How med student loan burdens can deepen health disparities

Contributing Writer
AMA Wire
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The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

 

 

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

For those students who do apply and graduate from medical school, the high amount of loan burdens they accumulate can mean that they are much more likely to choose a higher-paying specialty field rather than primary care. This higher income allows the students to pay off their loan burdens more quickly after residency. As a result, the AAMC predicts that by 2025 the U.S. will see a shortfall of up to 35,600 primary care physicians.

The need to pay off medical-school loan burdens is also likely to cause physicians to pursue practice in more affluent areas, further widening the gap between lower-income populations and access to available physicians. A lack of access to primary care physicians disproportionately affects lower-income patients. This makes it more difficult for them to seek preventive care and treatment and can increase the costs for care downstream.

In honor of Minority Health Month, follow the AMA Residents and Fellows Section Facebook page to learn more about the unseen impact of medical student loan burdens and their link to health disparities.

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My loan burden was 9,600 after finishing my rotating internship year. After working 6 weeks as an independent contractor in an ER in the upper peninsula of Michigan, I paid this all off to the Department of Defense Scholarship Program, and had about 1,500 to spare. At least we were not in debt. Now the cards are stacked against all but the most wealthy who wish to attend medical school. . .
This article offers an interesting look at the topic of education debt among medical students. However, it includes a few areas of concern. In the second and third paragraphs, the article describes debt levels as of the graduating class of 2014. The AAMC updates this data annually, the most recent data from 2016 can be found here: https://members.aamc.org/eweb/upload/2016_Debt_Fact_Card.pdf. In 2016, the median debt level for indebted graduates was $190,000. That total can be repaid via a number of different repayment plans that vary depending on specialty, residency length, and future income. For example, as the AAMC data shows, the total repayment could range from less than $340,000 to slightly over $400,000, or even less than $275,000 for those in public service plans such as the National Health Service Corps Loan Repayment Program (https://nhsc.hrsa.gov/loanrepayment/). Furthermore, over the last seven years inflation-adjusted medical student debt levels have been relatively stable despite growth in costs. After controlling for inflation, from 2009 to 2016, debt grew, on average, 0.9% per year while cost grew, on average, 2.3% per year. The article compares the racial and ethnic background of the physician workforce to the entire U.S. population when a more accurate comparison would be to the U.S. population with a four-year college degree, the starting point for any medical student. Numerous societal forces exist that result in the college degree population having a different racial and ethnic mix compared to the whole population; most of these forces are far beyond the ability of medical schools to influence them. The article offers some speculative statements without any supporting evidence, such as “the cost of medical school likely deters applicants from lower-income rural communities as well.” What is the evidence this occurs? The section discussing the potential influence of debt on specialty choice could benefit from a discussion of the impact of current federal income-driven repayment plans which base a borrower’s loan payments on their income, not their debt level. These plans are favorable for all borrowers and allow medical graduates to begin loan payments during residency and allow all borrowers, regardless of specialty, to make affordable payments after residency. A career in primary care is financially viable (http://journals.lww.com/academicmedicine/Fulltext/2013/01000/Can_Medical_Students_Afford_to_Choose_Primary.15.aspx). For example, under the federal Pay As You Earn (PAYE) plan, physicians make monthly payments equal to 10 percent of their discretionary income. The AAMC believes a career in medicine remains an excellent investment (http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Good_Investment_.98284.aspx). Strong job security and excellent income potential should enable any medical school graduate – practicing in any specialty – to both repay education debt and provide for a secure living and retirement. If you are accepted to medical school, you can pay for it. Federal loan programs are available to help US students accepted to medical school borrow up to the cost of attendance. All medical school graduates, with any debt level, practicing any specialty should be able to comfortably repay their student loans. The AAMC advocates on behalf of medical students to ensure the best possible borrowing and repayment options, including income-driven repayment plans and public service programs.
Show Comments (2)
Nov 22, 2017
With the right measure of discipline, medical students can create healthy financial habits that translate to a prosperous future.