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December 7, 2020

Debt-Free Medical Education—A Tool for Health Care Workforce Diversity

Author Affiliations
  • 1Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
  • 2Division of Healthcare Delivery Science and Innovation, Weill Cornell Medicine, New York, New York
  • 3Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
JAMA Health Forum. 2020;1(12):e201435. doi:10.1001/jamahealthforum.2020.1435

Marked disparities in health care access and outcomes by race, gender, geography, and wealth remain, in part driven by social determinants of health. The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has served to further expose these deep-seated disparities in health and health care in the United States.1

As an important strategy to address disparities in health care, the National Academy of Medicine, National Medical Association, Association of American Medical Colleges (AAMC), and American Medical Association have recommended diversifying the medical profession.2 This is in part because physicians from underrepresented and socioeconomically disadvantaged communities tend to practice medicine in those communities, where there is a substantial need to expand access to care.3 Diversity in the medical workforce also promotes trust between physicians and patients.4 Despite near-universal participation by US medical schools in the AAMC “Project 3000 by 2000,” which aimed to enroll 3000 students from underrepresented groups annually by the year 2000, diversity in academic medicine remains a significant challenge. Less than 15% of students currently enrolled in medical school (13 380 of 94 243 students) belong to groups underrepresented in medicine.

One of the less understood issues in medical school diversification is the role of the rising costs associated with medical education. Medical school debt remains a potential barrier to students as they consider applying to medical school and as they select schools after acceptance. According to a 2020 AAMC report, the median 4-year cost of attendance for the class of 2019 was $250 222 for public medical schools and $330 180 for private medical schools.5 Students also incur multiple hidden expenses associated with medical school training beyond the cost of attendance, including application fees, fees for testing and test preparation, and expenses for professional attire and travel to medical school and residency interviews. In the class of 2019, 73% of students graduated with debt, and the median education-related debt was $200 000. Debt associated with medical education also varies by race and ethnicity. Notably, not only did a higher proportion of Black students graduate with debt (91% of Black students vs 73% of all students), but the median debt was higher ($230 000 for Black students vs $200 000 for all students).5

A number of initiatives have been implemented to address the cost of medical school training. The AAMC has a Fee Assistance Program to support application fees for students at a set income level. Medical schools have traditionally offered a combination of scholarships, grants, and loans, and more recent strategies have continued to evolve. The University of California, Los Angeles, and the Washington University School of Medicine have leveraged merit-based scholarship programs; New York University covers tuition for its student body; Yale has increased grant funding for students with financial need; and Mount Sinai has set a cap of $75 000 of debt over 4 years for students with demonstrated financial need. To systematically address the cost of medical education for prospective students from socioeconomically disadvantaged backgrounds, an important financial intervention to level the playing field may be debt-free education.

With this goal in mind, Weill Cornell Medicine committed to a debt-free medical education program in September 2019. Beginning with academic year 2019-2020, all medical students with financial need, as defined by standardized institutional calculations, were offered debt-free education based on the annual cost of attendance, which includes both tuition and living expenses, such as housing and health insurance fees. The initiative is being financed by an initial $160 million endowment, and an additional $50 million will be needed to maintain the program in perpetuity. For individual students, the required institutional unit loans used in the past to cover financial needs are being converted into full grants.6,7

How has this program affected our incoming class of 2024? To answer this question, we compared our medical student applicants and matriculants in 2020 with those from the 4 previous years (2016-2019). Aside from the launch of the debt-free program, no other changes were made to our recruitment or admissions processes during the last application and admissions cycle.

The mean annual number of medical school applicants during 2016 to 2019 was 6205. For 2020, that number rose approximately 11% to 6882 (a statistically significant increase). More importantly, among matriculating students we observed statistically significant increases in the percentage of students from groups underrepresented in medicine (from 20% to 29%) and students who qualified for the AAMC Fee Assistance Program (from 13% to 24%). Furthermore, we found a significant rise (from 24% to 35%) in the proportion of matriculating students from public undergraduate institutions. What is striking about the increases in socioeconomic and ethnic/racial diversity is that they did not occur at the expense of traditional academic metrics, given that the median Medical College Admission Test (MCAT) scores and grade point averages remained comparable. Overall, 73.5% of students matriculating in 2020 qualified for the debt-free program.

There are several factors to consider in interpreting our preliminary observations. First, the debt-free medical education announcement occurred in the middle of the admission cycle. Therefore, some students who applied may not have been aware of the program. However, in a brief survey of the entering class, we found most students were aware of the program and confirmed it was a factor in their decisions to apply and to matriculate. Also, financial considerations have been listed as a key factor among those who in the past declined acceptance to our institution. Notably, our institution is located in 1 of the nation’s most expensive urban communities. Second, the COVID-19 pandemic has had a major economic impact on the nation. Therefore, the pandemic may have shaped student decisions this year. Finally, our institution has won the Higher Education Excellence in Diversity (HEED) award 3 years in row. Therefore, whether the cumulative effect of our extensive diversity programs informed interest in our school remains unclear.

Our preliminary observations indicate that the implementation of a debt-free medical education program for students with proven financial need might offer yet another potential approach to help to diversify medical school enrollment. This is an essential step in addressing socioeconomic and racial/ethnic disparities in health care.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Yoon Kang, MD, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, 1300 York Ave, Ste C-118, New York, NY 10021 (yok2006@med.cornell.edu).

Conflict of Interest Disclosures: None reported.

References
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Thebault  R, Ba Tran  A, Williams  V. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. Published April 7, 2020. Accessed August 7, 2020. https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true
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Sequist  TD; Association of American Medical Colleges.  Addressing Racial Disparities in Health Care: A Targeted Action Plan for Academic Medical Centers. Association of American Medical Colleges; 2009.
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Komaromy  M, Grumbach  K, Drake  M,  et al.  The role of black and Hispanic physicians in providing health care for underserved populations.   N Engl J Med. 1996;334(20):1305-1310. doi:10.1056/NEJM199605163342006PubMedGoogle ScholarCrossref
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Alsan  M, Garrick  O, Graziani  GC. Does diversity matter for health? experimental evidence from Oakland. National Bureau of Economic Research. Published June 2018. Accessed November 24, 2020. https://www.nber.org/papers/w24787
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Youngclaus  J, Fresne  J.  Physician Education Debt and the Cost to Attend Medical School: 2020 Update. Association of American Medical Colleges; 2020.
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Weill Cornell Medicine. Weill Cornell Medicine eliminates medical education debt for all qualifying students. Published September 16, 2019. Accessed November 15, 2020. https://news.weill.cornell.edu/news/2019/09/weill-cornell-medicine-eliminates-medical-education-debt-for-all-qualifying-students
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Hassan  A. Cornell’s medical school offers full rides in battle over student debt. The New York Times. Published September 16, 2019. Accessed November 15, 2020. https://www.nytimes.com/2019/09/16/us/weill-cornell-free.html
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