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-The State of Student FinancesUCSF School of Medicine

A special report by the Associated Students of the


School of Medicine (ASSM)
-June 2015-

Authors
Greg Zahner, MS2
Sidra Bonner, MS2
Sidney Le, MS2
Daniel Novinson, MS2
Flavio Oliveira, MS1
Brian Shaw, MS2
Angela Suen, MS2
Chelsea Young, MS4

Acknowledgments
This report would not have been possible without the support of our peers and numerous faculty
and staff. In particular, we would like to thank Dr. David Wofsy, Dean of Admissions, for his
tireless advocacy on behalf of students. Carole-Ann Simpson in the Financial Aid Office
supplied much of the data presented in this report and Lisa Raskulinec and Annie Osborne in
Student Academic Affairs were responsible for a very sophisticated forecast of UCSF costs and
cumulative debt. Furthermore, Dean Catherine Lucey, Vice Dean for Education, organized key
meetings with administrators and assisted us in gaining access to requested data. She also
provided valuable feedback on early drafts. Lastly, we would like to acknowledge Chancellor
Sam Hawgood who helped initiate the process leading to this report.
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Executive Summary
In response to student concern over financing their UCSF education, ASSM has conducted this
report to describe the current state of student finances. Our findings are summarized below.
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Cost of Attendance
For the 10-year period from 2005-2006 to 2015-2016, the overall Cost of Attendance
increased 51%, with tuition/fees increasing 78%, and Cost of Living increasing 40% at UCSF.
In terms of absolute dollar changes, this means that fees have contributed $69,165 to
increased COA, while COL has contributed $30,831, less than half of the amount.
According to Student Academic Affairs, from 2005-6 to 2013-14 the total COA has increased
on average 6.0%/year, while the average cumulative debt has increased 5.5% year indicating
that the financial aid budget will need to increase substantially to keep student debt stable.
The graduating Class of 2020 is predicted to pay $300,000 for a UCSF medical education and
their mean debt will be $153,950 a 33% increase from the graduating class of 2014.
For the average student, top-ranked private schools like University of Chicago and Duke cost
about the same as UCSF when you take grants/scholarships into consideration. Only for
students from wealthier backgrounds that can expect to receive minimal grant/scholarship
support is UCSF consistently the cheaper option.
Impact on Recruitment and Diversity
Nationally, ~50% of medical students come from families in the top-quintile by income. Less
than 5.5% come from the bottom quintile. SES diversity among medical students has been
decreasing since the 1970s.
Over the past five years, debt/cost/economy has been by far the #1 reason why accepted
students elect not to attend UCSF.
In the UIM Student Indebtedness Survey, 72% of participants responded that they declined
larger financial aid awards when deciding to matriculate into UCSF and 76% stated that they
have considered residency options in more affordable cities. Nearly all (91%) stated that they
had trouble finding affordable housing.
Impact on Current Students
Prior research indicates that higher levels of debt can adversely affect student performance,
well-being, and potentially even specialty choice.
In the State of Student Finances Survey, 89.7% were concerned about the cost of attendance
at UCSF and 51.2% of students felt that financing their medical education has negatively
impacted their mental wellbeing. Only 27% feel that the amount of financial aid offered is
adequate to cover their costs and 54.7% indicated that educational debt has or may in the
future influence their specialty choice.
At UCSF, our students self-reported level of debt is positively correlated with concern over
the cost of attendance (r(237) = .400, p < .01), impact on specialty choice (r(237) = .389, p <
.01), and poorer mental well-being (r(237) = .396, p < .01) - all with a moderately large effect
size.
For many students using federal repayment programs, debt continues to increase while they
are in residency. For the 21 students in the Class of 2014 with over $175,000 in debt at
graduation, many will have well over $200,000 in debt at the end of their residency.
Conclusion
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The increasing cost of attendance will require a much larger financial aid budget if we are to
avoid increases in student debt. Failure to prevent increasing debt will increase the already
tremendous burden on our students, negatively impact their well-being, and compromise our
ability to recruit a socioeconomically diverse student body, which will strike into the heart of
UCSFs mission as a public institution. This would be a colossal tragedy, as the strength of our
mission with its emphasis on diversity and combating health disparities is one of the institutions
greatest assets.
In conclusion, we recommend that the UCSF School of Medicine increase the financial aid
budget for grants/scholarships from its current level of ~$8 million/year to a new baseline of at
least $10 million a year for 2015/16 in order to counteract the pending 33% increase in student
debt by 2020 and preferably to $12-13 million a year to reduce UCSFs current level of
indebtedness. In subsequent years, the budget will need to increase with the increasing cost of
attendance in order to keep increases in indebtedness close to the level of inflation. While this
recommendation implies that the additional funds should be spend on grants/scholarships, ASSM
believes the SOM could also look at other methods of supporting students financially, such as
subsidized housing.
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Recommendations
Increase the financial aid budget to a new minimum baseline of $10-12 million for 201516 and subsequently increase it to keep increases in mean indebtedness at the level of
inflation.
How the additional money should be spent requires an ongoing discussion between
students and administrators, though we would argue that increased funding for need-based
grants/scholarships is the most progressive option proposed thus far.
Create a special task force to explore alternative forms of financing a UCSF medical
education.
Disburse funds in a timelier manner that is consistent with the world students live in.
Maintain progressive programs like the tuition guarantee to protect students from tuition
increases while they are students and loan interest support during an optional research
year.
Students should be aware that they are entitled to ask for loan increases if they can
demonstrate that their costs exceed UCSF cost of living estimates.
Financial advice for students: budget and track your expenses while in medical school and
project your costs during residency so you can select the repayment program that makes
the most sense for you.
Students should have frank conversations about class, SES diversity, and privilege.

Introduction
In the fall of 2014, talk of tuition increases reignited student anxiety about the increasing cost of
attendance and student debt at UCSF School of Medicine. Additionally, a feeling of disconnect
arose between what was being reported by the schools leadership and what students were
actually feeling. As the representative body for the students in the School of Medicine, ASSM
prioritizes keeping a UCSF MD affordable so that all pre-med students, regardless of family
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income, may have the opportunity to obtain a world-class UCSF education. We hope for the day
that no admitted student has to turn down our offer of admission for financial reasons. We
applaud the efforts of our schools leadership, which has worked to keep our level of
indebtedness among the lowest in the nation. Additionally, we are grateful for the guarantees
have been made to protect students from tuition increases while they are enrolled. But as a
world-class institution, there is a lot of work we need to do to support our students financially.
Innovation in medical education requires continued innovation in helping students afford and
finance that education. This report represents a modest student-driven attempt to dig below the
surface and describe the current state of student finances at UCSF School of Medicine.
In addition to a brief literature review on the topic, we have obtained data from a variety of the
sources within the institution and conducted several new analyses to enhance the schools
understanding of student finances. Furthermore, we present the results from two student surveys
conducted by ASSM. Overall, the results address three main areas: 1) the cost of attendance &
student debt, 2) the impact on recruitment & diversity, and 3) the impact on current students.

Literature Review
Cost of Attendance & Student Debt
In 2014 the average annual tuition for first year medical student was $34,540 for public schools
and $53,714 for private schools. Adding in other expenses including cost of living, the median
total cost of attendance for a single year was $56,779 for public schools (in-state) and $76,376
for private schools. Meanwhile, for the graduating class of 2014, the mean indebtedness of
medical students with debt (those with no debt are excluded) was $167,763 for public schools
and $190,053 for private schools a 4% increase from the previous year. Overall, 84% of
students graduated with debt and 37% of public school graduates graduated with more than
$200,000 in debt. For the graduating class of 2014, a student with $180,000 in debt at graduation
can expect to pay the federal government somewhere between $300,000 to $400,000, depending
on the type of repayment program they use (AAMC, 2014a).
A student with $180,000 in debt at graduation ends up paying the federal government
$300,000 - $400,000.

