Beyond PSLF: The Top Student Loan Repayment Alternatives for Doctors

By Andrew Paulson, CSLP, StudentLoanAdvice.com Founder

It’s no surprise that the No. 1 question StudentLoanAdvice.com is receiving from clients these days is:

“Will PSLF still be around when I hit my decade?”

While I’m confident Public Service Loan Forgiveness (PSLF) will remain intact for those currently enrolled in it, future doctors could face an entirely different approach to tackle their loans. I’m keeping a close eye on the federal government’s proposed changes and their impact on PSLF and repayment options. The current proposal in the Student Success and Taxpayers Savings Plan, passed by the House of Representatives in May 2025, would increase payments for existing borrowers, but it would leave PSLF as it is. For future doctors, it would cap federal borrowing at $150,000 for medical degrees and exclude residency years from PSLF. These provisions may severely hinder PSLF for future docs and even dissuade people from going into medicine.

The proposal is not final, and it will certainly see additional modifications by the Senate prior to it becoming law as part of “The One, Big, Beautiful Bill.” For those unfamiliar, this bill is a reconciliation bill. Unlike a traditional bill, reconciliation only needs a simple majority of 51 votes to pass in the Senate. Currently, Republicans hold a 53-47 majority and a clear path for the bill to be passed. Congress is aiming for the bill to be passed this July.

As we await the proposed changes, now is a good time to explore alternatives to the PSLF program. In this post, I’ll break down strategies to tackle your loans in an efficient manner that doesn’t entirely rely on PSLF.

Understanding PSLF and Its Limitations

PSLF was created by Congress in 2007 under the Bush Administration. PSLF has become a lifeline for doctors and other public servants with six-figure student debt. As of December 2024, more than 1 million borrowers have qualified for PSLF. The rules are:

• Work full-time for a qualifying nonprofit or government employer for 10 years,
• Make 120 payments in an Income-Driven Repayment (IDR) plan on direct federal student loans . . .

And your remaining loan balance is forgiven tax-free.

For doctors in public health, academia, or community clinics, PSLF is often the gold standard—particularly if your loan balance exceeds your annual income as a practicing doctor. However, PSLF’s track record wasn’t always so great. The first few years, the program had a less than 5% success rate, and it was riddled with paperwork errors, poor loan servicing, and confusion. With an entirely revamped electronic verification system, increased publicity, and recent pro-borrower initiatives, the success rate has drastically improved.

However, many fear the program could be entirely uprooted or rendered useless, particularly in light of recent proposed changes by the government. If you’re strongly considering PSLF, it’s a good idea to set up a side fund to offset career and legislative risk.

Doctors eying private practice, where salaries often outpace public sector pay, may hesitate to commit to a decade of nonprofit work while hoping for PSLF. Paying pennies on the dollar for student loans sounds appealing, but holding a $200,000-$400,000 balance at 7%-8% interest for a decade can be quite daunting.

Let’s explore some alternatives rather than relying solely on PSLF.

More information here:

Student Loan Repayment and PSLF in the Trump Era

Is Public Service Loan Forgiveness Worth It for Doctors?

The (Nearly) Perfect PSLF Situation for a Physician

Government-Based Loan Repayment Assistance Programs

The federal government has a handful of Loan Repayment Assistance Programs (LRAPs) to help you pay down your loans. They vary in commitment and award size. Many of these programs can be used in conjunction with PSLF. However, it’s difficult to combine the following programs, such as VA EDRP and NHSC, unless you want two full-time jobs.

VA Education Debt Reduction Program (EDRP)

The Veterans Affairs Education Debt Reduction Program (EDRP) currently offers a very generous repayment assistance program.

• Award: Up to $200,000 (tax-free, $40,000 per year max)
• Eligibility: Doctors in VA facilities (primary care, psychiatry)
• Commitment: Five years full-time; part-time prorated
• Pros: Generous, combinable with PSLF
• Cons: Limited to VA work, not all specialties qualify

NHSC Loan Repayment Program (NHSC)

The National Health Services Corp (NHSC) encourages doctors to work in a Health Professional Shortage Area (HPSA).

• Award: $50,000-$80,000 for two-year commitment (add-on possibility)
• Eligibility: Doctors in primary care, maternity care, psychiatry, and dentistry
• Commitment: Two-year commitment (full or part-time) in an HPSA
• Pros: Private practices can qualify, combinable with PSLF, participants can apply for continuation contracts
• Cons: Tend to pay less, limited to HPSA locations

NIH Loan Repayment Program (NIH)

The National Institutes of Health (NIH) loan repayment program is designed to recruit doctors into biomedical or biobehavioral research careers.

