When Kaiser Permanente announced Tuesday that it won approval to open its new medical school in California, the news that caught headlines was its decision to offer free tuition to all the medical students in its first five graduating classes.
Like the decision last year by NYU’s medical school to offer free tuition to all its students, Kaiser Permanente said it hoped by reducing the financial burden on future doctors for their education, it would encourage students to go into primary care and other lower-paying specialties.
“We’ve watched so many students over the years start off with dreams of working in underserved communities and/or going into primary care, or maybe infectious diseases, or a field that is not as remunerative as some others,” Mark A. Schuster, M.D., founding dean and CEO of the school, said in an interview with Fierce Healthcare.
“As they face the reality of their debt as they go through medical school and see the other options and how different the income can be, they often switch,” he said. “We don’t want debt to be changing what they want to do. We want them to follow their dreams.”
Before the announcement by NYU, annual tuition at the school was $55,018. Kaiser Permanente estimated tuition at $55,000, with the average nationally at $60,000 per year, Schuster said.
Will more students pursue primary care?
But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, will accomplish the goal of encouraging more students to go into primary care, where a major physician shortage is predicted in the coming years.
“That is mostly the excrement of horses,” Robert Centor, M.D., the former regional dean of UAB Medicine, Huntsville, said in an interview shortly after NYU announced last August that it will cover the tuition for all its medical school students regardless of their financial need—a first among the country’s major medical schools.
Centor said he thinks the reason behind NYU’s decision is to attract the best medical students it can as it competes with other high-ranking schools. He didn’t think a tuition-free education would influence whether students go into primary care. “I’m skeptical,” said Centor, who retired in 2016 after 12 years as regional dean at the Alabama campus and a long career as a professor of medicine.
And while NYU’s news was met with some criticism, the university has not wavered from its path. On Tuesday, the university announced it will also make a new medical school it will open on Long Island tuition-free. That school will offer a three-year program and focus on training primary care physicians, which Centor said is a critical factor in influencing students.
To get students to go into primary care, medical schools must expose students to the field and encourage them, he said.
Kaiser Permanente’s goals
Kaiser Permanente, one of the few health systems in the country to open a medical school that is not under the umbrella of a university, is also taking a different approach to medical education. In their first year, students will spend a half day each week working in a primary care setting, working one-on-one with a physician and as part of a team, Schuster said. Students, however, are under no obligation to go into primary care or to work at Kaiser-Permanente.
And while skeptics can speculate that NYU went tuition-free to compete with other top schools, they could argue Kaiser Permanente is offering free tuition to its first five graduating classes to draw some of the best and brightest to its Pasadena school.
“I can’t speak to NYU and its motivations. I can just speak to ours,” Schuster said. “I think we are going to get great students no matter what.” There are so few spots for students who want to attend medical school that many remarkable candidates don’t get in, he said. Its new accreditation means Kaiser Permanente can begin accepting applications in June for its 2020 opening, but the school is already receiving inquiries from interested students.
Among its goals is to help students understand health disparities and population health. “We are also in a health system that values primary care, that treats it with respect and supports it so primary care providers can really fulfill the goals of the field, which is to be at the center of all of the care and be the main communicator and health support for their patients,” said Schuster, a pediatrician who previously worked at Boston Children's Hospital and was a professor at Harvard Medical School.
In contrast to NYU, which began offering free tuition to current and future students, Kaiser Permanente plans to offer free tuition for only the first five classes of students but will then provide “very substantial financial aid” based on need, he said. Students will also have their health insurance covered and scholarships will assist with room and board for students who are in financial need.
Reservations from some doctors
So, while medicine looks to draw more doctors into primary care, other medical professionals join Centor in his reservations that free tuition will do that.
“Basically, making medical school free is a nice idea for medical students but I doubt it will have a big impact on the primary care shortage or the geographic maldistribution problem,” G. Richard Olds, M.D., president of St. George’s University in Grenada, an international medical school that sends many of its graduates to work in the U.S., said in an interview shortly after NYU made its announcement last August.
“I don’t want to sound too cynical,” Olds said, but he also attributed the NYU decision as a way for the university to compete for top students with Ivy League schools such as Columbia and Cornell University.
He also noted that 80% of medical students today come from the top two-fifths of the economic tier. “You’re basically offering free tuition to wealthy Americans,” he said.
And he compared the U.S. to Britain, where medical students have their tuition paid for by the government and where primary care salaries are much closer to those of specialists. Still, students there want to become specialists, he said.
In the U.S., orthopedic doctors who are at the top of the salary list make an average of $414,283, while primary care physicians rank near the bottom. Internal medicine physicians earned an average of $212,915; family medicine physicians earned $208,272 and pediatricians were last on the list at $199,616, according to one recent survey.
Some 75% of graduating physicians in 2017 had student loan debt as they began their careers, with a median tally of $192,000, according to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers. Nearly half owed more than $200,000.
Instead of tuition-for-all, Olds said medical schools could offer free education to those who commit to a career in primary care or will practice in a rural or underserved community. If students fail to keep their commitment, they will have to pay the money back as a loan. However, that could undermine existing federal loan repayment programs for doctors working in underserved communities, he worried.
Both Centor and Olds said medical schools need to work to change attitudes toward primary care. It doesn’t help when students work with doctors in major teaching hospitals who look down on primary care and tell students they are “too smart” to become primary care doctors.
Calling NYU’s proposal “ambitious and game-changing,” in theory, it’s possible that some students who would have chosen lucrative specialties will instead choose primary care because they will be less worried about paying back student loans, said Anupam B. Jena, M.D., an associate professor at Harvard Medical School, in an email. But he thinks the effect will be small.
A free-tuition policy at a top-ranking medical school like NYU will attract some of the most academically competitive students in the country, he said and noted that those students are more likely to enter lucrative specialties.
“It may not have its intended effects but ultimately that is a question that we can study, and we will very clearly be able to see the answer within a few short years,” he said.
One positive is that free tuition may encourage more students from diverse backgrounds to apply to medical school, said Inginia Genao, M.D., graduate medical education director of diversity, equity and inclusion at Yale University School of Medicine. “The prospect of owing over $200,000 can be intimidating to an aspiring medical student from a disadvantaged socioeconomic background,” she said in an email.
In fact, NYU’s offer of free tuition has resulted in a 47% increase in medical school applications for next year, according to Inside Higher Ed. Applications from minority students doubled.
But whether it will attract medical students to less lucrative specialties such as primary care is a complicated question, Genao said. A Graham Center study (PDF) found students with no debt and those with debt over $250,000 were both less likely to choose primary care, she said.
As to the question of whether other medical schools are likely to follow suit, Genao said her initial reaction was yes, but after the NYU announcement was met with some negative reactions, she is not so sure. Other schools may take a different approach, for instance, offering merit-based scholarships.
“More schools may get more innovative on how to address the student debt and link programs to shortages in the profession,” she said.