The high cost of medical education: Who should be trained to become doctors?

Medical school is expensive. College, for that matter, is expensive, but medical school is more expensive. According to a consultant website, based on data from the Association of American Medical Colleges,

On average, medical school tuition, fees, and health insurance during the 2019-2020 academic year ranges from $37,556 (public, in-state) to $62,194 (public, out-of-state). Average private school figures come in just below public schools for in-state and out-of-state students, at $60,665 and $62,111, respectively.

That is a lot of money. Per year. Multiply by 4 years. Add books, living expenses (you know, food, rent, like that), and miscellaneous other costs, and it is not surprising that the average medical student graduates a quarter-million dollars in debt.

Of course, if your family is very wealthy, it is not a problem. But given that the mean household income in 2019 was about $63,000, just about a year’s tuition in many of these schools, it would be a stretch for those families to pay such expenses. Indeed, at the 75^th%ile ($113,000) it would be more than half of gross income, and I doubt that even those at the 90^th%ile ($184,000) would find it easy to support a medical student. As medical schools (hopefully) strive for increasing diversity, by income of family of origin, race and ethnicity, and geography (rural vs. urban), this cost becomes a bigger and bigger issue, much more than when only children of the elite (including physicians) attended medical school.

Of course, these students are going to be doctors, on average the highest-paid profession in America. According to most sources, including this one based on a survey on the doctor site “Medscape”, even the lowest-income medical specialties would be easily in the top 10% of income, and several way into the 1% ($475K). (Indeed, the income for those highest-paid specialties seems to be lower than those I have known, who not uncommonly make over $1M.) But even using those numbers, there is a several-fold difference in being in, say, Pediatrics ($212K) or Family Medicine ($219K), and Orthopedics or Plastic Surgery ($500K). It is certainly understandable that, at such high debt loads, the greater income of a high-paid specialty seems more attractive, and may further decrease student choice of primary care (lower paid) specialties. (At a difference of almost $300K a year, a plastic surgeon could expect, over a 30 year career, to earn almost $9M more than a pediatrician! That is real money!)

In addition to their own cost of living, often having to help support, rather than be supported by, a family, is another reality for those who are in medical school and later in residency training. This is a major focus of an important NY Times article on the topic published November 26, 2019, “I have a PhD in not having money”, about the challenges that low-income medical students have, and by extension the challenges for medical schools that really might wish to have a diverse class. The challenge is not only for minority students, who on average come from families with significantly less wealth and income, but across-the-board for students from families with incomes that are not in the higher ranges. It includes most students from rural areas.

In fact, there is an enormously close correlation between students from areas and population groups which are most needed in medicine and those most poorly represented in medical school. In some ways this is a tautology; since doctors are likely to practice in communities like those in which they grew up, poor, minority, and rural communities which are dramatically underrepresented in medical school are the least served. Also, the higher income earned by subspecialists (and, let us not forget, the explicit and implicit encouragement by faculty for students to enter these fields) means that they can practice only in “major medical centers”, places with populations big enough to support a need for that specialty and with hospitals that can provide them a place to practice. Thus, fewer medical students train to be family doctors, who can practice in and are much needed in rural areas, exacerbating the existing reticence of students brought up in cities and suburbs to relocate there.

The Times article is good, but it focuses almost entirely on the issue of paying for medical school. Clearly this is incredibly important. The students featured in it say things like “You have to decide, do you use your loans for a study aid or for a rainy-day fund in case someone at home gets sick?...I haven’t had dental insurance in two years. When tuna is on sale for 80 cents a can, I go buy 30 at CVS,” and “There’s this idea that because we’ll all be doctors one day, the loans don’t matter and it’ll all even out. But that doesn’t account for day-to-day expenses now, like if my mom texts me asking for help.” This begins to get at the larger issues, that it is not only the question of how to pay for medical school, but a variety of related things that characterize students from lower-income backgrounds.

Students from poor families tend to live in poor neighborhoods. Because of the US’ regressive system of financing public education, which depends a great deal on local funds, the quality of the education is likely to not be as good. I refer not to the skill or dedication of the teachers, but the resources to provide additional instruction, instructional support, and special classes such as Advanced Placement. Similar conditions apply in rural areas. Where the student from an upper-middle-class suburb may have many advanced placement classes, especially in sciences, by the time they graduate from high school, and have learned disciplined study habits and been given lots of role models, students from less-well-off school districts are much less likely to have. In a rural area, there may be one science teacher who is shared by more than one district. This gives the more privileged students a leg up before they even start college. Before they start high school. Before they start school altogether.

