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No Debt, Better Education, and Better Health Care: What's Not to Like?

Bittrich, Amy MS; Albanese, Lisa MD; Albanese, Mark A. PhD

doi: 10.1097/ACM.0b013e3181f59354
Response to 2010 Question of the Year

Ms. Bittrich is an epidemiologist, Wisconsin Division of Public Health Southeast Region, Milwaukee, Wisconsin.

Dr. Lisa Albanese is a physiatrist, Oregon Medical Group, Eugene, Oregon.

Dr. Mark Albanese is professor emeritus, University of Wisconsin–Madison School of Medicine and Public Health, and director of research, National Conference of Bar Examiners, both in Madison, Wisconsin.

Correspondence should be addressed to Dr. Mark Albanese, University of Wisconsin–Madison School of Medicine and Public Health, 610 Walnut Street, 1007C WARF, Madison, WI 53726-2397; e-mail:

The major challenges for any effort to make an exchange of free medical school tuition and fees for public service are to avoid creating new bureaucracies, increasing overall costs, or depleting the funding of either schools or other publicly funded agencies. Ideally, the approach would not only relieve students of the burden of debt but also further their development as health professionals and provide needed services for the public. We propose a two-prong approach.

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Create Outpatient Clinics Affiliated With the Veterans Administration Hospitals

These clinics would serve the needs of all those who are newly insured as a result of the recent federal legislation. Each clinic would have a permanent director and core physicians but be mostly staffed with residents and physicians providing obligatory public service. Because a comprehensive clinic needs nurses, pharmacists, and other health providers to function, it could also serve the same purpose for students in these other health professions. Medical residents and the other graduate health professions students would receive one year of loan forgiveness for each two years of residency, and salaries would be similar to national salaries. Residents in this program would provide the same duties as current residents, but their continuity clinics would be based within this new system. New residency slots created in response to the predicted 30% increase in medical school class sizes would be dedicated to these outpatient clinics.

The outpatient clinics would be integrated with the Veterans Affairs (VA) system hospitals to take advantage of economies of scale, state-of-the art electronic medical records,1 and the VA's service-based administrative emphasis.2

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Expansion of Opportunities for Residents and Physicians and Other Health Care Providers in Public Health

These opportunities would be based partially in health departments and would help address the chronic shortage of medical and other health personnel working in public health. Physicians with public health training and experience are needed for chief medical officers at the state level and medical directors at the local level. Public health positions would expand the opportunities for residents and physicians to work on interventions aimed at disease prevention and health promotion that affect an entire population and extend beyond medical treatment.

In addition to a paydown of one year of school tuition for two years of service, residents could obtain an MPH, and some physicians could even become board certified in preventive medicine as they provide their service. These physicians and other health care providers would also be attached to the VA-based outpatient clinics and would assist with immunizations, health awareness campaigns for chronic diseases and communicable diseases (including STDs), and environmental health and other community health initiatives. The integration of the VA-based outpatient clinics with the public health departments would provide more ready access to populations for targeted public health initiatives and broader training opportunities for all residents in both services.

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Funding for both initiatives would be provided by what would otherwise be the premiums for insurance and the overhead costs of administering the insurance program for the 31 million citizens newly covered under the Patient Protection and Affordable Care Act.3 The only part of the new coverage that would remain insurance would be for catastrophic illness. Government support for a clinic would be based on the population within its “catchment area” determined by census information.

Physicians and other practicing health professionals would receive a 1–1 loan forgiveness, but their salaries would be less than the national average for first-year health providers by one year's tuition. There would be a 2% escalator for each year of satisfactory service. The difference between what is paid and the national average salary would transfer to the school from which the health care provider graduated. For patients, the clinic visits would be free or on a sliding scale to motivate patients to comply with care recommendations.

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Summing Up

The program we propose would not only address the issue of providing service for tuition remission for a broad range of health professionals but also would support the provision of health services to all citizens. In addition, it would improve the education of health care providers through more and better outpatient experiences during residency training within the service-oriented VA system or public health departments. It would expand our capability for disease prevention. Finally, it could be implemented within the frameworks of existing health care systems and without disabusing funding for medical schools, the VA, or public health departments.

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1 Zhang J. The digital pioneer. Wall Street Journal. October 27, 2009. Available at: Accessed July 19, 2010.
2 Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs health care system and commercial managed care: The TRIAD study. Ann Intern Med. 2004;141:272–281. Available at: Accessed July 19, 2010.
3 Henry J. Kaiser Family Foundation. Patient Protection and Affordable Care Act: Summary of Coverage Provisions. Available at: Accessed July 19, 2010.
© 2010 Association of American Medical Colleges