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Letters to the Editor

Tuition-Free Versus Need-Based, Loan-Free Medical School: Which Will Accomplish Its Goals?

Kinslow, Connor J.

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doi: 10.1097/ACM.0000000000003163
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To the Editor:

Several months after Columbia University announced that it would eliminate loans for medical students who qualify for financial aid, New York University (NYU) declared that it would offer full-tuition scholarships, regardless of financial need. Kaiser Permanente recently followed suit and will waive tuition for its first 5 classes. Columbia and NYU cited creating these programs to potentially decrease student debt, increase the number of students entering primary care specialties, and increase socioeconomic diversity.1 The tuition-free model seems more generous at face value, but is agnostic to socioeconomic status and less beneficial to students with the greatest financial need.

The tuition-free scholarship from NYU covers $55,000 per year but does not account for $28,000 of additional expenses.2 In contrast, Columbia University determines expected family financial contribution based on income and assets and provides the remaining cost in need-based scholarships. Students in the lowest income brackets could receive funding that exceeds tuition, covering living expenses as well. For example, families with incomes under $80,000 have little to no expected contribution.3 These students receive up to $30,000 more with need-based, loan-free aid, totaling $120,000.

Tuition-free scholarships are expected to attract top applicants from around the country. Most scholarships will likely be diverted to students who would not qualify for need-based support. Acceptance to NYU and other tuition-free schools will, in effect, turn more into a merit-based scholarship than financial aid. These schools will be able to increase their national rankings and student diversity. However, with stagnantly low application rates from underrepresented minority groups around the country, there will likely be a “zero-sum” effect on the total demographic.1 Columbia’s efforts alone are also unlikely to have a significant impact. However, the need-based, loan-free model is more resource efficient and practical to apply on a larger scale.

Reducing debt, rather than cost of attendance, is also more likely to increase entry into primary care, as debt correlates with desired salary and specialty choice. The percentage of medical students who report that debt did not affect their specialty choice increased from 51% to 55% in the past 5 years.1 However, the percentage of students who graduated without debt simultaneously increased from 18% to 28%, while median debt increased from $173,000 to $195,000. Furthermore, 51% of medical students come from top-quintile income families, compared with 5% from bottom-quintile families. These demographics have essentially not changed in the past 15 years. To directly address socioeconomic diversity, institutions should stress financial need-based support over tuition-free financial incentives for aspiring medical students.

Connor J. Kinslow
Fourth-year medical student, Columbia University Vagelos College of Physicians and Surgeons, New York, New York;


1. Thomas B. Free medical school tuition: Will it accomplish its goals? JAMA. 2019;321:143–144.
2. Chen DW. Surprise gift: Free tuition for all N.Y.U. medical students. N Y Times. August 17, 2018:A-22.
3. Student Financial Aid & Planning CUVCoPaS. Personal communication, 2019.
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