Then, disadvantaged students have to compete on academic criteria with those from wealthier backgrounds on Medical College Admissions Tests (MCATs), a type of test for which those others have been prepping for years. Medical school faculty on admissions committees often can’t – or don’t care to -- distinguish between the ability to perform well academically and the potential for becoming a good doctor if given the right support. A child of a well-to-do family who has had not only excellent schools but tutors and other support when needed, and who looks like the children of the MD and PhD faculty, might be “hitting on all cylinders” to do as well as they are, while the child of a farm worker or motel cleaner in a rural area may have unlimited untapped potential.

And, yet, it is still more. Producing more doctors from the top income levels means that the communities like those they come from, which already have enough or more than enough physicians, will become more overserved; that the specialties that exist in abundance in those locations will have more members. And lower income communities, rural communities, minority communities, communities that need primary care doctors, will remain underserved. And the health of the US population will be further jeopardized.

Some schools, like Mount Sinai in New York, have eliminated tuition. That is a good thing for the students who are admitted, especially for those who are from low-income families, but it does not explicitly choose students from low-income families. That is a major flaw; it mostly serves to further advantage the most-highly-advantaged students who comprise the bulk of the class. To care for the American people, medical schools need to admit and train physicians who “look like America”, for real, not a few token students in a class mostly comprised of scions of the top 25% or even 10%. This means that the first pass for admission should be demographic – students who come from low-income, from rural, from minority communities, students who don’t look like most current students, students who don’t look like the children of medical school faculty and their neighbors. If there are to be some slots reserved for those who are from privileged backgrounds and overserved communities, they should be for those who are most likely to practice in areas and specialties unlike those in which they were raised, those who have a demonstrated history (not an essay expressing intent) of real service. Were they in the Peace Corps, or AmeriCorps, or Teach for America, or something that actually required extended work and sacrifice?

Those students who are admitted will need maximal financial help, scholarships as much as loans, and even more educational support, so that they can reach their full potential and be able to become the doctors who can help their communities if they choose to return (not all will but they are much more likely to than others). That is what medical school funds should be spent for.

And we need it to start soon. It will be 30 years before currently accepted medical students replace the existing doctors, and we shouldn’t have half-measures.

Decreasing life expectancy in the US: A result of policies fostering increasing inequity

Four years ago, in 2015, economists Anne Case and Angus Deaton published a landmark article in which they documented decreasing life expectancy for white Americans, specifically those aged 45-54, which I discussed on November 14, 2015 in  Rising white midlife mortality: what are the real causes and solutions? This was somewhat shocking data, for it was the first time in decades that a decrease in life expectancy for a group in the US was seen. For a century, life expectancy had been rising.

Although the decrease in life expectancy was in whites of middle age (and lower income), and especially for low-income women (amazingly, low income women born in 1950 had, at the age of 50, a lower life expectancy than their mothers born in 1920!), it was important to remember that life expectancy for African-Americans and some other  minority groups still fell far short of that for whites. This decrease in life expectancy was not the case for other developed countries; it is a uniquely American characteristic – and obviously not a desirable one.

It is, thus, all the more depressing to have a comprehensive new study that finds that not only white people, but all Americans in the 25-64 year old age range have increasing mortality. “Life Expectancy and Mortality Rates in the United States, 1959-2017”,[1] by Steven H. Woolf and  Heidi Schoomaker, just published in JAMA, found that

Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups.

This new study confirms that a large part of the increase in middle-age mortality comes from what Case and Deaton called “deaths of despair”: suicide, drug overdoses, and alcoholism. But there was also a large contribution from “traditional” diseases such as heart disease, chronic lung disease, and stroke. People suffering from these conditions may increasingly be unable to receive adequate medical care for them, because they are uninsured or underinsured or because their out of pocket costs in co-payments and deductibles are unaffordable for them, and even because they live in the wrong places, rural areas far from hospitals. This is very different situation from that in other developed countries which, essentially universally, have universal health care. The New York Times article by Gina Kolata and Sabrina Tavernise quotes Dr. Woolf as saying “The whole country is at a health disadvantage compared to other wealthy nations…We are losing people in the most productive period of their lives. Children are losing parents. Employers have a sicker work force.”

Dr. Woolf also notes that “death rates are actually improving among children and older Americans,” unsurprisingly, “because they may have more reliable health care — Medicaid for many children and Medicare for older people.” Yes. Having health coverage and being able to access health care may actually make a difference, especially with treatment of chronic disease. And if there were adequate treatment for mental health and substance abuse, it could be even better.

