COMMENTARY

Should All Medical Schools Have Free Tuition?

Bioethicist Art Caplan discusses this issue with Robert Grossman, dean and CEO of NYU Langone Medical Center, and Tim Rice, deputy director of Health Policy at the Manhattan Institute

Arthur L. Caplan, PhD; Robert I. Grossman, MD; Tim Rice

Disclosures

January 29, 2019

Arthur L. Caplan, PhD: Hi. I am Art Caplan. I want to welcome you to Both Sides Now, our monthly program where we take a look at an interesting issue that is emerging in healthcare. We have an issue to discuss today with two very qualified and interesting guests.

Last summer, New York University (NYU) Langone announced that it would cover tuition[1] for all of its medical students, regardless of their personal financial situation. For the 2018/2019 academic year, that means full tuition scholarships of $55,000 per student—a significant sum of money. While several US medical schools offer free tuition based on need or in return for additional years of performing medical research, NYU is the first major medical school to waive all 4 years of [all] students' tuition.

The school announced that it took 11 years of dedicated fundraising to make the offer to its students who would be graduating in the class of 2022. They have plans for a $600 million endowment, so the interest on that will allow for continued tuition-free study for many years to come.

Seventy-two percent of graduates from medical school in 2017 graduated with a median of $180,000 of debt. Some maintain that to make up for the debt, graduates then seek more profitable specialties versus lower-paying career paths in primary care or in pediatrics. Today we will address the question: Should medical school tuition be free?

Before we jump into an introduction of our guests, I have to say that I am at NYU. I have confessed that already to the audience, but for today's discussion, even though I am somewhat of a fan of this program, I am going to remain neutral and try to push the guests hard to make clear what the policy decision was, why some think it is a good idea, and why some might have issues with it.

Joining us for this discussion today are Bob Grossman, a physician, Saul J. Farber Dean at the NYU School of Medicine, and CEO of the NYU Langone Health System; and Tim Rice, deputy director of health policy at the Manhattan Institute, which is a think tank here in New York City. Welcome, both of you.

Bob, tell us a little bit about how one day you woke up and said, "Let's be tuition-free."

Making NYU Langone Tuition-Free

Robert I. Grossman, MD: First, I will stipulate that I was a significant scholarship and loan student in college and medical school.

Caplan: You realize what you are saying? That means that the deanship is a version of primary care.

Grossman: Exactly. I think I understood exquisitely what it meant to go through college and medical school with a small debt burden. I had a rather interesting career trajectory, but I was a house officer for longer than you can imagine, starting in neurosurgery, switching careers, doing radiology, and then neuroradiology. I also married a doctor. All of those things contributed to my understanding of the particular needs of medical students.

[O]ne of the most important things NYU could do was to help students with their debt. I called it a moral imperative.

When I ascended to the deanship in 2007, I thought one of the most important things NYU could do was to help students with their debt. I called it a moral imperative. A moral imperative requires action.

Caplan: You were first thinking about this in 2007?

Grossman: Yes. The first development gift I got was from a prominent investor who wanted to do something special for Ken Langone, the chairman of our board. I said that the best thing he could do was to create an endowment for scholarships. He wanted to do this anonymously, which he did.

Caplan: I think Ken also worked his way up from relatively poor circumstances.

Grossman: From very poor circumstances, so he understood what it means to be on the receiving end. This person gave us $5 million; that was the first scholarship. We worked for 11 years to try to accomplish this feat and we did it as soon as we could.

Caplan: I think some of our viewers might be interested in how you worked on it. You said that every time you had a meeting of the board of trustees that this was a priority, and that you knew there were other people who might be interested. How did you campaign to get there?

Grossman: I spoke about it in the plight of students. Every time we had a significant fundraiser, all of the money went for scholarships. We did one big fundraiser a year. We endowed those scholarships. We campaigned for it and there were a number of unbelievable people who stepped up to the plate...there are so many people who made significant contributions.

