Abstract

The passage of House of Representatives (HR) One, or the "One, Big, Beautiful Bill Act," brings official changes to students' ability to borrow federal loans. The federal Graduate Plus Loan will sunset, leaving medical students with unsubsidized loans as the primary federal borrowing option, capped at $50,000 per year and a total of $200,000 for professional degrees. Advocates argue the changes are needed to check tuition increases in higher education. Students may need to rely on private loans or institutional support to cover the remaining tuition or living expenses. Some of the challenges will be particularly daunting for Appalachia and West Virginia, a state entirely within the region. These new challenges present three realities to consider as well as three potential solutions. First, medical education tuition has been increasing substantially across the country, which has left in-state indebted students at public medical schools graduating with a median of approximately $200,000 to pay back. At the three medical schools in WV, tuition increases have aligned with national trends. However, as a second reality, specific to WV, there is a small applicant pool for the 392 open medical school seats in the state. Finally, Appalachia and WV have faced a perpetual provider shortage, particularly in rural areas, with many new doctors leaving the state and region soon after graduation. Despite these challenges, there are a few ways forward that may position the region well in the future. Medical schools may consider curbing tuition increases, cutting tuition, or ultimately subsidizing education for students with the greatest needs. Several institutions have already taken this route with support from philanthropists. Schools should also consider innovations to abridge the traditional four-year curriculum where possible and invest in accelerated tracks. Finally, health systems may need to rethink costly recruitment strategies and instead consider providing medical students with loans that are forgiven with years of service to the system.