During the first Trump administration, we promulgated new regulations for accrediting agency recognition that restored a college’s freedom to select an institutional accrediting agency that best aligns with its mission, purpose and priorities. We did this by making clear that no accrediting agency owns the accreditation function in a state or region, that colleges can join more than one institutional accrediting agency since some focus on location and others focus on mission, and that the Higher Education Act recognizes only one type of institutional accrediting agency—the nationally recognized accrediting agency.
The artificial distinction that the former regional accrediting agencies made between themselves and mission-based institutional accrediting agencies—a distinction that was perpetuated by the Department of Education—created a two-tiered system that does not exist in statute or regulations and that harmed millions of students. Choice is the foundation upon which the Higher Education Act was built, and it remains an essential component of a voluntary accreditation system. We were proud to restore it.
During this term, the Trump administration must focus on restoring choice to programmatic accreditation, which, because of changes in state occupational licensure requirements, has in many cases become a mandate rather than a voluntary activity. In the past, states often supported multiple pathways to licensure eligibility, including completion of a non-programmatically accredited prelicensure program at an institutionally accredited college or university, completion of a programmatically accredited prelicensure program and, in some cases, completion of rigorous on-the-job training with sponsorship by a licensed practitioner.
Multiple pathways allowed institutions to chart their own course when they determined that programmatic accreditation was too costly, too disadvantageous to its students or communities, or too much in conflict with the institution’s mission. Graduates of those programs still had to pass a national licensure exam to demonstrate competency in their field.
However, as state legislators and licensing boards have in many cases eliminated all but the programmatically accredited pathway to licensure eligibility, requiring students to have graduated from a programmatically accredited program before sitting for a licensure exam, these private, membership-based organizations that pretend to be authorities on academic quality—which they are not—have been handed control over the future of entire occupations. One result of these accrediting agency monopolies has been rampant, costly and unnecessary credential inflation in fields like pharmacy, physical therapy and nursing.
‘Everyone Wants to Be Called “Doctor”’
To take one example, the five-year baccalaureate degree served as the minimum entry-level credential for pharmacy from the 1960s until 2000, which explains why even as late as 2023, more than 90,000 licensed pharmacists (approximately a quarter of licensed pharmacists) had a baccalaureate degree as their highest academic credential. In 1984, a group of pharmacy leaders recommended that the entry-level credential for pharmacy be increased from the five-year baccalaureate to a six-year pharmacy doctorate (Pharm.D.) degree.
This change was inspired mostly by the vision that pharmacy should transition from a dispensing-focused profession to a clinical one and therefore justify expansion of Medicaid to reimburse pharmacists for medication counseling. Credential inflation often runs concurrent with trade association efforts to expand scope of practice rights and increase access by their members to new or higher payments from Medicaid and Medicare programs.
In 1985, the recommendation to move to a universal Pharm.D. entry-level requirement was put to a vote by the American Association of Colleges of Pharmacy and was defeated by a narrow margin—likely because relatively few colleges had doctoral-level pharmacy education programs at the time. Nonetheless, in 1989, the Accreditation Council for Pharmacy Education (ACPE) declared its intent to adopt the Pharm.D. as the minimum entry-level credential by 2000.
The National Association of Chain Drug Stores was opposed to the measure, as were many colleges and universities—as evidenced by the 1985 vote. Nonetheless, academics in favor of the change pressed on, presenting at conferences and publishing papers promoting the virtues of Pharm.D. programs and the promise of community-based pharmacy. It’s just so easy to make claims that higher-level degrees will improve patient care, even when there is no empirical evidence to substantiate these claims.
ACPE moved forward as planned to end its accreditation program for B.S. in pharmacy programs and, by 2000, the last student had entered a subdoctoral program. Had programmatic accreditation remained voluntary, colleges that had achieved strong results from their bachelor’s-level programs could have continued to operate them under the auspices of their host university’s institutional accreditation. Licensure exams would have continued to provide safeguards to the public regarding pharmacist competency, and new pharmacists could enter roles as retail pharmacists with the same education and training as their incumbent worker peers.
