T

he announcement that New York University is abolishing tuition for its medical students elicited surprise and joy from the incoming class of 2022 (and pangs of jealousy from students like us who had chosen to go elsewhere for medical school). Some pundits see this as the first of many tuition dominoes to fall. Given the financial investment that a school needs in order to forego tuition as a source of revenue, an analysis we performed suggests that many schools won’t be able to pull that off.

The rationale for making medical school free goes something like this: Tuition alone for four years of medical school is currently in the neighborhood of $250,000, for which the average medical student accrues more than $190,000 in debt. Upon graduation, these students become medical doctors, and can put M.D. after their names. But they then must spend anywhere from three to 12 more years receiving specialized training at below-market compensation before they can begin earning “doctor’s salaries.”

When students dream of wearing the white coat, do they also dream of starting their careers in their early 30s, having spent more than a decade in all-consuming training, saddled with six-figure loans?

Saying that alleviating the debt burden of new doctors is a “moral imperative,” Dr. Robert Grossman, dean of the NYU School of Medicine and CEO of NYU Langone Health, told the incoming class of medical students that their $55,018 annual tuition had been completely waived. While a handful of medical schools, such as Columbia and UCLA, have attempted to provide tuition-reduction programs or limited full-tuition scholarships, NYU’s blanket guarantee is the first of its kind.

“We believe that with our tuition-free initiative, we have taken a necessary, rational step that addresses a critical need to train the most talented physicians, unencumbered by crushing debt,” Grossman said. “We hope that many other academic medical centers will soon choose to join us on this path.”

Judging by the aftermath of his statement, other institutions are feeling the pressure. NYU, already one of the world’s most competitive and prestigious institutions with an acceptance rate of 1.6 percent, is expected to see a massive surge in student applications. (Forbes headlined its reaction “How NYU Poised Itself to be the Most Coveted Medical School in the World.”) Our quick scan of the public’s response showed similarly breathless rhetoric entreating other institutions to follow suit or risk losing ground.

But how realistic is abolishing tuition at all medical schools? To answer that question, we looked at the financial investments that other schools would need to make to forego tuition as a source of revenue. Using available data about medical schools’ existing endowments, enrollment figures, and tuition expenses, we created a model (details available upon request) that rated 86 of the country’s 141 allopathic medical schools on their ability to fund tuition-free, four-year M.D. programs. (We excluded those for which complete financial data was not available.)

Just 20 medical schools (23 percent) were in an equal or better financial position than NYU to begin contemplating such a shift in education financing. Familiar names such as Johns Hopkins, Stanford, Harvard, and Yale hold membership in this exclusive club, which includes 15 of the top 20 research institutions.

Ratio of medical school endowment to tuition
Figure 1. U.S. medical schools ranked from left to right on the X-axis in order of potential ability to offer tuition-free medical education (each school’s US News Research ranking is in parentheses). The Y-axis represents the ratio of 2018 institutional (or affiliated university) endowment, serving as a proxy for fundraising capabilities, compared to estimated tuition endowment requirements (see Figure 2).

It took NYU 11 years to raise enough money to make free tuition sustainable, collecting pledges approaching $600 million in a dedicated endowment fund from more than 2,500 individual donors, with Home Depot magnate Kenneth Langone contributing $100 million of his own fortune. Even for those institutions capable of matching NYU in fundraising muscle, it would take years of dedicated effort and aggressive solicitation of mega-donors to do the same.

Given the cumulative $2.2 billion dollars in tuition that medical schools charge each year, we estimate it would take close to $53 billion dollars in endowment fundraising for just the 86 schools surveyed to offer free tuition programs in perpetuity.

Endownment needed to waive medical school tuition
Figure 2. Tuition endowment requirements estimated for 86 select U.S. medical schools (US News Research ranking in parentheses). Requirement calculation was based on available data on in-state/out-of-state tuition and enrollment figures for the 2018-2019 school year. Investment return estimate was based on five-year average rates from latest available report on college and university endowments. Inflation was set at 2.5 percent and administration fees were capped at 1 percent.

