Making Medical School Free Is No Cure-All
It’s an admirable and generous decision. The only problem is that it may not have its intended effect.
The NYU decision marks an unprecedented move to eliminate the large educational debt that most medical students face. Three-quarters of medical students graduate with debt. In 2016, the four-year cost of attending medical school was nearly $250,000, and the median debt of graduating medical students was $190,000. These costs don’t include college debt or living expenses. Medical education debt for private universities is also considerably higher.
What are the hoped-for results?
Promoting economic and racial diversity is certainly one of them. In 2017, 6 percent of medical students were black and 5 percent were Hispanic. Among matriculating white students in 2015, 38 percent had family incomes exceeding $200,000 per year compared to 15 percent among black students. There is room to improve racial and socioeconomic diversity in medicine, and it is easy to see how removing the fear of debt would work to that end.
Encouraging doctors to move into socially important but less lucrative practices is another. The ratio of specialist to generalist physicians is higher in the United States than in most other countries, and many believe that increasing the number of primary care physicians, particularly in poorer rural areas, is an important policy goal.
Here the NYU plan may not have its intended effect.
Physicians are generally wealthy. In one recent survey, the average physician salary was nearly $300,000 per year, with primary care physicians earning $217,000 and specialists earning $317,000. Physicians in specialties such as radiology, cardiology, orthopedic surgery and thoracic surgery earn, on average, $431,000, $473,000, $538,000, and $603,000 per year, respectively.
Even with educational debt that nears $200,000, the financial returns to a medical education are large. Further evidence to this point: As medical school tuition has gone up, applications have risen, not fallen.
Making medical education free for all students, then, may not be the soundest economic approach — at least from this perspective. A better tactic would be to expand means-testing beyond what medical schools already offer: to prioritize tuition coverage for applicants with low parental income, to waive their application fees, to pay travel expenses for medical school interviews, and to increase research and clinical opportunities for high-school and college students who fall in this demographic. Simply applying to medical school can cost upward of $10,000 per applicant, and relief here would yield large returns.
It’s also not clear that making tuition free will incentivize students to choose primary care specialties. In a study of medical students who graduated debt-free between 2010 and 2016, the greatest proportion went into the high-paying fields of ophthalmology and dermatology. There are no quasi-experimental studies that suggest that graduating medical students will choose less lucrative specialties if tuition is lowered.
Increasing interest in primary care among medical graduates could also be addressed through more direct means. Tuition could be retroactively reimbursed to students who choose primary-care careers, like family medicine, though this approach is hampered by the fact that physicians often choose their specialties several years after medical school. Subsidizing education for students who ultimately select careers in lucrative specialties is therefore akin to a tax policy that offers tax credits to the highest earners.
There is, however, one clear prediction of making medical school free, though it has little to do with debt relief: better recruitment. Many of my own undergraduate students have forgone admission to the highest-ranked schools in favor of lower-ranked — but still phenomenal — schools that offer them full scholarship. Social media surveys aren’t exactly representative, but a straw poll of 1,139 respondents after the NYU announcement found that 77 percent would choose to attend NYU with full scholarship over Harvard, Johns Hopkins, and Stanford.
Attracting better students doesn’t just raise a school’s profile or its national ranking — it creates a pipeline for talented medical students to remain in the school’s affiliated residency programs and hospitals. Many students continue their residencies at the same hospitals at which they were medical students. All this benefits an institution, and its wider community, but it doesn't necessarily help relieve student debt.
NYU should be praised for its willingness to address a genuine problem faced by American medicine. I would not be at all surprised if other schools try to follow its lead. Before they do, though, they should think carefully if the proposed therapy will actually offer a cure.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
Anupam B. Jena is an economist, physician and the Ruth L. Newhouse Associate Professor at Harvard Medical School.
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