By Victoria Liu, BS and Odmara L. Barreto Chang, MD, PhD
Photo courtesy of University of California, San Francisco
The Growing Financial Burden in Medical Training
Medical education has always required a great deal of personal and professional sacrifice, though it increasingly comes with a steep financial burden as well. According to the Association of American Medical Colleges, 71% of graduating medical students from U.S. medical schools carry educational debt, with a median debt of $205,000 in 2024.1 This represents a 2% annual increase from the year prior, a trend present since 2009.2 At the same time, the median four-year cost of attendance, which includes tuition, fees, and living expenses, continues to rise. In-state costs for medical school are estimated to exceed $300,000 in 2025.2 Compounding this problem, the rise in cost of medical education has far outpaced inflation as measured by the Consumer Price Index,3 further deepening the financial burden placed on trainees.
However, this burden does not fall equally across all trainees. Trainees from historically underrepresented and socioeconomically disadvantaged backgrounds carry a disproportionate share of the debt. A study from the University of Michigan found that first-generation college (p=0.004) and medical students (p<0.001) were significantly more likely to have higher educational debt.4 Data also show that underrepresented in medicine (URiM) trainees are more likely to enter residency with debt compared to White trainees (OR = 4.16 for Black trainees, OR = 1.71 for Hispanic trainees).5 These disparities are not merely financial but reflect deep-rooted structural inequities that continue to shape who has access to medical training.
Debt and Workforce Diversity: A Vicious Cycle
The high and rising financial strain of medical training in many ways shapes the physician workforce. High student loan burden creates barriers for students from underrepresented and lower-income backgrounds to pursue medical education.6
This directly impacts patients. Minority, non-English-speaking, low-income, and Medicaid patients are much more likely to receive care from non-white physicians.7 When disparities in debt affects these physicians from entering the workforce, access to healthcare becomes threatened in communities that are most in need of care.
Intersection of Loan Burden and Gender-based Inequities in Anesthesiology Trainees
The financial pressures associated with medical education are also evident among anesthesiology trainees. A recent cross-sectional study of U.S. anesthesia trainees found that those who identified as URiM and first-generation college graduates are more likely to carry high loan burdens.12 Additionally, trainees with greater debt were more likely to delay major life milestones, most notably having children (OR = 3.69) or homeownership (OR = 5.27). Crucially, even after adjusting for loan burden, female-identifying anesthesia trainees remained at higher odds of delaying childbearing (OR = 1.49) and reported lower wellbeing (–3.47 points on the Mental Health Continuum-Short Form), showing that financial stress compounds already existing gender-based challenges in training.
These findings must be taken together with the fact that women are underrepresented in anesthesiology; while women have made up half of U.S. medical school graduates over the past two decades, they account for only 33% of anesthesiology residents and 37% of academic faculty.8 Gender-related inequities persist. Women hold fewer leadership positions13 and report the highest rate of maternal discrimination compared to all other specialties (47%, OR = 1.92).14
These gender-based inequities in anesthesiology reflect not only pipeline and representation gaps but also the intersecting impacts of financial burden and workplace stressors that constrain career progression and wellbeing for women. Ensuring that female trainees can thrive in specialties that may unintentionally favor males is important and requires intentional institutional policies that address both the financial and gendered barriers documented here.12
A Changing Landscape
Beginning July 1, 2026, newly enacted federal student loan policies will eliminate the Grad PLUS loan, a critical financing tool for medical and professional students.9 Under the One Big Beautiful Bill Act,10 graduate students will face a loan limit: $50,000 annually and a $200,000 lifetime limit in Direct Unsubsidized Stafford Loans. While framed as a measure to “simplify” borrowing and reduce government expenditures, these limits fall far short of the actual cost of medical education, which exceeds $333,000 at many institutions.2 The inevitable effect of this legislation is to remove a means of financing costly medical education in a manner that disproportionately impacts lower-income and URiM trainees.
The stated intent, according to the Committee Report, is to “curtail excessive government spending” and “hold colleges accountable for the outcomes of their graduates” by “charging [educational institutions] a fee for the taxpayer losses on the loans they disburse to students.” In practice, however, it punishes institutions that serve students who are more likely to struggle with repayment, exacerbating inequities in medical school admission. Proponents of the bill argue that reducing federal lending and demanding better outcomes will drive tuition reform; however, in practice these reforms shift the financial risk onto students and the schools committed to training them.
