Free medical school won’t solve the doctor shortage

Michael Bloomberg last week gave $1 billion to his alma mater, Johns Hopkins University, to make medical school free for most students there. It’s a well-meaning gesture, aiming to remedy America’s doctor shortages that have left more than 100 million Americans without access to regular primary care, particularly in rural and low-income communities. “By reducing the financial barriers to these essential fields, we can free more students to pursue careers they’re passionate about — and enable them to serve more of the families and communities who need them the most,” Bloomberg said in a statement. But a donation to an elite, big-city medical school is unlikely to be much help, experts told me. “If you have this pot of money and you could bestow it on health professional schools with the goal of improving geographic distribution, with the goal of getting more folks from historically underrepresented low-income backgrounds, I wouldn’t have chosen Hopkins,” said Janet Coffman, a health services researcher at University of California San Francisco. Here is the fine print on Bloomberg’s billion: Beginning this fall, the Hopkins medical school — which is ranked second in the nation according to US News — will offer free tuition to any student pursuing an MD whose family has an annual income of less than $300,000. Students whose families make less than $175,000 will also qualify for free room and board. Nearly two-thirds of Hopkins’s current and entering students will be eligible for assistance under the new program, according to the school. Some of the money will also support financial aid for students in the Hopkins public health and nursing programs. It’s part of a recent pattern of philanthropic intervention to make medical school, which costs $236,000 on average, more affordable. Earlier this year, Ruth Gottesman, a former professor at the Albert Einstein College of Medicine in New York City and the widow of a Wall Street investor, announced she would make a $1 billion donation to Einstein to make school free to all students pursuing a medical degree. Billionaire Kenneth Langone and his wife Elaine have given multiple donations to New York University’s medical schools, including a $200 million sum last year, to help provide free tuition to all students there. But a review of early outcomes from NYU’s free tuition program found that it was doing very little to get more of its graduates into communities with the most need. “Unfortunately, on training primary care physicians or sending graduates to underserved areas, tuition-free medical school gets an F,” the University of Pennsylvania’s Ezekiel Emanuel and Matthew Guido wrote in April. A real fix to America’s health care access crisis would require investing directly in those underserved communities and equipping their hospitals with the resources to train the next generation of physicians. To appreciate why, we have to better understand the problem that actually needs to be solved. The real doctor shortage I have been hearing about the doctor shortage for the decade-plus that I have been covering health care. But the problem is more complex than it sounds. When you hear there is a shortage of physicians, you probably think: Okay, I get it, America doesn’t have enough doctors overall. Right? “That question in and of itself is not decided,” Gaetano Forte, assistant director of SUNY Albany’s Center for Health Workforce Studies, told me. The US does have significantly fewer doctors per capita than some other wealthy nations, such as Germany and Sweden. But America’s physician-to-patient ratio is actually about the same as other developed countries — Canada, the United Kingdom, Japan, France — that still generally rank better on measures of health care quality than the US does. So aggregate numbers alone are not enough to explain the access problems that patients face, and experts disagree over whether we need to boost the overall supply of providers in the short term. The bigger problem is misallocation in the US physician workforce, Coffman told me last year. We know that we don’t have enough doctors in certain important specialties: primary care, obstetrics, and psychiatry, for example. We also don’t have nearly enough providers in a broad swath of specialties practicing in rural and other low-income communities. Between 2010 and 2017, while large urban counties added 10 doctors per 100,000 people on average, rural counties lost three. As a result, metro regions had 125 doctors per 100,00 patients, while rural areas had 60. America is littered with doctor deserts, areas where there are not enough primary care providers, much less specialists or hospital-level services. The federal government estimates that 80 percent of rural Americans live in medically underserved communities. In the long term, the US will undoubtedly need more doctors in rural and urban areas alike. Groups like the Association of American Medical Colleges continue to project long-term workforce shortages, as boomer-generation doctors reach retirement age and the population of seniors requiring medical care swells. Why the doctor shortage is so hard to fix It would be nice if simply paying for new doctors