• Award: Up to $50,000 per year (taxable, with additional payment to cover federal taxes)
• Eligibility: Physicians (all specialties) conducting at least 20 hours per week of qualified research; includes extramural (non-NIH employees) and intramural (NIH employees)
• Commitment: Two years; renewable with no limit but capped at 25% of eligible debt
• Pros: Open to all specialties, renewable, tax offset provided
• Cons: Taxable income, research-intensive requirement, debt repayment cap

Military Loan Repayment Assistance

There’s a lot of content on The White Coat Investor about military docs. Dr. Jim Dahle, WCI’s founder, started his career as a military doc and utilized the HPSP scholarship to pay for his medical school. He has mixed feelings on the whole matter. Pursuing this route can be a fantastic way to graduate debt-free or pay off your existing six-figure loans. But you need to be aware of what you’re getting yourself into. For each type of financial assistance, there is a service commitment required.

Here’s a refresher on the two types of military financial assistance for doctors

1. Tuition Assistance (Scholarships) — Covers tuition, fees, and living expenses upfront for a service commitment post-graduation
2. Loan Repayment Programs — Repays existing educational debt for those who enlist or serve after completion of medical or dental school, also requiring a service commitment

Each branch of the military has its own program. Here’s a breakdown of how these programs work.

Another factor when determining which branch of the Armed Forces to join is the type of existing student loan debt you’ve already incurred. Generally, any educational debt that is held by the federal government—think direct federal student loans—would be eligible. If you have student loans offered through a state program or private lender, the repayment assistance is case-by-case.

Here’s the page for each branch:

More information here:

NHSC – Loan Repayment or Scholarship?

National Institutes of Health (NIH) Loan Repayment Program

Is HPSP Worth It? Will the Military Pay for Medical School?

State-Based Loan Repayment Assistance Programs

Most states have their own LRAP (if not more), and many are listed on the AAMC website. This is a really handy resource if you’re graduating from training or potentially looking to move states. Below are a few notable programs I’ve seen work for clients. Most state LRAPs are for those working in rural, shortage areas and primary care. Docs can typically combine a state LRAP with PSLF.

CalHealthCares

CalHealthCares is a loan repayment program for newer physicians and dentists in California. The program was created to increase the number of providers in designated Health Professional Shortage Areas (HPSAs).

• Award: Up to $300,000 ($60,000 per year max, paid in arrears after each year of service)
• Eligibility: Doctors in California working in a HPSA, must maintain a patient caseload minimum of 30% Medi-Cal beneficiaries (within 10% of the proposed caseload in the application), full-time work requires at least 32 hours per week of direct patient care or supervision (part-time award prorated)
• Commitment: Five years
• Pros: Generous award amount, full- or part-time work
• Cons: Strict Medi-Cal caseload requirement, long commitment period

Texas Physician Education Loan Repayment Program (PELRP)

Texas-based physicians can qualify for the Physician Education Loan Repayment Program (PELRP).

• Award: Up to $180,000 over four years ($30,000 in Year 1, $40,000 in Year 2, $50,000 in Year 3, $60,000 in Year 4)
• Eligibility: Physicians working full-time (at least 32 hours per week of direct patient care) in primary care in an outpatient HPSA or correctional facility
• Commitment: Four consecutive years of service in a qualifying HPSA or correctional facility
• Pros: Increasing award amounts over time, supports rural and underserved communities
• Cons: Limited to primary care in outpatient settings, long commitment period, requires full-time work

Tennessee Center for Health Workforce Development (TWCD)

TCWD Health Smiles Student Loan Repayment Program is offered to Tennessee dentists in exchange for a service obligation to practice full-time at dental clinics in medically underserved areas.

• Award: Up to $300,000 over three years
• Eligibility: Dentists practicing full-time at dental clinics in medically underserved areas in Tennessee
• Commitment: Three years of full-time service in a qualifying underserved area
• Pros: High award amount for shorter commitment period, supports underserved communities, combinable with PSLF
• Cons: Limited to dentists, restricted to medically underserved areas, requires full-time work, may exclude private practices

Alaska SHARP Program

The Alaska Strengthening Healthcare Access Recruitment Program (SHARP) incentive aims to improve healthcare for rural and underserved populations in Alaska. SHARP is a great option if you’d like to be a small-town doctor in Alaska.

