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Friday Aug 16, 2013

Medical Students Need Washington to Do More

As a recent medical school grad, I spend a great deal of time thinking about my educational debt. I owe $234,000 (and the total is increasing even as I write this). There are many ways I can pay off this debt: National Health Service Corps (NHSC), Public Service Loan Forgiveness, arrangements with future employers, escaping to Mexico, etc.

But what about those who are unable to secure a NHSC slot or a job that qualifies for loan forgiveness? For many students considering careers in medicine, the high cost will be a burden or even a barrier.

The Student Loan Certainty Act cleared the House and Senate last month, and President Obama signed it into law Aug. 9. The Academy supported the legislation because interest rates on federally subsidized student loans had doubled from 3.4 percent to 6.8 percent on July 1. The new legislation ties undergraduate and graduate loan rates to U.S. Treasury notes and retroactively lowers them -- for now -- to 3.86 percent and 5.4 percent, respectively.

The new law, however, isn't perfect, which is why the AAFP is continuing to advocate for related measures. Specifically, the Academy is asking lawmakers to

  •  expand funding for federal loan programs targeted to support family medicine and primary care,
  • allow deferment of interest and principal payments on medical student loans until after completion of postgraduate training, and
  • grant tax-deductibility for interest on principal payment for such loans.

The potential problem with the law is that federally subsidized student loans now will be tied to 10-year U.S. Treasury notes. If bond rates rise, so will the interest rates on this type of loan, which accounts for roughly one-fourth of federal student loans.

The rates are capped at 8.25 percent and 9.5 percent for undergraduates and graduates(www.americanprogress.org), respectively, (www.americanprogress.org)but those potential rates would be significantly higher than current rates and could make education more expensive and more unattainable for some low- and middle-income students.

That scenario could present a problem for our already unbalanced workforce because we know that students with lower income expectations are more likely to choose family medicine as a specialty. Today, our workforce stands at roughly 70 percent subspecialists and 30 percent primary care physicians. What will the workforce ratio be in the future if interest rates approach double figures, making the cost of education an even bigger hurdle?

Three-fourths of medical students come from the top two quintiles of parental income.

Without scholarships, low- and middle-income families disproportionately feel the hit of tuition. A 2002 study from the U.S. Department of Education found that high-achieving, low-income students were five times less likely than high-achieving, wealthy students to enter college in their first two years after high school.

I was fortunate enough to earn a full-tuition scholarship to Saint Louis University as an undergraduate. Without that scholarship, there is no way I could have afforded the $36,000 annual tuition. My parents did not earn the "big bucks." My mom is a speech pathologist and my dad is an economics professor at a community college. The scholarship award was much needed.

So what's the bottom line for family medicine? A 2009 study by the Robert Graham Center(www.graham-center.org) (www.graham-center.org)evaluated what influences specialty choices and found that as long as debt did not exceed $250,000, students were not deterred from a family medicine career. What we don't know, however, is how many students who are interested in primary care careers are deterred from even entering medical school because of the high cost.

Exposure to the NHSC was one of the strongest predictors of careers in family medicine in the Graham Center study. I know several students who have no medical student debt because of the NHSC's Students to Service Loan Repayment Program(nhsc.hrsa.gov)(nhsc.hrsa.gov)which provides assistance to fourth-year medical students dedicated to working in areas with physician shortages.

It's worth noting that the Academy has a Web page devoted to debt managementAs for me, I will enroll in the Public Service Loan Forgiveness(studentaid.ed.gov) program. As long as I work at a nonprofit organization, my loans will be forgiven after I make 10 years of qualifying monthly payments -- if the program is not discontinued, that is. Signed into law in 2007, this program soon will start to see its first wave of enrollees apply for loan forgiveness. My fear is that the program could be discontinued before I have the chance to apply, and then, since I was able to enroll in a discounted payment plan, I will have significantly more interest to pay. I feel very uncertain going forward.

And if I'm feeling uncertain, what are students from low-income families experiencing? When parents discuss undergraduate and medical school debt burden with their children, what are the results of those dinner table conversations?

Lowering the interest rates on student loans, at least temporarily, was a first step, but more work is needed to create a physician workforce that is diversified and represents the population. The time is now to let your voice be heard(www.capwiz.com)(www.capwiz.com)Talk to your House and Senate representatives about the importance of a strong primary care workforce. Talk to them about how education should be valued just as much as a home purchase. I encourage you to act.

Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.

Posted at 02:02PM Aug 16, 2013 by Aaron Meyer

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