You may have heard about New York University’s appalling plan to make tuition free at its medical school.  This is, I am sure, a great gimmick to promote NYU among the upper classes of the Northeastern US.  But it is a terrible use of money.  The beneficiaries will come from BY FAR the most privileged stratum of society and once they graduate they will themselves join that same ludicrously privileged stratum.  If one were trying to design a post-secondary subsidy that was as regressive as the Trump tax cuts, something intended to give as much money as possible to the current and future one percent, this would be it.

And so, immediately, predictably, someone in Canada fell for the gimmick and decided it would be an awesome idea to do the same thing.  That someone?  The Globe and Mail’s health-reporter-for-life André Picard, who last week decided to write a column claiming this was an incredibly smart thing to do and that all Canadian medical schools should follow suit.

His rationale is essentially this: medical school debt is high – he claims an average of over $160,000, citing the Association of Faculties of Medicine of Canada (AFMC) as a source – which on the basis of no evidence whatsoever claims is a major contributing factor both to a lowering of interest in practicing family medicine in rural areas and rising physician suicide rates (apparently the rules for evidence-based policy that Picard is always banging on about in medicine don’t apply when it comes to social sciences and pet theories).  He also echoes the NYU claim that free tuition will mean a more diverse student body.

There are a number of reasons why all of this is utter hogwash.

[the_ad id=”12791″]

First: that “average debt is $160,000” figure is…um…suspect.  I went and checked the AFMC Graduating Student Survey for 2017 (available here) and could not find it.  What I did find is a figure which said that median debt is $94,000.  Now it’s not impossible to have an average of $160,000 and a median of $94,000, but some of your observations have to be pretty massive outliers to make the math work.  And those outliers can’t be driven by tuition (since if they were, they would apply to everyone and wouldn’t be outliers).  Remember, not all that debt is tuition-related debt.  Medical students have a lifestyle which is much cushier than the campus average, and this is funded in large part by banks who throw rather generous lines of credits to students who, given their future incomes, are pretty good credit risks.  A lot of that debt is simply people with high future incomes choosing to smooth their consumption over time.  If you eliminated tuition, they’d probably just do more of it and banks would be happy to lend them the money to do so.

Still, if we focus on the median instead of the probably seriously-inflated $160,000 figure, you might still think $94,000 is a lot of debt.  To which the answer is “yes and no”: it’s something you can only really judge as a function of income.  For specialists who make $200,000 or more, a $94,000 debt is fairly easily handled: for family physicians making about half that, it’s certainly harder.  Conceivably, there’s a rationale to target some debt relief to family physicians.  But not one to reduce debt for everyone via lower tuition.

But more importantly, there is zero evidence that low tuition would alter the composition of the student body in medicine one whit.  The social background of Canadian medical students has always been vastly tilted towards the children of professionals, whether you look at data from 2012 (see p.36), 2002 or 1965.  Take any one of those time periods and what you find is that children from the top income quintile are vastly overrepresented in medical schools, despite vastly different tuition regimes in place in each time period.

And it’s not just in Canada.  The children of the wealthy are substantially over-represented in medical schools pretty much everywhere even where tuition is free from start to finish.  Look through all the literature you want: from France, Denmark, Greece, or wherever, and medicine is the most socially stratified field of study there is.  Or take a look at the UK, where medicine can either cost tens of thousands of dollars a year (England) or nothing (Scotland).  Guess which country has the higher proportion of students from the top income decile?  Yep: it’s Scotland.

The reason fees don’t affect the social stratification of medicine much is because regardless of fee regime, the primary rationing device in medical schools is academic merit, not price.  Medical school is highly selective, and kids from wealthier backgrounds have an enormous head start on students from less wealthy backgrounds because of advantages in social and cultural capital.    Eliminating tuition can’t change that: the only thing it can do is make an already wealthy group of students even wealthier.

If we want to diversify medical school intake, we need more programs like the University of Manitoba’s ACCESS program, which has been helping put First Nations students through that university’s medical school for decades now.  We need to relax minimum entrance criteria and bring in admissions lotteries to students with good but not outstanding prior records a chance; alternatively, we could weigh social background a lot more heavily in the applications process – anything to reduce the heavy hand of inherited privilege (we won’t do either of these things, of course, because the point of privilege is to maintain it, but stay with me).  To the extent that debt is a problem for family doctors, either cap their debt or give them some kind of graduation bonus.

I might also add that what we need is for health reporters to apply principles of evidence they espouse in their own field to social science when they come up with pet theories outside their area of expertise.  Either that, or stay in their damn lane.

[the_ad id=”12811″]