At a time when more doctors refuse to see the elderly and poor on Medicare and Medicaid -- the government programs pay too little, doctors say -- Kelly Jensen thought she had an answer, something she could do to help reverse the trend and provide care for those most in need.
She would get a degree as a family nurse practitioner, a doctorate that would allow her to do much of what a physician does, including write prescriptions, but at roughly half the salary -- making it possible for her to serve the poor at a low-cost community clinic.
Last spring, after four years as a program coordinator at Seattle Children's Hospital, the 30-year-old Jensen took the first step, entering an accelerated program at the University of Washington School of Nursing. She'll become a registered nurse in August.
After that, her plans and those of 33 nurses already in the program are up in the air.
As a result of this spring's massive state cuts to the UW's funding, the School of Nursing told students earlier this month that the three-year nurse practitioner program would be turned over to the university's night-school arm, UW Extension, and that tuition would go up. For incoming state residents like Jensen, the tuition and fees will increase June 22 from $4,600 to more than $6,800 -- a 48 percent spike that has left many students reeling, wondering how they can continue in the program and where it and other graduate nursing tracks are ultimately headed.
The school is giving returning students a break, raising their tuition and fees 14 percent, to $5,300. But Choua Yang, a 38-year-old second-year student who's a part-time nurse and full-time mother of five, says she's not sure how she's going to pull it off. "We heard it was going to go up but were not expecting this kind of increase," Yang says. "It was pretty shocking."
For three students who work as nurses at the UW's own hospital or at Harborview Medical Center, which the UW oversees, the sticker shock was worse. With the increases, the program is canceling traditional UW-employee exemptions, taking the tuition from $660 to $6,800 -- a jump the School of Nursing agreed to hold at $1,900 for two quarters after students objected at a June 5 picket and a meeting with Dean Marla Salmon on June 9.
As the school's most expensive program -- one that gets no state funding -- the nurse practitioner track had to cover its costs through tuition, Salmon says, or else lay off its faculty and staff. But the school unfairly targeted the program to fill a nearly $1 million cut, Jensen and other students say, when it could have cut salaries or put staff on unpaid furloughs. By shifting the total cost to them, the students say, the school is privatizing a program that they joined, ironically, to increase health care for poor and underserved communities.
"There's a big difference between having access to health care and not having access and how that affects people's day-to-day lives," Jensen says. "The family nurse practitioner degree is excellent because it enables me to prescribe medicine, to order tests and do primary care for a population at a much lower cost than for physicians to deliver the same kind of care'' -- if MDs will even do the work.
Because primary care pays less than specialties, there is a shortage of providers that creates a vicious cycle for the poor, Jensen says. "You have people who can't get care and things get worse and they end up in the hospital and that's very expensive," she says.
Salmon says she was one of the nation's early advocates of putting nurse practitioners in primary care, serving as the director of the federal Division of Nursing that developed the model. "From a social justice perspective, this whole thing breaks my heart," Salmon says. "It's sad."
But in 2006, she says, when the university agreed to let the program move from a two-year master's to a three-year doctorate, it was with the understanding there would be no state funding -- the doctoral nurse practitioner program would have to support itself through fees and grants.
"We were optimistic about where the state was going and the possibility of additional support coming in," Salmon says. "What happened, obviously, is not only did we not get any additional support for the program, but we took a huge hit in the dollars available for teaching."
Other graduate nursing programs that were planning to move from two to three years, such as midwifery, have since pulled back to save students money -- a decision the nurse practitioner faculty is still considering. In the meantime, Salmon says, the school is working hard to mitigate the tuition increase for students while it looks for funding.
For students entering the program, the university has provided an additional $70,000 in financial aid, she says, and the school has started a new scholarship fund. There are also student loans, Salmon says, which the National Health Service Corps or other programs pay off in exchange for working with rural or underserved populations.
But Jensen says she's already taken out $56,000 in student loans just to get through one year of nursing school -- at $7,000 a quarter -- and was counting on getting a UW nursing job this year to reduce her tuition bill. With that option now gone, she's re-evaluating her whole plan.
"The possibility of me continuing to [borrow like that] for three more years -- it's not doable, especially because nurse practitioners don't make that much money," Jensen says. "They do well, but not enough to pay back over $100,000 in debt."
Yang had already worked five years as a full-time nurse when she reduced her hours to enter the nurse practitioner program. She, too, has student loans, along with a scholarship that covers most of her tuition. But she's not happy with the short notice or feeling like she's caught between a rock and a hard place.
"I made a huge sacrifice when I decided to do this because I believe in the potential [the program] has for the future of nursing," Yang says. "At this point, I'm thinking I can't back out because I've put too much time and taken out loans to do this, so I have to push forward."