(AAMC)

According to Annie Osborne in Student Academic Affairs, the AAMC calculates this mean
indebtedness based on self-reported data from the AAMCs Graduation Questionnaire.
Therefore, it includes any premedical education and/or consumer debt that a student might have.
The more standardized data that only includes medical school debt comes from what is reported
directly by institutions to the AAMC Medical School Profile System (MSPS) and to the Liaison
Committee on Medical Education (LCME). According to the data shared by Annie Osborne, the
mean indebtedness at graduation was $155,087 nationally for the Class of 2014. More
specifically, it was $148,675 for public schools, which is 34% higher than UCSFs mean
indebtedness of $115,965 for the same year. The mean indebtedness numbers for UCSF are
directly comparable to the national means as reported directly by institutions to the MSPS &
LCME and not the self-reported student data that goes to the AAMC.
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Since 1990 median physician income has increased 34.6 percent, almost exactly in line with
consumer prices. Since medical graduate indebtedness has increased more rapidly,
repayment of educational loans is clearly more difficult today than it has ever been.
(Jolly, 2005, p. 531)

But how did we get to this astronomically high level of debt? From 1984 to 2004 tuition and fees
increased 150% at private schools and 312% at public schools.1 To finance this increase, medical
education debt was 4.5 times as high in 2003 as 1984 (Jolly, 2004). From 2002 to 2012, the
percentage of medical graduates with more $200,000 in debt increased from 5% to 29%
(Rohlfing et al., 2014), and in 2011 aggregate medical student debt exceeded $2.3 billion per
graduating class (Greysen et al., 2011). In fact, student debt has gotten so high that there are now
concerns that debt levels may soon exceed the debt ceilings for Department of Education loans,
the primary mechanism for financing medical education (Greysen et al., 2011). The problem was
further exacerbated by the elimination of subsidized Stafford loans for professional students in
2012, which has been estimated to increase student debt by $10,000-20,000 per student
(Rohlfing et al., 2014).2 To consider this in the context of inflation, the consumer price index
(CPI) has increased 2.5% annually since 1992, while medical education debt has increased 6.3%.
When comparing public and private schools, the cost of attendance has increased more rapidly at
public schools since 2000 (5.8% annually compared to 4.5%) and while the average COA at
private schools was still 40% higher, they gave 100% more in scholarships/grants (Youngclaus
& Fresne, 2013). Since 1998, the percent increase in medical school tuition has outpaced private
medical schools, physician salaries, and undergraduate schools both public and private
(Steinbrook, 2008). A public medical school education is clearly more expensive than ever
before, and becoming a less attractive option when compared to private schools, especially for
low-income students.
Impact on Recruitment & Diversity
A 2006 report on diversity in the physician workforce by the AAMC cites several landmark
studies and concludes that there is evidence of the increasing need for diversity in the physician
workforce to serve an ever-growing multicultural demographic in the United States. Moreover,
because of evidence that minority physicians are more likely to serve minority communities and
Medicaid patients, they believe that overall, research to date cogently illustrates that increasing
diversity in the physician workforce has benefits for everyones health care (AAMC 2006).
SES diversity among medical students (%of all students)Top Quintile by Family Income: 48.1-56.9%
Bottom Quintile by Family Income: <5.5%
(Jolly, 2008)

More specifically, minority residents are three times as likely to see minority patients, and twice
as likely to practice in federally designated shortage areas. An earlier report by the American
Medical Student Association/Foundation, which was sponsored by the Department of Health and
1

When adjusted for inflation, this was a 50% increase for private schools and 133% increase for public
schools.
2
UCSF will see this effect with the graduating class of 2016, as described in the results section.
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Human Services, concludes that the costs of medical school are either prohibitive or provide a
large disincentive for minority students considering medicine (1996). As a result, the high cost
of medical school decreases the already small pool of qualified minority pre-med applicants.
Economic diversity among medical students is socially just and considered to enhance
education and, eventually patient care. Yet more than half of U.S. medical students come from
families in the top quintile for family income.
(Steinbrook, 2008, p.2632)

Using data from the AAMCs Matriculating Student Questionnaire (MSQ), Jolly (2008) found
that from 1987-2005 between 48.1-56.9% of medical school students came from families in the
top quintile by income. By comparison, the bottom quintile never represented more than 5.5% of
medical students. Although this reflects a pattern seen in undergraduate colleges, a prerequisite
for medical school admission, the SES disparity is even more extreme in medical school.
Research by the AAMC indicates that cost is a major deterrent for low income and minority
applicants (Jolly, 2005; Rosenblatt & Andrilla, 2005). On a societal level, failure to enroll more
low-income students in healthcare also represents a wasted opportunity for upward social
mobility. As Jolly (2005) calculates, the net present value of a medical education is $1.2 million
when using a 6.0% discount rate. However, the problem for a lower-income family is that even if
you understand the future value of an investment, you still need sufficient cash flow to pay short
and medium-term expenses.
The percentage of medical students from the bottom two quintiles by family income
decreased from 27% in 1971 to 10% in 2004. (Greysen et al, 2011).

In a New England Journal of Medicine publication, Steinbrook (2008) states: economic


diversity among medical students is socially just and is considered to enhance education and,
eventually patient care (p.2632). Unfortunately, with regards to SES diversity, we appear to be
heading in the wrong direction. In his publication, Paul Jolly, an expert on medical student
finances, expresses concern that the increasing cost of attendance relative to physician pay
threatens to further exacerbate this disparity. In fact, the percentage of students from the bottom
two quintiles of family income has been decreasing since the 1970s from 27% in 1971 to 10% in
2004 (Greysen et al., (2011). According to Greysen et al. (2011) a review of current evidence
suggests that increasing cost has been the major deterrent for minority and low-SES students,
while loans seem to preferentially incentivize higher-SES students. Although students graduate
with similar levels of debt across all quintiles for family income, students in the top quintile are
less likely to take any debt and Jolly (2004) argues that wealthy families are more likely to use
debt to their advantage choosing to take on Department of Education loans and use their own
money for alternative investments because they believe they can make more than the interest rate
on student loans.3 As current evidence demonstrates, the increasing cost of attendance in medical
schools has relied on heavier use of student loans, which disproportionately benefits wealthier
families, reinforcing the huge SES disparities in the medical student population.
3

Since this publication of this article, the interest rate on federal student loans has increased
substantially, making student loans less of a bargain, even for students from the wealthiest of families.
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Policy efforts to improve physician workforce diversity and mitigate shortages in the primary
care workforce are inhibited by rising levels of medical student indebtedness.
UCSF Hospitalist, Dr. Greysen, in a 2011 publication.

