Profiteering in Education

In September 2022, over 1,600 students at Stratford University, a for-profit institution, received notice that their school would be closing, leaving them unsure of options to complete their training in a variety of fields, including nursing and health sciences.¹ Stratford’s accreditation status had been in limbo, and during that time, the US Department of Education restricted the school’s ability to enroll new long-term students. The school’s access to federal student aid was also in jeopardy. Because Stratford was fully reliant on student tuition from a steady flow of new recruits, the bulk of which came from federal student aid dollars, Stratford owners decided it was better to cut their losses and run than to wind down operations in an orderly manner.

As a result of Stratford’s precipitous closure, hundreds of nursing students were left stranded, many already multiple thousands of dollars in debt with no details about how to transfer their credits or how to continue their training elsewhere. After intense public pressure, about 40 nursing students who were extremely close to graduating were offered a pathway to finish. But many more, including those with only a handful of courses left, are now stranded. Kathleen Estrada, for example, had just six courses left, but because few of her credits will transfer, she faced an extra year and tens of thousands of dollars at another institution. Instead of pursuing her dream to become a nurse, she has switched to a psychology program.²

Stratford students have been left holding the bag, through no fault of their own. Worse, they have been doubly victimized by an underregulated for-profit college industry and a broken healthcare training pipeline. This country faces an urgent need to address a worsening shortage of healthcare workers—and this requires addressing issues within the educational pipeline. We need to ensure that there are adequate training programs and funding for prospective nurses and allied health workers to prevent them from graduating overwhelmed by debt. But equally important is protecting future healthcare workers from predatory and subpar programs that take advantage of students—an issue plaguing the healthcare education ecosystem and threatening our entire healthcare system as a result.

Context: An Unregulated Pipeline

Before the emergence of COVID-19, the strain on the US healthcare workforce—and the critical role of nurses and other professionals—was often overlooked. The pandemic pushed these concerns to the forefront, highlighting the threat of a worsening health workforce shortage. It is estimated that by 2030, the number of registered nurses alone that will be needed will reach 3.6 million, and this 28 percent increase in demand is not projected to be met.³ Although accelerated by untenable working conditions during the pandemic, this crisis is caused in part by a generational shift; many baby boomers—who make up a substantial portion of the health workforce—are retired or near retiring⁴ just as the nation’s aging population is expected to require an increased capacity for care.

The US Department of Health and Human Services Bureau of Health Workforce projects shortages of registered nurses, licensed practical nurses, nurse practitioners, nurse anesthetists, and nurse midwives.⁵ Washington, Georgia, and California are predicted to be the hardest hit by shortages, though the distribution of supply and demand of healthcare workers varies dramatically between states. It also varies between urban, suburban, and rural areas, with supply far more adequate (even too great) in urban areas than in rural ones.⁶ For example, a 2017 Bureau of Health Workforce analysis of supply and demand for healthcare workers in rural areas found a 69 percent deficit of surgeons in rural regions. In reality, the overall supply of surgeons matches the demand, but those surgeons are concentrated in urban areas.⁷

The majority of today’s registered nurses worked in roles like nurse assistant or licensed practical nurse before pursuing their RN.⁸ Over the past 50 years, there have been substantial increases in the proportion of nurses who hold bachelor’s degrees and in the number of nurses pursuing graduate-level training.⁹ A major impact of increasing credentialism in nursing (and allied health fields) is increasing student debt held by the workforce. Debt taken on by nursing students incentivizes them to remain in clinical positions rather than to take on lower-paid roles in nurse training and education. Nearly 70 percent of nursing graduate students surveyed in 2016 financed their education with federal student loans.¹⁰ Nursing students faced a median debt between $40,000 and $54,999 after graduating—so it’s unsurprising that half of those surveyed named repayment of loans as their biggest concern upon completing their programs.