However, as credential inflation took hold, the National Association of Boards of Pharmacy limited access to the North American Pharmacist Licensure Examination (NAPLEX) it administers to graduates of ACPE-accredited pharmacy schools (as well as foreign-educated candidates who have earned an equivalency certification).
By 2004, every state had adopted the NAPLEX as the standardized licensure exam, and since access to the NAPLEX is limited to graduates of ACPE-accredited pharmacy programs, once ACPE stopped accrediting baccalaureate degree programs in pharmacy, those programs could no longer operate. Thus, state boards of pharmacy were co-conspirators in handing to ACPE a monopoly over the education of all future pharmacists, which then forced every pharmacy program to engage in unnecessary credential inflation.
The community-based pharmacy concept remains a dream rather than a reality, and it might be time to consider a move back to the baccalaureate-level degree in pharmacy, especially since technology now provides automated patient education, prevents dosage errors and flags contraindications—activities that once required pharmacist expertise.
Not to be outranked by the pharmacists, physical therapy leaders similarly elevated the minimum entry-level credential from the master’s degree to the doctor of physical therapy (D.P.T.) degree and limited licensure exam access to graduates of programmatically accredited programs. Once the Commission on Accreditation in Physical Therapy Education decided to stop accrediting programs below the D.P.T. level, it was impossible for universities to continue offering their master’s-level programs.
The impetus for credential inflation in physical therapy was a 2000 initiative by the American Physical Therapy Association, the trade association parent of the programmatic accrediting agency, to convince states to expand direct access to physical therapy (meaning that a physician’s order or referral would no longer be necessary). From 1927 to the 1990s, the baccalaureate degree served as the point of entry to physical therapy. Yet in 20 years, the minimum entry-level credential moved from the baccalaureate to the master’s degree and then to the doctoral degree. By 2016, the physical therapy accrediting agency had ceased accreditation of programs below the doctoral level.
As John D. Wiley, former provost at the University of Wisconsin at Madison, correctly noted almost 20 years ago, “We are already seeing this very phenomenon of degree inflation, and it is being caused by the professions themselves! This is particularly problematic in the health professions, where, it seems, everyone wants to be called ‘doctor.’ I have no problem whatsoever with the professional societies and their accreditors telling us what a graduate must know to practice safely and professionally. I have a big problem, though, when they hand us what amounts to a master’s-level curriculum and tell us the resulting degree must be called a ‘doctor of X.’ This is a transparently self-interested ploy by the profession, and I see no conceivable argument that it is in the public interest. All it does is further confuse an already confusing array of degree names and titles, to no useful purpose.”
Not surprisingly, in 2004, members of the American Association of Colleges of Nursing voted to endorse elevating the minimum requirement for advanced practice nurses from the master’s to the doctoral level—primarily through expansion of shortcut “practice”-oriented doctoral programs (D.N.P.s). At the time, there were only eight current or planned D.N.P. programs. By 2024, there were 42,767 students enrolled in 439 D.N.P. programs, with another 100 programs in the planning stages.
Given the time and institutional resources required to launch legitimate doctoral programs, the rapid increase in D.N.P. programs and enrollments over such a short period of time suggests that minimal standards were put in place to ensure their rigor. It is notable that enrollments in more traditional research-oriented nursing Ph.D. programs remained flat at around 5,000 enrollments during the same period when D.N.P. programs were growing at a rapid pace. Like the pharmacists and the physical therapists, nursing leaders had, with the approval of their programmatic accrediting agencies, created a shortcut to the coveted “doctor” title, mostly to achieve advocacy goals around scope of practice rights and Medicaid and Medicare reimbursement rates.