Impact on Students
Increasing student debt has also had a negative impact on students performance as well as other
psychosocial factors. Additionally, there is debate over whether increasing debt influences
specialty choice. With regards to performance, West et al. (2011) found that internal medicine
residents with >$200,000 in debt scored 5 points lower on the Internal Medicine In-Training
Examination (IM-ITE) for IM residents when compared to residents with no debt. To put this
effect size in perspective, 2nd year residents score 4.1 points higher than 1st year residents. The
drop in performance associated with debt level is similar in magnitude to the increase in score
that comes with a years experience on the wards. In a report for the AAMC, Brewer & Grbic
(2010) found that although attrition rates were low overall, low SES students were more than
twice as likely to dropout. Fortunately, Cooter et al. (2004) provided some positive news;
although performance among low SES students was lower in the basic science years, these
students caught up with their peers during the clinical years. However, their analysis was limited
to students at Jefferson Medical College.
With regards to psychosocial factors, the odds ratio for having 1 symptom of burnout is 1.72 (CI,
1.49-1.99) for residents with >$200,000 in debt compared with no debt (West et al., 2011).
Students with higher levels of debt are also more likely to depersonalize others and reported
higher levels of dissatisfaction with becoming a physician. They were also more likely to delay
getting married and having children, and delay buying a home (Rohlfing et al., 2014).
Whether debt influences specialty choice has been the subject of debate and the evidence is
mixed. While it seems to make sense that students with higher levels of debt would want to
pursue higher paying specialties, recent evidence from the AAMC seems to refute this
(Youngclaus & Fresne, 2013). Jolly (2005) hypothesizes that the lack of a strong effect might be
due to the fact that some students with high debt might actually prefer lower paying specialties
with short residencies, so they can earn a steady income more quickly, while others prefer to wait
for the higher paying specialty. Additionally, there is the consideration that low SES and
minority students are also more likely to work in underserved communities. In their analysis of
AAMC data, Rosenblatt & Andrilla (2005) found that the majority of students with debts over
$150,000 report that debt influences their career choices (p.818).
In conclusion, the literature review makes clear that a medical school education is more
expensive than ever before, and that student debt, primarily in the form of loans, has increased at
a rate far exceeding inflation and physician pay. The increase is particularly steep for public
medical schools like UCSF. As a result of increasing cost, medical schools have become
increasingly homogeneous in terms of socioeconomic status. Additionally, debt levels can have
tangible effects on students by leading to increased burnout and potentially decreased
performance. Our report attempts to apply this prior research to the current state of student
finances at UCSF.

Methods
Institutional Data
The Registrars Office keeps a public record of cost of attendance data that was used for our
COA analysis and compared with national data reported by the AAMC. The Financial Aid
Office and Student Academic Affairs provided additional information on student debt as well as
a forecast produced by Lisa Raskulinec and Annie Osborne that shows the projected increase in
COA and student debt over the next several years. Information on housing was providing by the
UCSF Housing Office. Dean Wofsy in the Admission Office provided data on the SOM financial
aid budget for scholarships/grants as well as the reasons why admitted students dont attend
UCSF. Furthermore, the UME office provided data on student zip codes, so we could track
whether students have had to relocate around San Francisco in response to increasing rent prices.
State of Student Finances Survey
The State of Student Finances survey was a brief instrument designed to take less than 90
seconds to complete in order to maximize participation rates. Because of the controversy
surrounding the impact of debt on specialty choice, we decided to measure the association using
an item from Rohlfing et al. (2014) rather than creating our own. Otherwise, all other items were
created by ASSM and informed by prior research. The survey was coded into Qualtrics and
distributed via class listservs in February 2015. Of the 259 anonymous responses, 243 were
complete representing about 38% of registered students in the School of Medicine. All
descriptive statistics and statistical analysis were performed using SPSS.
UIM Student Indebtedness Survey
The UIM Student Indebtness survey was a brief 10-question survey also designed to take
minimal time to complete in order to maximize participation. The leadership board for the
student organization, Underrepresented in Medicine, comprised of 6 members representing the
Latino Medical Student Association (LMSA), Student National Medical Association (SNMA),
and Asian Pacific American Medical Student Association (APAMSA), were contacted for the
distribution of the survey to their respective listservs. The survey was created using Google
Forms and was sent to listserv recipients as a link through which participants could access the
survey anonymously in February and March 2015. The survey was sent to the APAMSA listserv
once, while the LMSA and SNMA listservs were sent the survey two and three times
respectively. A total of 47 responses were collected representing about 27% of Underrepresented
Students within the UCSF SOM. All statistical analyses were performed using Microsoft Excel.

Results
Cost of Attendance & Student Debt
Cost of Attendance and Indebtedness at UCSF
In 2014, UCSFs tuition for in-state MS1s was $36,427 compared to the national median of
$34,540 for public schools and $53,714 for private schools. The one-year cost of attendance
(COA) for UCSF for the same year was $60,830, in comparison to the national median of
$56,779 for public schools and $76,376 for private schools (AAMC. 2014a). The total 4-year
COA at UCSF can be seen in Figure XX. The total COA (i.e., tuition + cost of living) has
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increased 84% since 2003 (Figure XX),4 far outpacing the rate of inflation. Figure XX puts the
increasing COA in context of increases in fees (including tuition), cost of living (COL), and
mean student indebtedness.
The cost of living (COL) in San Francisco is one of the major reasons cited by students and
faculty for why UCSF is so expensive. Each year the Financial Aid Office provides a student
budget that includes both a monthly cost of living allowance as well as an annual total cost of
attendance (COA), which varies depending on a students medical school year. Between the
2004-05 and 2015-16 academic years, the estimated monthly cost of living allowance has
increased from $1,701 to $2,520, representing a 48% increase. Specifically within the monthly
cost of living allowance, the budget for a students off campus housing, including utilities, has
Figure XX. Tracking the Increase in UCSFs Cost of Attendance

increased from $925 for the 2004-05 academic year to $1,465 for the 2015-16 year, representing
a 58% increase.

For the purposes of this analysis, COA was calculated by adding up the total cost for each year (i.e.,
Med1, Med2, Med3, and Med4) at the time point indicated. Students could end up paying more since the
tuition and cost-of-living would increase in subsequent years. Currently, the financial aid guarantee from
the School of Medicine helps protect current students from tuition increases while they are students.
Additionally, the 4% annual increase in the Medicine Grant helps provide modest relief from increases
in non-tuition costs.
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Figure XX. Absolute increases in COA, fees, COL, and mean student indebtedness at
graduation.

Despite the common perception that the cost of living in San Francisco is
driving up the cost of attendance, tuition and fees have had a relatively larger
impact.
To look at the relative impact of fees and COL on COA, Figure XX shows the percent increase,
year over year for each of these variables. For the 10-year period from 2005-2006 to 2015-2016,
COA increased 51%, fees increased 78%, and COL increased 40%. In terms of absolute dollar
changes, this means that fees have contributed $69,165 to increased COA while COL has
contributed $30,831, less than half of the amount. Therefore, despite the common perception that
the cost of living in San Francisco is driving up the cost of attendance, tuition and fees have had
a relatively larger impact. Figure XX shows the year-over-year percent increase in each of these
variables, demonstrating that until recently, increases in fees outpaced increases in COL.

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Figure XX. Percent increase year-over-year in tuition, fees, and cost of living from 2004-05
to 2014-2015.

Additionally, it is important to look at cost of living from multiple sources in order to ensure that
UCSFs estimates for COL are consistent with other graduate institutions in San Francisco.
Detailed searches allowed for the acquisition of COL data from the University of San Francisco
(USF) School of Law and UC Hastings College of Law for the past six years.5 In figure XX, we
see the COL for all three of the institutions for the years 2010-2011 up to the current academic
year (2015-16). In absolute dollar amounts, UCSF has a COL similar to our neighboring
institutions. Additionally, in the last five years, UCSFs COL has increased 24% compared to
28% at Hastings and 34% at USF.

Note that the COL for USD and Hastings was calculated using data obtained from each institutions
website. For USD, COL was calculated by summing the Room and Board, Personal Expenses and
Transportation. For Hastings, COL was calculated by summing the Housing and Utilities, Food,
Personal Expenses, and Transportation. Sample budgets for each institution can be seen at the
websites below (USF: http://www.usfca.edu/law/jd/tuition and Hastings:
http://uchastings.edu/about/admin-offices/financial-aid/cost/2015-16/index.php).
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Figure XX. Cost-of-living allowance at UCSF, UC Hastings, and USF Law from 2010/11
to 2015/16.