Barriers to education and the burden of nursing education loans inherently impact women disproportionately: only 9.4 percent of registered nurses and 8.1 percent of licensed practical nurses and vocational nurses are male.¹¹ Despite making up the majority of the workforce (90 percent of registered nurses), women in the field earn less than men, with female RNs making $7,300 less annually than their male counterparts¹² (though some of that gap may be due to male RNs working in facilities that pay more, doing more overtime, and taking more premium-pay shifts¹³). The gender wage gap in nursing persists regardless of level of education, certification, age, or experience. Mirroring the pay inequities across other industries, the wage gap facing Black and Latina women is particularly egregious; these wage gaps are closing so slowly that they are on pace to remain for 350 and 432 years for Black and Latina nurses, respectively.¹⁴

On top of disparities in pay, women in nursing are experiencing the strains on family care that have become even more extreme since the start of the pandemic. In the United States, women provide the vast majority of unpaid care—and most do so while holding full- or part-time jobs. With so many women leaving the workforce due to childcare or eldercare responsibilities,¹⁵ on-site childcare centers have been put forth as part of the solution to the nursing shortage in particular.¹⁶

Building a Better Pipeline

To address this crisis, it is necessary to turn upstream to educational and training programs because this shortage is closely tied to challenges in the nursing education pipeline, including a lack of instructors and preceptors (experienced clinicians who supervise nursing students’ clinical rotations).¹⁷ Without attractive salaries for education positions, advanced degree nurses are incentivized to stay in clinical tracks, where pay is higher. In interviews conducted to inform a report by the Center for American Progress, low salaries* were identified as the driving factor in the nursing educator shortage.¹⁸

Without sufficient educators, clinical sites, or preceptors, potential nurses are being turned away from programs despite the growing need for nurses. From 2011 to 2020, schools turned away roughly 47,000 to 68,000 qualified applicants annually.¹⁹ Even more concerning, the types of nursing degree programs that are seeing declines in enrollment are the same programs that train students for future careers in nursing education, research, and administration.²⁰

This unmet demand for training is coupled with a weak infrastructure of program quality assurance.²¹ This dangerous combination allows unscrupulous for-profit colleges and education companies to take advantage of students. Predatory schools may appear to meet demand and churn out graduates at a breakneck pace, but they leave many worse off than when they started: in debt with no degree and no job prospects. If this pipeline issue goes unresolved, the nursing shortage will only deepen in the coming years, ultimately putting the US healthcare system in an even more precarious position.

Seeking Training? Proceed with Caution

Given the underregulated training pipeline, nurses, allied health workers, and prospects should be cautious when reviewing their education and professional development options. The largest programs for nurses and allied healthcare workers are found in all types of colleges: public (any institution controlled by a state or local government), private nonprofit (typically controlled by a governing board that, by design, does not gain financially from the school’s operation), and private for-profit (schools that are privately owned or publicly traded in which management answers to owners and investors).

In the past, a college’s business model was a reliable indicator of how cautious a prospective student should be. Predatory practices like high-pressure or deceptive student recruitment were more often found in the for-profit college sector.²² Today, the lines between college control and business practices are blurred. One reason for this is that the US Department of Education previously relied on the Internal Revenue Service’s (IRS) determination of which organizations were legitimate nonprofits. Under this process, the IRS in turn relied on the word of college executives and managers in their self-attestations, rather than conducting independent reviews. With lax oversight of college integrity, a number of for-profit colleges—some with dubious track records—converted to nonprofits to take advantage of the benefits that are conferred to nonprofit organizations.²³ Many of these are operating as nonprofits in name only; they can be considered covert for-profit colleges. The US Department of Education is beginning to increase its oversight and no longer relies on IRS determinations, but many schools that converted to nonprofit status in recent years are in fact set up to enrich former owners and other insiders.

