Sam Houston State University's pitch to open a medical school in Conroe — a program school officials said would draw primary care physicians to rural and underserved parts of the state — was approved by the Texas Higher Education Coordinating Board Tuesday with a 5-4 vote.

With that sign-off, Sam Houston officials have overcome a crucial hurdle in their bid to launch a doctor of osteopathic medicine program at a campus about 30 miles from the Huntsville-based school. The program, which is expected to enroll some 150 students starting in 2020, must now receive accreditation.

University President Dana Hoyt said school officials were thankful for "such a thorough and deliberative process" and are looking forward to "being a piece of the solution for primary care in rural and underserved areas."

The approval comes as Texas faces a shortage in rural health care providers, but also amid concerns from Higher Education Commissioner Raymund Paredes and some lawmakers that the state is building too many medical schools and should be funding entry-level residency positions instead.

Sam Houston's proposal does not require state money and was approved on the condition that the school never seek nor accept formula-based funding from the Legislature. School officials have turned to a private-school model that would charge students nearly triple the tuition and fees of other public universities in the state. The school's first three years of operating expenses, and the land where it will be based, have been donated.

In an unusual meeting last month, the coordinating board tabled a vote on the Sam Houston proposal after Paredes recommended it be denied.

“Rural communities are dying,” Paredes said at the July 26 meeting. “People don't want to live in small towns,” he added, suggesting that telemedicine and funding entry-level residency slots would better serve those rural areas.

Paredes' comments rankled some lawmakers, including state Rep. Will Metcalf, a Republican who represents the Conroe district where Sam Houston's doctor of osteopathic medicine program would be based.

In a letter to Paredes and the board, Metcalf wrote that he was "extremely disappointed with certain remarks made" and that "a significant portion of our population does indeed desire to live in rural communities."

"I know the Commissioner is not an elitist and that he truly does respect the rural communities of our great state," Metcalf wrote. "Sam Houston has put forward a potential solution to at least address the shortages of rural health care. Is it a silver bullet that will solve all of our problems? Of course not, but we cannot allow the perfect to be the enemy of the good while our rural communities suffer from a lack of medical coverage."

Paredes apologized for the remarks at Tuesday's meeting, saying they were over-generalized.

Sam Houston's proposal says that graduates of osteopathic medicine programs are more likely to practice primary care in rural areas than those who complete doctorates of medicine, making their proposal particularly well-suited to addressing a physician shortage in underserved parts of the state.

Coordinating board staff have said the program's high cost could make it financially challenging for its graduates to practice in rural regions, or in areas that offer lower salaries — though school officials counter the debt would not be unmanageable considering graduates' earning potential and loan-forgiveness options.

“Your reservations are sincere,” John Steen Jr., a member of the coordinating board, told Paredes after the vote. “We have absolute confidence in you, and you’re doing an outstanding job.”

Paredes responded that he respected the decision of the board and would “do whatever I can to make this program a success."

Disclosure: Sam Houston State University and Raymund Paredes have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.