to go to school in Baltimore or New York City led to more physicians practicing in small towns of the Midwest or poor neighborhoods in other big cities. But America’s doctors don’t work like that. Physicians tend to practice in communities similar in density and socioeconomic status to where they grew up. Over the years, some federal policies have tried to change that behavior — such as by repaying a new doctor’s medical school debts if they practice in a underserved community for a certain period of time — but the efforts have yielded limited results. Making medical school free faces the same problem: Unless you change the pool of new doctors, the benefits to underserved communities are likely to be marginal. Coffman contrasted Bloomberg’s gift to Johns Hopkins with a hypothetical donation to a historically Black college or university, given that Black communities have striking gaps in their access to health care. “If your goal is, ‘I wanna see more Hopkins students come out of Hopkins without a lot of debt,’ [Bloomberg’s gift] is excellent. If your goal is ‘Across the whole country, I want to address the problem of the maldistribution of physicians by geography, by specialty, I want more folks from historically underrepresented groups,’ I would choose other institutions,” Coffman told me. “In general, one of the challenges of relying on philanthropy, particularly philanthropy in the form of very well-off individuals donating from their own personal wealth, is that these are individuals like Mr. Bloomberg who have their own priorities and understandably their own attachments to particular institutions.” State and local policymakers have explored setting up their own programs that recruit students directly from underserved communities. In California, a UC San Francisco program in the San Joaquin Valley is guaranteeing medical school admission to students from low-income areas, in the hopes that they will return to their communities or similar ones to practice after they graduate. But those efforts are necessarily small; some early returns have been promising, but their long-term impact is still undetermined. Research has also consistently found that most doctors tend to practice near where they completed their residencies, the post-graduation period of supervised, hands-on work experience. Almost all residencies — 98 percent — are in large academic medical centers located in urban areas, like Johns Hopkins. There are some good reasons for that: Those facilities tend to be well-staffed, have experienced mentors, and see high caseloads that allow doctors in training to get a lot of experience quickly. But this system has left much of the country scrambling to find doctors to work in their communities. That is the result of deliberate policy choices. Medicare funds most medical residencies in the US, and it has not meaningfully changed its funding structure since the 1990s, even as the maldistribution of the health care workforce has gotten worse. For example, the program does not pay for hospitals to set up their graduate residency programs, something large hospital systems are better equipped to do than undercapitalized rural hospitals that have a greater need for new doctors. Some large hospital systems even fund their own residencies alongside Medicare-funded slots because having residents is good business for them: They get a lot of young, cheap doctors who nevertheless get to bill for services like any other white coat. Absent congressional action to expand them, the number of residency slots is limited. That makes the large academic centers, which are enormously influential with lawmakers, deeply invested in maintaining their hold on the medical training pipeline. More funding to help rural hospitals set up their own residency programs and more slots earmarked for rural facilities or understaffed specialties could help draw more young doctors to underserved areas — but sweeping reform is unlikely anytime soon. Absent a systemic overhaul of the medical profession, the Bloomberg money may be better than nothing. Some young doctors do say that the high debts they carry from medical school discourage them from practicing in less wealthy areas. Maybe a few of the scholarship recipients will decide to practice in an underserved community, providing much-needed help to its residents. For those people, the former NYC mayor will have made a tremendous gift indeed. But in the long term, we need “a multi-pronged approach” to fix the medical pipeline outside of well-funded and centrally located programs like Hopkins, Coffman said. We need to recruit and support medical students who come from the underserved areas in Wisconsin and Wyoming and Tennessee, as well as New York and California. We need far more equally distributed residency programs. We need to make family medicine and pediatrics as appealing to young doctors as the more glamorous and lucrative specialties. These will be difficult and potentially expensive problems to solve. But it is necessary work. In the meantime, Bloomberg’s billion, and other donations like it, may be at best a Band-Aid on a broken system.

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Free medical school won’t solve the doctor shortage