While there has been a constant increase in COA, including tuition and fees, over the last decade,
the average indebtedness of students has remained relatively stable. Based on Figure XX
provided by Carole Ann Simpson in the Financial Aid Office, the increased discrepancy between
the cost of tuition/fees and overall indebtedness will require a rapid increase to the budget for
grants/scholarships in order to keep debt relatively stable, otherwise student debt will increase.
According to Student Academic Affairs, from 2005-6 to 2013-14 the total COA has increased on
average 6.0%/year, while the average cumulative debt has increased 5.5% year.

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Figure XX: Cumulative Fees Paid and Average Indebtedness

For the graduating class of 2013-2014, 83.8% of students had debt with an average of $116,000
well below the national average, though more comparable to many of our competitors for top
applicants. In this class, 48 students graduated with less than $100,000 in debt, 65 graduated with
$100,000-175,000 in debt, and 21 graduated with over $175,000 in debt.6
Financial Aid Budget & Effective Cost of a UCSF Education
UCSF School of Medicines current financial aid budget is approximately $8 million per year, up
significantly from about $5 million in 2008-09. This budget represents the amount of financial
aid given to students in the form of scholarships and grants. To understand how much the
average student really had to pay for a UCSF MD, we calculated the effective cost to attend
UCSF and compared this to Duke and University of Chicago, representatives of top-tier private
schools.
This means that for a student from a high-income family who expects no
grant/scholarship, he/she could save money by attending UCSF, which is great.
However, the same may not be true for a student from a low-income family, who
might save money by attending a private school because these schools have larger
grants/scholarships.
6

Consistent with the rest of the report, indebtedness only includes Department of Education and UCSF
institutional loans taken out while in medical school.
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In 2015-16, UCSFs COA was $275,764, while Dukes was 18% higher at $326,513 and
University of Chicagos was 20% higher at $330,910.7 However, while the average UCSF
student can expect to receive $49,000 in scholarships/loans over their 4 years, a Duke student
receives $86,000 and a UChicago student receives $95,000. Therefore, each of these schools
ends up having a similar effective cost i.e., COA minus grant/scholarship. The effective cost for
UCSF is $227,000, while it is only slightly higher for Duke at $241,000 and UChicago at
$236,000 (Table XX).
Table XX. The Effective Cost at UCSF, Duke and University of Chicago. The effective
cost is calculated by taking the cost of attendance (COA) and subtracting the average
grant/scholarship per student.
COA
Average
Effective Cost
Grant/Scholarship
UCSF
$276,000
$49,000
$227,000
Duke
$327,000
$86,000
$241,000
UChicago
$331,000
$95,000
$236,000
Because Duke and University of Chicago have higher tuition, the students that can afford to pay
will provide more revenue for the school, which in combination with the larger per capita
scholarship/grant budget, will allow these institutions more financial flexibility to provide
generous financial aid packages to low-income applicants. This means that for a student from a
high-income family who expects no grant/scholarship, he/she could save money by attending
UCSF which is a good thing. However, the same may not be true for a student from a lowincome family, who might save money by attending a private school because these schools have
larger grants/scholarships. For UCSF this is troublesome for two reasons: 1) cost is an important
factor in accepted students decisions about which school to attend and 2) according to our
literature review, higher levels of debt adversely affect students. If we are able to increase our
grants & scholarships, we will have a greater capacity to recruit a socioeconomically diverse
class and reduce the projected debt of our most indebted students, which will reduce the range of
indebtedness at graduation. Because schools do not publically report the SES diversity of their
students, we were not able to study whether these differences in COA and average
grant/scholarship appeared to influence the SES diversity at particular institutions. ASSM
requested data on the SES diversity of the student body at UCSF, but the data was not ready in
time from Student Academic Affairs for the writing of this report.
Does UCSFs reported indebtedness for recent grads reflect the situation of current
students?
One of the issues we wanted to address in this report was the feeling expressed by some students
that their debt load was not reflected in the official indebtedness data reported by UCSF to the
AAMC for recent graduating classes. During the fall 2014 discussions about tuition increases,
some members of our schools leadership frequently mentioned the official average of $115,965
for the graduating class of 2014. While it is understood that there will always be some outliers
7

The 2014-2015 cost of attendance for the University of Chicago was used because the updated 20152016 numbers were not available at the time of writing.
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in fact 21 students from last years graduating class had over $175,000 in debt it did seem that
there were more current students expecting to have even higher levels of debt. We explored two
explanations for some of the discrepancy subsidized Stafford loans and the Graduation Gift.
The graduating Class of 2020 is predicted to pay $300,000 for a UCSF medical
education and their average debt will be $153,950 a 33% increase from 2014.
Subsidized Stafford Loans
Until July 1st, 2012 medical students could get subsidized Stafford loans where no interest
accrued during medical school. Until then you could borrow up to $34,000 in these low-cost
loans over 4 years. These loans were such a bargain that many students from wealthier families
borrowed them, even though they had family support to pay for school. Therefore, prior to 2012,
there were about 15-20 students per class that would borrow $34,000 in these subsidized loans,
as they were entitled to do. Unfortunately, the $34,000 figure would drag down the institutions
mean indebtedness figure and held it artificially low. Since 2012 these students are no longer
taking any debt and are not considered when calculating average indebtedness i.e., you dont
count a zero when calculating average indebtedness since the national standard is only to
consider indebted students in this calculation. As a result, the mean indebtedness will soon
increase and more accurately reflect the debt of our peers. (Note: All medical schools, not just
UCSF, will see the same bump in indebtedness for the Class of 2016.)
The Graduation Gift
Through the process of writing this report, we discovered the existence of scholarships and loan
repayment that were not previously known to any of the authors. For example, near graduation a
few of our most indebted peers will receive scholarships created by some of our generous
alumni. One such scholarship is specific for students entering surgery. The loan repayment
programs were created due to a few surpluses in financial aid funding, which the SOM disbursed
to help pay down the highest interest loans for the most indebted graduating students. As a result
from feedback from students, SOM will try to disburse this additional money to students earlier
through increased grants/scholarships rather than loan repayment. An example of the new
strategy was the 10% one-time boost to student scholarships announced in May 2015. The net
effect of these programs is that for the students that benefit from them, their actual debt at
graduation will end up being less than they are currently projecting. In other words, while the
subsidized Stafford Loans have held mean indebtedness artificially low, the loan repayments and
additional scholarships have actually lowered mean student indebtedness, although the impact
may be relatively minor due to the modest size of the program.
Cost of Attendance & Debt Projections
In response to UC Office of the Presidents proposed increase in fees, Chancellor Hawgood
directed Student Academic Affairs (SAA) to create a forecast of how COA and debt will
increase in the coming years. In making their projections, SAA made several assumptions, which
tended to error on the side of over-estimating cost and debt, rather than potentially
underestimating the impact of increased fees. They also took into account the ending of the
subsidized Stafford loan program for graduate students, which is mostly responsible for the
projected 16% increase in average debt for the Class of 2016. The graduating Class of 2020 is

16

predicted to pay $300,000 for a UCSF medical education and their average debt will be $153,950
a 33% increase from 2014 (Table XX).
Table XX. Projected Costs & Average Cumulative Debt 2015-2020 (Source: Student Academic
Affairs).
Graduation Year
Cost of Attendance
Average Indebtedness
2014-2015
$253,058
$118,294
2015-2016
$260,084
$137,378
2016-2017
$268,033
$133,779
2017-2018
$277,522
$138,280
2018-2019
$288,434
$144,073
2019-2020
$299,991
$153,950