These are all board members and all understood what it meant to have $180,000 to $200,000 worth of debt. During the course of these years, I spoke to a primary care physician who had so much consternation about his children. One was a [medical] student at NYU and had about $250,000 worth of debt. And the other one had over $500,000 worth of debt. Both of [his children] had married physicians. That is just unsustainable. Despite what the public thinks [about physician income], I think doctors are ashamed that they are not making a lot of money. Even neurosurgeons finish paying off debt in their 50s. It is a very challenging problem for the country.

Caplan: I have one more question for you to lay out the groundwork: Do you think that every medical school should be tuition-free or is there something unique about NYU?

This cannot be scaled to every other medical school in the country.

Grossman: I do not have an opinion about that. I would like other medical schools to join us, because I do think it is important, but for us it was about NYU.

Addressing a 'Larger Problem'

Caplan: Tim, in the spirit of "no good deed goes unpunished," do you have some thoughts about free tuition?

Tim Rice: It's not a scalable solution for a larger problem, which is the incredible amount of time and money that it takes to become a physician in the United States. I think it's a fantastic thing and it's wonderful that Bob and everyone over at NYU have been able to make this happen. It's important to realize, though, that the actual cost of a medical degree at NYU has not changed. It was $55,000 a year last year, and it's $55,000 a year this year. The only difference is that rather than students paying it through their tuition dollars, it is coming from donors.

This cannot be scaled to every other medical school in the country.

Caplan: Those tuition numbers are not so different from what an undergraduate faces at many schools.

Rice: Of course, and that points to the issue that the problem with medical school tuition is twofold. One is that it might deter otherwise promising students from seeking a medical degree; and the other, as has been discussed, is [that it might affect] specialty choice for those that graduate. The [first problem] resonates a lot with me, because I graduated college just a few years ago. I was also a scholarship student; I am still paying off my student loans. I washed dishes in the cafeteria to help pay for college.

Caplan: We do hear schools often say that they have reduced the financial barriers for their students, but what you are saying is that they were reduced through loans. It is not like somebody said, "It's free."

Rice: Yes. Loans are always factored in. I have friends now that are in medical school and friends considering medical school. People are grappling with this. If they do not wind up going to NYU, they are still going to have to grapple with this.

If they wind up going to a school that has free tuition now, but some years down the line decides to rescind it, we have not done anything to reduce the cost of a medical degree. There are also plenty of upstream effects, such as undergraduate debt and opportunity cost. NYU is a top-tier medical school. You need to get a 4.0 grade point average (GPA) from a top-tier undergraduate degree or something similar to get into NYU.

If you are working three jobs to pay for Harvard, your GPA might be less than if you were not. None of this is to say that making medical school free does not reduce some of this burden. It is a substantial burden; this is a huge load off the shoulders of these students. But there are a lot of things that come before it and that surround it that this does not address.

[T]he underlying problem is the huge cost of medical education.

'Huge Cost of Medical Education'

Caplan: What about that, Bob? People say that it's great to make it free, but the underlying problem is the huge cost of medical education.

Grossman: That is an interesting issue, because other institutions ought to say, "Why is the tuition so high? What are we paying for?" If you analyze the resources that are needed, it does not compute with the dollar amount.

Caplan: You think it is actually bigger than $55,000?

Grossman: No, I think it is much lower than that. I think there is cost-shifting. Students are supporting faculty and buildings and whatever else. The university needs to justify what the students should be spending versus what the universities are charging.

Caplan: Who sets the tuition for medical school?

Grossman: I do not think it is a very precise process, frankly, and that is one of the things that always bothered me. A lot of it is looking at your peer institutions and looking at how much money you want to generate—the total dollar amount to support all of the services and everything. If you think about medical school, it probably takes 12 or 13 teachers to really teach the classes. Part of the first year and the rest of the years is in clinics. If you cost that out, it's pretty low.

Caplan: It's happening anyway.

Grossman: Correct. You need some teachers, but you don't need [a lot]. Classes of virtually all of the medical schools are 150-200 students; they are not thousands of students. Medical schools have more faculty than they have opportunities to teach.