While these business structures wouldn’t normally be of concern to a prospective student, they often go hand in hand with predatory practices that affect students’ academic and financial well-being. In 2020, the Government Accountability Office found that one-third of college conversions from for-profit to nonprofit involved transactions that personally financially benefited former owners and other related individuals. The transactions that result in covert for-profits are known as insider conversions; they tend to have worse financial performance, and many such schools engage in deceptive marketing practices.²⁴

Where you attend school matters for the experience you will have, for how employers perceive your qualifications, and for your own financial outcomes.²⁵ For example, registered nurses with bachelor’s degrees from public colleges or universities hold an average federal student loan balance of $27,301, while graduates of for-profit colleges have an average student debt load of $34,118.²⁶

In the allied health field, graduates from associate degree and undergraduate certificate programs take on substantial debt considering the amount of time required to complete those courses of study. At public institutions, like local community colleges or state universities and their regional branches, allied health students take on an average of $13,311 in federal student debt. At private nonprofit institutions, they take on $16,601, and at private for-profit schools, they take on an average of $22,682 in federal student loans.²⁷ (Students’ debt load could be higher from prior programs or courses; these figures represent only the federal debt taken on by graduates in their allied health programs.²⁸) Graduates feel the effects of their debt when bills come due. The average allied health graduate has a $203 per month payment due on their federal student loans, but that average masks disparities. For graduates of public colleges, the figure is just $150. Nonprofit college grads pay closer to the average, at $200, and for-profit grads owe a whopping $270 per month.

American consumers generally enjoy a level of comfort knowing there are standards when it comes to product safety, whether it be from the automobile, food, or toy industry. Unfortunately, that reality is not directly applicable to the higher education marketplace. Higher education consumers are at an extreme disadvantage when weighing their options. The most prominent seal of approval a prospect may see is a college’s accreditation status listed on its homepage. Unfortunately, accreditor reliability has declined along with nonprofit integrity; the two issues are deeply intertwined. Not only have signifiers of quality and business practices eroded, but the digital infrastructure that leads a prospective student from searching to enrolling in courses is also rigged in the favor of the college industry.²⁹

For-Profit Problems in Nonprofit Schools

Given the intricacies of accreditation and higher education policy, the downstream impact of nefarious institutions can be difficult to grasp, and it often goes unacknowledged in conversations about healthcare workers in particular. To better understand how for-profit and covert for-profit institutions are harming students and impacting the health workforce, we can examine the practices of one especially bad actor: Ultimate Medical Academy.

Ultimate Medical Academy (UMA) is a private career college specializing in allied health training that opened in Clearwater, Florida, in the mid-1990s. It offers programs for people seeking careers as medical and dental assistants, medical office assistants, pharmacy technicians, and related positions. In 2005, the school was acquired by an investment management group that was focused on “unlocking value and improving educational quality by bringing world-class management and staff to its client companies.”³⁰ The investment firm did just that by transforming the tiny career college into a large online enterprise with 10,000 students.

UMA’s enrollment peaked in 2018 at over 15,000 students, almost all of whom were studying online. UMA’s student body is 96 percent women, and the vast majority are over the age of 22. Over half of UMA students identify as a racial or ethnic minority, and in recent years, more than 75 percent of UMA students qualified for a Pell Grant, meaning they demonstrated exceptional financial need.³¹

In 2015, UMA’s investment firm cashed out by selling the school to a Denver-based nonprofit called Clinical and Patient Educators Association (CPEA). Publicly available documents indicate this was an insider transaction. According to public records, CPEA, UMA, and the private investment firm all included executives with personal stakes and connections to each other. UMA’s chief executive officer at the time of the transaction simultaneously served on the board of directors at CPEA. CPEA’s then-chairman and president also held a substantial ownership stake in UMA. In other words, for the initial years it claimed nonprofit status, UMA was in fact still under the control of its former owners, who stood to gain from its sale and conversion.³²

The school continues to operate with a questionable business structure, a fact recognized by the US Department of Education, which has yet to fully certify the school for participation in federal student aid programs. Instead, the school is considered provisionally certified and must submit itself to cash and financial monitoring by the department. Further, UMA has a revolving door of for-profit college executives, owners, and investors, including key executives from disgraced Trump University.³³