What the Education Department Should Do
Trade associations and accrediting agencies generate cognitive dissonance when on one hand they claim that programmatic accreditation is a sure way to maintain educational quality, but on the other, they justify credential inflation by explaining that current workers—many of whom completed accredited programs—are somehow unable to keep pace with changes in medical science and patient needs. So, which is the truth? Apparently, accrediting agencies no longer consider the possibility that to the extent curricular gaps exist, they can often be filled at the current degree level by refocusing the curriculum on topics with direct clinical applications, even when these topics may be of less interest to academics.
Changes in occupational licensure that made programmatic accreditation mandatory certainly provide numerous benefits to the accrediting agencies—and to their parent trade associations—that have fought for these changes. The financial and other obligations between trade associations and their subsidiary accrediting agencies have been kept out of the public domain, including by the Department of Education, which has permitted legal documents to be submitted with a confidential demarcation.
The secretary must immediately require every programmatic accrediting agency to post conspicuously on its independent (from the parent trade association’s) website all of the legal documents that explain the purpose and nature of the organization, any and all obligations it has to support or advance trade association priorities, and all financial exchanges that occur between the two. The agency should also be required to report publicly on their website the amount of revenue and fees that were paid to the parent organization, disaggregated by the source and purpose of those funds.
But increased transparency is only the first step. It is now time for the secretary of education to take decisive action to end the manipulative practices of programmatic accrediting agencies and their parent trade associations that have resulted in unnecessary credential inflation. The Higher Education Act has provided tools to prevent just such troubling conflicts of interest.
First, the HEA requires that programmatic accrediting agencies that serve as gatekeepers to Title IV student aid eligibility operate “separate and independent” of their parent trade organizations in terms of finances and administration. In the past, the Education Department applied this requirement only to programmatic accrediting agencies that also served as institutional accreditors for small, single-program schools. That may have been the correct interpretation of the statutory requirement when programmatic accreditation was voluntary.
As states eliminated all but the programmatic accreditation pathway to licensure, however, thus transferring the authority legally conferred upon state occupational licensing boards to private, self-interested, membership organizations, programmatic accreditation became a mandatory requirement rather than a voluntary membership activity.
State authorization requirements have long limited Title IV participation to programs that met all occupational licensure requirements—including mandatory programmatic accreditation requirements where they existed— in the state in which the institution was located. The Obama administration expanded this requirement for certain online programs to include the state in which any enrolled student was located.
The Trump administration expanded the requirement further to include all prelicensure programs— meaning both ground-based and online programs at any institution of higher education—though it limited the requirement to a student’s official address and created a safe harbor in the event that an institution did not know a given state’s requirements, such as in the event that a state was in the process of changing its requirements and the final decision was yet unknown. The Biden administration eliminated the safe harbor and further expanded the requirement to include not just the location of the student or the institution, but also any state in which an enrolled student expressed an interest in eventually working.
There is no question that once programmatic accreditation is required for occupational licensure, programmatic accrediting agencies become the Title IV enablers for those programs, since institutional accreditation alone is no longer sufficient to permit such programs to participate in Title IV programs. In light of this, the secretary should immediately withdraw recognition from any programmatic accrediting agency that serves as an occupational licensure gatekeeper—and therefore a Title IV gatekeeper — but is not in compliance with the “separate and independent” requirement of the HEA.
There are even deeper questions that the secretary should contemplate regarding her authority to recognize a programmatic accrediting agency once it becomes an occupational licensure gatekeeper. The HEA limits the secretary’s authority to accrediting agencies with a voluntary membership, but once programmatic accreditation is required for occupational licensure, membership in such an organization becomes mandatory. Therefore, the secretary likely lacks the statutory authority to recognize any agency that serves as a mandatory occupational licensure gatekeeper, since membership in the organization is no longer voluntary once it takes on that additional role.
She should also ask the Federal Trade Commission to investigate the extent to which mandatory programmatic accreditation violates U.S. antitrust laws, especially when only one agency is recognized by the secretary or named by a state to serve in that capacity.
It is time for the secretary to require all accrediting agencies to comply with the requirements of the HEA and to consider the limits of her own recognition authority, especially as changes in occupational licensure requirements have fundamentally changed the nature and purpose of programmatic accreditation.
