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Medical school tuition

Should we be worried about skyrocketing medical school tuition rates and ballooning debt for new doctors? An article in this week's NEJM says yes. The solutions it proposes reinforce my growing conviction that our society has abandoned any commitment it may once have had to ensuring equality of opportunity through education.

Gail Morrison, the Vice-Dean for Education at Penn's medical school, says tuition hikes contribute to two undesirable trends in medical education. First, medical students are increasingly drawn from affluent families, and second, graduates are choosing well-paid specialties partly because their debt loads are so high:

At the same time, for the past two decades, approximately 60 percent of medical students have come from families in the top quintile of income, with the bottom three quintiles together accounting for about 20 percent,3 arousing concern that medical education may be beyond the reach of students from middle-class and working-class families. A recent national survey of underrepresented students indicated that the cost of attending medical school was the number-one reason they did not apply. An Institute of Medicine report found that though Hispanics constituted 12 percent of the population, they accounted for only 3.5 percent of all physicians, and though 1 in 8 Americans is black, fewer than 1 in 20 physicians is black. Continuing this trend has far-reaching consequences for the national health care workforce, which needs diverse physicians in order to address the needs of an increasingly heterogeneous patient population.

Moreover, 32 percent of students who graduated in 2002 indicated that their level of debt influenced their choice of specialty. Indeed, the latest match conducted by the National Resident Matching Program shows a continuing decrease in the number of medical students pursuing careers in primary care (37 percent in 2003, as compared with 49 percent in 1997) and an increase in the number gravitating toward careers in radiology, orthopedics, ophthalmology, and dermatology, which offer higher discretionary income.

It's a reflection of our era that Morrison is pessimistic about finding solutions in state or federal government policies:
How do we stop this vicious circle of increasing tuition and student debt? Although the federal government contributes to undergraduate medical education by guaranteeing low-cost student loans, it needs to do more. Securing adequate funding for Title VII health professions programs, reauthorizing the Higher Education Act, expanding and protecting the National Health Service Corps Loan Repayment Program, and broadening the tax-exempt status of medical scholarships would ameliorate debt. But these initiatives may not be top priorities for a government dealing with war in Iraq, a growing national debt, and threats of terrorism.

State legislatures could provide additional financial support to public medical schools to enable them to cap tuition, allow tax deductions for interest on loans, and authorize more programs whereby new physicians can pay off loans in the form of state service. But most states are also facing a precarious financial balance.

Morrison suggests that in the absence of any governmental commitment or ability to assist, the burden rests entirely on individual medical schools to find ways to slow tuition hikes. Ironically, she suggests that schools pursue the same kinds of "de-facto privatization" that others have suggested as a way of allowing schools to raise tuition.

It's a shame that there seems to be no vigorous efforts to push back against the continuing withdrawal of community support for education. Perhaps it's a sign of Grover Norquist's governmental baby being almost drowned that no one dares to propose that government use tax revenue to subsidize tuition. It would have been fantastic if Morrison had pushed a little harder for government responsibility, instead of accepting as a fait accompli the sad fact that our government sees no problem in diverting tax revenue to our President's dubious adventure in Iraq, and that it prefers to watch the middle class slowly crumble rather than rethink its huge tax cuts for the super-wealthy.

I suppose, if the battle is already lost, that all medical schools, law schools, graduate schools, and colleges should immediately privatize themselves. They should all start chasing after private donors to raise their endowments and abandon the myth that there are any such thing as "public" schools in this country. At least this might allow the schools themselves to survive. Whether it will do anything to protect against the inequities that Morrison's article complains of is much more uncertain.