Impact on Recruitment and Diversity


Diversity is an important institutional ideal, emphasized at this years Deans Leadership Retreat
and enshrined as one of the pillars for UCSF 2.0. The SOM has diversity numbers that compare
very favorably to Californias other medical schools.8 Over the last six years, our entering class
of medical students has averaged 28% UIM students, with a record of 34% for the entering class
of 2015. But the diversity pipeline at the institution tails off dramatically as you climb to
residency and faculty positions, which earned the University a citation from the Liaison
Committee of Medical Education (LCME). While we await the numbers on SES diversity at
UCSF, which wont be available until after this report, the available data does not paint a
particularly encouraging picture with more than half of medical students nationally coming from
the top quintile by family income. We should be asking is UCSF as
Figure XX. Number of
diverse as it could be? Is it as diverse as it should be?
The effect on SOM admissions yield
In the State of Student Finances survey, 50.4% of respondents
indicated that UCSF was not their cheapest option. If you eliminate
the 21.8% of respondents that were not sure, presumably because
they didnt get other financial aid offers by the time they decided to
attend UCSF, then 64% of the remaining respondents turned down
cheaper options. While no hard conclusions can be drawn from this
data, it does show that a majority of current students came here even
though it has cost them more money. That demonstrates a strong
commitment to the school and a desire to look beyond cost. In the
survey, respondents were also given the opportunity to write which
other schools were cheaper. The results are included in Figure XX.
Although the absolute numbers arent very informative, the relative
frequencies are about what we expected.

respondents that indicated a


particular school was
cheaper.
School
UCLA
UCSD
UCD
UChicago
USC
Columbia
UCI
UMich
UPenn
WashU
Stanford
Duke
Harvard
Vanderbilt

Frequency
23
13
11
11
10
9
8
8
7
7
6
5
5
5

The Deans of Admissions for each of Californias medical schools confidentially share data on
diversity. The data was made available to ASSM but we elected not to include specifics in this report out
of respect for the nature of this voluntary data sharing between institutions.
17

The more conclusive institutional data on recruitment and diversity comes from Dr. David
Wofsy, the Associate Dean for Admissions. For the past few years, UCSF yields 55% of the
students it accepts. For reference, the national average is 52.8% (Smith-Barrow, 2014), though
various admission strategies can be used to manipulate the numbers thus limiting the value of
yield as a comparison tool to other universities. Considered in isolation, UCSFs yield, while
highlighting many of the successes of our recruitment efforts, still indicates that we are losing
many desirable applicants.
To understand why accepted students choose not to attend UCSF, Dr. Wofsy personally emails
each of them. Over the past five years, debt/cost/economy has been the #1 reason why accepted
students elect not to attend UCSF. While UIM students are even more likely to indicate
cost/debt/economy as the reason why they dont come, the disparity has been nearly eliminated
in the last three years. While ASSM was granted special access to the data for the purposes of
this report, we were asked not to include specific figures since they are used internally and may
not be comparable to similar figures reported by other universities due to differences in
measurement.
Socioeconomic Diversity at UCSF
Income inequality is at an all-time high, with California leading in terms of poverty rate as well
as ultra-wealthy residents (US Census). While UCSF is obviously not responsible for this fact,
we believe that UCSF must be responsive to these realities if it wishes to attract a student body
that fully represents the stunning socioeconomic diversity in the state of California.
To take a closer look at socioeconomic diversity at UCSF, Daniel Novinson, one of the authors
of this report, worked under the supervision of Dr. Rene Salazar, the GME Director of Diversity,
as part of a RAPtr summer research project. He found that the mean income and urbanicity of
each of Californias 58 counties strongly correlates with that countys per capita application rate
to UCSF SOM, such that compared to a theoretical application pool in a state of absolute
equality, 25% of the actual application pool is missing altogether. These missing applicants are
disproportionately students from poorer, rural, inland California counties areas most in need
of additional medical providers. Second, for students who do apply, higher socioeconomic status
strongly predicts eventual admission: After controlling for measures of achievement and
demographic variables (MCAT score, undergraduate GPA, age, underrepresented minority status
and gender), students who attended a private high school had admissions odds 2.5 times those of
their peers, a boost equivalent to nearly six points on the MCAT, or 0.34 on an undergraduate
GPA.9 (See Table XX below) As lower-SES students are less likely to attend private high
schools, the two above findings have a multiplicative effect, with poorer students both less likely
to apply and then disproportionately rejected, further reducing SES diversity.

The data for this analysis comes from the entering Classes of 2006 and 2007. Under the direction of
Dr. Wofsy, the SOM has instituted a new review process and is actively investigating whether students
who attended public high schools are disproportionately rejected in the admissions process. Of note,
requesting a fee waiver had no impact on admissions odds.
18

Table XX. Applicant Characteristics and Their Admissions Weight


95% C.I. for Odds Ratio
Variable (SD)
HS* GPA
(0.34)1
MCAT*
Private (Ind.)
HS
GPA* MCAT
(5.9)1
Age1
Constant

S.E.

Sig.

Odds Ratio

Lower

Upper

.758

.179

.000

2.134

1.502

3.032

.637

.096

.000

1.891

1.565

2.285

.857

.108

.000

2.355

1.907

2.908

.158

.066

.017

1.171

1.029

-4.143

.098

.000

.031

----

1.332
----

Table N. Applicant characteristics ordered by their effect on admissions odds, as determined by logistic
regression.
1
Variable standardized to allow for comparisons of relative impact, standard deviation in parentheses. Above
statistics reflect effect of one standard deviation increase. One-unit increases in age, MCAT score, and GPA
(increase of 0.10), respectively predict 5.1%, 16.3% and 32.0% increase in admissions odds.

Overall Novinsons findings reinforce the prior research demonstrating that students from poorer
families are less likely to apply in the first place. As the UCSF SOM community debates tuition
and financial aid policies, it is important to remember that these decisions do not merely change
the numbers on a spreadsheet they are public signals as to the Universitys openness to students
from all socioeconomic backgrounds.
Results from UIM Student Indebtedness Survey
In the UIM Student Indebtedness Survey, 72% of participants responded that they declined larger
financial aid awards when deciding to matriculate into UCSF. This data demonstrates that similar
to the school-wide State of Student Finances Survey, a majority of students who identify as
Underrepresented in Medicine (UIM) chose to attend UCSF in the presence of cheaper options.
When UIM students were asked about the importance of Financial Aid when choosing which
medical school to attend, 72% of respondents stated it was very or extremely important. This
suggests that financial aid packages serve as a key determinant in the decision making process
for UIM students choosing a medical school.
When students perception about the relationship between financial aid and diversity within the
SOM student body was surveyed, 89% of students agreed or strongly agreed that the cost of
attending UCSF and living in San Francisco has limited student diversity in the SOM.
Furthermore, 100% of participants answered that they believed providing subsidized housing
would help increase the recruitment of a diverse student body. In order to understand the
potential impact that finances could have on retention of UIM students for residency, participants
were asked if the cost of attending UCSF and living in San Francisco has caused them to seek
potential residency options in more affordable locations with 53% reporting that it had. If we
remove the not applicable respondents, since 90% of them were MS1s or MS2s who
19

potentially have not thought extensively about residency, then 76% of UIM students have
considered residency options in more affordable locations. Given these responses, it is clear that
UIM students feel as though the cost of living in San Francisco and attending UCSF has not only
impeded SOM from being as diverse as possible but has also led them to consider other medical
institutions for their graduate medical training.
Finally, students were asked about specific financial barriers, including timing of financial aid
disbursement, providing financial support for family members or relatives and housing that until
now have only been discussed anecdotally in terms of their impact on UCSF UIM students. The
results from the survey are listed below in Table XX. Below, we have also listed some specific
comments from UIM students.

The cost of housing is by far the largest obstacle limiting the recruitment of students,
especially UIM students. Our peer institutions not only offer better financial aid
packages, but many offer subsidized housing, especially those in similar housing
market places, such as New York, Chicago, LA, and Boston. It seems extremely
disconnected that the administration and financial aid office believes that $1250 is a
reasonable amount for financial aid to budget for student's rents.

