• Should We Socialize Medical School Costs?

    Residency match day has brought a flurry of folks talking about specialty choice and the perpetual shortage of primary care docs as compared to specialists in the U.S.  David Williams at Health Business Blog brings up the issue of medical school (added onto college) debt and the role that it plays in dissuading medical students from picking primary care residencies.  Three questions:

    • If a student has $150,000 in medical school debt, by the end of residency how much money has society (Medicare direct and indirect medical education payments, state subsidies, indirect NIH grant funds, etc.) invested in their training?  I suspect the answer is substantially (several times) more than $150,000, but I am unsure.
    • Would we be better off to make medical school ‘free’ and therefore take student debt out of the specialty choice equation?
    • If the subsidy of medical education was complete and more explicit than it currently is, how would this change the profession of medicine?
    • New doctors can easily make back their entire debt in a single year.
      Pay primary care doctors more and specialists less.
      I doubt that doctors would be altruistic enough to accept lower pay in return for free education. Even if they would, it would take 20-40 years for them to be the majority of docs.

    • The biggest cost to society and to the student in the time. The time makes it difficult for the market to respond to changed in demand.

      The current system intern system though improved in recent years still seems like an anachronism. To me it is like the fraternity initiation hazing that is meant to strengthen the union (the AMA) which is against the consumers interests.

      IMO Apprenticeship and on the job training to people with 4 year degrees would improve things. Provider companies could bring in people with advanced degrees for the though cases as needed.

    • A few things to consider-
      1) Would making medical education free increase the quality of the physician labor force, irrespective of what track (specialist or primary care) folks took? If so, it may be worth pursuing ( assuming benefits outweigh costs). Especially since…
      2) Making medical education free for everyone is not likely to drastically alter the distribution of physicians, given that compensation would still vary (assuming that salary differences are not merely accounting for the opportunity costs of additional training for specialization and higher malpractice premiums; not clear how reasonable such an assumption would be).
      3) Any forgiveness program/incentive structure to enter primary care must be large enough to actually move a significant number of physicians into primary care. My own experience in law school is that public interest programs that have measurable impact are few and far between. And that some/much of the time, we are merely compensating people who would have made that career choice anyhow.

    • “New doctors can easily make back their entire debt in a single year.”

      I have just hired two new docs out of fellowship. They are both facing between $250,000 and $300,000 in debt. I will not pay them that much for their first year. Assuming that they want to eat, have a place to live and need to pay taxes like the rest of us They could pay if off in a few years if they lived pretty frugally.


    • I wonder how much of the cost of medical school is endogenous with physician pay. That is, how much is directly related to how much the doctors who teach are paid? Anyone have an idea? I know most of academic costs are labor.

    • There are already several (maybe many) debt forgiveness/financial aid programs exclusive to graduates that go into primary care. Most operate by forgiving one year of debt/expenses for every year of service. I suspect medical school is almost certainly more affordable for those docs that go into primary care, than it is for those that become specialists.

    • 2 issues:

      All educational debt – medical school, law school, undergrad is increasing at a rate of 6 to 10% a year for the past 10 years? Why is there such significant tuition increases — how do the schools justify it? There is some suggestion that as loan programs expand their offering – schools increase tuition – making students request larger loans and the cycle perpetuates itself.

      In terms of physician supply, check out the paper by Martin Palmeri “The Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation” published in Academic Medicine 11/2010. In a nutshell, if you have significant debt, you could find yourself in a dire financial predictament if you choose a primary care career. Unfortunately, if you apply the same analysis to many careers (even medical subspecialties), you would get the same result due to skyrocketing educational debt.