The Washington PostDemocracy Dies in Darkness

Med school doesn’t have to lead to crushing debt

Even as applicants receive admission offers from medical schools, many of those students are worrying about how to pay for such an expensive education. But there is an alternative to debt, these school officials argue. Arthur L. Kellermann is dean and Aaron Saguil is associate dean for recruitment and admissions at the Hébert School of Medicine at the Uniformed Services University of the Health Sciences, in Bethesda, Md. This essay was first published in Health Affairs. Their views are their own and do not necessarily represent those of the university, the Department of Defense or the U.S. government.

Three years ago, Sayi Lindeire worked three jobs as she struggled to become the first college graduate in her family. Samantha Green was an engineer after putting herself through college. James Andrews was a military physician assistant. He got his position by enlisting, becoming a combat medic and then qualifying for army physician assistant training. His parents didn’t graduate from high school.

Most young adults in circumstances similar to those of Lindeire, Green and Andrews can only dream of becoming doctors. But today, these three are second-year students at the Uniformed Services University of the Health Sciences, the only medical school in the United States that offers a tuition-free education in exchange for national service.

For most students, a U.S. medical degree is hugely expensive. According to the Association of American Medical Colleges, the median four-year cost to attend public medical school exceeds $240,000.

A private medical school degree can exceed $340,000.

An institutional scholarship can ease this burden, but the typical four-year award is only $18,000. Fewer than one medical student in five receives $100,000 or more in financial assistance.

Because few medical students are wealthy enough to pay cash, most borrow heavily.

The median education debt of a new medical school graduate is $190,000. Fourteen percent start their residency training owing $300,000 or more.

In many other countries, the costs of medical school are largely borne by the public sector. This is not true in the United States.

Although the higher earnings U.S. doctors receive compared to other countries subsequently offset this expense, it can take years to dig out of debt. Ultimately, the public bears the cost of high physician fees and other aspects of U.S. health care.

Some worry that high debt and the prospect of relatively low pay discourage many medical students from entering primary care, choosing instead the higher wages earned in many medical specialties. The evidence of this is mixed. One study found that students with high levels of debt are less likely to choose primary care, but the effect was modest when sex, race and other demographic factors were taken into account.

An even bigger concern is that the prospect of piling up debt deters students of modest means from even considering medical school.

Since 1987, the proportion of applicants from the lowest quintile of U.S. households has not exceeded 5.5 percent. In contrast, half come from the richest quintile.

A 2004 Institute of Medicine report titled “In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce” noted, “The costs associated with health professions training pose a significant barrier for many [underrepresented minority] students, whose economic resources are lower, on average,” than students who are not underrepresented minorities.

Federal scholarships exist, but they support fewer than 5 percent of U.S. medical students.

Each year, about 700 to 750 students enroll with the help of the armed forces’ Health Professions Scholarship Program. These scholarships not only cover tuition and fees; they provide a monthly stipend. After residency training, recipients owe four years of national service as a military doctor.
About 200 students each year secure a National Health Service Corps scholarship. These scholarships also cover tuition and fees, plus a monthly stipend. In return, recipients agree to practice primary care in a federally designated physician shortage area for at least four years.

Finally, 171 students are selected to enroll at Uniformed Services University, the leadership academy for military health. Because Uniformed Services University students are commissioned as members of the armed forces on matriculation, they pay no tuition or fees and receive the salary of a junior officer. After residency, they provide a minimum of seven years of service as an Army, Navy, Air Force or Public Health Service physician.

The benefits of debt avoidance are larger than most students realize. A recent analysis found that borrowers start practice $300,000 to $400,000 behind classmates who finance their education with a national service scholarship.

Those who enter a lucrative specialty such as orthopedic surgery catch up, but it can take four to 11 years to do so. Lower-paid specialties take longer.

Borrowers who enter primary care never close the gap.

National service scholarships are an equally good deal for the United States.

Many recipients keep serving long after they satisfy their legal obligation. Colonel (Dr.) Robert Mabry is one example. When he graduated from high school in rural Oklahoma in 1984, he saw no path to college. Instead, he enlisted in the Army, became an airborne Ranger and later, a Green Beret medic. Between deployments, he earned a bachelor’s degree in night school. At age 28, he started medical school at Uniformed Services University.

Today, 18 years later, Mabry leads the Joint Medical Augmentation Unit for the Joint Special Operations Command in Fort Bragg, N.C.

In its 2004 report, the Institute of Medicine recommended that “Congress should increase funding for Public Health Service Act Titles VII and VIII programs shown to be effective in increasing diversity, and should develop other financial mechanisms to enhance the diversity of the health-care workforce.” It also recommended that “state and local entities . . . should increase support for diversity efforts through programs such as loan forgiveness, tuition reimbursement, loan repayment, GME and supportive affiliations with community-based providers.”

The recent creation of Teaching Health Centers, which support primary care medical and dental residency programs in community-based ambulatory patient care settings, is a step in the right direction. So is the Department of Veterans Affairs’ growing involvement in providing education assistance to aspiring trainees. If primary care evolves to focus more on team-based care and perhaps one day use of telehealth-enabled “primary care technicians,” this may make it more attractive for young, tech-savvy physicians.

Perhaps now, with health care spending reaching $3.3 trillion annually, a growing shortage of primary care physicians and U.S. life expectancy falling for a second straight year, it is time to revisit these recommendations.

Expanding the number and range of national service scholarships would not only enable more students of modest means to become doctors; it could improve Americans’ access to care, reduce health care costs and help more families pursue the American Dream.