The Perverse Consequences of Tuition-Free Medical School

Six years ago, the New York University Grossman School of Medicine, in Manhattan, announced that it would become tuition-free for all students. The change was made possible in part thanks to a $100 million donation from Kenneth Langone, a Home Depot co-founder, and his wife, Elaine. “It would enable graduates to pick lower-paying fields like primary care and pediatrics, where more good doctors are desperately needed, without overwhelming debt to force them out,” Kenneth said in an interview at the time. In a triumphant report, the school declared, “The ultimate success of this tuition-free initiative will be measured over time by the clinical and research achievements of future graduates, as well as the improvements in diversity of the physician ranks.”

The school’s shift to a tuition-free model has no doubt been a tremendous boon to those students fortunate enough to gain admission. But judged against the standards set out by the Langones and NYU itself, the initiative has been a failure. The percentage of NYU medical students who went into primary care was about the same in 2017 and 2024, according to an analysis by Chuck Dinerstein, the medical director at the American Council on Science and Health. The locations of the hospitals where students do their residencies—often a clue about where they will end up practicing long-term—also remained essentially unchanged. And although applications from underrepresented minority students increased by 102 percent after the school went tuition-free, the proportion of Black students declined slightly over the following years, according to data from the Association of American Medical Colleges and provided by Jared Boyce, a medical student at the University of Wisconsin. (The share of Latino students grew by a few percentage points.) Perhaps most alarming of all, doing away with tuition appears to have made the student body wealthier: The percentage of incoming students categorized as “financially disadvantaged” fell from 12 percent in 2017 to 3 percent in 2019.

Despite the lackluster results, bankrolling tuition-free medical education has become a popular social cause of the über-wealthy. This past February, Ruth L. Gottesman, the widow of the billionaire investor David Gottesman, donated $1 billion to make the Albert Einstein College of Medicine, in the Bronx, tuition-free in perpetuity. In July, Michael Bloomberg gave $1 billion to Johns Hopkins University, though his gift will cover tuition only for students whose families make less than $300,000 annually. The Langones gave another $200 million last year to NYU’s Long Island School of Medicine to make that campus tuition-free too. Each of these donations has been hailed as a game changer for the medical profession. They may well allow for the medical education of some brilliant doctors who might otherwise never have entered the field because of financial obstacles. But health economists are nearly unanimous that such gifts, no matter how generous and well intended, will do little to achieve their broader stated aims—and might even be making health-care inequality worse.

The philanthropists have picked up on some real problems. Recent graduates have turned away from primary care—usually defined as internal medicine, family medicine, pediatrics, and obstetrics and gynecology—in favor of more lucrative specialties. At the same time, the nation is projected to have a shortage of about 86,000 primary-care physicians by 2036. The problem is worse in poorer areas, many of them in rural communities or urban centers, which have shortages of all physician types. Meanwhile, the profession has a long-running diversity problem. As of 2022, only about 6 percent of the nation’s doctors identified as Black and only 7 percent as Hispanic.

In theory, tuition-free medical school is an antidote to these problems. Medical-school debt has ballooned, from an average of about $147,000 (in today’s dollars) in 2000 to $235,000 in 2024. Freed from that burden, graduates could pursue less lucrative specialties and work in underserved areas, where the pay is generally lower, without worrying about how they’ll pay off their debt over time. Talented students from low-income backgrounds who are currently dissuaded from entering the field because of the cost would be more likely to apply and matriculate.

But in practice, eliminating tuition at elite medical schools is a terribly designed solution based on an intuitive but false premise. Rising tuition is not really the cause of the medical profession’s problems. Although medical students take out hundreds of thousands of dollars of loans, even the bottom quartile of physicians by income can expect to earn about $6 million in their lifetime. “Even for primary-care physicians, tuition is a fairly small share of their lifetime income,” Maria Polyakova, a health economist at Stanford, told me. Her research finds that the overall income differential between specialties—primary-care physicians can expect to make about $200,000 a year, compared with more than $500,000 for a specialist—is what dictates which fields people enter. The argument that making med school free would cause many more students to go into primary care “is just not supported by the data,” she told me.

