plan, graduated repayment that increases over time, and plans in which payments are based on income and any remaining debt is forgiven after 20–25 years. However, this is a “chaotic time” for student loans, said Mayotte, with multiple proposals from Congress to eliminate some options,⁴ which would leave fewer income-based plans and eliminate or push back the opportunity for forgiveness. Additionally, proposals to limit the federal loans available would result in medical students relying on larger private loans to cover the remaining cost of school.

Other repayment and forgiveness plans are available for loan holders working in certain areas or for certain employers, said Mayotte. Many states have programs that help health care workers repay their loans while working in underserved areas. Some employers may also offer loan repayment assistance. Although some federal loan repayment options exist for health care workers, these can be difficult to comply with and expensive to default on.

Apprenticeship Degrees

Joe E. Ross, Reach University, told participants about his nonprofit institution, serving 2,600 working adults across seven states. Its mission, he said, is to turn jobs into degrees through an “earn as you learn” model. The university was established 5 years ago with a focus on teachers. This country has a significant shortage of teachers, said Ross. At the same time, many professionals in schools have the interest and ability to become teachers but cannot afford to stop working to pursue a degree. If only a fraction of them could become teachers, he said, the shortage would be eliminated. Ross emphasized that affordability is achieved through both seeking a variety of funding sources and designing the program itself to be efficient and affordable. The success of the apprenticeship model in education could be adapted and scaled to address workforce shortages in areas such as health care, said Ross.

Cooperative (Co-Op) Models

John Doherty, Drexel University, said that the school uses a unique co-op educational model, allowing students to test-drive a career and get hands-on workplace experience. Students can integrate what they learn in the classroom with what they learn in the workplace, enhancing both experiences. First, he noted, students take Co-op 101, a class that helps them learn about the working world—how to create a resume, network with professionals, and explore job opportunities. Drexel students

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pursuing undergraduate degrees in nursing, health sciences, and health services administration complete their co-op experience at a variety of employers in a variety of roles, said Doherty. Nearly all the jobs in the health care field are paid positions, with an average wage of $15.50–17.00 per hour.⁵ After graduation, about half of students receive a job offer from their co-op employer; about a third end up working for a previous employer, some work for other employers in their field, and some pursue further studies. Doherty said that the co-op experience makes Drexel graduates very appealing to employers.

HPE Pathway Programs

Another approach for funding HPE is pathway programs designed to help students navigate their education and training, often with a commitment to a specific employer or area of employment after graduation. Sara North, University of Minnesota, told workshop participants about two such programs. The Doctor of Physical Therapy (DPT) program at the University of Minnesota has partnered with the company Big Stone Therapies to offer a rural health care scholarship. In the second program, undergraduate students in biology and exercise science at the University of Minnesota—Morris (in a nonmetro area) can apply for early assurance to the DPT program. If selected, students receive mentoring and research opportunities and a guaranteed seat in the DPT program upon successful progression. North emphasized the need for data on whether these types of programs accomplish their goal of getting more health care professionals to work in rural and nonmetro areas of the state.

Merrick joined North to discuss three more examples of HPE pathway programs. The first is a partnership between the University of Toledo College of Nursing and ProMedica, a large health system that operates multiple hospitals. Pre-nursing students are hired by ProMedica for non-nursing roles, such as registration or transport. They obtain on-the-job training and familiarity with the health system. This program gives the health system and student a longitudinal relationship, said Merrick, and creates a graduate who is “ready to hit the ground running.” A second example Merrick shared was the Great Minds Fellowship, which Ohio sponsored in response to a need for more mental and behavioral health providers. It provides scholarships to behavioral health students in the final 2 years of their program. Because it is only available to enrolled students, it rewards people who have already decided to join these fields but does not drive enrollment into them. The third example that Merrick discussed was a supplement to the fellowship; the Ohio Behavioral Health Workforce Expansion program made funds available to institutions that had proposals to address the shortage of behavioral health workers.

