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.

Should We Socialize the Cost of Med School?-ctd.

I asked ‘should we socialize medical school costs?’ a few weeks ago, and sat beside someone with some answers at a meeting this week. Bob Phillips of the Robert Graham Center shared this 2009 study with me on the determinants of physician specialty choice; a key goal of the Graham Center is to encourage medical students to choose primary care.

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

A related question I asked a few weeks back was how much ‘public money’ was invested in a physician’s career from medical school through their residency. The conservative estimate that Bob and I ‘back of the enveloped’ was around ~$500,000. I am going to try and nail that figure down a bit more over the next few weeks. Aaron has written often about physician supply and related issues.