NYU has suggested that its approach is a blueprint for medical schools to enroll more students from disadvantaged backgrounds as well as to free up future physicians to pursue less lucrative but increasingly essential careers in family medicine and primary care. Those are great and necessary goals, but free medical tuition probably won’t be enough to achieve them.

Even if a handful of schools follow NYU’s lead, it will do little to solve the financial challenges inherent in medical training or increase the socioeconomic diversity of the nation’s applicant pool. Most institutions and students across the country are not in a financial position to benefit from this strategy, a strategy that does nothing to address the upstream barriers that keep disadvantaged students from becoming viable medical school candidates in the first place.

And the promise of no-strings-attached free tuition isn’t likely to end the emphasis on high-paid specialties that dominates the culture at elite schools. A 2016 Brown University study found that debt burden had no correlation to students’ choosing primary care as opposed to other specialties. As we can personally attest to, the culture of elite academic medical centers is heavily biased toward specialized training, with faculty historically telling students they were “too smart to go into family medicine.” As of 2016, a notable fraction of top 20 institutions had yet to establish departments of family medicine, a sign that institutional priorities have yet to reflect changing national needs.

Langone deserves praise for his generous contribution to NYU and its medical students. But looking to super-rich business mavericks to bankroll medical education shouldn’t be seen as a sustainable — or even advisable — solution to the rising costs of training the future physician workforce. Such reliance may foster unhealthy relationships between powerful donors and influential academic centers. And for the majority of the nation’s medical schools, access to such donors simply does not exist.

Instead of triggering a seismic shift in medical education by lowering the barrier to entry into the profession, NYU’s new policy further highlights the growing gap between a handful of elite institutions who can afford to “keep up with the Langones” and the rest of the country’s institutions for training physicians.

Daniel Thomas and Daniel Charytonowicz are medical students at the Icahn School of Medicine at Mount Sinai in New York City. Their model and views are personal and do not necessarily reflect those of their school.

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  • The 1% are richer than ever, with Apple and briefly Amazon being valued at a trillion dollars each. The US stock market has enjoyed the longest bull market in over 18 years. The wealthy are not suffering; help us become the best doctors in the world to take care of the ageing baby-boomer population and fight cancer with renewed vigor. We implore you to invest in the American dream for our next generation, just like the great returns made from investments in the stock market or entrepreneurship.

  • Finance burden is not enough to take off real burden from students. What about 4 years of unnecessary premed course where as vast medical curriculum is taught in just 4 years amongst millions of distractions including talk of their peers finishing in 4 years and start making 6 figures in finance or computer science etc ?

  • Great idea but I am sure it comes with a lot of baggage like not being able to leave the state for as long as you receive the free education. It w ould be like the military academies.

    • I don’t believe it does. Rather it’s just a great way to compete for the best students and move up the medical school rankings (while also being benevolent).

  • You are correct that the “NYU model” of free tuition is not applicable to most of the country’s medical schools- $1/2 billion (even for Sinai) isn’t easy to raise. But the following statement is beyond flawed:

    “seismic shift in medical education by lowering the barrier to entry into the profession”

    Lowering tuition RAISES (not lowers) the barrier to entry into “the profession.” If a trend emerges from NYU’s bold move then medical school, in general, will become more accessible (financially) but much more selective/competitive as the opportunity cost of medical school (vs. alternative career paths- Silicon Valley/Wall St) lessens- which is good!

    • Agree. I predict fewer NYU grads will go into primary care / family medicine now. Their already tiny acceptance rate will go down even more — which means acceptance at NYU will be a signal of how competitive / strong a student is. Therefore NYU grads will probably get even more selective residencies and fellowships in specialties at top centers.

  • One problem with your charts is that it assumes that cost of tuition is equivalent to the school’s COST to educate a student. For many schools that overcharge for tuition they could get away with a much smaller endowment than what your charts suggest, because the tuition they currently charge is well above their actual costs (for facilities, faculty, etc) to educate the students in their medical schools.

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