Repayment Through Military Service

One way that health profession students can fund their education, said Lynette Hamlin, Uniformed Services University, is military service. Several approaches exist, with different eligibility criteria and service obligations. The Uniformed Services University of Health Sciences offers four military-operated schools in medicine, nursing, dentistry, and allied health sciences. Like undergraduate academies (e.g., West Point), students are not charged tuition but repay their debt through service obligation. These schools are all accredited by relevant national organizations, said Hamlin, but have a unique emphasis on military health and leadership.

Hamlin also mentioned the Health Professions Scholarship Program offered by the Air Force, Army, and Navy that covers tuition, a living stipend, books, and equipment. It is available for medical, dental, veterinary, nursing, counseling and clinical psychology, and optometry programs and can be used at any accredited school. Funding HPE through military service has benefits for both students and the military, said Hamlin. Students can earn a degree with no payment or debt and have a guaranteed job after graduation. At the same time, these programs ensure ROI for the military and allow it to scale up or down its health care providers.

IMPACT OF COST ON INTENTION TO ENTER PRIMARY CARE⁶

On April 1, 2025, the third part of the workshop series was held to discuss how the cost of HPE impacts the intention or ability to enter primary care and/or work in rural settings of students with high income-potential career paths. A presentation about the primary care workforce shortage set the stage, followed by a panel discussion among representatives from nursing, med-

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icine, and dentistry. The second half of the session featured speaker presentations about strategies used around the globe to incentivize entry into the primary care workforce.

A Dire Shortage in the Primary Care Workforce

“Primary care physicians are important,” opened Asaf Bitton, Ariadne Labs and Harvard University. A higher density of them is associated with higher life expectancy at the county level. Unfortunately, their density and number per capita are falling, as is the percentage of U.S. people with a usual source of care (Basu et al., 2019). Bitton noted that density is higher in high-need areas, but the share of all clinicians (physicians, nurse practitioners [NPs], and physician associates) in primary care has remained stagnant. The outlook is poor, with only 15 percent of physicians entering primary care (21.6 percent including hospitalists) and the COVID pandemic pushing many clinicians out of practice. Bitton stated that the job of a primary care physician can be difficult to manage. In addition to the low expenditure on primary care, they deal with frustrating electronic health record systems and increasingly fragmented patient care. Bitton highlighted that Medicare patients are seeing an increasingly large number of physicians (Rawal et al., 2023), resulting in more information, messages, medications, and procedures for primary care teams to coordinate and integrate.

Cost of Education and Intention to Enter Primary Care

Miko Rose, Indiana University of Pennsylvania, moderated a discussion about HPE financing and primary care among global leaders in medicine, nursing, and dentistry. She asked each panelist to briefly describe the HPE system in their region and comment on how cost and debt may impact graduate entry into primary care.

Medical Education in the United Kingdom

A medical degree in the United Kingdom (UK) requires 4–6 years of school; the majority of graduates complete a 5-year undergraduate degree, said Courtney Krstic, Medical Schools Council UK. Tuition fees are standardized at just over £9,000 per year, and most students rely on student loans provided through a partnership between the government and loan companies. Repayment begins once a graduate earns over a threshold amount and is taken out of their paycheck automatically. If a loan has not been fully paid after 30 years, the balance is forgiven. Undergraduate student loans provide tuition—paid directly to the university—and a stipend of about £10,000 per year. About 90 percent of medical students report that this stipend does not cover their living expenses, said Krstic; some students work, and many receive family support to be able to continue their studies. This gap in financial support serves as a barrier to lower-income students entering medical school, said Krstic. She added that these loans only cover a student’s first degree. Students who already have an undergraduate degree and are entering a 4-year graduate medical program generally have to pay out of pocket or through a bank loan.

Rural areas have fewer general practitioners, said Krstic, and the United Kingdom has responded to this shortage by increasing the availability of medical education and training in rural areas. She found that students who learn and train in rural areas are more likely to stay in those areas when they become qualified doctors, she said. The expansion of medical schools into rural communities has generally been successful, said Krstic, though more research is needed.

