The New York University School of Medicine announced last week that it will now be offering free tuition to all its students. “There is a moral imperative to reduce the amount of debt people have,” Rafael Rivera, associate dean for admission and financial aid at NYU, told The Wall Street Journal. He’s right about one thing: This is a moral and philosophical issue as much as an economic one.

The move has three principal goals:

  • Free future doctors of the crushing debt load many are saddled with;
  • Give graduates the freedom to pursue lower-paying careers in family medicine and pediatrics rather than high-paying specialties such as cardiology (which some do to deal with debt);
  • Attract the best and brightest students rather than just those who can afford medical school and, in the process, a student body that better reflects the society, in terms of race, gender, ethnicity and socio-economic status.

NYU medical-school graduates are fairly typical: 62 per cent are indebted, with student loans averaging US$184,000. And most students come from relatively well-off families, with median parental income of US$125,000.

Annual tuition at NYU is US$55,018, relatively low by U.S. standards, and that figure doesn’t include living expenses.

The free tuition initiative – which will benefit 442 students immediately – has attracted a lot of attention and it is part of a growing trend among U.S. medical schools.

The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University has offered free tuition to its students for the past decade, but it’s a small institution (32 students) geared toward those who want to pursue academic or research careers, rather than clinical medicine.

The Vagelos College of Physicians and Surgeons at Columbia University in New York has eliminated loans, meaning about half its students get grants rather than loans to cover their tuition, and graduates leave with far less debt. Similarly, the David Geffen School of Medicine at the University of California Los Angeles has more than 20 per cent of its students on full scholarships.

These free-tuition programs benefit only a tiny number of the 20,000-plus medical students in the United States. They also depend on the generosity of philanthropists. NYU estimates that it will need US$600-million to fund tuition in perpetuity. To date, it has raised more than US$450-million.

If free tuition is a smart investment for a handful of elite U.S. schools, isn’t it an even better idea for all medical schools?

Leaving aside the larger question of whether all postsecondary education should be tuition-free (as is already the case in many European countries), let’s focus instead on whether Canada’s 17 medical schools should envisage tuition-free medical school.

The situation of Canadian medical students is similar to those in the United States in that far too many graduate with crippling debt. According to the Association of Faculties of Medicine of Canada, the average debt of medical-school graduate exceeds $160,000 – half of that from tuition fees and half from living expenses.

While tuition fees are cheaper in Canada – about $25,000 a year – compared with $35,000 at public universities and $60,000 at private universities in the United States, there is far less philanthropy in Canada and not a tremendous amount of public grants and awards. So getting a financial break based on merit is more difficult for students.

Financial barriers create the same problems in Canada as in the United States: a lack of diversity in medical schools, and financial considerations weighing heavily when medical students pick where and what they practise.

As the cost of medical training has soared, interest in family medicine in rural areas has dropped steadily. It is probably no coincidence.

In Canada, physicians are almost all on the public payroll. Soaring debt has fuelled demands for higher fees and that, in turn, makes it more expensive to deliver publicly funded care. That makes it all the more sensible that we make it affordable for people to get a medical education and promote a more diverse work force in the process.

Rates of physician burnout, depression and suicide have also soared, and some of that is likely being fuelled by financial pressures. It is not unusual for physicians to be still be paying off student debt a decade after they start practising.

The problem is clear, and the solution equally so.

The unanswered question is whether tackling medical-student debt can best be achieved with private dollars, or with public funds – a perennial Canadian health-care dilemma.

Health Reporter
The Globe and Mail, August 21, 2018