By Larry Kravitz, MD, Natalie Close, and Jonathan Tao
To quote Robert Grossman, the dean of New York University Health, free medical school tuition “recognizes a moral imperative that must be addressed, as institutions place an increasing debt burden on young people who aspire to become physicians.”
Seven medical schools offer free tuition in the United States: NYU, Cornell, Columbia, UCLA, Kaiser Permanente, Cleveland Clinic, and Washington University, although only NYU, Kaiser Permanente, and Cleveland Clinic cover 100% of their students. Some schools, such as TCU, University of Houston, and Dell Medical School offered free tuition for their initial entering class.
NYU became the first nationally ranked program to waive tuition and fees for all students in 2018. The NYU initiative was the creation of Ken Langone, co-founder of Home Depot, who donated $100 million to help pay tuition for every NYU medical student. Since offering free tuition, the NYU applicant pool increased 47% and they had a 100% increase in applicants identifying themselves as underrepresented.
What does under-represented mean? In the United States, 13.6% of the population is Black and 18.9% are Hispanic, yet only 6% of physicians are Hispanic, and only 5% are Black. The premise of schools like NYU is that free tuition will be an effort to solve this mismatch, and likewise, will encourage the development of more physicians committed to going out and serving society’s needs rather than populating more lucrative, and already saturated specialties such as radiology, ophthalmology, anesthesia, and dermatology.
Texas has about 2,000 medical students in its entering classes each year, which is more than double the number in most states. At about $65,000 of student total cost per year, the cost of educating doctors through medical school in Texas is $520,000,000 per year. The state of Texas chips in about $350,000,000 of that cost annually, or about $45,000 per student. That leaves medical students in Texas responsible for about $20,000 per year in tuition. An average financial aid package per student runs around $4,000.
How does this compare to other countries around the world. Brazil, Germany, and Norway provide medical training for free. But Ireland, Canada, and Sweden have comparable charges to the United States. In Spain, citizens attend medical school for €27.67 per credit (approximately 360 credits to graduate). Italian medical schools begin with a €156 administration fee, with additional fee based on family economic situation (maximum 2000 euros per year).
Average debt from the completion of American medical schools is currently $200,000. The average debt of underprivileged students is $40,000 before entering medical school. Although the average time to pay off that debt in medical practice is approximately 8 years, that time may be longer for those choosing primary care specialties and prioritizing work in underserved areas.
In March, 2022, UTMB Galveston just received a $1 billion endowment from The Sealy and Smith Foundation to further the legacy of support established by the Sealy family over a century ago. Assuming that a university endowment generates 4% revenue, an endowment of $500,000 would be required to pay for one medical student spot per year going forward. With 951 students enrolled in medical school at UTMB, tuition could be covered for 100% of its students if $692,000,000 (just over one half of the Sealy gift), were devoted to that purpose.
At UT Southwestern, the endowment is $1,285,900,000. Again, large enough to fund all medical students at the school. For reference, the cost of funding a Distinguished Chair at UTSW is the same cost as endowing one medical student position through all of medical school in perpetuity.
Will free or low-cost medical school lead to more primary care physicians? This has been the burning question since NYU began its experiment in 2018. In theory, student debt would deter students from ethnic minorities and lower socioeconomic status, from entering a career in medicine. It also might encourage medical students to choose higher paying specialties over lower paying primary care fields. General internal medicine, family medicine, public health, and pediatrics are within the six lowest paid physician specialties.
Exploring this further, it turns out that financial issues do not appear likely to influence the choice of specialty. In a survey of 11 factors that influence specialty choices of medical students, only 22% reported educational debt as influencing their choice, and only 48% based their choice on income expectation. More than 98% reported that their decision was based most strongly on personality fit and specialty content.
So, how do we increase the supply of primary care physicians in the US? The most obvious way would be to import them from other countries. Over 25% of American physicians were trained abroad. Unlike American trained physicians, a large portion (30-40%) of these foreign medical graduates work in poverty areas and in areas of non-white populations, presumably underserved Black and Hispanic populations.
Furthermore, we can pursue better primary care mentorship in medical schools. Programs such as the Rural Medical Education Program and The Physician Shortage Area Program of Jefferson Medical College have shown high success in placing and retaining physicians in rural areas by establishing a comprehensive curriculum in rural medicine within a medical school. In fact, “the PSAP has been successful in (1) increasing the percentage of rural family physicians (greater than 8 times that of their peers), and (2) retaining rural family physicians (87% retention rate over 5-10 years in practice).”
It’s clear that free medical school is not the answer to the primary care crisis. But I will argue that free medical school should happen. The sustainable argument is that it will increase the representation of students of lower socioeconomic status and underprivileged minorities, and these groups should increase, not only for the sake of simple human equity, but also because it is well established that these groups are more likely to serve the underserved areas of medicine, even if it is not in primary care. It would level the playing field, and remove one more obstacle from achieving a better medical system. It would give us a chance to recruit a larger spectrum of bright youth that have a better chance of entering our nation's areas of medical need. Blacks and Hispanics have been shown to have multiple barriers more than white students in achieving success in medicine. The prohibitive cost of medical school should not be an additional barrier.
This fall I met with the Dell Medical School fundraisers, and started calculating that even with my modest means as a family physician, with less than my usual annual charity contributions, I could eventually endow enough to pay at least one quarter of a medical student position in perpetuity. I imagined multiplying this by the number of my colleagues who could easily do the same. It started to add up to quite a lot of student slots. So, before we fund another endowed research chair, before we fund another research building, and before we fund another research fellowship, let’s designate our endowment contributions to funding medical school tuition. Now that would make our various medical school alma maters so much better than just adding another research building. To quote the Home Depot advertisement, from the company of Mr. Langone, who made NYU medical school free: “Let’s do this.”