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When Free Is Not Enough

eye on the news

When Free Is Not Enough

Covering medical school tuition for all students is a generous gift but not a long-term solution. August 30, 2018
Education
New York

New York University’s School of Medicine made headlines last week when it announced that it will waive tuition for all current and future students. Robert Grossman, dean of the medical school, was emphatic that the decision to eliminate tuition—currently $55,000 a year—“recognizes a moral imperative that must be addressed, as institutions place an increasing debt burden on young people who aspire to become physicians.”

NYU’s decision has been met with praise. Without an average $184,000 debt load awaiting them, NYU graduates will be able to pursue meaningful careers, unburdened from financially driven decisions. This will mean, the argument goes, more doctors choosing primary care over higher-paying specialties, and more doctors setting up shop in underserved areas. The elimination of tuition, says NYU—with agreement from health-care advocates—will also result in greater numbers of lower-income and minority students enrolling in medical school than ever before.

NYU is half right: medical school is too expensive, and the burden of student debt poses a serious problem, not just to doctors but also to America’s health-care system. However, the proposed solution, noble as it may be, is wrong. The better answer isn’t making medical school free—it’s making it shorter. The path to obtaining a medical degree in the United States is unnecessarily long and expensive. After four years of undergraduate education, four years of medical school are required before placement in a residency program. Meanwhile, in England and Germany, students begin studying medicine right after high school, skip a bachelor’s degree, and often get their medical degree in six years or less. As a result, these countries have far more medical doctors graduating each year, while the U.S. faces a projected shortfall of practitioners, estimated between 42,600 and 121,300 physicians by 2030.

While the existing system places a heavy financial burden on doctors, and constrains the physician supply nationwide, the NYU model is unsustainable. The cost of obtaining a medical degree at NYU hasn’t changed—it’s still $55,000 a year. Rather than trying to lower costs, NYU is simply getting the money from donors instead of students. The school has already raised three-quarters of the $600 million needed to fund the initiative.

Like so much in our health-care system, what’s heralded as a visionary change is really just cost-shifting. Eliminating tuition would certainly help the students who attend tuition-free schools, as long as the money keeps rolling in. But most medical schools don’t have such generous donors, and will have to keep charging their students tuition. Meantime, nothing will have been done to lower the real cost of medical school in America. And despite excited chatter to the contrary, making medical school free won’t necessarily make it easier for lower-income students to attend. In 2015, the average college graduate in New York owed more than $30,000 in undergraduate student loan debt, above the national average. In addition to undergraduate debt, prospective medical students incur other expenses, including MCAT prep courses and application fees. The cost of living and the opportunity cost of going to school must also be considered. Taken together, these expenses may not equal the bill for medical-school tuition, but their potential impact on students is no less important.

Unlike eliminating tuition, reducing the amount of time it takes to obtain a medical degree would address these issues in a sustainable, scalable way, and would reduce costs across the board. As my colleague Chris Pope and I have argued, America’s medical schools should begin offering integrated undergraduate- and medical-degree programs that can be completed in six years. While some schools already offer “accelerated” medical programs, they tend to be small and usually shave off only a year from the standard eight-year track.

With integrated degree programs, medical graduates not only enter the workforce with less debt; they also enter faster—a crucial factor, as the first wave of the coming physician shortfall is being felt in lower-income rural and urban communities. Students enrolled in integrated programs can avoid the pitfalls of undergraduate burnout, and in many cases will be able to bypass the MCAT, which has limited predictive validity for medical school performance.

Additionally, integrated programs eliminate the fourth year of medical school, which experts agree is unnecessary; in the words of a former president of the Association of American Medical Colleges, a fourth year offers “nothing more than a chance to travel about the country or to engage in audition clerkships.” Most important, studies have shown that graduates of integrated and accelerated medical programs achieve similar outcomes as those who completed the traditional eight-year pathway.

By eliminating medical-school tuition, NYU has brought attention to one of the pressing challenges facing our health-care system. In doing so, however, the university may have triggered a knee-jerk response among policymakers, who will see in this act of generosity a solution to a widespread problem. Making medical school free for all students is unrealistic, and will not address the high costs and other problems associated with American medical education. Administrators, medical school deans, and public-health experts genuinely committed to lowering barriers to entry to the medical profession should instead focus on the ready, sustainable solutions available now.

Photo: SolStock/iStock

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