UMA is owned and operated by a nonprofit organization but has the revenue and expenditure profile of a for-profit college. For example, the school derives the vast majority of its revenue from federal sources, including student loan dollars and military student benefits. There are limits to how much of a for-profit college’s revenue can come from federal sources, so the incentive for schools like UMA to be designated as nonprofit is high. According to industry analysts, UMA has not engaged in fundraising or set up any long-term investment funds—common fiscal strategies of legitimate nonprofit colleges.³⁴ Additionally, UMA spends just 17 cents on instruction for every tuition dollar it collects from students.³⁵

A 2017–2019 US Department of Education review of UMA found the school in violation of federal aid disbursement rules for running a diploma mill for prospective students who wished to enroll but had not graduated from high school. UMA did so by forming a relationship with a for-profit online education company called ed2go. For a fee, prospective students were sent work to complete that the school said would satisfy high school diploma requirements (sometimes completing said work in less than one day); their diplomas were then sent to UMA, which the department claimed held the document until students enrolled in UMA.³⁶

Business structure aside, UMA’s impact on students is also of concern. UMA employees have alleged they are encouraged by management to engage in high-pressure sales tactics to recruit students. The average annual cost of attendance in UMA’s largest program (medical administrative/executive assistant and medical secretary) is $18,214. And average earnings of UMA’s allied healthcare graduates who took out federal student loans to attend are just $22,862 three years after graduation.³⁷ In fact, just 30 percent of UMA graduates earn more than the typical high school graduate six years after attending. Nearly three-fourths of UMA graduates who borrowed to attend are either not repaying their loans or have defaulted.³⁸ According to data acquired via a public information request, at least 460 UMA students have filed for what is known as borrower defense to loan repayment with the Department of Education, which means those borrowers allege they were misled or were subjected to illegal practices in the process of enrolling in the school.³⁹ While the public does not have access to the content or status of those applications, the number of claims puts UMA on par with campuses of some of the most notorious predatory colleges in the country.⁴⁰

Although it is problematic to deny access to students who lacked previous opportunities—like the opportunity to complete secondary education and pursue a career in healthcare—a lack of viable options along with little to no regulation means hazards can be set up anywhere, and they are easy for students to fall into. UMA has served as a cash generator for executives, and it happens to have a side hustle of providing allied health training to a relative handful of students at its Clearwater campus.⁴¹

Unfortunately, career colleges like UMA are the standard, not the exception. Some of the largest producers of nurses and allied health workers are colleges with the same profile as UMA: they converted from for-profit to nonprofit status without changing their governance or business practices to match. These schools include Keiser University, Herzing University, Remington College, Altierus Career College, and Purdue University Global (plus recently closed Independence University).⁴² For-profit career colleges are also still in operation, as are for-profit education companies that operate in the background of many public universities’ online nursing programs. Prospective students seeking online nursing education opportunities should be aware that many online programs offered by public colleges and universities are in fact managed by for-profit education companies called online program managers (OPMs).⁴³ OPMs get paid based on their success in procuring new students for their clients (i.e., colleges), which means the admissions and enrollment process will seem more like a pressurized sales pitch than it otherwise would be.

Until the federal government and states increase the availability of training opportunities at public colleges, scam-ridden programs will continue to pull in students looking for career opportunities, the harms of which disproportionately impact women, Black and Latinx communities, and those in healthcare and education deserts.⁴⁴ College quality assurance systems have largely failed, and prospective students aiming to enter any industry have reason to be cautious—but when it comes to the healthcare field, these flawed systems have ripple effects that affect medical patients downstream. We must move beyond viewing prospective college students—especially prospective health clinicians—as education consumers and treat them as the integral part of the common good that they are.

Systemic Fixes to Protect the Healthcare Workforce

Fortunately, there are policy levers to address nursing and healthcare worker shortages, and some steps are already being taken at the federal level. Most recently, the US Department of Health and Human Services announced an investment of $13 million through the Health Resources and Services Administration to strengthen nursing education and training with two grant programs. Grants awarded through the Clinical Faculty and Preceptor Academies Program will address pipeline issues by creating academies to train clinical nursing faculty and preceptors. Funding awarded through the Registered Nurse Training Program, meanwhile, will enhance nursing education to better prepare nursing students for the provision of culturally sensitive, high-quality care in underserved areas.⁴⁵ Although these investments are a step in the right direction, greater funding is needed to comprehensively address the workforce shortage.