Of course, increasing mortality is not just about access to health care. It is mainly about the overall lives many people in the US live. Working-class and formerly-working class people who often no longer have jobs, or at least good jobs, and have given up hope of getting them and re-creating their vision of the American dream, have joined the long-term disenfranchised, underserved, and underemployed. This is a common narrative provided for white working-class people who have turned to Donald Trump because of his (empty) promises to bring back manufacturing and mining jobs to the US. And it is the lack of any reasonable set of social services to prevent large swaths of the American population, of all races and colors and ethnicities, from going hungry, or being homeless or inadequately sheltered, or having heat in the winter and education (and thus hope) for their children.

This is another major issue; the US spends a much lower percent of its GDP on social services of all kinds than do other Western nations. If we add in the money spent on “health care” the gap narrows, but most of that money is being spent on medical care, and medical care often for those with far advanced conditions and a lot of money and/or good insurance, and much of that expense going into health system, insurance company, and pharmaceutical company profit. This was documented by Elizabeth Bradley and Lauren Taylor in 2011 (see To fix health care, help the poor, NY Times and my blog post To improve health the US must spend more on social services, December 18, 2011).

Dr. Woolf says “We need to look at root causes. Something changed in the 1980s, which is when the growth in our life expectancy began to slow down compared to other wealthy nations.” He, of course, knows what changed, and so do we. It was the election of Ronald Reagan and the rapid elimination of the social safety net that had developed in the New Deal, and a move toward greater economic aggrandizement of the already richest and most powerful at the expense of the poorest and least empowered, a trend that accelerated under both the Bush administrations, was only slightly slowed by the Clinton and Obama administrations, and has taken off full steam under our current President.

Yes, there is also an opioid crisis, brought on by not just despair but aggressive marketing by pharmaceutical companies such as the Sacklers’ Purdue. Yes, there is, as the Times article notes, a dramatically higher mortality with powerful synthetic opiates like fentanyl. But this is not a root cause. When you died from an episode of pneumonia complicating your lung cancer, it is misleading to say your death was from pneumonia; the real cause was your lung cancer. Ultimately all deaths are caused by cardiopulmonary arrest (your heart and lungs stopping working), but this is a mechanism, not a cause. Similarly, opioid deaths are the mechanism of death, but the cause is a very inequitable and unjust society. And this is the biggest difference between the US and other wealthy nations.

Ironically, some would say, the parts of the US that are most affected by the increasing death rates are those that not only supported, and are likely to again support, President Trump, but those that provided – and may again provide – the electoral vote margin for him. In addition to northern New England (Vermont, New Hampshire and Maine), the hardest hit states are Ohio, West Virginia, Indiana, and Kentucky. A third of all the excess deaths in the US are concentrated in four Ohio Valley states: Ohio, Pennsylvania, Kentucky, and Indiana. One commentator notes that there are “bright spots”: ‘Life expectancy in the coastal metro areas — both east and west — has improved at roughly the same rate as in Canada.’ But I don’t see this as a bright spot, I see the desperation and death and increasing mortality in the rest of the US as the sore spot. We could do better, but we haven’t; as I noted above even the 16 years of Democratic presidency (admittedly, often with a GOP-controlled Congress) have been more focused on meeting the desires of the wealthiest than the needs of most Americans.

We need to do better, and despite the fact that the Trump administration is the least likely to do so in recent history, it may well be re-elected because of the failure of “mainstream” opposition to come up with effective solutions.

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[1] Woolf SH and Schoomaker H, Life Expectancy and Mortality Rates in the United States, 1959-2017. JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932

Should the price of drugs be based on what pharmaceutical companies can get or what people can afford?

The high cost of prescription drugs is an issue that seems to engage most people, including politicians both Democratic and Republican, left and right. The Speaker of the House of Representatives, Nancy Pelosi (D-CA), has proposed a bill (called, in fact, the Lower Drug Costs Now bill) that would control drug prices, at least for essential medication, a proposal endorsed by the Editorial Board of the New York Times. The President of the United States, Donald Trump, who disagrees with Ms. Pelosi on almost everything else (and indeed is in the process of being impeached by the House of Representatives over which she presides) is telling Americans that they will be able to buy their drugs, at lower prices, from abroad. Indeed, the President has gone even further, announcing that he will require health providers to post their actual prices, that is what insurers actually pay, not posted un-discounted prices, on line.

