Michael Bloomberg last week gave $1 billion to his alma mater, Johns Hopkins University, to make medical school free for most students there.
It’s a well-meaning gesture, aimed at alleviating America’s doctor shortage More than 100 million Americans Without access to regular primary care, especially in rural and low-income communities. Bloomberg “By reducing financial barriers to this essential field, we can free up more students to pursue the careers they’re passionate about — and enable them to better serve the families and communities that need them most,” Bloomberg said In a statement.
But a grant to an elite, big-city medical school isn’t likely to help much, experts told me.
“If you had this pot of money and you could give it to health professional schools with the goal of improving geographic distribution, with the goal of getting more people from historically low-income backgrounds, I wouldn’t choose Hopkins,” says Janet Kaufmanis a health services researcher at the University of California, San Francisco.
here Fine print Bloomberg Billionaires: Earlier this fall, Hopkins Medical School — ranked second in the nation According to US News — Will offer free tuition to any student pursuing an MD with an annual household income of less than $300,000. Students whose families make less than $175,000 will also qualify for free room and board. About two-thirds of Hopkins’ current and entering students will be eligible for aid under the new program, according to the school. Some of the money will also support financial aid for students in Hopkins public health and nursing programs.
This is part of a recent pattern of philanthropic interventions to build medical schools The average cost is $236,000, more affordably. Earlier this year, Ruth Gottesman, a former professor at Albert Einstein College of Medicine in New York City and the widow of a Wall Street investor, announcement He would donate $1 billion to Einstein to make school free for all students pursuing a medical degree. Billionaire Kenneth Langone and his wife Elaine have made multiple donations to New York University’s medical schools, including 200 million dollars last yearThere to help provide free tuition to all students.
But a review of the early results of NYU’s free tuition program found it was doing little to move the majority of its graduates into the communities of greatest need. “Unfortunately, when it comes to training primary care physicians or sending graduates to underserved areas, tuition-free medical schools get an F,” Ezekiel Emanuel and Matthew Guido of the University of Pennsylvania. wrote in april
A real solution to America’s health care access crisis requires investing directly in those underserved communities and equipping their hospitals with the resources to train the next generation of physicians. To understand why, we need to better understand the problem that actually needs to be solved.
Lack of real doctors
I’ve been hearing about the doctor shortage for a decade now that I’ve been covering health care. But the problem is more complicated than it sounds.
When you hear physician shortage, you probably think: OK, I get it, there aren’t enough doctors in America overall. right?
“That question is not decided by itself,” Gaetano Fortassistant director of SUNY Albany’s Center for Health Workforce Studies, told me.
The United States has significantly less Doctors per capita Compared to other rich countries like Germany and Sweden. But America’s doctor-to-patient ratio is similar to that of other developed countries — Canada, the United Kingdom, Japan, France — which is still typical good rank On measures of health care quality compared to the United States. So total numbers alone aren’t enough to explain the access problems patients face, and experts disagree about whether the overall supply of providers needs to increase in the short term.
The biggest problem is misallocation in the US physician workforce, Kaufman told me last year. We know that we don’t have enough doctors in some important specialties: for example primary care, obstetrics and psychiatry. We don’t have nearly enough providers in a wide swath of specialties practiced in rural and other low-income communities. Between 2010 and 2017, when large urban counties The average added 10 doctors per 100,000 people, rural counties lost three. As a result, metro areas had 125 doctors per 100,000 patients, compared to 60 in rural areas.
America is Garbage with the doctor desert, where there are not enough primary care providers, much less specialist or hospital-level services. The federal government guess That 80 percent of rural Americans live in medically underserved communities.
In the long term, the United States will undoubtedly need more doctors in rural and urban areas alike. Groups such as the Association of American Medical Colleges persist project Long-term workforce shortages, as boomer-generation doctors reach retirement age and the population of seniors requiring medical care swells.
Why is it so difficult to fix the doctor shortage?
Paying for new doctors to go to school in Baltimore or New York City would help more physicians practice in small towns in the Midwest or poor neighborhoods in other big cities. But American doctors don’t work that way.
Physicians tend to practice in communities Similar to the density and socioeconomic conditions in which they grew up. Over the years, some federal policies have tried to change that behavior — such as paying off a new doctor’s medical school debt if they practice in underserved communities for a certain period of time — but the efforts have paid off. Limited results.
Making medical school free faces the same problem: If you don’t change the pool of new doctors, benefits to disadvantaged communities can be marginal. Kaufman compared Bloomberg’s gift to Johns Hopkins to a hypothetical donation to a historically black college or university, which has black communities. Significant gaps in their access to health care.
“If your goal is, ‘I want to see more Hopkins students come out of Hopkins without a lot of debt,’ [Bloomberg’s gift] Well if your goal is ‘Across the country, I want to solve the problem of physician maldistribution by geography, by specialty, I want more people from historically underrepresented groups,’ I’ll choose other institutions,” Coffman told me. “Typically, philanthropy. “One of the challenges of relying on philanthropy, especially in the form of very wealthy individuals donating from their own personal wealth, are individuals like Mr. Bloomberg who have their own priorities and understandably their own attachments to certain institutions.”
State and local policymakers have sought to set up their own programs that recruit students directly from underserved communities. california, A UC San Francisco program in the San Joaquin Valley Guaranteeing admission to medical school for students from low-income areas, with the hope that they will return to their community or similar to practice after graduation. But those efforts are necessarily small; Some early returns have been promising, but their long-term impact remains uncertain.
Studies have also consistently shown that most physicians Tend to practice close to where they have completed their residency, postgraduate period of supervised, hands-on work experience. Almost all habitats – 98 percent — are at large academic medical centers located in urban areas, such as Johns Hopkins. There are some good reasons for this: these facilities are well-staffed, see experienced consultants and high caseloads that allow doctors-in-training to gain a lot of experience quickly. But the system has left many parts of the country scrambling to find doctors to work in their communities.
It is the result of deliberate policy choices. Medicare funds Most medical residencies in the United States, and it has not meaningfully changed its funding structure since the 1990s, have even worsened the skewed distribution of the health care workforce. For example, the program doesn’t pay hospitals to set up their graduate residency programs, which some large hospital systems are better equipped to do than less-capitalized rural hospitals where the need for new doctors is greater. Even some large hospital systems funds The Medicare-funded slots as well as their own residencies because having residents is good business for them: they get lots of young, cheap doctors who still get billed for services like any other white coat.
Absent congressional action to expand them, the number of residency slots is limited. This makes large academic centers, which are heavily influential with lawmakers, deeply invested in maintaining their hold on the medical training pipeline. More funding to help rural hospitals set up their own residency programs and earmarking more slots for rural facilities or understaffed specialties could help attract more young doctors to underserved areas — but sweeping reforms are unlikely anytime soon.
Absent a systematic overhaul of the medical profession, Bloomberg may mean nothing. Some young doctors do say The high debt they incur from medical school discourages them from practicing in less affluent areas. Maybe some of the scholarship recipients will decide to practice in an underserved community, providing much-needed support to its residents. For those people, the former NYC mayor makes a really great gift.
But in the long term, we need “a multifaceted approach” to fixing the medical pipeline beyond well-informed and centrally located programs like Hopkins, Kaufman said. We need to recruit and support medical students from Wisconsin and Wyoming and Tennessee, as well as from downstate New York and California. We need more evenly distributed residential programs. We need to make family medicine and paediatrics attractive and attractive specialties to young doctors.
These will be difficult and potentially expensive problems to resolve. But it is necessary work. Meanwhile, Bloomberg’s billions, and other grants like it, may be the best Band-Aid for a broken system.