Congress has other opportunities to bolster the nursing workforce, in part through investing further in existing programs like Title VIII of the Public Health Service Act, the Nursing Workforce Development programs. This funding is critical for loan repayment and scholarship programs for nursing students. Crucially, this funding also provides loans for nursing faculty development and grants for improving outcomes and increasing diversity in nurse education. Progress was made when funding for Title VIII was included in the CARES Act⁴⁶ and in the appropriations package for 2022, which increased funding for the Title VIII programs over the previous year to $280 million.⁴⁷ More funding is needed to address this crisis, however, as evidenced by the ongoing shortage and debt faced by nursing graduates; a coalition of nursing professionals has asked for $530 million for the Title VIII program to meet the demand.⁴⁸

Even as the pandemic receives less attention (and less funding), we must continue to prioritize the health workforce, and educational programs in particular. Other health crises continue to worsen, including a maternal health crisis that disproportionately impacts Black and Indigenous women and birthing people.^† Congress should move swiftly to pass the Perinatal Workforce Act,⁴⁹ part of the Black Maternal Health Momnibus Act,⁵⁰ to expand and diversify the maternal health workforce. Funding for the perinatal workforce, which unfortunately stalled in Congress early in 2022, would have provided funding to train nearly 170,000 new maternal health professionals.⁵¹

The US Department of Education indicated it plans to release in 2023 what could be the most impactful regulation for protecting nursing and allied health students and other career education students from expensive training programs that do not pay off. The so-called gainful employment rule ensures students do not go into an unmanageable amount of debt relative to their earnings.⁵² Unfortunately, the earliest the rule will go into effect is 2024, meaning thousands of prospective students stand to fall deeper into needless debt in the meantime.

While the public waits for new accountability rules that will address predatory career education programs, the US Department of Education could use a tool it already has at its disposal: its own contracts with colleges that participate in federal student aid programs. These contracts, or agreements, put colleges on the hook for following the department’s laws and regulations in exchange for access to federal student aid funds. Most colleges sign agreements with the department that last for years at a time. However, some of the worst providers in the career education space are only provisionally certified by the department, meaning the agency proactively approves their approval for federal funding monthly, despite documented abuses.⁵³ It is time for the US Department of Education to enforce these contracts and make sure colleges are delivering on their obligations.

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Stephanie Hall, PhD, is a senior fellow at the Center for American Progress. Previously, she worked at The Century Foundation, the University System of Maryland Office of Academic and Student Affairs, and various P–12 schools in the United States and Brazil. Anna Bernstein, MPH, a healthcare policy fellow and the deputy director of healthcare reform at The Century Foundation, focuses on maternal and reproductive health issues. Previously, she worked at the Institute for Women’s Policy Research.

*To read about how low salaries disincentivize prospective nurse educators—and how union activism can help— see “Our Healthcare System Is Crashing” in the Fall 2022 issue of AFT Health Care. (return to article)

^†To learn about the maternal health crisis, see “The Importance of Respectful Maternity Care for Women of Color” in the Spring 2021 issue of AFT Health Care. (return to article)

Endnotes

1. J. Foretek, “The Latest on the Stratford University Saga; Students Still Seeking Answers After School Shut Down,” InsideNoVa, October 4, 2022, insidenova.com/news/education/fairfax/the-latest-on-the-stratford-university-saga-students-still-seeking-answers-after-school-shut-down/article_46fb2768-43f6-11ed-baf3-cb4c3769a3e6.html.

2. J. Foretek, “What’s Next for Stratford University Students?,” WTOP News, December 15, 2022, wtop.com/virginia/2022/12/whats-next-for-stratford-students.