The question of why the cost of medical education is so high is an important issue, but we wanted to take that out of the debate and just say that this is an opportunity for us as an institution to make a statement about what we think is important for our students. It is not scalable. We agree. We think it is the right thing to do, and we would like a lot of other institutions to join us. Certainly, students should be asking their medical schools with a lot of endowment, "What are you doing with your endowment?" For us, we answered the question.

Caplan: Tim, it is a steep price, but you might say that it is a market-driven price. Whatever they do, whatever they can get, they have some consideration for student interest. You do not want to drive away everyone who cannot make it to Stanford or Minnesota, or whatever. Do we need regulation?

'Do We Need Regulation?'

Rice: I do not think we need regulation. I think that Bob is absolutely right, that what goes into a tuition number or what students are really paying for is a big problem at medical schools, other graduate schools, and undergraduate schools. Tackling or taming the academic bureaucracy is certainly a Herculean task and a noble goal, but I do not think that there is really one single top-down way. Could somebody pass laws that say, "Here is a set student-teacher ratio" or "You can only spend X amount of dollars on new equipment and you have to prove need"? Yes, we could, but I do not think anyone wants those things. I do not think we want this micromanagement, this heavy-handed regulation so that, 5 years from now, NYU has to fill out a 500-page report in order to justify buying new equipment.

Caplan: We would probably say another 500-page report.

Rice: Right, we do not want to add to that paperwork. Rather than more regulation or more requirements or restrictions, I think that there are other tweaks that we can make to the overall structure of medical education and the pathway from high school graduation to residency.

Does Less Debt Mean More Primary Care Docs?

Caplan: If we can eliminate or reduce that debt burden, it will weigh on the minds of people selecting their specialties. We all know that we are overspecialized in the United States; we do not have enough primary care folks and we have a lot of specialty care. Other countries' ratios look a little bit different. I think most people would like to see more primary care. Do you think the debt relief in the NYU case is going to help alter that situation?

Rice: Yes and no. I am certainly of the mind that debt amount does impact or correlate with specialty choice. There are other issues at play, though. One of the main ones is that highly educated people like to cluster in urban areas. For the pool of medical students and doctors that we have now, I think under the NYU model they might now be more willing to become primary care physicians—but in an urban area or in a suburban area, which is good. We need more primary care physicians, period full-stop. But we also need more primary care physicians in underserved urban and rural areas. I do not think that just eliminating medical school tuition may affect one or two people, but I do not think it is going to open the floodgates for young physicians who want to move out to rural Minnesota to become primary care physicians. In order to do that, you need to expand the applicant pool. You need to bring in a wider variety of people, and to do that, I think, requires looking at the entire medical school pipeline.

Our goal was choice and to enable the choice, and hopefully we will succeed.

Grossman: There are a lot of things; let me go point by point. First of all, I agree about medical school costs. One thing we have done at NYU Langone is have a 3-year medical program. It has been fabulous and it is growing. It takes 1 year out of training, which is also important, and it decreases the cost by 1 year. It also enables better mentoring—people get into NYU residencies from college. I would hope other institutions would do that, because not only is medical school expensive, but the length of training is interminable.

Caplan: Years and years—residency, fellowships...

Grossman: Medical school, let's face it, is mostly learning a language. That is the first thing. I would disagree with Art on the need for primary care physicians. We need physicians, and I believe in specialty care. I think all of us, when we have a particular problem, would opt for specialists, even though primary care is important. We need more physicians. Our goal was not to create more primary care physicians; it was to give people opportunities to choose where their talents lie. If people go into primary care precisely because they have decreased debt, great. If they decide to be a plastic surgeon because they are very talented with their hands, great. If they have a proclivity for looking at images, great. Our goal was choice and to enable the choice, and hopefully we will succeed.

Caplan: Now I am going to ask you the tough question. Some people say, "Choice sounds good, but how about rankings?" Did that drive the decision to go tuition-free?

