Free Medical School Tuition Is Only Part of the Solution

This transcript has been edited for clarity. 
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at NYU’s Grossman School of Medicine. 
NYU’s Grossman School of Medicine has, for a number of years now, been tuition free. Not only are we tuition free, we have a second medical school that we operate on Long Island, NYU Long Island, a smaller medical school, which is also tuition free.
Through a major gift from a donor, Ken Langone, for whom the whole health system is named in his honor, and working with our dean, Robert Grossman, they built up a sufficient fund to cover costs for every single medical student. It doesn’t matter if you’re rich or poor or what your family income is, they have built up enough funds so that everybody that is taken into the school gets to go for free. 
Another school, Albert Einstein, had a faculty member who inherited a large sum of money when her husband died. She loves Einstein so much in New York that she gave it as a gift for free tuition for students. Some of you watching may know that Michael Bloomberg, the wealthy entrepreneur, gave to his school $1 billion for people who earn, I believe it was less than $300,000 in family income, to go to Johns Hopkins for free.
This movement of trying to come up with scholarship funds, not things that have to be paid back but to permit free tuition, I wouldn’t say it’s taking off. It’s difficult to achieve it. Some other schools I know have partial forgiven scholarships. Many of them have to give medical aid, but it’s something to pay attention to.
The average cost at a private medical school in the US is very, very high. It can be as much as, I believe, $250,000 to go through med school, and obviously, you may also come out saddled with debt from your undergraduate years. 
Many of these medical schools are using, if you will, means testing. Hopkins, I think, has a $300,000 income cutoff to get free tuition. I know Columbia is a school that will forgive loans with, again, a means-tested income cap that the student or the student’s family may have. At NYU, things are totally free. I believe Einstein is totally free, which is impressive because Einstein is a very big medical school with a big class.
There’s a function of class size and total cost of the school that is somewhat determining who gets in free and who doesn’t. The push is obviously underway because medical school costs a large sum of money. You can see estimates of $250,000 to get through medical school, and what that means is kids come saddled with loans or debt from their undergraduate years, then they’re piling on money to get through med school. Then they’re not going to earn very much, at least early on in residency. So they’re building up quite a debt. 
People have long felt that one of the factors leading to the shortage of people entering into primary care medicine is this huge amount of debt that US medical students have to carry. They’ve got to pay it off. If you’re thinking about pediatrics or family medicine vs a much higher-paying specialty, you go to the specialty because you want to get rid of that debt, get your career underway, and get your life finally settled down. 
I think there’s some truth in that, but not as much, I fear, as proponents of free tuition may believe. We see some impact at NYU on specialty choice, but not much. So far, I don’t think there’s been a drastic move — maybe a little trickle, but not a big jump toward primary care specialty. 
I know why that is. At NYU, at my med school, the culture is still very oriented toward creating specialists. That’s in the culture, it’s in the classes, it’s in the faculty attitudes, and it’s in what we do. Our Long Island medical school is oriented more toward primary care culture. We’ll have to see, as that’s a newer one so we don’t really have data on that, whether that’s a little bit more effective. 
Other things start to drive what happens in terms of whether people end up choosing a primary care specialty, a generalist type thing, or practices that are specialist or hyperspecialist. The culture of their school counts. Whether or not they’re going to try to be a two-career family counts. 
Sometimes somebody may say, “I’d like to be a primary care person, but it looks like the person I’m going to get married to is going to be a specialist. I don’t know what they’re going to do if I’m in a rural area or someplace that just doesn’t have the kind of specialty they do. Maybe I have to reorient and get closer so that both of us can get work together in the same region.” 
Other people wonder whether we get more diversity from having free tuition. The NYU experiment does show some growth in diversity, but it isn’t clear whether that diversity growth is taking away from other schools because our school became more attractive because of free tuition, or whether we’re adding overall to diversity within the medical profession. 
I think, again, the way to probably build a more diverse medical school class and a more diverse medical school profession is starting early to introduce kids from all kinds of backgrounds. I don’t just mean race. I mean rural backgrounds, people who’ve served in the military, and people with disabilities should be introduced in high school or in college to programs that orient them toward healthcare careers, including medicine. 
I think by the time you’re saying tuition is free at med school, it’s not likely to be pulling in many folks at the high school level saying, oh, well, I guess because I go to X for free, maybe that’s a career path for me in 6 years. That just seems to be counterintuitive. 
There are good motives try to make the class more generalist in terms of letting them pick what they want to do, as opposed to do what debt might force them to do. Diversify? We’ll see. 
Overall, at the end of the day, probably the biggest problem and barrier, however, is we don’t have enough medical schools. We need more. Some new ones have been opening over the past decade, and that’s great. As I pointed out, NYU has opened a new one itself, but we need more. 
We need schools that can have a culture that orients to where primary care need might be, rather than trying to take our big research emporiums and say, within them, we can reorient some of the class toward more primary care.
I think we need a medical school model and a healthcare model that is both generalist in the new schools, and perhaps shorter. There are some schools going to the 3-year model. That reduces debt quite a bit and makes it perhaps more attractive to go through medicine, knowing you can get done a little quicker than you would if you perhaps got an MBA or even a law degree and launched your career more quickly down that path. 
Time spent may help, if you can reduce it, in drawing more people from diverse backgrounds into the field. 
I’m all for free tuition. I praise those who’ve made it possible. It’s a great thing to do. Can it serve all of the goals that we hope for in diversifying and making a more flexible, medical profession? It helps a little, but I don’t think it’s going to be the total answer. 
I’m Art Caplan, at the Division of Medical Ethics at NYU Grossman School of Medicine. Thanks for watching.