3. C. Burger, “The States with the Largest Nursing Shortages,” RegisteredNursing.org, December 15, 2022, registerednursing.org/articles/largest-nursing-shortages.

4. D. Auerbach, P. Buerhaus, and D. Staiger, “Will the RN Workforce Weather the Retirement of the Baby Boomers?,” Medical Care 53, no. 10 (October 2015): 850–56.

5. National Center for Health Workforce Analysis, “Nurse Workforce Projections, 2020–2035,” US Department of Health and Human Services, Health Resources and Services Administration, November 2022, bhw.hrsa.gov/sites/default/files/bureau-health-workforce/Nursing-Workforce-Projections-Factsheet.pdf.

6. National Center for Health Workforce Analysis, Using HRSA’s Health Workforce Simulation Model to Estimate the Rural and Non-Rural Health Workforce (Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration, 2020), bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/hwsm-rural-urban-methodology.pdf.

7. National Center for Health Workforce Analysis, Using HRSA’s Health Workforce Simulation.

8. National Center for Health Workforce Analysis, Nursing Education and Training in the United States: 2018 National Sample Survey of Registered Nurses (Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration, 2020), bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/nchwa-nssrn-nursing-education-training.pdf.

9. The Numbers Behind the Degree: Financing Graduate Nursing Education (Washington, DC: American Association of Colleges of Nursing, October 2017), aacnnursing.org/Portals/42/Policy/PDF/Debt_Report.pdf.

10. The Numbers Behind the Degree.

11. National Council of State Boards of Nursing, “National Nursing Workforce Study,” 2020, journalofnursingregulation.com/article/S2155-8256(21)00027-2/fulltext.

12. NurseJournal Staff, “The Gender Pay Gap in Nursing,” NurseJournal, December 14, 2021, nursejournal.org/resources/the-gender-pay-gap-in-nursing.

13. D. Searls, “Do Male Nurses Earn More? Survey Says Yes,” Nursing News, Onward Healthcare, January 8, 2018, onwardhealthcare.com/resources/blog/nursing-news/do-male-nurses-earn-more-survey-says-yes.

14. NurseJournal Staff, “The Gender Pay Gap.”

15. J. Kashen, “Paid Leave, Child Care, and an Economy That Failed Women,” The Century Foundation, May 5, 2021, tcf.org/content/commentary/paid-leave-child-care-and-an-economy-that-failed-women.

16. Advisory Board, “The Newest Way to Retain Nurses: On-Site Child Cares,” Daily Briefing, August 2, 2022, advisory.com/daily-briefing/2022/08/02/hospital-childcare.

17. A. McInnis, T. Schlemmer, and B. Chapman, “The Significance of the NP Preceptorship Shortage,” Online Journal of Issues in Nursing 26, no. 1, (January 31, 2021): manuscript no. 5.

18. M. Zhavoronkova et al., How to Ease the Nursing Shortage in America (Washington, DC: Center for American Progress, May 23, 2022), americanprogress.org/article/how-to-ease-the-nursing-shortage-in-america.

19. Charting the Future of Academic Nursing: 2021 Annual Report (Washington, DC: American Association of Colleges of Nursing, 2021), aacnnursing.org/Portals/42/Publications/Annual-Reports/2021-AACN-Annual-Report.pdf.

20. American Association of Colleges of Nursing, “Nursing Schools See Enrollment Increases in Entry-Level Programs, Signaling Strong Interest in Nursing Careers,” press release, April 5, 2022, aacnnursing.org/News-Information/Press-Releases/View/ArticleId/25183/Nursing-Schools-See-Enrollment-Increases-in-Entry-Level-Programs.

21. T. Moultrie, “Leading with Integrity on College Accreditation,” The Century Foundation, March 24, 2022, tcf.org/content/commentary/leading-with-integrity-on-college-accreditation; and A. Flores, The Unwatched Watchdogs: How the Department of Education Fails to Properly Monitor Accreditation Agencies (Washington, DC: Center for American Progress, September 19, 2019), americanprogress.org/article/the-unwatched-watchdogs.

