Should medical school be free-ctd.

Peter Bach and Robert Kocher think so, and argue that the high cost of medical school is a barrier to students choosing lower paying primary care specialties.

I was asking the question of whether socializing the cost of medical school (making it free to students) was an answer a few months ago. After some investigation, I think the answer is no, if the goal is to increase the supply of primary care physicians. A 2009 study from the Robert Graham Center casts a great deal of doubt over the effectiveness of this strategy. As I wrote in April:

The upshot of my question was that if we made medical school ‘free’ to students, then this would remove student debt as a barrier to choosing primary care. It turns out to be more complex than my question implied, and making medical school ‘free’ would likely not be a panacea to the problem of too few primary care physicians:

  • Differential income between primary care and specialists was the biggest barrier to primary care choice (the study found a $3.5 Million lifetime income gap between primary care and specialty care).
  • Student debt has a complicated relationship to specialty choice. The medical graduates who are least likely to choose primary were those with no debt; there is a linear relationship between some debt and $250,000 debt, with more debt decreasing the likelihood of choosing primary care. Above $250,000 in debt, very few medical graduates choose primary care. The conclusion of the study is that those from family backgrounds that produce debt-free medical school are less likely to choose primary care, so simply making medical school ‘free’ would not be a well-targeted subsidy.
  • Another factor was the culture of the medical school in which students were trained

Update: Steve H rightly says in comments that their proposal is more nuanced that simply ‘free medical school.’ They want free medical school for all, then primary care training to continue as is (physicians receive a stipend), and then when physicians do sub-specialty residency and/or fellowship training they will then PAY ~$50,000/year instead of be paid a stipend of similar amount today. So, docs getting sub-specialty training will be paying for someone else in medical school, either out of their own wealth, or borrowing the money. They say the number of physicians in sub-specialty training is very similar to the number of medical students, so these costs are essentially just shifted within the group of people training to be physicians. I am sure there would be moves to reclassify things are primary care, etc., but Steve H is right this is a more nuanced policy than is simply saying ‘medical school is free.’

h/t for the continuing convo to Suzy Khimm in Ezra Klein’s blog.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

6 Responses to Should medical school be free-ctd.

  1. Floccina says:

    IMO

    1. Medical education should be free, maybe even paid because it should be mostly internship. BTW in reality most education only cost one’s time, degrees and licences are what cost money.

    2. Socializing the cost of medical school will not have a big effect in the problem because it is a supply and demand. Even with the current cost there are plenty who would become GPs if they could. There are more than enough qualified students willing to go to school to be GP and there are Doctors who have practice medicine in other countries that are not allowed to practice here.

    3. If GPs made more money and had more prestige than specialists we would have more of them and fewer specialists.

    4. If there is an excess of specialists you could make it more difficult to become a specialist.

    Oh what a tangled web we weave when we restrict supply.

  2. foosion says:

    The problem is that we restrict supply, due to an inadequate number of medical school slots, restrictions on licensing, restrictions on immigration, etc.

    Your first bullet point is the main issue – future earnings are higher in specialties, to students will go there if possible. However, even primary care pay is a lot higher than many alternatives, so if more could go to medical school or be allowed to practice, more would go into primary care. In other words, the balance would be better without barriers to entry.

    The notion that lower debt would lead to more primary care doctors is similar to the notion that if you restrict a bank’s ability to charge large fees here, they will start charging large fees there. If they were able to do so, they would have already done so. I hope this point isn’t too cryptic.

  3. Floccina says:

    Also I bet that many medical students see GP work as boring.

  4. SteveH says:

    Don, Bach and Kocher’s proposal is to make Med School free for Primary care docs, but specialized training would not be, so it differs from your proposal to simply make Med School free for all. The Graham Center study shows that debt isn’t the only consideration, but doesn’t eliminate possible positive effects of Bach and Kocher’s proposal either.

    There isn’t one answer to most problems, but lowering costs of medical school could be an important step if only to attract applicants who can’t face the kind of debt-load med school requires.

  5. DKR says:

    The federal government periodically publishes a list of Health Professional Shortage Areas for primary care and mental health care. Choosing to practice in those areas can lead to loan repayment options that would alleviate debt load for physicians. Most of these HPSAs are in rural areas and very few physicians go there to practice (compare to how many potential slots are available). That just shows that debt load is just one of many factors that influences what docs do with their careers.

    • Don Taylor says:

      @DKR
      Docs practicing in a HPSA are also eligible for a 10% Medicare part B bonus. The HPSA and MUA designation methods are being redone for release in October, 2011 in draft form. You are correct there are many, many NHSC slots available and designated for each actual Corps placement. That is one of the issue being addressed in the redo: should the initial designation be tightened down. It really goes to a policy question of is goal to get docs in worst off areas, or would you rather get them to marginal areas where they might be more likely to later locate permanently

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