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USTIN — When Caitlin Comfort decided to go to medical school, the Yale grad had her heart set on staying on the East Coast. But her wallet had different ideas. Facing $90,000 per year price tags for tuition, she said no thanks, and started applying to schools back home in Texas.

That’s exactly what state legislators and educators want.

In Texas, a decades-old law caps tuition at public medical colleges in a bid to bridge a doctor shortage by a) getting students like Comfort to come back, or, b) getting students like her partner, Justin Cardenas, to stay in Texas to get their degree. Right now, tuition is about $6,550 per year for in-state students.

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This puts Texas medical schools at the top of rankings of cheap (as well as reputable) places to get a medical degree, and several students who spoke with STAT said it was an important, if not the deciding, factor for them.

“It was just a much better deal,” Comfort said, rattling off interest rates and payments and how much she’d owe today if she had gone to one of those $90,000 schools. “Thinking about trying to keep up with a $500,000 loan is crazy.”

Like many states in the South, Texas has a growing population. Children under age 18 make up more than one-quarter of its residents. Having enough doctors is a constant challenge, said Stacey Silverman, a deputy assistant commissioner at the Texas Higher Education Coordinating Board.

“In Texas, we have a shortage of just about everything,” she said. “We need physicians in all specialties, but especially primary care.”

Texas ranks 47th in physician-to-patient ratio. The state has often recruited foreign medical graduates to fill shortages, with about 14,000 currently in practice, according to the Texas Medical Association. But that’s not enough, so the state has also invested heavily over the last several years to build new medical schools.

“In Texas, we have a shortage of just about everything. We need physicians in all specialties, but especially primary care.”

Stacey Silverman, Texas Higher Education Coordinating Board

Texas Tech University converted a satellite campus in El Paso to a full four-year medical school in 2009. The University of Texas Rio Grande Valley School of Medicine and Dell Medical School at the University of Texas at Austin admitted their first classes in 2016. Other schools are in the works.

All public schools abide by the tuition cap, as do some private schools, like Baylor College of Medicine in Houston, where Comfort, from San Antonio, and Cardenas, a Texas A&M graduate, are in their fourth year.

Tuition, of course, isn’t the only expense for students; there are fees, books, housing, and travel costs to consider as well. So some med students do end up with six-figure debt. But it’s typically a lot less than they would owe if they’d gone to schools elsewhere. The Association of American Medical Colleges puts median medical student debt at $180,000 for public schools and $202,000 for private schools for 2017.

“It kind of made a difference for me,” said Michael Lapelusa, a second-year student at the University of Texas Rio Grande Valley (which waived two years of tuition entirely for its inaugural class). Lapelusa, who is hoping that time spent working in Houston will qualify him for in-state tuition for years three and four, wants to work in medically underserved areas, estimates his debt will be less than $100,000 at graduation.

“With smart decisions during residency and shortly after, I think that amount of money won’t dominate my life,” Lapelusa said.

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The med school building boom in Texas has drawn some questions. Namely: Where are the residencies for all these new doctors? They all need years of supervised training in a hospital after graduating from med school, and those slots can be sparse.

Texas officials see an urgency to keep newly minted M.D.s in the state for that training — about 65 percent of young doctors end up staying in Texas after residency, according the AAMC.

So the state legislature has earmarked $97 million in the 2018-2019 budget to support residency programs and expand the number of slots, said Silverman. There are about 6,700 medical students in Texas, according to the AAMC’s 2016-2017 data, and so far, Silverman said that the state has started eight new residency programs.

But it’s unclear who will stay. One irony: The lower debt they have after graduating from med school in Texas often gives young doctors more flexibility to travel the country looking for their ideal residency instead of staying close to home.

Cardenas, for instance, will leave Baylor with about $40,000 in debt. Comfort will leave with about $200,000 in debt. The two are trying to match to residencies in the same city. They’d like to stay in Texas, Comfort said, but on the other hand, both agree that now might be the time for adventure.

“We’re looking at where’s the best programs for us and the best cities to raise a family,” said Cardenas. “And not to be eating peanut butter jelly all the time.”

This story was updated to reflect the correct name of the Association of American Medical Colleges and the median private medical school debt.

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  • Texas student is correct in his/her response. The article is inaccurate – medical school tuition $90,000 somewhere in the us, I don’t so, tuition in Texas $6550 and capped, not even close. Poorly researched.

  • Triple Threat is the reason for decades of failure to address primary care, rural health, small practices, small hospitals, underserved areas, mental health, and basic services. Within practices the number of patients that can be seen per week is declining – due to design changes. Worsening designs since 2010 have resulted in turnover higher and productivity lower for more insult. Now 6 billion dollars a year is forced to leave these primary care practices that only get 40 billion a year in revenue, the wrong direction from the 70 billion minimum required for adequate primary care in places where every other specialty is at even lower concentration and local support resources are least.