22. R. Shireman, The For-Profit College Story: Scandal, Regulate, Forget, Repeat (New York: The Century Foundation, January 2017), tcf.org/content/report/profit-college-story-scandal-regulate-forget-repeat.

23. R. Shireman, “These Colleges Say They’re Nonprofit—but Are They?,” The Century Foundation, January 5, 2021, tcf.org/content/commentary/colleges-say-theyre-nonprofit.

24. US Government Accountability Office, IRS and Education Could Better Address Risks Associated with Some For-Profit College Conversions (Washington, DC: US Government Accountability Office, December 2020), gao.gov/assets/gao-21-89.pdf.

25. J. Kinneer, “The Acceptability of Online and For-Profit Nursing Degrees: A Study of Hiring Gatekeeper Protections,” Online Journal of Distance Learning Administration 17, no. 2 (Summer 2014), citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=40c52fe2d7f7da540bba8d9b518a9973e5d9b5bc;%20https://publichealth.gwu.edu/content/profit-ownership-nursing-schools-significantly-associated-lower-performance-nurse-licensure; and GW Public Health, “For-Profit Ownership of Nursing Schools Significantly Associated with Lower Performance on Nurse Licensure Test,” George Washington University, January 15, 2019, publichealth.gwu.edu/content/profit-ownership-nursing-schools-significantly-associated-lower-performance-nurse-licensure.

26. Author analysis of federal College Scorecard data: US Department of Education, “College Scorecard: Find the Right Fit,” collegescorecard.ed.gov.

27. Author analysis of federal College Scorecard data: US Department of Education, “College Scorecard.”

28. According to the College Scorecard, graduates of for-profit allied health programs have an average overall student loan balance of $28,636. Graduates of nonprofit allied health programs have an average overall student loan balance of $21,441. Graduates of public allied health programs hold an average overall student loan balance of $17,392. US Department of Education, “College Scorecard.”

29. R. Shireman, The Covert For-Profit: How College Owners Escape Oversight Through a Regulatory Blindspot (New York: The Century Foundation, September 22, 2015), tcf.org/content/report/covert-for-profit; Moultrie, “Leading with Integrity”; and S. Hall, The Students Funneled into For-Profit Colleges (New York: The Century Foundation, May 11, 2021), tcf.org/content/report/students-funneled-profit-colleges.

30. Conversion Partners, “About Us,” web.archive.org/web/20160315194021/http://www.conversionpartners.com.

31. Integrated Postsecondary Education Data System, “Look Up an Institution: Ultimate Medical Academy,” US Department of Education, National Center for Education Statistics, nces.ed.gov/ipeds/datacenter/institutionprofile.aspx?unitId=441371&goToReportId=6.

32. ProPublica, “Nonprofit Explorer: UMA Education Inc,” projects.propublica.org/nonprofits/organizations/472578950.

33. Shireman, “These Colleges Say.”

34. According to federal data, 100 percent of UMA’s revenue comes from student tuition and fees. Integrated Postsecondary Education Data System, “Look Up an Institution: Ultimate Medical Academy.”

35. S. Hall, “How Far Does Your Tuition Dollar Go?,” The Century Foundation, April 18, 2019, tcf.org/content/commentary/how-far-does-your-tuition-dollar-go.

36. Chris Miller to Thomas Rametta, “RE: Final Program Review Determination,” September 4, 2019, drive.google.com/file/d/1xxdlyWoSYFgqSvM0uo9FcyyodYOiAp5P/view.

37. Author analysis of federal College Scorecard data: US Department of Education, “College Scorecard.”

38. US Department of Education, “College Scorecard: Ultimate Medical Academy,” collegescorecard.ed.gov/school/?441371-Ultimate-Medical-Academy.

39. Student Defense, “Borrower Defense Data and Reports at the Institutional Level,” January 21, 2022, defendstudents.org/foia/borrower-defense#Borrower-Defense-Data-and-Reports-at-Institution-Level.