Medical Education in the United Arab Emirates (UAE)

Medical education in the United Arab Emirates has traditionally used the UK model of the Bachelor of Medicine and Bachelor of Surgery (MBBS), said Eman Alefishat, Khalifa University College of Medicine and Health Sciences. Khalifa is home to the first U.S.-style medical program in the country, and it was launched with merit-based scholarships to attract top applicants and differentiate it from the MBBS programs in the region. Many students rely on these and other institutional scholarships, she said, while the rest have family support. Taking out student loans is uncommon. When selecting an area of specialty, students tend to focus more on quality of life and personal interest rather than salary. Alefishat said that this is due to several factors, including the lack of financial pressure to pay off loans; availability and accessibility of general practice residencies; and relatively small difference in salary between general and specialty practice. Some residents who enter general practice later decide to pursue a specialty, said Alefishat, but the majority remain in primary care.

U.S. Dental Education

The ratio of generalists and specialists in dentistry is very different from that of medicine, said Richard Valachovic, New York University (NYU) Dentistry Center for Oral

Health Policy and Management. About 80 percent of U.S. dentists are generalists and 20 percent are specialists, in contrast to medicine, with only about 30 percent of physicians in general primary care—including family medicine, internists, geriatricians, and pediatricians—and 70 percent specialized. Dental education is a 4-year program after a 4-year undergraduate degree. At the end of this intense training, said Valachovic, a dentist should be competent and able to practice independently. He noted that dental school is a relatively short period in a lifelong career; these 4 years need to prepare dentists for the next 40 years. The number of dentists graduating each year has not grown significantly, said Valachovic, despite population growth. Demand is huge for both general and specialty dental care, particularly in rural communities. New dental schools are opening, said Valachovic, some of which are meant to address rural provider shortages, but with “a long way to go” to meet the dental needs of the entire population.

U.S. Tuition-Free and Accelerated Medical Schools

Rafael Rivera, NYU Grossman School of Medicine, discussed the tuition-free medical school model. There were two goals in making Grossman tuition-free, he said. First, to reduce graduate debt; with the average U.S. graduate carrying a debt of $200,000, it is a “moral good” to address this burden. Second, to keep the country’s best and brightest students on the path to becoming physicians. If a potential leader in medicine is pushed into another field due to financial reasons, this is a big loss. It took about 10 years to raise the funds for the model, said Rivera, and it has resonated with applicants. In the first year, applications increased by 50 percent, and applications from socioeconomically disadvantaged students increased by 75 percent. Rivera noted that while primary care is important, increasing the number of primary care physicians was not a main driver of this tuition-free model.

Another tuition-free program at Grossman (Long Island campus) is dedicated specifically to primary care, said Rivera, offering an accelerated pathway for students to graduate in 3 years with guaranteed acceptance into one of 21 residency programs. After its early success, the model was scaled up to 32 medical schools across the country. Research has shown that 3-year graduates are academically equal to 4-year graduates, and residency directors report no difference in performance (Satyamoorthi et al., 2025). The difference, Rivera emphasized, is the significant financial value for the students. The best way to improve the value is to shorten the time to degree; a study found that the additional value of an accelerated pathway is $240,000, primarily due to an extra year of salary and foregoing the costs associated with the fourth year of school. Of the students who graduate from either tuition-free program at Grossman, 83 percent have no medical education debt. The remainder have about a quarter of the average debt of U.S. medical graduates.

U.S. NP Education

The cost of NP education is significantly less than physician education, said Melissa Stoudmire, Cleveland Clinic. Debt for graduates is $40,000–60,000, she said, and cost does not seem to be a barrier for entering primary care. Six recognized certifications exist, with three in primary care: adult gerontology, family, and pediatrics. Of the 385,000 U.S. NPs, about 89 percent are certified in and 69 percent work in primary care. Stoudmire observed that the choice of specialization is often related to experience as an RN; for example, an RN in endocrinology may want to pursue a NP specialty in it. Primary care and specialty NPs do not have a significant difference in salary, said Stoudmire, but their work hours and schedule may differ by specialty.

Global Efforts to Alleviate Primary Care Shortages

The second panel of the primary care session included presenters sharing initiatives or models that could help alleviate primary care shortages in their country (Brazil, Canada, and United States), with potentially global lessons.

