Yes. Medical school should be free. But so should all higher education.
An interesting article in the New York Times appeared last Saturday, proposing that medical school should be free. The justification for this idea being that it might encourage more doctors to become primary care physicians.
We have an incredible shortage of primary care physicians (PCPs). The American Academy of Family Physicians estimates we’ll be short 40,000 PCPs by 2020. Part of this has to do with Affordable Care Act (ACA) expanding insurance coverage over the next few years. PCPs, who are already stretched to the limit, will not have the capacity to meet the increased demand.
One reason for the shortage comes down to money. PCPs are the lowest paid doctors (though they do the most work by far). With their crucial training and the services they provide comes loan debts of about $155,000 on average as medical school tuition is approximately $38,000 per year.
All doctors make a fair amount of money – doctors of all specialties make up almost all of the 15 highest paid professions in the US. Specialists are reported to make $325,000 per year. PCPs make about $190,000 a year. Granted, doctors pay huge malpractice insurance fees (which ties into other policy issues about tort reform). But these earnings are in contrast to the average American income at $49,777 (according to the Census Bureau). Undergraduate studies alone leave students on average $24,000 in debt (excluding PLUS loans). Then if pursuing graduate studies, the additional debt added comes with a price tag of $25,000 for a Master’s degree, $52,000 for a doctoral degree, and $79,836 for a professional degree. But these degrees don’t necessarily result in lucrative careers – particularly for those working as teachers, for non-profits, or for the government, certainly not the $190,000 PCPs make. Among lawyers, unless hired by a large firm, average starting salaries are $40-45,000 with equally staggering debt to their physician cohorts.
Though debt is high, doctors choosing primary care have options to relieve this burden. The National Health Services Corps helps doctors repay their loans in exchange for working in underserved areas. The National Institutes of Health also helps with loan repayment to promote work in research and public health. Then there are state programs that offer all sorts of loan forgiveness programs. ACA includes incentives, including bonuses for PCPs who treat Medicare patients.
Other professions have similar debt forgiveness programs. The government has set up loan forgiveness for those working for non-profit organizations, for the state or federal government, and for teachers (Public Service Loan Forgiveness). However, those in debt only get this forgiveness if they make regular payments on their loans for 10 years. For those making paltry salaries in these professions, loan repayment may not be feasible (instead they need deferments or forbearances), thus the forgiveness may not be attainable for many (and many don’t know the program exists).
The opportunity to receive an education beyond high school isn’t available to all because of the sheer cost. While there are great college savings plans, Pell and other grants, and scholarships – not everyone has access to these. For those without college tuition paid for upfront or through grants and scholarships then must scrounge for loans and work extra to make ends meet (work that may diminish their ability to focus on their studies). For many, a college education, let alone graduate education will never be an option. And even for those who find it an option, the prospects of leaving school with massive debt discourages those who want to use their education to serve our country in low paying positions like teachers.
The crisis of PCP shortages is a serious issue. Medicaid woefully underpays doctors – to the point PCPs no longer can afford to see these patients (the most needy among us, who likely need PCP services more). PCPs are also blamed for excessive health care costs (I would maintain they are not – in fact they should not be criticized at all when considering other aspects of today’s health care “system”). As such, “innovations” in payment reform (see yesterday’s post about why we shouldn’t trust Medicare payment reforms) focus on PCP payments, threatening to decrease reimbursements under Medicare. At the same time, PCPs are expected to take the brunt of health care changes under the ACA. PCPs will have to adopt health information technology, increase patient-centered medical homes, join ACO’s, meet new performance measures (some of which are clearly excessive and will not improve care), among others. PCPs already are our front line of care (besides the overused emergency rooms, overused due to lack of access to care). They are expected to check our injuries, illnesses, provide preventive care advice, order and review labs but then are tasked with ensuring they screen for mental health illnesses, listen to patient’s psychosocial needs, connect patients to care and coordinate that care. All of this while serving massive numbers of patients a day to ensure care for all and keep their practices in the black. Who would want to go into this profession if they could work fewer, more flexible hours with a higher salary?
While providing education to medical school free of charge is important to attract PCPs, it will not address the wage gap between PCPs and their specialist counterparts, ameliorate the incredible obligations place on our PCPs, or increase Medicaid or Medicare payments.
So should medical school be free? Yes. The ends justify the means – increasing the number of PCPs we so desperately need, who we ask so much of and leave with burdensome loans is worth the free tuition (which the authors propose could be paid by fees for specialty training instead of government subsidies).
Yet, I think it’s unfair to only consider free education for one profession when so many of those working equally hard to improve society face the same barriers to education and loan impediments. The opportunity to receive an education so that we can enter whichever field we endeavor to should not just be available to those fortunate to have the means to pay. Educational opportunities should be available to all, particularly those who endeavor to serve us, whether through public service or as primary care physicians.