Both of those White House proposals would be terrific. They would not, by a long shot, solve the problems afflicting Americans in the arena of their health and health care – after all, posting the prices is not the same as making them affordable – but it would sure help. I have previously told the story of an outpatient hernia operation I had some years back. I left home at about 6am and was back there in my own bed by noon. Then I received the hospital bill – not including the charges from the doctors, the surgeon and anesthesiologist – for $10,000! I then got a notice from my insurer that I would have to pay $400, they would pay $1600, and the hospital would make a “contractual adjustment” for the rest. That is, the hospital, based on a contract with my insurer, would write off $8000. Whew. I only had to pay $400. But the thing is – the official hospital charge was $10,000. If I didn’t have insurance, I not only wouldn’t have been billed only $400, I wouldn’t have even been billed the $2000 that was the total the hospital collected from me and the insurance company; I would have been billed $10,000! This is absurd, and while requiring hospitals to post the prices they are actually paid by the insurance companies would not necessarily change this, it would bring the flagrant abuse of uninsured people out into the open. If you doubt the significance of this, note the objections of the hospital industry: ‘“This rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations,” the American Hospital Association and three other major hospital groups said in a statement.’ Yup, they hate it so it must be a good thing!

But back to drug prices. They are currently unconscionable. Americans pay a lot more for most drugs that they need than people in other countries. The main reason is that other countries regulate drug prices, and the US doesn’t. Indeed, when the Medicare Drug Plan (Part D) was passed by Congress during the GW Bush administration, it specifically forbade Medicare from using its clout as the nation’s largest insurer to negotiate drug prices. That was a win-win for the drug companies (The government requires every Medicare recipient to buy drug insurance and forbids it from doing anything but pay full price.) So, frankly, the White House proposal to allow American to buy drugs abroad is a minor step – nothing like actually regulating prices for drugs or even allowing Medicare to negotiate those prices for its recipients – but it is something. I support it as far as it goes. I also support Nancy Pelosi’s more extensive intervention.

There is reason, however, to be skeptical of whether the White House will actually implement these changes. Impeachment aside, promising things that he cannot or will not deliver on is the routine modus operandi of President Trump. I hope this is the exception. Pelosi’s Democrats are, I believe more sincere in their desire to limit drug costs, but it is unlikely that a plan of theirs will pass the Senate, and if it should, the President would likely veto it because it is not his plan. And, of course, it might hurt the drug companies; he likes to use them as whipping boys, but they are a big part of the huge corporate complex that has benefited from all of the Republican’s policies, and contribute a lot. They also contribute a lot to Democrats.

Sometimes in discussions about drug prices, similar to discussions about other situations that lead to enormous industry profits, we hear arguments that include the need for research and development on new drugs and the possibility that Americans do better as a result of paying more for their drugs than people in other countries who pay less for the same medicines. We also hear that since insurance companies pay for these drugs, the high cost really doesn’t hurt Americans. All of these arguments are worse than baloney – they are purposely produced propaganda funded by the pharmaceutical industry as part of their marketing budgets, in the interest of maintaining their profits. Luckily most Americans are now seeing through the smokescreen, as indicated by these proposals from both parties.

A recent study by Navindra Persaud and colleagues published in JAMA Internal Medicine[1] found that adherence to treatment was significantly higher among a group that received their drugs free of charge. This should surprise no one, least of all pharmaceutical companies. (The fact that only some disease outcomes improved may have more to do with how well these drugs actually are effective in doing what they are supposed to do.) The idea that lowering prices would inhibit access to medicines is belied by the fact that drug companies make plenty even with lower prices or they wouldn’t sell their drugs abroad.

So reducing drug prices and thus limiting the exorbitant profits made by the pharmaceutical industry is important. The cost of those drugs eats into the ability of Americans to pay for other things – not just luxuries, but also food and rent. And, as always, while it can affect most of us, the impact is greatest on those with the lowest income. It may happen, although the corporate ownership of both the mainstream Democratic as well as Republican parties will be a big obstacle.

But we need more than just lower drug prices, and certainly more than the ability to purchase drugs abroad. We need to have comprehensive health system reform that provides coverage and access for all health care for all people at affordable cost to them. This means cutting the income and profits of not only pharmaceutical companies but insurance companies and – absolutely not to be missed – health systems. After all, a recent article in the Mayo Clinic Proceedings describing the major individuals with an influence on health policy indicated that

there were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.

 The objection that we cannot take on too much all at once is specious; it is only by taking on everything more-or-less simultaneously (or in quick succession) that we can prevent gaming of the system and actually improve health care for all Americans.

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[1]  Persaud, N, et al.,  Effect on Treatment Adherence of Distributing Essential Medicines at No Charge: The CLEAN Meds Randomized Clinical Trial, JAMA Intern Med. doi:10.1001/jamainternmed.2019.4472

Published online October 7, 2019.