    Women’s health, general surgery, and general orthopedics are losing 2 to 3 percentage points a year 2005 to the present. Yes individual schools and programs can show off their stats, but these are essentially a rearrangement of the deck chairs as health access goes down. Local capacity for care delivery must increase for true improvements in access. The focus must be on the team members that deliver the care rather than “quality” or “metrics” or other outcomes that are predominantly determined by the patient factors with little that clinicians can influence.

    Expansions of MD have actually resulted in even fewer for primary care due to the collapse of internal medicine for primary care (45% of MD and international and Caribbean grads and these down to 10% for IM primary care for a career). IM grads were once dependable for 3300 for primary care per class year for 1970s graduates but were down to 1500 for the 1990s grads and have decreased below 1000 a year. 1000 x 30 class years is a maximum of 30,000 for IM primary care as a workforce (down from 120,000) but would be more like 22,000 as hospitalists claim 45,000 and continue to increase.

    Family medicine was once 85,000 active in primary care but the 2010s graduates at 3000 a year will likely result in only 1500 for primary care or less than 40,000 for FM primary care workforce. Internal medicine was 13% of physician workforce where needed and family medicine was 24%, but these will change as fewer replacements emerge. Also the new designs result in the least experienced primary care workforce in the history of the US as fewer spend careers in primary care and as more leave after only a few years. Revolving door primary care/care where needed is a major consequence of Triple Threat.

    Such are the consequences of designs that pay so little for basic services with so much for those taking one or more fellowships while costs of delivery and complexity accelerate.

    The epic destruction of health access is hidden as more profess to be solutions while adding no primary care result. What should be most obvious is that expansions have resulted in increases in workforce where it is already most concentrated and specialized. Less than 13% of health spending goes to lowest concentration counties with 40% of the US population and additional deficit spending will result in even less spending, workforce, and access.

    Only the Metro Counties shaded Blue in the last election have higher to highest concentrations of MD DO NP and PA (and hospitals and VA facilities and specialty hospitals and research, training, faculty, foundations, corporations, associations, institutions) but this still does not mean that all of the populations in these counties have access. There are pockets of shortages in these counties where patients with worst public and private insurance plans are concentrated. These tens of millions are added to 132 million in lowest concentration counties for over 50% of Americans behind.

    Most Americans need designs specific to their needs, but this is prevented by designers that clearly do not understand them, their needs, or the needs of those who attempt to provide care for them.

  • The failure of expansion for health access result is total. Little or no change has been the result as NP has increased from 1500 to 21000 graduates, as PA increased from 1500 to 9000 graduates, and US MD has had a 30% increase since 1980. There have been at least two doublings of DO graduates and many doublings of Caribbean grads while international graduates have remained at a constant of 25% of physician workforce.

    But claims that expansions can solve access woes continue from deans, program directors, pipeline promoters, associations, and workforce experts. The maps do not lie but the Dean’s Lie is well known.

    There is no indication of any expansion related to addressing deficits dating back an entire generation of class years of physicians (30 – 35 class years). Utter failure has an ultimate reason – the design.

  • Expansions of MD DO NP and PA have failed for primary care and for lowest workforce concentration counties in Texas (190 of 254) and in the US (2621 of 3200). These counties only have 110 active physicians per 100,000 and only about 45 primary care physicians per 100,000. This is half enough primary care for what will be half of the US population by 2040.

    The financial design dictates revenue too low with costs of delivery accelerating along with worsening complexity of care for practices in these counties. This Triple Threat defeats any and all training interventions as these counties have concentrations of patients with the worst insurance plans – least supportive for local care. Health care in these counties is 90% generalist and general specialty services and these services are paid 15% less where patients are care are most complex.

    Not surprisingly, more MD DO NP and PA enter specialty and subspecialty areas with more specialties added and more added to each specialty – also as dictated by the more generous financial design. This allows more team members, more specialized duties, shared complexity, higher salaries, and better benefits. It is the financial design, not the salaries, that should be the focus of true reform such as cognitive more with procedural less.

    Only family practice positions filled by MD DO NP and PA place 36% of this workforce where this 40% of the nation is found, but each source results in fewer and fewer in family practice – by design.

  • It takes being alive to be a mass murderer. A better specimen is a live one and a physician at that by the name of Michael Swango, M.D. He is now at Florence, Colorado maximum prison. Study him. He might cooperate as a pay back.

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