The donations also appear unlikely to affect where people practice medicine. The schools that have gone tuition-free are all prestigious programs in major cities. None of them rank even in the top 100 medical schools with the most graduates practicing in underserved areas. “You can’t take somebody that grew up in the suburbs and transfer them into New York City as a medical student and really expect that they’re going to take a job in Iowa,” Chuck Dinerstein told me. “Some will, but just not in general.” Although there’s plenty of need in the areas surrounding elite medical schools, making tuition free doesn’t create any new incentives for students to opt for community health centers over distinguished hospitals. “The medical schools that have gone tuition-free, they take strivers,” Dinerstein said. “And strivers, for all the things they had to do to get to medical school, are not going to stop now.”

In fact, tuition-free status could perversely be making it harder for low-income and underrepresented minority students to go to medical school. In the year after NYU went tuition-free, the number of applicants shot up by 47 percent. Because the number of slots did not increase proportionally, this made getting admitted dramatically more difficult. High-income applicants have extensive advantages at all levels of higher education admissions, so making a school more selective all but guarantees that its student body will become more wealthy, not less, which is exactly what happened at NYU.

In an email, Arielle Sklar, an NYU spokesperson, said that tuition-free initiatives should not be evaluated solely on the metrics: “Reducing student indebtedness was a moral imperative to ensure that the best and the brightest from all backgrounds can pursue their passions in medicine, ultimately benefiting society.” Theodore DeWeese, the dean of the Johns Hopkins medical school, said in a statement that previous financial-aid investments had improved diversity. “We don’t know for sure whether making medical school tuition-free—with living expenses covered for the neediest students—will lead graduates to return to their communities or choose to serve in lower-paying specialties, but we know they are less likely to do this without significant assistance,” he wrote.

People who are generous enough to give their money away have the right to do with it what they wish, and lavish donations to replace tuition at medical schools are better than many other ways billionaires choose to spend. At the very least, they improve the lives of individual students who don’t have to pay tuition. Bob Kocher, who advised Barack Obama on health policy, said that his family could never have afforded medical school. A full scholarship allowed him to enter primary care, which he now balances with a career in venture capital. Jorge Moreno, a medical professor at Yale, believes that the full effects of the donation will take years to appear, but that more and more students will eventually choose primary care.

But plowing billions of dollars into an approach with results ranging from neutral to regressive is deeply unfortunate given that better alternatives exist. If the goal is to help low-income students and to train more primary-care doctors, targeted relief for low-income students or for people who go into primary care would work better than blanket subsidies. Toyese Oyeyemi, the director of Social Mission Alliance, a nonprofit that tries to improve equity in the medical profession, told me that donations need to be coupled with admissions reform or accountability efforts to have any effect. And experts generally agree that the real bottleneck to getting more physicians is the cap on student and residency slots. Philanthropic money would be better spent expanding class sizes, establishing new schools, or lobbying Congress to allocate more federal funding to increase residency spots, instead of subsidizing demand. “People have plenty desire to go into medicine,” Joshua Gottlieb, a health economist at the University of Chicago, told me. “You’re making medicine more attractive for the people who were already at these top schools.” (To be fair, NYU’s Long Island School of Medicine, to which the Langones donated $200 million, mostly focuses on primary care.)

So far, the most obvious beneficiary of tuition-free policies might be the schools themselves. In 2017, NYU Langone was ranked the 11th-best medical school in the country for research by U.S News & World Report. Five years and $100 million later, it was the second-best. (The rankings are based in part on students’ standardized test scores and undergraduate GPAs, which improved as the top students were lured by the promise of a free ride. This year, U.S. News replaced its numbered list with a tiered ranking system. Some medical schools, including NYU, declined to participate.) “That’s really the margin where this seems most relevant, is one med school competing with another med school,” Gottlieb told me. This is the irony of elite medical schools going tuition-free. A public-spirited policy intended to help disadvantaged people and benefit society ends up giving more benefits to those who were already ahead. Medical schools that are already prestigious jockey for even higher rankings. Students from wealthy families get an extra leg up. And the whole thing gets wrapped up in the language of social justice.

In NYU’s statement about making history, the school wrote: “And while we are fortunate to be the first top-ranked medical school to offer full-tuition scholarships to all of our medical students, it is our sincere hope that we will not be the last.” Perhaps it should have been.