• Award: $20,000-$50,000 per year (total award varies by specialty and commitment)
• Eligibility: Physicians in primary care or high-need specialties (e.g., psychiatry) working full- or part-time in HPSAs, such as tribal health clinics; private practices may qualify
• Commitment: 2-3 years of service in a qualifying HPSA
• Pros: Flexible for full- or part-time work, supports private practices, benefits rural and underserved populations, shorter commitment period
• Cons: Lower award amounts compared to other programs, award size varies by specialty, may require relocation to rural areas

Employer-Based Loan Repayment Programs

Many hospitals, clinics, and private practices now offer student loan repayment assistance as part of sign-on bonuses or retention programs specifically to attract and retain doctors. These programs can be a valuable alternative if you’re working in a setting that doesn’t qualify for PSLF or the other government/state programs. When negotiating a job offer, ask about loan repayment assistance up front. Some employers even structure the payments as direct contributions to your loan servicer, mimicking retirement plan matching. I’ve seen offers range from $5,000-$50,000 per year.

Income-Driven Repayment Forgiveness

Income-Driven Repayment (IDR) Forgiveness is an alternative to PSLF, where you pay for 20-25 years on an IDR plan rather than 10 years on the PSLF plan. I typically advise against this option since it takes so long to pay down the loans and costs at least 2x what you would pay with PSLF. The other aspect I dislike is the tax bomb. After paying for two decades, your outstanding student loan balance (principal + interest) that is forgiven is taxed as ordinary income. Suppose you owe $400,000 in student loans and live in a high tax state like New York. You could end up paying $200,000 in taxes on top of the 20 previous years of repayment. The tax bomb number can be jaw-droppingly large, and it needs to be factored into your initial decision if you want to pursue this track.

While this forgiveness program has its downsides, there are rare scenarios where a doctor may actually benefit from it. IDR forgiveness is more flexible than PSLF; you don’t have to work in public service or be employed full-time, and you don’t need to certify your employment annually. This opens the door for doctors to have more freedom in their occupation.

For the numbers to work out in your favor, your student debt needs to be 3x, 4x, or 5x your income once you’re done with training. It’s an uncommon situation for doctors or dentists to have debt that much larger than their income. It’s more typical for veterinarians, pharmacists, and chiropractors. If you’re considering this approach to your loans, it’s a good idea to chat with a student loan professional.

More information here:

8 Controversial Student Loan Management Techniques

12 Reasons I Hated Income-Driven Repayment Forgiveness Programs

Live Like a Resident

Living like a resident is one of the key mantras of The White Coat Investor to get out from behind massive student loan debt. Many newly minted practicing doctors have a negative net worth from loans and little savings. Living like a resident can help set you up for success by paying off your student loans in 2-5 years, maxing out retirement accounts, or saving up for your first home down payment. Taking this approach does not leave you susceptible to the government eliminating a program like PSLF.

When aggressively paying down student loans, most doctors will look to refinance their loans out of the federal government. As a result, they could lower their interest rate and pay less overall on their student loans.

Suppose you owe $300,000 at a 7.5% interest rate, and you are planning to pay off your loans in five years. You check refinancing rates and receive a quote for 4.5% (I had a physician client receive this rate recently) on a five-year term. Here’s an idea of what you’d be saving to refinance.

Over five years, you would save $25,000. It’s a win-win if you want to be out of debt quickly and save some money. You could even refinance the loan to a five-year term and pay it off in three years. There are no prepayment penalties with refinanced student loans.

The overall savings go down, but it still saves you about $5,000 per year.

Refinancing does have its downsides since you’d no longer benefit from federal programs such as IDR or PSLF. Make sure to run the numbers if you feel like you are on the fence about refinancing vs. staying with federal programs. Once you’ve decided on your optimal path to set goals and become debt-free, you will feel liberated.

Choosing the Right Path Forward

Choosing the optimal approach to student loans is not an easy task. You’re faced with a plethora of repayment options offered by the federal government, your state, and employers. Unfortunately, student loans have been thrust into the middle of the political sphere and tend to change quite regularly. It’s imperative you stay up to date on student loan program changes and are aware of your best options. PSLF has been a fantastic approach for many doctors, and it is still viable. However, I’d urge you to have a backup plan in case PSLF falls through.

If you’re struggling with your loans or simply need a second opinion, schedule a time with us today at StudentLoanAdvice.

What do you think? What is your backup plan for PSLF? Are you still banking on PSLF? Why or why not?