H.R. 1 & Nursing Doctorates: Complete Series

Confused about whether nursing degrees are still "professional"? This 5-part series breaks down what Trump's H.R. 1 actually changes, and what it doesn't.

• Part 1: Are Nursing Degrees Still Professional Degrees? What Trump's H.R. 1 actually changes

Currently reading: Part 1 of 5

Listen to the audio version here.

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In this article, you'll move from confusion about your professional standing to confident clarity about what this policy actually means, for your education credentials, your loan repayment strategy, your clinical practice in dermatology and aesthetics, and your ability to build a cosmetic business. You'll learn what H.R. 1 actually does (and doesn't do), how this affects your scope of practice and business positioning, and what this means for your financial future regardless of what Congress decides next.

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How DNP and PhD Nurses Can Address Medicaid Coverage Gaps Through Research, Education, and Entrepreneurship

The One Big Beautiful Bill Act (H.R. 1) became law on July 4, 2025, and while much of the conversation has centered on what it takes away, we need to talk about what it creates: opportunity.

For nurse practitioners, especially those of us working in dermatology, cosmetics, and serving communities of color, this legislation doesn't just signal policy change. It signals where the gaps will widen, where patients will fall through, and where founder-level practitioners, researchers, and educators need to step in.

Let me be clear: I'm not celebrating these changes. But I am strategic enough to recognize that when traditional systems contract, innovative practitioners who understand how to serve underserved populations don't just survive, they lead.

What H.R. 1 Actually Does (The Parts That Matter for NPs)

H.R. 1 is a massive reconciliation package that touches Medicaid eligibility, provider reimbursement, and access to care. Here's what you need to know:

Eligibility Redeterminations & Coverage Instability

Starting in early 2027, states must redetermine Medicaid eligibility every six months for expansion enrollees. Additional work and community service requirements kick in for certain populations.

Translation: More people will lose coverage. More patients will experience coverage gaps. More dermatologic conditions will present late-stage because patients delayed care.

Limits on Provider Taxes & Medicaid Funding

Beginning in fiscal year 2027, the bill restricts states' ability to use provider taxes to fund Medicaid, a key mechanism states have used to maintain reimbursement rates and expand coverage.

Translation: Medicaid reimbursement may shrink. Facilities may close or reduce services. Rural and underserved areas, where many of us work, will feel this first and hardest.

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Who Gets Hit Hardest

Communities of color. Rural populations. Low-income patients. Older adults navigating chronic conditions. The exact populations that dermatology and aesthetic nurse practitioners specializing in skin of color already serve, often as the only practitioners who will.

Why This Matters for Dermatology & Aesthetic NPs

If you're a nurse practitioner working in dermatology or aesthetics, particularly with skin of color populations, you already know this: patients delay care when coverage is unstable. They show up later, sicker, with more complex presentations.

Keloids that could have been managed early become surgical cases. Acne that could have been controlled becomes scarring. Skin cancers that could have been caught at Stage I present at Stage III.

And when Medicaid reimbursement drops and facilities close? The NPs who built founder-level practices, the ones who understand how to operate outside traditional systems, who know how to serve patients regardless of payer mix, those are the ones who stay open. Those are the ones patients can still reach.

If you're a DNP or PhD-prepared nurse, you've heard it. Maybe from colleagues. Maybe from patients. Maybe from the voice in your own head at 2am when you're questioning why you went back to school:

"It's not a clinical doctorate like an MD."

"You don't get paid more for it."

"What's even the point?"

This comparison to physicians isn't just unhelpful; and it's costing us.

When we measure the value of nursing doctorates against physician doctorates, we're using the wrong ruler. We're asking the wrong question. And we're missing the entire point of what doctorally-prepared nurses actually do.

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Here's What Nursing Doctorates Actually Are

The DNP (Doctor of Nursing Practice) graduate is not trying to be an MD. It's designed to prepare expert clinicians who can also lead systems change, translate evidence into practice, design quality improvement initiatives, and build models of care that work in the real world, not just in the ideal conditions of a clinical trial.

Think of it this way: A DNP graduate is closer to an MBA with clinical expertise than it is to an MD.

When someone gets an MBA, nobody questions the value. Everyone understands that an MBA-holder brings:

• Strategic thinking and business acumen

• The ability to analyze systems and identify inefficiencies

• Project management and implementation skills

• Leadership and change management expertise

• Financial analysis and operational improvement capabilities

That's exactly what a DNP graduate brings, plus advanced clinical expertise.

A DNP graduate can do what an MBA does (analyze systems, lead change, improve operations, manage projects) but they do it in healthcare settings with clinical credibility and patient care expertise that MBAs don't have.

The PhD in Nursing is not trying to compete with medical research. It's designed to generate nursing knowledge, examine how people experience health and illness, evaluate interventions in complex real-world contexts, and build the evidence base for nursing practice.

Both degrees are about something physicians aren't trained to do: building, implementing, and studying the systems that make healthcare actually work for patients.

And here's the part nobody wants to say out loud but we all know is true: physicians don't do this work. They're trained to diagnose and treat. They're excellent at it. But they're not trained to design sustainable care delivery models. They're not trained to navigate regulatory systems. They're not trained to build businesses that serve underserved populations while staying financially viable.

