Does Merit Aid Have Merit?

Why opening a national dialogue is imperative to the future of medical education.

By Roy Ziegelstein, M.D.

Illustration by Andre DaLoba

In 2016, the average cost of attending medical school (including tuition and fees) in the United States was $253,720 for in-state graduates and $313,897 for out-of-state graduates. Nearly three in four graduates had educational debt, and average debt related to medical education alone was $167,172. These figures suggest that, without scholarship support, only students with access to substantial personal resources or students willing to incur large amounts of educational debt can hope to attend medical school.

To ensure that students with limited financial means are able to attend medical school, many schools provide need-based scholarships or low-interest loans as part of financial aid packages. Some schools also offer selected students “merit-based aid,” which is usually not related to a student’s ability to pay. At times, these scholarships cover tuition and the full cost of attendance for all four years. Because applicants receive merit-based scholarship offers from some schools and not others, each spring, schools are asked by some admitted students to match offers made by other schools. 

There is broad agreement that something must be done to address medical students’ increasing educational debt, especially in light of findings that greater amounts of educational debt are related to higher levels of emotional exhaustion, burnout and lower quality of life during residency. An important question is whether merit scholarships are part of the solution—or part of the problem. If schools have a finite pool of funds for student scholarships, then offering aid based on factors other than financial need reduces the amount of support available for students with greater need. As a result, a higher percentage of financially needier students will incur an increased debt burden.

Indeed, U.S. medical schools are increasingly concentrating more debt among fewer students. Consider: Between 2012 and 2017, the percentage of medical students graduating with at least $300,000 in medical school debt increased from 3.2 percent to 7 percent, according to the Association of American Medical Colleges. At the same time, the percentage of students reporting no medical school debt increased in each of the past four years: 27.6 percent reported no medical school debt in 2017, compared with only 15.9 percent in 2013. 

Why would a medical school move scarce scholarship funds from students with more financial need to those with less financial need? Look no further than the influential U.S. News & World Report rankings of medical schools, which favor schools that admit students with higher MCAT scores and grade point averages by bestowing higher rankings. And the higher a school’s ranking, the more likely it is that top students will apply to that school. 

Most would agree that wealthy applicants tend to be advantaged long before they get to graduate school. As a result, they often have the greatest “merit” if assessed on the basis of standardized test scores and grade point averages. Thus, applicants who are financially advantaged will probably be more likely to be offered merit scholarships by medical schools—with important implications for public health. 

Throughout the United States, health disparities based on race, ethnic group and socioeconomic status call for a diverse pool of physicians who can care for increasingly diverse patient populations. Any practice that intentionally or unintentionally provides fewer opportunities for young people from socioeconomically disadvantaged backgrounds who could otherwise contribute to a more diverse population of physicians is a violation of public trust.

We question whether merit aid has merit with respect to medical school and the training of physicians, and we believe the potential benefits and harms of merit-based scholarships should be the subject of a national dialogue. As part of this process, we recently proposed to U.S. News & World Report that it consider adding another metric to its annual medical school rankings: the percentage of a school’s total scholarship funding that is committed to need-based aid. 

Medical school must be accessible to all who gain admission, regardless of their socioeconomic status.

This article was adapted from a New England Journal of Medicine Perspective (Oct. 25, 2017). Additional authors included Charles G. Prober, M.D.; Lloyd B. Minor, M.D.; George Q. Daley, M.D., Ph.D.; Paul B. Rothman, M.D.; and Edward M. Hundert, M.D.