Brazil

To become a doctor in Brazil, said Mario Dal Poz, Rio de Janeiro State University, an individual applies for admission to an undergraduate medical program, completes 6 years of medical coursework, and begins a residency. Medical schools have different funding structures and are both public and private. The public programs are tuition free and funded with federal and state money. Admission is competitive, and enrollment accounts for 20–30 percent of total medical students. Private medical programs are tuition based and of varying quality and cost, said Dal Poz. Funding for these programs comes from tuition, government student loans, government scholar-

ships, private scholarships, and out-of-pocket payments. Several factors affect primary care and rural practice, he said. These include high debt among medical school graduates, limited government loan and scholarship support for medical programs, retention issues in rural areas, a concentration of medical schools in urban areas, and a lack of prestige in primary care.

Canada

The pathway to becoming a family physician in Canada, said Milena Forte, University of Toronto, involves a bachelor’s degree, 3–4 years of medical school, a 2-year family medicine residency, a licensure exam, and an optional fellowship. The average debt of a graduate is $164,688 CAD, which takes most students around 10 years to pay off (AFMC, 2022). Family medicine practices bring in less money than medical or surgical specialists, said Forte, with nearly all the earnings coming from the single-payer government health care system.

Efforts to address what has been termed a “primary care crisis” are underway through federal and provincial government funding and educational strategies within family medicine residency programs, said Forte. Funding strategies include loan forgiveness and repayment plans, incentives to practice in rural areas, return of service agreements and financial incentives, grant programs, and efforts to address relativity in remuneration. One promising effort, said Forte, is a multi-pronged initiative in Ontario to connect all people to primary care within the next 5 years. It will include creating robust, interprofessional primary care teams, enhancing digital tools, and reducing administrative burdens. Educational strategies to increase family physicians include early exposure to the field and experience in underserved areas, distributed medical education sites, and new medical schools with enhanced focus on primary care. These recruitment and retention strategies, said Forte, can bolster the primary care pathway, distribute workforce in underserved areas, and support physician well-being through robust, interprofessional teams.

Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Program

The WWAMI program, said Frank Batcha, University of Washington School of Medicine, Idaho WWAMI, is a partnership among the states of Washington, Wyoming, Alaska, Montana, and Idaho that aims to provide high-quality medical education to students from these states. It has had several initiatives to increase primary care physicians in rural areas. One program is aimed at reducing the burden of student debt for those who practice rurally, said Batcha. The Rural Physician Incentive Program awards up to $100,000 in loan repayment over 4 years and is funded through WWAMI student contributions of $2,000 per year that are matched 2:1 by the state. In addition to financing incentives, WWAMI increases opportunities to train in rural areas through Targeted Rural and Underserved Track, a program that provides continuous connection between underserved communities, medical education, and health professionals in the region by creating a full-circle pipeline.

VALUE PROPOSITION FOR HEALTH PROFESSIONAL EDUCATION⁷

On April 23 and 24, 2025, Part 4 of the workshop was held. Building on information gathered from the three earlier segments, it explored the value proposition of HPE and whether the ROI improves with shifts in payment and/or educational structures.

Value Proposition

Value Proposition for Higher Education

Affordability is one of the major challenges in improving access to higher education, said Catharine Bond Hill, managing director, Ithaka S&R, Ithaka Harbors. The data is clear that higher education has a strong ROI. For individuals, median cumulative lifetime earnings are directly correlated with the level of education, even when accounting for loan repayment, tuition, fees, and other costs of education. However, it can still feel risky for an individual to invest in education, she said. While some individuals will earn an average or above-average salary, some will earn a lower salary that may not balance out the costs of education. For others, a lack of financial liquidity means they cannot pay the initial costs, even with the expectation of future returns. Hill stated, “The United States has 44 million people who have some credit but no degree. This translates into roughly 13 percent of the population who paid or borrowed the initial costs of education but are not getting the returns associated with a higher degree, including personal and public benefits.” She noted that public benefits include higher productivity, higher net tax revenue, less reliance on government financial support, lower crime and disease rates, better

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social cohesion, and more voter participation. Ultimately, education is a public good, she said, the government has a role in facilitating accessibility and affordability.

