Peter Bach and Robert Kocher have an op-ed in the Times arguing that medical school should be free. As they put things:
Huge medical school debts â€” doctors now graduate owing more than $155,000 on average, and 86 percent have some debt â€” are why so many doctors shun primary care in favor of highly paid specialties, where there are incentives to give expensive treatments and order expensive tests, an important driver of rising health care costs….
Bach and Kocher’s preferred way to cover these costs would gladden the hearts of many within the primary care and public health communities:
We estimate that we can make medical school free for roughly $2.5 billion per year â€” about one-thousandth of what we spend on health care in the United States each year. Whatâ€™s more, we can offset most if not all of the cost of medical school without the governmentâ€™s help by charging doctors for specialty training.
Like Don Taylor, I find their financial analysis rather uncompelling. Differences in compensation across medical specialties are far larger than differences in debt. Medical debt itself, though an issue, is no higher than is assumed by many professionals who receive advanced training. My handy mortgage calculator indicates that monthly payments on a $155,000 30-year, 5 percent loan are only about $832. Primary care is in difficult straits for many economic and organizational reasons that go well beyond the burden of loans.
At the level of psychology and behavioral economics, though, I wonder if such a policy might have greater impact than one’s narrow calculation might otherwise predict. Six-figure debt provides a large overhang of anxiety at a critical moment in people’s careers. It creates a salient reason to pursue a higher income.
These common burdens also reinforce questionable professional attitudes and norms. I often speak with doctors about the need to make difficult changes in medical practice to improve patient care. When these changes are too unpalatable, or when doctors’ status or income comes into question, the words “we have our loans” are spoken with striking regularity. It is as if a Greek chorus has been summoned. This becomes a powerful call for insularity and for drawing sharp, often unconstructive boundaries between insiders and outsiders to the medical profession.
If relieving physicians of practical burdens would loosen these boundaries and the accompanying sense of grievance, $2.5 billion would be well worth it.