Grossman: No, it had nothing to do with that, because we were ranking [high]. When you think of [US News and World Report], we were number 3 before we were enabled to do that. It actually had no bearing. We had this trajectory for 11 years, and rankings are irrelevant to decision-making for medical school. It did not matter to us, and I do not pay that much attention to rankings. They mean something—I get it—but a lot of the rankings are very ambiguous and opaque. I know we have a great medical school for all of the reasons that you can imagine.

It was about the students and the incredible stress and the burdens of debt that they are under every day. It was also about their families. A lot of students are first- and second-generation individuals who have families working to support them. I thought that any relief that we could give was critical.

Tuition-Free or Not, 'Medical School Is Still Expensive'

Caplan: Tim, some people would say, "It's great that NYU did this.” In a certain sense, it's private gifts from donors making a choice to help relieve this burden. The dean encourages that and says it is a priority. Others might say, "But wait a minute—could their gifts have gone to something else?" Do you have any issue with the idea of private generosity allowing this to take place as opposed to, say, giving the money to, I don't know, better elementary schools or something else?

Rice: Of course not. Private donors should be able to give their money to whomever and spend their money however they want. You would be hard-pressed to find a more noble use of that money. Again, my one concern is that if all medical schools in the country went tuition-free tomorrow, 15 years from now, if all of those donors decided to back out, medical school is still expensive.

Any school that can go tuition-free should by all means go tuition-free. But I still think that as a country, our policymakers or the medical community need to continue to take steps to lower that underlying cost. It is easier to make $33,000-a-year medical school free than $55,000-a-year.

[I]f all of those donors decided to back out, medical school is still expensive.

Caplan: Bob would not be horrified if prices came down.

Rice: Right. Then again, if the worst happens and a previously tuition-free medical school has to go back to collecting tuition dollars, I would just rather see it go back to collecting $30,000 instead of $60,000 a year.

Caplan: Bob has already said that paying off your debt until you are in your 50s as a neuroradiologist or other hi-tech specialist is a pretty big burden, but nonetheless, some people are going to say, "Free tuition for doctors?" How about free tuition for nurses or free tuition for social workers or some group that does not stand to earn much of anything?

Rice: Sure, and I am pivoting off of what Bob was saying about the 3-year program at NYU. That is a fantastic idea. I have long been on the record for 3-year medical school and even an integrated BA/MD track. The 6-year track is great. Get them right out of high school; give them that security. In addition to the debt, this [affects] a lot of those opportunity costs. If you know that you are in, you can study and apply yourself. You do not have to worry about getting top grades or getting into college or getting a perfect score on the MCAT or the SATs, for that matter.

Encouraging those programs and clarifying the regulations that are currently on the books for med school accreditation and accreditation of those programs would be a monumental step forward in expediting this pathway.

You mentioned nurses. A lot of very talented physician assistants (PAs) and nurse practitioners (NPs) are doing a lot of work [in underserved areas]. One study[2] that I read recently focused on rural California. There are some medical centers where NPs and PAs are doing the lion's share of the work, while in some states like New York, they are prohibited from doing as much as they otherwise could because they need physicians to sign off. There are ways to empower these other medical practitioners.

Caplan: While I appreciate that primary care is not necessarily the main driver here, [delivery of] primary care could shift in the future. We could see more nonphysicians doing more tasks and specialty care picking up different loads, but that is for another program.

Grossman: Let me just mention one thing about nursing. We agree that nurses are giving more and more primary care. We are starting a medical school out at Winthrop on Long Island. It is for people interested in primary care. It is a small medical school, tuition-free. It will be 3 years and we are hoping to attract nurses who graduate out of nursing school into that program.

Rice: That is fantastic.

Potential Impacts From Tuition-Free Education

Caplan: What do you think is going to happen to the applicant pool this year? I go around giving a lot of talks, and people tell me they want to apply.

Grossman: Before we did this, metrics for our matriculants were a grade point average of 3.93 and 99th percentile on the MCAT.

Caplan: Always room for improvement.

Grossman: Exactly. We have had great medical students and we will continue to have them. The challenge for us is to choose those students who we think will benefit from an NYU Langone education.

When you give something to people, will they value it? That is the question that I ask myself.

