Three years ago, at my class’s white coat ceremony during the first week of medical school, the photographer told us to smile and yell “Tuition-free!” rather than “Cheese!” We were horrified: The notion of tuition-free medical school — admittedly something that had been circulating in the pre-orientation rumor mill — seemed imaginative at best, delusional at worst, and thoroughly inconsiderate on day four of probably the most debt-accumulating pursuit in our adult lives. The following week, the photographer issued an apology.
At yesterday’s white coat ceremony for its class of 2022, New York University School of Medicine announced it will cover tuition for all medical students, regardless of their financial situation. The announcement (which I certainly wouldn’t have minded coming three years earlier) isn’t just great news for NYU medical students. It could also help shape the landscape of health care in the United States in four key ways.
Alleviate the looming physician shortage. Tuition alone for four years of medical school has increased up to fourfold in the past three decades. It now averages $125,000 for public schools and $212,000 for private ones. The American Association of Medical Colleges (AAMC) estimates that more than eight in 10 graduating students bear a debt burden in excess of $100,000, with a median debt of $192,000. That’s a major deterrent for qualified premedical students considering a medical degree. Tuition and its debt burden may be a factor contributing to the projected shortage of up to 120,000 physicians in the United States by 2030.
To be sure, applications to medical schools exceed the available seats — the admission rate was just over 41 percent in the most recent application cycle. Yet the invisibility of “lost applications” may underrepresent interest in the medical profession that could drive the acceleration of development and credentialing of new medical training programs.
Improve the diversity of the physician workforce. Debt incurred by paying for medical school tuition fundamentally influences the demographic profile of medical school classes. In the most recent application cycle, only 18 percent of matriculating medical students were African-American, Hispanic, American Indian, or native Alaskans, even though they make up nearly 33 percent of the U.S. population. Tuition is a key contributor here — 77 percent and 57 percent of African-American and Hispanic medical students respectively report educational debt in excess of $150,000, and African-American students are 2.7 times more likely than others to accumulate that much debt. Potential medical students from underrepresented minorities cite cost as the top barrier to application.
This application and enrollment gap is relevant to the health disparities that exist in the U.S. The life expectancy of blacks is 3.4 years shorter than whites, and every seven minutes an additional black individual dies prematurely relative to whites. Given that graduating medical students from underrepresented minority groups are 2.5 times more likely than white students to work with underserved populations, the increase in diversity that tuition-free medical school might engender has profound implications for reducing health disparities in this country.
Increase primary care physicians. Debt accumulated during medical school influences decision-making about what specialty to choose. In the U.S., only 3 in 10 students choose to practice in the primary care specialties of internal medicine, family medicine, and pediatrics, which generally have lower salaries than specialties like cardiology or anesthesiology. That is partly propelled by the fact that nearly half of third- and fourth-year students say that their choice in medical specialty is influenced by projected income — or by debt burden.
Income is a particularly sensitive issue for those pursuing primary care. They incur expenses in excess of earnings for up to five years after residency (until the age of 33, on average). Yet by 2030, as the prevalence of chronic disease continues to skyrocket and the population of Americans over age 65 years increases by 50 percent, the primary care physician shortage may end up larger than that of every other specialty combined.
Eliminating medical school tuition, and thus medical school debt, could help nudge more students to choose much-needed careers in primary care.
Ease burnout. Educational debt can affect practicing physicians on highly personal level: the 48 percent of students graduating with greater than $200,000 in debt are 1.7 times more likely to experience symptoms of burnout. To the extent that burnout precipitates depression and early retirement —as well as increased medical error rates and poorer patient care — debt incurred during medical training is yoked to patients and providers alike.
The decision by NYU to provide free tuition to all of its students may cause ripples well beyond a four-block stretch along the East River. By liberating both prospective and present medical students from the shackles of educational debt, a medical school can alter the topography of American health care by helping increase diversity in the provider population, improve access to care by minority patients, resolve the deficit of primary care physicians, and empower the battle against burnout. These benefits would be vastly compounded if other schools follow suit.
And that would be something to smile about.
Eli Cahan is a fourth-year medical student at New York University School of Medicine.