The medical profession seems caught in a “Catch-22”: The growing cost of medical education is generating crushing levels of debt. This debt, in turn, is contributing to a doctor shortage and discouraging students from filling our growing needs for primary care physicians serving in poor, rural, and other underserved areas.
There is hope, however, as students return to campus. A single solution involving the Public Service Loan Forgiveness Program can solve both problems if educators and government can come together and transform debt relief into an instrument for improving health care.
The numbers are stark and dispiriting. Seventy-six percent of medical students graduate with education loans, according to the Association of American Medical Colleges. Their average debt is $190,000. Interest can push the repayment total well over $400,000. That is an especially troubling prospect for young doctors who typically begin their careers in low-paying residency programs that generally last three to five years.
This crushing debt is harming the delivery of care in many ways. Start with our looming physician shortage. A recent study prepared for the AAMC estimates the shortfall at between 61,700 and 94,700 by 2025. Older people use far more health care than anyone else (except the very young) so the need for doctors shows no sign of decreasing as our population ages.
High levels of debt also influence the career paths of many young physicians. Numerous studies have shown that it pushes many students to forsake careers in primary care for higher paying specialties such as cardiology, dermatology, and radiology, and to settle in urban areas where salaries are higher.
Echoing findings across the country about the growing shortage of primary care physicians in rural areas across the country, a 2015 study by the Citizens Research Council of Michigan found that physician shortages in at least one primary care field existed in three out of every four Michigan counties.
Medical school debt is also countering efforts to bring much-needed diversity to medicine. Although the combined percentage of people in the U.S. from African-American, Native American, and Hispanic backgrounds is 31 percent, only 15 percent of current medical school applicants, 12 percent of medical school graduates, and 6 percent of practicing physicians are from those backgrounds. Worries about educational debt can have a strong influence on the decision to attend medical school.
The finding takes on wider significance when paired with other studies that have found minority students are more likely to practice in underserved area.
Crushing debt also has more subtle effects. Another 2014 study found that students with higher debt were more likely to report “feeling callous towards others.” They were also more likely to report higher levels of stress, to delay marriage, and to question their choice of career.
There are no easy answers to this problem. Like all institutions of higher learning, medical schools have raised tuition and other fees faster than inflation for several decades. But the need to train students on the expensive new technologies that are reshaping medicine makes it hard to bend the cost curve.
Scholarships can help. Currently, 48 percent of medical students at the University of Michigan, where I work, receive such aid — about $7.3 million per year. Nevertheless, our graduates leave us owing about $147,000 in student debt encompassing their entire education.
Philanthropy can also make a difference. Ultimately, though, only the government has the resources and the reach to be a game changer. Budget constraints, however, limit our options. Realistically, instead of pushing for more federal funds, we should explore ways to use current programs to relieve debt and our doctor shortage.
A key place to begin is the Public Service Loan Forgiveness Program. Started in 2007, it completely forgives students loans for graduates who are employed by public or nonprofit institutions once they have made 120 qualifying payments. A study published last year in the Journal of General Internal Medicine reported that participation in the program among medical school graduates has grown 20 percent per year since 2010. The study also found that about 95 percent of medical school loans are eligible for forgiveness under this program, in part because about 75 percent of U.S. hospitals are nonprofit or public entities.
Unfortunately, this has led to a backlash among some taxpayers and interest groups who argue the government should not pay off loans for “rich doctors.”
The Trump administration has proposed phasing out the loan forgiveness program for people taking out loans on or after July 1, 2018.
Rather than ending the program for medical students, I believe that we should reform it. Where the current system is aimed at helping doctors, let’s transform it into a program that serves patients by focusing this taxpayer-supported program on meeting society’s needs.
This begins by seeing debt as a form of leverage to encourage young doctors to practice the types of medicine we need, where we need it. Instead of offering the same loan relief to everyone, let’s offer more generous subsidies for those who choose to work in understaffed specialties, such as geriatrics and primary care, and in underserved communities. At the same time, we should cut back on loan forgiveness to others, such as orthopedic surgeons and cardiologists practicing in major cities.
We should also factor income into the load forgiveness equation — considering not just where doctors work but how much they make — to better target limited funds to those who need them most.
Student debt is not going away. Neither is the need for more qualified doctors from diverse backgrounds to serve in poor and rural communities. Seeing both issues as symptoms of the same condition may be the first step in developing a better treatment for these growing problems.
Marschall S. Runge, M.D., is executive vice president for medical affairs and dean of the University of Michigan Medical School.
Only a true reform can increase primary care delivery capacity from less than 50 primary care per 100,000 to the 80 or 90 needed to address the demand, complexity, and broad scope of 40% of the US population in rural and in lowest physician concentration counties. True reform demands 30% more revenue for primary care. True reform requires equitable payment for primary care services in these places where such services are paid 20% less by the worst private and public insurance plans. Not surprisingly these are places where lowest concentrations of MD DO NP and PA are found and no incentive or training intervention can create the dollars to support the workforce of any type. Innovation, digitalization, certification, and regulation are worsening the financial design. Academic entities and leaders can best address care where needed by supporting true payment reform. Frankly, only a local only medical education training design can work with local origin preparation, admission, and training – because the financial design prevents care where needed.
I’m not convinced this is 100% accurate, though it certainly helps. Seats in med school and residency spots are also going to be key. I am a career changer and have already worked towards (though have not completed) public service loan forgiveness in my current field. The possibility of having any future medical school loans also forgiven would ease a great burden, since I already have one masters degree to pay off. I am passionate about holistic primary care and service in rural areas. My tuition for medical school, should I be accepted, will be the same as a future cardiothoracic surgeon, but my income earning potential will be probably a quarter of theirs if I go into family medicine in a rural area as is my goal. Perhaps schools should also consider grants, scholarships and even tuition wavers up front to help encourage interested students to pursue high-need/low-pay fields?
This only works if it is possible to make a living in a rural area. Given lower insurance reimbursement, lack of support services, and the cost of starting a practice (including tens of thousands of dollars for a computer system needed to meet the reporting requirement) it’s a complex issue. Government run and supported health systems are helpful. I did receive loan repayment from my state. I wanted to stay rural but it just wasn’t doable. I’m a family practice doc.
This idea has been proposed for veterinary medicine to try to encourage more graduates to practice in under served communities in inner cities and rural communities across America. Unfortunately, it has never been fully funded, so its effectiveness cannot be fully gauged. However, many of the challenges facing the program in veterinary medicine could potentially effect its success in the human medical field, such as work load, quality of life issues, and cultural differences between the new graduates and their patients. I fully appreciate the differences in medical practices and business models between our professions, but people choosing to become medical doctors are very similar to the people choosing to become veterinarians. Many of them simply do not choose to live in rural or inner city communities or to serve these populations. I believe both programs have immense potential to solve many problems facing our professions and our society; however, they have similar challenges, as well. Thanks for the informative article. I hope our government officials will consider your proposal (and finally fund ours!).
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