I turned down a full tuition scholarship and partial tuition scholarship at schools in less
expensive cities to UCSF. As an older student who is interested in primary care or a
"low-paying" specialty & looking at a boat load of debt, I often wonder if I made a
responsible choice.

I remember one very vivid moment when speaking with a financial aid officer about a
gap in my budget. I was told that I wouldn't be able to have my disbursement on time
so I would have to live off of credit cards in the meantime. I was told I should "beg,
borrow, and steal" that money for the two month period before money came in. Beg,
borrow, and steal." This is how low-income students are treated at this institution. I
have a master's degree and am told to beg, borrow, and steal for rent. When
administrators and leadership wonder why there's a paucity of low-income, highachieving, first-generation students at UCSF or why they're all choosing to go to other
schools, it's because at other schools they don't have to "beg, borrow, and steal.

I declined to go to a school where I would have my entire tuition covered because I


felt like UCSF would make me a better physician. I still believe that I made the right
choice but when I am running low on funds and have to worry about paying my rent or
groceries, I think about how much easier it might have been if I had decided to attend
the other school. I am worried because rent is so expensive and I might not be able to
stay in the student housing for next year. I don't know that I will be able to afford living
close to campus and am concerned that living far from campus will affect my grades
and the extracurricular activities that I am able to take part in. I think having more
student subsidized housing would help but am also concerned about gentrification
and whether the student housing will displace disadvantaged communities.

20

It is as if, outside of the UIM community, everyone assumes that family is a source of
emotional and financial support. This is frequently not true! I think that the students
who do have families who provide financial support are throwing off whatever
calculations go into determining how well UCSF is doing at providing Financial Aid.
Maybe many students would answer "no" to whether or not their family provides
support. But are they counting the free flights home, being on their parents' phone
bills and insurance coverage, gifts of books or computers, the stocking of their
refrigerators when family visits... probably not. Do they realize that some of their
classmates need to help support their families? That them entering med school was a
serious blow to their familys financial security? I doubt it.

I love the Bay Area. I have spent my entire adult life here, but it is important to me as a
physician to be able to live in the area in which I serve. Being a physician, for me,
means interacting with my patients in and outside of the clinic/emergency room. That
experience may not be possible as a resident, and it is a really saddening realization.

Do [other students] realize that some of their classmates need to help support their
families? That them entering med school was a serious blow to their familys financial
security? I doubt it.

Table XX: Specific financial obstacles for UIM students.


Trouble Receiving
Providing Financial Support
Trouble Finding
Financial Aid
for Family Members/
Affordable Housing
Disbursements on Time
Relatives
________________________________________________________________________
Yes

36.96%

43.48%

91.49%

No
63.04%
56.52%
8.51%
________________________________________________________________________

In summary, not only is cost a major barrier to recruiting a diverse applicants, it creates
substantial burdens for our current students and causes many of them to look elsewhere for
residency. Addressing these issues may serve to further the cause of diversity at UCSF by
increasing the diversity pipeline for our residency and faculty positions.

Impact on Current Students


Results from State of Student Finances Survey
Survey respondents represented a broad spectrum of the student body with representation from
all four classes as follows: 17.9% MS1s, 25.8% MS2s, 17.5% MS3s, and 38.9% MS4s.
21

Additionally, about a third (34.9%) of respondents self-identified as UIM. The survey had the
following key-findings on a scale of 1 (strongly disagree) to 5 (strongly agree):

I am concerned about the cost of attendance at UCSF.


o The average response was 4.40 with 89.7% of students agreeing with the
statement. In fact, the majority of students (56.1%) strongly agreed.

I feel that the amount of financial aid offered is enough to cover tuition, fees, insurance,
books & supplies, and cost of living.
o The average response was 2.65 with 26.9% of students agreeing with the
statement and 50.2% disagreeing.

Financing my medical education has negatively impacted my mental well-being.


o The average response was 3.43 with 51.2% of students agreeing with the
statement.

I have already or may in the future make decisions about my medical specialty choice
based on my educational debt.
o The average response was 3.42 with 54.7% of students agreeing.

We failed to find any statistical relationship between any of the items on the survey and UIM
status. However, there were significant correlations between each of these four items and a
students projected debt level. Projected debt level correlated positively with concern over the
cost of attendance (r(237) = .400, p < .01), impact on specialty choice (r(237) = .389, p < .01),
and negative impact on mental well-being (r(237) = .396, p < .01). All of these correlations
represent medium to large effect-sizes. Additionally, there was a smaller negative correlation
between projected debt and financial aid satisfaction (r(237) = -.129, p = .048). It should also be
noted that our survey found that UCSF students had very little debt prior to medical school,
similar to national trends in national data collected by the AAMC.
Overall, these findings indicate that students have a very high level of concern over the cost of
attendance and slight dissatisfaction with the amount of financial aid. Additionally, some
students, particularly those with higher levels of debt, report impaired mental wellbeing as a
result of concern over financing their medical education. Lastly, while a majority of students
agreed that debt influenced their specialty choice, this was particularly true among more indebted
students.
Modest yet adequate lifestyle
When determining the cost of living allowance, the Financial Aid Office must comply with
federal guidelines that permit a modest yet adequate lifestyle. However, Annie Osborne and
Carole Ann-Simpson will quickly point out that this means a lower standard of living in San
Francisco relative to Durham, North Carolina because of the astronomically high cost-of-living
in San Francisco. However, we believe they do their best to give us maximum access to
Department of Education loans. They can also grant us loan increases if we can demonstrate
additional costs in areas that are eligible for government loans such as housing, food, and
healthcare expenses. Furthermore, consistent with what is permitted by federal regulations, they
22

left the books & supplies allowance to reflect full retail value, which gives students additional
flexibility to save money in this category and use it for food, housing, etc.
Nevertheless, students tend to complain specifically about trying to find housing, though this
may become a little easier with the big jump in the housing allowance to 1,465/month for the
2015-2016 academic year. However, even with the big increase, it will still be difficult for
students to find housing in the Inner Sunset, one of San Franciscos cheaper neighborhoods.
The average cost for a single room in San Francisco is $2,200 according to the UCSF Housing
Services Manager. In the Inner Sunset, the average costs are as follows: $2,122 for a studio,
$2,800 for a 1-bedroom, $3,355 for a 2-bedroom, and $3,900 for a 3-bedroom. So with a $1,465
the average apartments are simply unaffordable in the neighborhoods around Parnassus (Cole
Valley is even more expensive). This reality gives students a strong incentive to move in with
significant others, find a 3-bedroom apartment, or convert common rooms like living rooms into
makeshift bedrooms.
In order to find affordable housing, many students have wondered whether students are
increasingly moving further and further away from campus to places such as the Richmond,
Outer Sunset, and Daly City. ASSM was provided with local zip codes of students from the
Classes of 2006, 2012, and 2018. Based on the data we were able to collect (Table XX), these
concerns appear unwarranted thus far. However, our analysis is limited by the lack of detailed
information on the exact location of student residences. For example, the 94122 zip code
includes UCSF as well as places in the Outer Sunset that are a 30+ minute commute by public
transportation.
The role UCSF has played in helping students find housing has been relatively minimal. We
provide no housing guarantees, and with the exception of single bedroom in a shared unit, our
housing options tend to be more expensive than many of our peer institutions. Since UCSF
provides housing for <10% of medical students, finding off-campus housing is a reality we must
all face, and although students find housing, it is a major stressor and a potential deterrent for
applicants.

23

Table XX. Where students are living by zip code for the class of 2006, 2012, and 2018.

