Why Medical School Should Be Free

By PETER B. BACH and ROBERT KOCHER
New York Times Opinion
Published: May 28, 2011


DOCTORS are among the most richly rewarded professionals in the country. The Bureau of Labor Statistics reports that of the 15 highest-paid professions in the United States, all but two are in medicine or dentistry.

Why, then, are we proposing to make medical school free?

Huge medical school debts — doctors now graduate owing more than $155,000 on average, and 86 percent have some debt — are why so many doctors shun primary care in favor of highly paid specialties, where there are incentives to give expensive treatments and order expensive tests, an important driver of rising health care costs.

Fixing our health care system will be impossible without a larger pool of competent primary care doctors who can make sure specialists work together in the treatment of their patients — not in isolation, as they often do today — and keep track of patients as they move among settings like private residences, hospitals and nursing homes. Moreover, our population is growing and aging; the American Academy of Family Physicians has estimated a shortfall of 40,000 primary care doctors by 2020. Given the years it takes to train a doctor, we need to start now.

Making medical school free would relieve doctors of the burden of student debt and gradually shift the work force away from specialties and toward primary care. It would also attract college graduates who are discouraged from going to medical school by the costly tuition.

We estimate that we can make medical school free for roughly $2.5 billion per year — about one-thousandth of what we spend on health care in the United States each year. What’s more, we can offset most if not all of the cost of medical school without the government’s help by charging doctors for specialty training.

Under today’s system, all medical students have to pay for their training, whether they plan to become pediatricians or neurosurgeons. They are then paid salaries during the crucial years of internship and residency that turn them into competent doctors. If they decide to extend their years of training to become specialists, they receive a stipend during those years, too.

But under our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average. Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.

While this may seem like a lot to ask of future specialists, these same doctors will have paid nothing for medical school and, through their specialty training, would be virtually assured highly lucrative jobs. Today’s specialists earn a median of $325,000 per year by one estimate, 70 percent more than the $190,000 that a primary care doctor makes. (Although a large shift away from specialty training may weaken the ability of our plan to remain self-financed, the benefits would make any needed tuition subsidies well worth it.)

Our proposal is not the first to attempt to shift doctors toward primary care, but it’s the most ambitious. The National Health Service Corps helps doctors repay their loans in exchange for a commitment to work in an underserved area, but few doctors sign up. The National Institutes of Health offers a similar program to promote work in research and public health, but this creates more researchers, not more practitioners.

Many states have loan forgiveness programs for doctors entering primary care. The health care reform law contains incentive programs that will include bonuses for primary care doctors who treat Medicare patients, and help finance a small increase in primary care training positions.

Our proposal is certain to raise objections. Because some hospitals that provide training to specialists are not associated with medical schools, we will need a system to redistribute the specialty training fees and medical school subsidies. Several entities that have not collaborated before, including the organizations that license specialty training programs and medical school associations, would have to work together to manage this. For the plan to work, it will also be critical that medical schools do not start raising tuitions just because people other than their students are footing the bill.

Our plan would not directly address the chronic wage gap between primary care providers and specialists. But efforts to equalize incomes have been stymied for decades by specialists, who have kept payment rates for procedures higher than those for primary care services. When Medicare has stepped in, most of the increases given to primary care have been diluted by byzantine budgetary rules that cap total spending.

Nothing in our plan would diminish the quality of medical school education. If anything, free tuition would increase the quality of the applicants. Neither would our approach quash the creativity of medical schools in developing curriculums. Medical students would still be required to pass the various licensing examinations and complete patient care rotations as they are today.

Critics might object to providing free medical education when students have to pay for most other types of advanced training. But the process of training doctors is unlike any other, and much of the costs are already borne by others. Hospitals that house medical residents and specialist trainees receive payments from the taxpayer, through Medicare. Patients give of their time and of their bodies in our nation’s teaching hospitals so that doctors in training can become skilled practitioners.

We need a better way of paying for medical training, to address the looming shortage of primary care doctors and to better match the costs of specialty training to the income it delivers. Taking the counterintuitive step of making medical education free, while charging those doctors who want to gain specialty training, is a straightforward way of achieving both goals.

Peter B. Bach, a senior adviser at the Centers for Medicare and Medicaid Services from 2005 to 2006, is the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center. Robert Kocher, a special assistant to President Obama on health care and economic policy from 2009 to 2010, is a guest scholar at the Brookings Institution. They are both doctors.