Value Proposition for HPE

Foo spoke about the value proposition for HPE specifically. When a prospective student looks at different pathways, they consider the value offered by each one—whether the benefits outweigh the costs of securing them. For HPE, benefits could include future earnings, prestige, and job satisfaction. The costs include tuition, time, cost of living, and opportunity costs. If costs are reduced, the value of HPE rises, said Foo. This can be achieved by either making education less expensive or shifting the costs to a different payer. Foo added that value depends on perspective. HPE has value for all stakeholders—health organizations, government, patients, students, and academic institutions—but the specific benefits and costs are different and may be weighed differently. For example, said Foo, students who are older, from a rural or disadvantaged background, or the first in their family to go to college may experience the benefits and costs of HPE differently than traditional students.

Improving the Value Proposition

As Foo noted, the value proposition of HPE can be improved by either shifting costs to another stakeholder or reducing the costs of education. Presenters discussed both approaches.

Shifting Costs to the Employer

Brittany Burke, Norton Healthcare, said that its Student Nurse Apprenticeship Program provides paid work experience during school. It is a 12–18-month program open to students pursuing their Associate Degree in Nursing or Bachelor of Science in Nursing. From 2017 to 2024, over 1,000 students have participated, ranging in age from 18 to 59, from 24 different nursing schools. Each participant completes more than 280 practice hours and more than 66 education hours. During this time, said Burke, they learn how to have conversations with patients and families; administer medication; and assess, admit, and discharge patients—in other words, “the ins and outs of what it is to be a licensed nurse.” After graduation, nine out of 10 graduates stay at Norton as full-time RNs, and 92 percent of these stay at least 1 year as bedside RNs. Burke said that each student costs the program on average $6,000–7,000 but that savings far exceed these costs; after eight completed cohorts, Norton has avoided over $47 million in turnover costs. In addition to the financial benefits, she said nurses come into the workplace confident, competent, and ready to work. Employers can no longer wait for students to graduate and then train them, said Burke. Being at the table from the beginning benefits employers but also helps their academic colleagues understand current practice needs and ensures student training is the most up to date. If employers want a prepared and competent workforce, they need to look at students as human capital and make the investment, she concluded.

Cost-Effective Education

Reducing the cost of HPE is another approach for increasing its value, said Jennifer Cleland, Lee Kong Chian School of Medicine, Singapore. However, this is not a simple task. Education budgets are finite—there is only “one pot of money.” Some of this money is restricted to a certain use, she said, and cannot be reallocated. In some cases, the pot is getting smaller while costs are increasing. Cleland said that every choice made in HPE has a cost; for example, if a school decides to put more resources into simulation education, that money cannot be used somewhere else. Cleland shared a formula, known as the “assessment utility index” and based on Van Der Vleuten’s framework for designing and evaluating an assessment process, that can be used to assess the utility of HPE (Van Der Vleuten, 1996):

U = Utility, R = Reliability; V = Validity; E = Educational impact; A = Acceptability; C = Cost; W = Weight.

To have a strong ROI, education needs to be reliable, be valid, have an educational impact, be acceptable to individuals and groups with varying interests, and consider costs, said Cleland. Two basic strategies exist for cutting costs to achieve the best ROI—revising current practices or restructuring to do things differently. Revising practices begins by asking a series of questions about an HPE program, said Cleland. First, what do things “actually” cost? What are the major expenses? What could be changed, and what is immutable? What is the balance between cost and value? Cleland noted that some aspects of HPE are unchallengeable because of standards and regulations, while others persist largely due to tradition.

Cleland encouraged educators to ask questions when considering integrating emerging technologies or any innovation into HPE:

• How does the new tool fit with the rest of the curriculum and wider learning?
• How does it change things?
• Is it necessary?
• Does it improve patient safety and health care outcomes?
• What are the costs and the benefits?

Cleland concluded by saying, “if it were easy to balance cost and value in HPE, we’d have done it already.” Ultimately, this requires a mix of small and major changes, both of which are difficult but necessary.