Finances While Doing Research


Since the government no longer provides subsidized loans to graduate students, UCSF students
with high levels of debt had to consider whether or not taking a research year was worth having
another year of unpaid interest accumulate on the loans they had taken out during the first three
years of medical school. To address this issue, Associate Dean for Curriculum, Susan Masters,
was credited with recently starting a program to pay for a students loan interest during the year
they are conducting research. For example, for a student with $100,000 in federal loans at the
end of their 3rd year, this program will save them approximately $6,000 in unpaid interest during
the research year. This guarantees that all students are on a more equal playing field when
considering the costs versus benefits of taking time off to do research.
In contrast, the summer Pathway to Explore program was less student-friendly in terms of
finances. This past year disbursements for $3,000 went out halfway through summer leaving
many students scrambling to pay rent in advance of the disbursement. Additionally, students
24

didnt receive the final $500 until over 7 months after the summer ended. Additionally, the
$3,500 does not cover the cost-of-living for a 10-week period as determined by the Financial Aid
Office. Fortunately, Dean Lucey has already begun taking steps to address these issues.
Loan Repayment Programs & Debt During Residency
Graduates must start repayment during residency on an average salary that starts at $51,586 for a
PGY1 and gradually increases to $67,238 for a PGY8 (AAMC, 2014b). For a first year resident
with the average public indebtedness of $167,763 at an interest rate of 6.0%, they would owe
$10,066 in interest. Luckily, several federal repayment programs and loan forgiveness programs
exist to minimize the burden.10 For example, the popular Pay-As-You-Earn (PAYE) program
would reduce that interest rate to ~$3,360. There is also the Public Service Loan Forgiveness
Program, which forgives all remaining debt after 10-years of service for non-profit and public
sector employees. That means that after 7 years of residency/fellowship at UCSF and 3 years of
working for the VA (as an example), while making 120 minimum payments under PAYE, you
would be eligible to have the remaining balance of your loans forgiven.11 This is potentially a
huge savior for our most indebted students, which could walk away from medical school having
paid relatively little for their UCSF education. However, the 2015 budget proposal from the
Obama Administration proposed capping the amount forgiven at about $60,000 (U.S. Dept. of
Education, 2014) and the prospects for the program look even worse in the context of our
shifting political environment. Furthermore, the program was enacted in 2007, which means it
will start hitting the Department of Educations budget in 2017. This hit to the budget may
trigger legislative action from Congress to cut the program. Ultimately, the fate of this program
is a huge wild card for our peers.
A UCSF graduate with $175,000 in debt that wants to become an interventional
cardiologist will have at least $230,000 in debt by the end of her residency.
If we assume that the Public Sector Loan Forgiveness Program will be eliminated, students will
still have access to the PAYE program. However, by lowering the minimum payments, the rest
of the unpaid interest will be added to your principal, as it did in medical school. This means that
the debt you graduate with may be less than the debt you end up with after residency. This effect
is even more drastic for students with high levels of debt, as illustrated in Table XX.12 This
shows that for the 21 students with over $175,000 in debt in last years graduating class, many of
them can expect to have well over $200,000 in debt by the end of residency.13 Even a student

10

A small minority of UCSF graduates will choose forbearance and delay payment, though this option is
not recommended by ASSM because it will cause your outstanding debt to compound during residency.
11
The forgiven amount may have to be reported as income, causing a significant tax penalty during the
year the loans were forgiven.
12
The calculator created to make this table was produced by Greg Zahner in consultation with CaroleAnn Simpson in Financial Aid. We plan to eventually make it publically available, but if youd like it in
advance, please email Greg.Zahner@ucsf.edu to receive the excel file.
13
The calculations use the interest rate for Stafford loans in 2014-15 and assume a monthly increase in
the minimum PAYE payment of $17/month for each subsequent year of residency due to increasing
resident income.
25

with $150,000 in debt - the projected average for the Class of 2020 can expect to have
$175,000 to $200,000 in debt by the end of residency.
Table XX. What happens to debt during residency? Debt will drastically increase during
residency for a student with $175,000 in debt at graduation that is making minimum payments under
the Pay As You Earn loan repayment program.
Year

Starting Debt

PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
PGY7
PGY8

175,000
182,508
190,265
198,300
206,619
215,250
224,213
233,523

Interest
Rate
0.0621
0.0621
0.0621
0.0621
0.0621
0.0621
0.0621
0.0621

Interest Owed
10,868
11,334
11,815
12,314
12,831
13,367
13,924
14,502

PAYE
Payment
3,360
3,576
3,780
3,996
4,200
4,404
4,608
4,812

Unpaid Interest

Ending Debt

7,508
7,758
8,035
8,318
8,631
8,963
9,316
9,690

182,508
190,265
198,301
206,619
215,250
224,213
233,529
243,219

Conclusion
In conclusion our review of the State of Student Finances reviews several areas of concern. The
COA has increased 84% since 2003 and will soon reach $300,000. While strong leadership from
the administration has kept mean indebtedness relatively stable, shielding our students from the
full extent of financial pressure facing students nationally, our mean indebtedness is projected to
increase 33% by 2020 to over $150,000. Even with the projected increase, it is important to also
consider that UCSF still compares favorably with national averages. Yet ASSM argues that we
are no average institution and even in the Class of 2014 a class with a mean indebtedness more
than $30,000 lower than the national average 21 students graduated with over $175,000 in
debt, highlighting how averages can ignore the hardship faced by individual students.
Additionally, cost is a major deterrent to potential applicants, which costs the school diversity.
Although the data on the SES makeup of UCSF students is not yet available, we anticipate that
these data will show a strong overrepresentation of the top quintile by family income, consistent
with what is seen across the rest of the nation. Furthermore, the effective cost analysis shows that
for many students, private schools like Duke and University of Chicago cost about the same.
Only for the wealthiest families is UCSF most likely to be the cheapest option. In order for us to
compete with these private schools for highly qualified, low-income students, we will need a
larger financial aid budget for grants/scholarships.
Possibly the most troubling issue that we found is the impact that debt is having on our current
students. More indebted UCSF students report that debt influences their specialty choice as well
as adversely affects their mental wellbeing. They are more concerned about the increasing cost
of attendance and less satisfied with the financial aid offered.
We would be remiss not to recognize the common counter-argument that if physicians make so
much money, why do they need more scholarships? After all, Net Present Value calculations of a
medical education show that it a great long-term investment. However, NPV doesnt fully take
into account the short and medium-term costs of making that investment while students are in
26

training. Students face the decision of whether to make nothing for 4-5 years followed by
relatively little for another 3-8 years, or enter the workforce immediately. This presents a huge
dilemma for all students and particularly lower income students for whom cash flow and
financial flexibility is a particularly big concern. Entering the workforce gives them financial
flexibility to support their families and build up savings so that they can weather an emergency
like unexpected medical bills or death of a parent. For the students that enter medical school,
they have relatively few financial options if such emergencies arise. Imagine the stress of living
disbursement to disbursement knowing that if you get sick, get into a car accident, receive an
expensive parking ticket, need to fly home for a family emergency, or need to pay copays for
physical therapy or psychiatry appointments, that your financial aid disbursement does not have
an allowance for these expenses and you will need to cut from food, books & supplies, or the
modest catch-all miscellaneous. Additionally, their income is constrained during a time in life
when many are getting married, starting families, or supporting elderly parents. Furthermore, the
debt burden is higher and more expensive than ever before, even when adjusting for inflation and
changes in physician salaries. For these reasons, debt is an increasing burden on all students and
a major cause of the decreasing SES diversity in medical schools.
While UCSF might have one of the most diverse medical student bodies, available data indicates
that we are still falling short. Unfortunately, as long as we continue to compare favorably to
other medical schools at the UME level in terms of percentage of UIM students, there may be
little incentive for the University to prioritize increasing SES diversity. Additionally, we cannot
idly accept the finding that projected student indebtedness at UCSF is negatively correlated with
mental wellbeing especially considering the enormous concern we have for the mental health
of our students. In 2014 a survey of first year medical students, found that 30% reported
currently dealing with a mental illness.14 Therefore, it is incumbent upon students and visionary
leaders within the University to push for allocating more financial resources toward financial aid.
We must truly innovate and lead the change to make medicine more diverse, and this process
cannot happen without greater financial support for students that allows for greater
socioeconomic diversity, equity, and student wellbeing. As a public medical school, it is
particularly incumbent upon us to educate students of all backgrounds, so that students regardless
of socioeconomic status all have the opportunity to join in the privilege of receiving a UCSF
MD.