That's nursing doctorate work.

What Systems-Level Thinking Actually Means (And How It Shows Up Daily)

When we say "systems-level thinking," here's what that actually looks like in practice:

Example 1: Appointment No-Shows

A master's-prepared NP sees: "This patient keeps missing appointments."

A DNP-prepared NP sees: "30% of our patients in this ZIP code miss appointments. Let me look at: transportation access, appointment scheduling system, reminder processes, cultural barriers, work schedule conflicts, childcare limitations, and health literacy around appointment importance. Now let me design an intervention that addresses the actual barriers, which means creating new policies, writing standard operating procedures, training staff on the new protocols, potentially building strategic partnerships with transportation services or community organizations, and implementing automated reminder systems, then I'll measure whether it works and train staff to sustain it."

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Example 2: Uncontrolled High Blood Pressure

A master's-prepared NP sees: "This patient's blood pressure isn't controlled."

A DNP-prepared NP sees: "40% of our patients with high blood pressure aren't at goal. Let me examine: medication affordability and access, patient education effectiveness, cultural beliefs about blood pressure, diet and lifestyle factors, appointment follow-up systems, how we're measuring outcomes, whether our protocols are evidence-based for this population, and whether our clinical team is using the same approach. Now let me design and implement an intervention that improves outcomes at the population level, which means conducting a SWOT analysis of our current blood pressure management program, rewriting our clinical protocols, creating staff training modules, potentially automating parts of the follow-up process, and establishing leadership buy-in for the changes."

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Example 3: Financial Losses

A master's-prepared NP sees: "We're losing money on this service line."

A DNP-prepared NP sees: "Let me analyze: payer mix, reimbursement rates, coding accuracy, visit duration vs. compensation, overhead costs, staffing model, patient volume, referral patterns, and operational efficiency. Here's where we're losing money, here's why, here's the intervention to fix it, which might include developing new policies around scheduling and billing, creating SOPs for the front desk and clinical staff, implementing staff training on proper coding and documentation, exploring strategic partnerships with referring providers or payers, introducing automation for billing and claims management, and providing leadership development for the practice manager, and here's how we measure whether it worked."

This is the MBA-level thinking applied to healthcare, and it's exactly what DNP graduates are trained to do.

Here's What Most NP Entrepreneurs Either Don't Understand, Don't Care About, or Don't Have Time For:

• Writing and implementing formal policies and standard operating procedures

• Conducting SWOT analyses (Strengths, Weaknesses, Opportunities, Threats)

• Designing and delivering staff training programs

• Building strategic partnerships that create operational efficiencies

• Identifying what can and should be automated

• Developing leadership structures and succession planning

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DNP graduates are trained in all of this. It's literally what implementation science and quality improvement methodology teach you to do.

Most NP entrepreneurs are excellent clinicians who learned business through trial and error. They're making it work, but they're often:

• Reinventing the wheel

• Missing inefficiencies they can't see because they're in the day-to-day

• Stuck because they don't know how to systematize what they do

• Unable to scale because everything depends on them personally

A DNP-graduate can walk into that practice and see the systems-level solutions immediately, because that's what we're trained to see.

Why This Matters Right Now

When systems contract, like they're about to under H.R. 1, the people who can build new systems become invaluable.

Physicians aren't trained for this. They're trained to work within systems. And when those systems fail or disappear? They're often the first ones saying "I can't practice under these conditions."

But doctorally-prepared nurses? We're trained to ask: What system do we need to build so patients can still access care?

That's the entire point of practice doctorates and nursing science doctorates. We don't just deliver care. We design, implement, and study the models that make care delivery possible, especially when traditional structures fail.

So when someone asks "what's the point of a nursing doctorate if it doesn't pay more?"

The answer is: Because we're not trying to get paid more to do the same job. We're trying to build something entirely different.

And that's exactly what this moment requires.

What's Next in This Series

Yes, you're right: getting a nursing doctorate doesn't automatically increase your salary. In many traditional employment settings, a DNP or PhD makes zero difference to your paycheck.

And now? H.R. 1 just made this problem significantly worse.

In Part 2 of this series, we'll break down the student loan crisis and, more importantly, how to negotiate for compensation that actually reflects your doctoral preparation.

Because the problem isn't the credential. It's the negotiation.

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Coming in this series:

• Part 2: Why Is Nursing Not a Professional Degree Anymore? The student loan crisis explained

• Part 3: Nursing Degree No Longer Professional: What this means for DNP and PhD nurses

• Part 4: List of Degrees No Longer Professional: Six ways to lead through change

• Part 5: Trump Nursing Professional Degree Changes: How to fight back through public comments

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Dr. Kimberly Madison, DNP, AGPCNP-BC, WCC, is a Board-Certified, Doctorally-prepared Nurse Practitioner, educator, and author dedicated to advancing dermatology nursing education and research with an emphasis on skin of color. As the founder of Mahogany Dermatology Nursing | Education | Research™ and the Alliance of Cosmetic Nurse Practitioners™, she expands access to dermatology research, business acumen, and innovation while also leading professional groups and mentoring clinicians. Through her engaging and informative social media content and peer-reviewed research, Dr. Madison empowers nurses and healthcare professionals to excel in dermatology and improve patient care.