40. Project on Predatory Student Lending, “Student Borrowers Win Final Approval of Settlement to Cancel Over $6 Billion in Loans for 200,000 Borrowers,” press release, November 16, 2022, ppsl.org/news/student-borrowers-win-final-approval-of-settlement-to-cancel-over-6-billion-in-loans-for-200000-borrowers.

41. D. Halperin, “Ex-Trump University Executives Run College That Gets $150 Million from Taxpayers,” The Blog, Huffpost, December 6, 2017, huffpost.com/entry/ex-trump-university-execu_b_10699880.

42. Shireman, “These Colleges Say”; and author analysis of federal College Scorecard data: US Department of Education, “College Scorecard.”

43. S. Hall, “Who Controls Online Courses?: How For-Profit Companies Are Harming Higher Education,” American Educator 46, no. 1 (Spring 2022): 25–32, 47.

44. N. Hillman, Place Matters: A Closer Look at Education Deserts (Washington, DC: Third Way, May 21, 2019), thirdway.org/report/place-matters-a-closer-look-at-education-deserts; and V. Jackson and B. Williams, “How Black Women Experience Student Debt,” Education Trust, April 2022, edtrust.org/wp-content/uploads/2014/09/How-Black-Women-Experience-Student-Debt-April-2022.pdf.

45. US Department of Health and Human Services, “HHS Invests $13 Million to Grow and Strengthen Nursing Workforce,” press release, October 21, 2022, hhs.gov/about/news/2022/10/21/hhs-invests-13-million-grow-and-strengthen-nursing-workforce.html.

46. A. Stone, “Title VIII Nursing Workforce Funding Included in CARES Act,” ONS Voice, April 9, 2020, voice.ons.org/advocacy/title-viii-nursing-workforce-funding-included-in-cares-act.

47. C. Davis, “Nursing Workforce Development and Research Are Big Winners of New Legislation,” HealthLeaders, March 23, 2022, healthleadersmedia.com/nursing/nursing-workforce-development-and-research-are-big-winners-new-legislation.

48. Nursing Community Coalition to Patty Murray and Roy Blunt, March 16, 2021, aacn.org/~/media/aacn-website/policy-and-advocacy/legislation-regulatory/senate-approp-request.pdf?la=en.

49. A Bill to Direct the Secretary of Health and Human Services to Issue Guidance to States to Educate Providers, Managed Care Entities, and Other Insurers About the Value and Process of Delivering Respectful Maternal Health Care Through Diverse and Multidisciplinary Care Provider Models, and for Other Purposes, S. 287, 117th Congress, congress.gov/bill/117th-congress/senate-bill/287.

50. J. Taylor and A. Bernstein, “Tracking Progress of Black Maternal Health Momnibus,” The Century Foundation, January 24, 2022, tcf.org/content/data/black-maternal-health-momnibus-tracker.

51. J. Taylor and A. Bernstein, “Four Ways the Build Back Better Act Could Improve Black Maternal Health,” The Century Foundation, October 20, 2021, tcf.org/content/commentary/four-ways-build-back-better-act-improve-black-maternal-health.

52. N. Schwartz, “Education Department Delays Gainful Employment Proposal Until 2023,” Higher Ed Dive, June 22, 2022, highereddive.com/news/education-department-delays-gainful-employment-proposal-until-2023/625919.

53. Y. Cao, “Predatory Colleges Think They Are Too Flawed to Fail. Biden’s Department of Education Should Prove Them Wrong,” The Century Foundation, September 9, 2021, tcf.org/content/commentary/predatory-colleges-think-flawed-fail-bidens-department-education-prove-wrong; and National Student Legal Defense Network, “A Blank Check: U.S. Department of Education Renews Contracts for Troubled For-Profit Colleges,” November 2022, defendstudents.org/news/body/NSLDN_BRIEF_Failing-to-Hold-Wrongdoers-Accountable_FINAL.pdf.

[Illustrations by Pep Montserrat]