Recommendations

Increase the financial aid budget to a new minimum baseline of $10 million for 2015-16 and
subsequently increase it to keep increases in mean indebtedness at the level of inflation.
For the upcoming year the financial aid budget for grants/scholarships should be increased to at
least $10 million to help counteract projected increases in student indebtedness and preferably
$12-13 million/year to help reduce baseline levels of student indebtedness, a stated desire of
several UCSF leaders we consulted. These new funding levels would need to be increased in
subsequent years to keep increases in student indebtedness at the level of inflation.
Unfortunately, declining state support means that the University will need to raise most of this

14

The survey was conducted as part of the Mental Illness Among Us event and had a 73% participation
rate.
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money on its own. While we encourage continued advocacy at the state and federal levels, we
must face the reality that while UCSF is a public institution, it must increasingly behave like a
private school when it comes to funding financial support for its students.
According to information provided by Vice Chancellor Jennifer Arnett in the Development
Office, UCSF has an endowment of ~$61,371,830 for medical student scholarships, which
provides an annual payout of ~$3 million. In the last fiscal year, they raised $1,336,950 for
scholarships, with $451,128 for immediate use. The rest was added to the endowment. While
these totals are the result of years of hard work and carefully forged relationships with donors, it
is clear that fundraising will need to dramatically increase in order to meet the demand for
financial aid resources. Students should take an important role in helping the University raise the
additional funds.

How should the money be spent? The answer requires an ongoing discussion between
students and administrators, though we would argue that increased funding for need-based
grants/scholarships is the most progressive option.
The literature provides limited advice on this issue. For example, Steinbrook (2008) recommends
the following: capping tuition increases at CPI, providing majority of financial assistance as
scholarships, and expanding loan-repayment programs.
In the State of Student Finances survey, students were asked how they would want SOM to
spend a $200 million endowment in support of student finances. Students were pretty evenly
split between wanting lower tuition/fees for all students, building subsidized housing for
students, and increasing need-based scholarships. Other less popular options included meritscholarships and offering loan forgiveness to students matching in primary care/working in
underserved areas. The results are shown in Figure XX.
Our effective cost analysis indicates that decreasing tuition for all students preferentially favors
students from higher income backgrounds. While an argument can easily be made that this is
most fair and that all students are facing difficulties due to the high COA, the counterargument
would point out that this would be a relatively regressive policy compared to concentrating
additional financial support among the highest need students. Since ASSM represents all
students, we do not wish to pit one group of students against another. Instead, we want to
highlight the differing opinions among students and encourage greater dialogue about how the
university can best
Figure XX. If UCSF raised $200 million to support student finances, how
support us.
should it spend it?

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Create a special task force to explore alternative forms of financing a UCSF medical
education.
We are acutely aware of how difficult it will be to increase the budget for student
scholarships/grants in order to keep pace with the increasing COA. To fund a new baseline
scholarship/grant budget of $12 million/year, as we recommend, it will require an endowment of
~$250 million or a substantial amount of annual fundraising/reallocation of funds from other
areas. If the COA continues to increase at current rates, that budget would need to quickly
increase to $15-20 million/year.
Therefore, it would be well worth going back to the drawing board and asking some fundamental
questions. For example, what really matters in financing a medical education? Should students
have skin in the game? What is the right amount of debt? Are their other ways to fund a UCSF
education? Are there any ways to make it cheaper, like a 3-year accelerated program? A task
force of some of UCSFs brightest minds in medical education, health policy, finance, and
development could begin to answer these questions and come up with more creative and
sustainable long-term solutions.

UCSF should disburse funds in a timelier manner that is consistent with the world students
live in.
Disbursement of funds needs to occur at equal and regular intervals that allow students to pay
rent and other bills. For example, disbursement should occur before the end of the month so that
students have funds to pay for the next months rent. Unfortunately, this recommendation runs
into Department of Education regulations that state loans can be disbursed a maximum of 7 days
before the start of a quarter. We strongly encourage the schools leadership to work with federal
regulators and available school resources to develop a creative solution to this problem.
Additionally, since holds on student accounts delay disbursement, we encourage a better system
for notifying students of holds and making sure that no holds are placed on an account too close
to a scheduled disbursement date so that students have adequate time to respond and comply.

Maintain progressive programs like the tuition guarantee to protect students from tuition
increases while they are students and loan interest support during an optional research
year.
The tuition guarantee spearheaded by Dean Lucey and Dean Wofsy helps provide predictability
once students have matriculated at UCSF. Students can rest assured that if the Regents increase
tuition/fees, UCSF will shoulder the additional cost for students that receive financial aid.
Additionally, providing financial support to cover the unpaid interest on student loans during a
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research year is a very progressive program started under the direction of Dean Masters. ASSM
encourages UCSF to continue subsidizing the interest of student loans during the optional
research year.

Students should be aware that they are entitled to ask for loan increases if they can
demonstrate that their costs exceed UCSF cost of living estimates.
Students can successfully request more loans from the Office of Financial Aid if they can
demonstrate that their costs for things like books, food, and rent reasonably exceed the
allowances provided by UCSF. More information is available online:
http://finaid.ucsf.edu/continuing-students/student-budget-increases

Financial advice for students: budget and track your expenses while in medical school and
project your costs during residency so you can select the repayment program that makes
the most sense for you.
The University already offers a lot of assistance for students, including budgeting tools that can
help students make ends meet from disbursement to disbursement. ASSM has also worked with
the Financial Aid Office to create a debt during residency calculator. We encourage more
students to take advantage of these resources and meet with advisors in Financial Aid.

Students should have frank conversations about class, SES diversity, and privilege.
While not explored formally in this report, the research that we conducted highlighted many
differing views among students best highlighted by this comment from the UIM survey: Do
[other students] realize that some of their classmates need to help support their families? That
them entering med school was a serious blow to their familys financial security? I doubt it. The
differing comments in the UIM Survey and the State of Student Finances Survey highlighted the
vast differences in attitudes among students toward financing their medical education. The
results in Figure XX above, further illustrate this point.
Our education has gotten so expensive that all of us feel it. Even for the majority of us from the
first or second quintile by family income, paying for our education has been difficult and
stressful, requiring us to take well over $100,000 in debt to graduate. These difficulties can make
it easy for us to ignore the privileges many of us still have. For example, some may have families
that pay for trips home, for phone bills, insurance, or copays for unexpected medical bills.
Perhaps their parents bought them a house in SF, pay for their rent, or provided a car for third
year rotations. For others, these privileges were not a part of their reality. They cant count on
their family to provide a safety net in case of an emergency or on future inheritance to pay down
student debt. There is also inequity and unfairness inherent to the system of financial aid.
Students that worked hard and saved money before medical school feel penalized because their
savings may have led to less financial aid. In recent years, some students who budgeted more
strictly during school didnt qualify for loan repayments from UCSF because they didnt borrow
as much as some of their less thrifty peers. We encourage all students to discuss and explore
these issues so that financing our education becomes something that unites rather than divides us.

Citations
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