Caplan: I will confess that I have been angling to be on the admissions [committee] this year just to see what [is happening]. Every place I go, people are telling me, "I am going to apply. I never thought of NYU. I want to apply." I was at New Jersey Institute of Technology, which is an engineering school that has a pretty diverse student base of undergraduates. It has a lot of tech students and first-generation college kids. They are very interested in tuition-free. If anybody doubts that it is going to have a welcoming impact to get people to think about medicine, that group was my proof.

Grossman: I will ask a different question: When you give something to people, will they value it? That is the question that I ask myself. Will it be valued the same as if you pay for it? I hope so, because they have to put in a lot of sweat equity in learning, but it is an important question that we are going to have to address.

Caplan: Do you think it will impact future giving from the loans?

Grossman: No. I think people are very committed to NYU and we were incredibly fortunate, but the question is really about the students and their families. Will [free tuition] in any way change the way they view their medical education? Will they feel even more grateful and change the way they react to patients or what they give in their future?

Caplan: Tim, do you think that American education overall can honestly come to grips with this high-cost tuition problem, whether it is medicine or philosophy degrees or whatever? This problem has been around for a while. This is not today's news. Tuitions keep going up and people complain about it. Schools get more exclusive and their admissions policies come under tighter scrutiny because everyone is trying to grapple with these huge costs. Is there hope to rectify this?

Rice: I think there is. I have looked more at medical school in what I have written and what I have researched. As I have said, there are a couple of relatively simple concrete changes we can make to that pathway to make things cheaper and reduce the burden. I am no expert on higher education in general, but I have spent time in the American higher-education system recently and I think that anyone—whether student or professor—can point to certain functions ballooning probably unnecessarily that can be cut. I am speaking more in terms of the balance between administrators or offices of this and that.

Caplan: I can speak for Bob here, and he would tell you that we run a pretty lean operation, both for the medical school and for the health system. A lot of places do not.

Rice: I am speaking just in general, but again, as Bob said, at a medical school, it takes 12 or 13 professors to do the work. A philosophy degree is salaries and textbooks and a classroom. The materials required to teach someone philosophy have not really changed in the past 1000 years, right?

Caplan: Probably have gotten worse, but yes.

Rice: There are always ways. There is always some office that maybe could be trimmed or a facility that maybe could be built for less money or whatnot. Again, I am no expert, but yes, I think it is surmountable.

Will the Future Be Filled With Tuition-Free Medical Schools?

Caplan: Let me wrap up by asking each of you a last question: Fifteen years from now, how many medical schools do you think will have joined the NYU ranks and gone tuition-free?

Grossman: I do not think many. I think there will be a few because of pressure from the students. Students are going to want to talk about education value. Why are we here and what are we getting? I agree; it is probably not scalable. For us, it was important to do.

Rice: I will defer to that answer and also say probably not many. Although, I would imagine that in the next couple of years, there will be pressure from student bodies and donors who have seen the impact that NYU's donors have made, who are wanting to make similar impacts on their alma maters or their preferred donor base. I think that, if not completely tuition-free, there may be a boost in scholarships or tuition-free for certain programs or for certain pools of students, or things like that.

Grossman: Clearly, after we made the announcement, the Mayo Clinic had an announcement. Bloomberg made the announcement for Johns Hopkins Colleges—not medical school. In a school letter, Johns Hopkins [medical school] said that they wanted to follow us. There is this halo effect that will be very good. That is important.

Caplan: I will end by telling you both the saddest criticism I have heard of this program, which is the guys who call me up and say, "I just graduated."

Grossman: I will answer that. We would have done this years ago if we could have. This was the first time we could do it, and we did it. We did it for all of the classes, not just the entering class.

Caplan: What are you going to do? You have to start somewhere. There is nothing you can do, but I occasionally get a sad, mopey phone call about it.

I want to thank both of you for spending some time with us. This was a useful discussion, shining light on a really innovative step in medical education. We all will be able to study it and watch and see what the impact is, whether it gets emulated and if it helps drive the cost down of expensive medical education and expensive medical training.

Thank you, the audience, for watching Both Sides Now.

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