FINAL REFLECTIONS

In the final session, participants, speakers, and planning committee members shared their thoughts and reflections. Merrick began by describing a shift in perspective that he experienced during the workshop. Many health professions have recently begun to require more education, moving the entry-level credential from bachelor’s to master’s or from master’s to doctorate. This is the “just in case” approach to education, said Merrick; learners are prepared to deal with any situation that might arise, and curriculum expands to fit all the content that may possibly be useful. An alternative approach, he said, is “just in time” education, in which learners are prepared to handle the issues they will be dealing with daily and acquire additional skills as needed. The aim of education is to not only prepare graduates for a specific job but also equip them with the ability to adapt as job requirements shift. “The world is changing, and we’re going to have to change with it,” said Merrick. Frogner added that “just as the world is shifting, so too is the HPE student body.” More learners are coming back later in life but are now taking care of families, juggling jobs and school. Rather than serving as an impediment to education, she said, these characteristics can be seen as a complement to it. Frogner closed the workshop, remarking that ways exist to align the needs and realities of today’s learners with the needs and realities of HPE and the health care system, so that both achieve a ROI.

REFERENCES

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Murphy, B. 2024. Medical student financial FAQ: Insight on loan forgiveness, repayment. American Medical Association. https://www.ama-assn.org/medical-students/medical-school-life/medical-student-financial-faq-insight-loan-forgiveness (accessed July 11, 2025).

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Shields, R. K., S. Manish, B. E. Shields, J. N. Tofte, and S. Dudley-Javoroski. 2023. Healthcare educational debt in the United States: Unequal economic impact within interprofessional team members. BMC Medical Education 23(1):666.

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DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Erin Hammers-Forstag and Patricia Cuff as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

PLANNING COMMITTEE Bianca Frogner (Cochair), University of Washington; Mark Merrick (Cochair), University of Toledo; Eman Alefishat, Khalifa University, UAE; Edson Araujo, World Bank; Richard Berman, University of South Florida; Kashon Corley, Ubiquitous Counseling Services; Siobhan Fitzpatrick, World Health Organization; Valarie Fleming, University of Tennessee Health Science Center; Jonathan Foo, Monash University; Lynette Hamlin, Uniformed Services University; Elizabeth Mayotte, Institute of Student Loan Advisors; Sara North, University of Minnesota; Miko Rose, Indiana University of Pennsylvania; and JoAnn Yánez, Association of Accredited Naturopathic Medical Colleges. The National Academies’ planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Stephanie Petrosky, Nova Southeastern University. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop series was supported by the Global Forum on Innovation in Health Professional Education. The Global Forum is supported by contracts with the Academic Collaboration for Integrative Health; Academy of Nutrition and Dietetics; Accreditation Council for Graduate Medical Education; American Association of Colleges of Osteopathic Medicine; American Board of Family Medicine; American Council of Academic Physical Therapy; American Dental Education Association; American Medical Association; American Nurses Credentialing Center; American Physical Therapy Association; American Speech-Language Hearing Association; Association of American Medical Colleges; Association of Schools and Colleges of Optometry; Athletic Training Strategic Alliance; Council on Social Work Education; Indiana University of Pennsylvania; Intealth; Kutztown University of Pennsylvania; MGH Institute of Health Professions; National Academies of Practice; National Board of Certified Counselors, Inc. and Affiliates; National Board of Medical Examiners; National League for Nursing; Physician Assistant Education Association; Society for Simulation in Health Care; Southern California University of Health Sciences; Texas Tech University Health Sciences Center; Uniformed Services University; University of California, San Francisco; University of Utah School of Nursing.

STAFF Patricia Cuff, Senior Program Officer; Erika Chow, Research Associate; Carolyn Shore, Global Health Lead and Senior Program Officer; Taylor Windmiller, Senior Program Assistant; Adaeze Okoroajuzie, Senior Program Assistant; and Breanne Jaqua, NAM Fellow.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2025. Affordability of Health Professional Education: Proceedings of a Workshop Series—in Brief. Washington, DC: National Academies Press. https://doi.org/29271.

For additional information and all archived recordings, visit https://www.nationalacademies.org/our-work/affordability-of-health-professional-education-a-workshop

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.