The likely result? A narrower applicant pool, skewed towards those who can better afford medical school’s steep out-of-pocket costs. This bill now makes upfront financing a decisive hurdle, inequitably shaping the pipeline of future physicians. Admission once offered to exceptional students from underrepresented and economically disadvantaged backgrounds may increasingly be filled by other applicants who can better finance their cost of attendance. This could jeopardize decades of strides towards a more diverse and representative medical workforce, one that is crucial for delivering culturally competent and equitable care.
Medical schools must now confront this challenge urgently. Institutions should begin to proactively explore alternative methods to support aspiring students who cannot attend medical school due to this bill. While current programs like the National Health Service Corps offer loan repayment for those who serve in high-need areas,11 these opportunities are limited and retroactive. Now more than ever, coordinated advocacy by schools, professional societies, and physicians is needed to protect equitable access to medical education and to ensure that financial policies do not unravel the progress we have made toward a just and representative healthcare system for our patients.
References:
1. Association of American Medical Colleges. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card for the Class of 2024.; 2024. https://students-residents.aamc.org/media/12846/download
2. Hanson M. Average Medical School Debt [2024]: Student Loan Statistics. Education Data Initiative. https://educationdata.org/average-medical-school-debt. August 28, 2024. Accessed July 12, 2025.
3. Association of American Medical Colleges. Examining Long-Term Trends in Reported Tuition and Fees Revenues at U.S. Medical Schools.; 2024. https://www.aamc.org/media/75126/download
4. McMichael B, Lee Iv A, Fallon B, Matusko N, Sandhu G. Racial and socioeconomic inequity in the financial stress of medical school. MedEdPublish (2016). 2022;12:3. doi:10.12688/mep.17544.2
5. Holaday LW, Weiss JM, Sow SD, Perez HR, Ross JS, Genao I. Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014–19. Health Aff (Millwood). 2023;42(1):63-73. doi:10.1377/hlthaff.2022.00446
6. Zimmerschied C. How med student loan burdens can deepen health disparities. American Medical Association. https://www.ama-assn.org/education/medical-school-diversity/how-med-student-loan-burdens-can-deepen-health-disparities. April 27, 2017. Accessed July 14, 2025.
7. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority Physicians’ Role in the Care of Underserved Patients: Diversifying the Physician Workforce May Be Key in Addressing Health Disparities. JAMA Internal Medicine. 2014;174(2):289-291. doi:10.1001/jamainternmed.2013.12756
8. Marroquin BM. Wake up to the gender gap in academic anesthesiology and address the pipeline. Proc (Bayl Univ Med Cent). 2022;36(1):135-137. doi:10.1080/08998280.2022.2128624
9. Federal Student Aid. Grad PLUS loans. Accessed July 14, 2025. https://studentaid.gov/understand-aid/types/loans/plus/grad
10. One Big Beautiful Bill Act. H.R. 1, 119th Cong. (2025). Available at: https://www.congress.gov/bill/119th-congress/house-bill/1/text. Accessed July 12, 2025.
11. National Health Service Corps. NHSC Loan Repayment Program. May 2025. Accessed July 12, 2025. https://nhsc.hrsa.gov/loan-repayment/nhsc-loan-repayment-program
12. Pawar N, Boscardin CK, Chen D, Earnest G, Barreto Chang OL. A U.S. based survey of loan burden among anesthesia trainees and its impact on well-being. Original Research. Frontiers in Education. 2025;Volume 10 – 2025. doi:10.3389/feduc.2025.1480957
13. Lorello GR, Gautam M, Barned C, Peer M. Impact of the intersection of anaesthesia and gender on burnout and mental health, illustrated by the COVID‐19 pandemic. Anaesthesia. 2021;76(Suppl 4):24-31. doi:10.1111/anae.15360
14. Adesoye T, Mangurian C, Choo EK, et al. Perceived Discrimination Experienced by Physician Mothers and Desired Workplace Changes: A Cross-sectional Survey. JAMA Internal Medicine. 2017;177(7):1033-1036. doi:10.1001/jamainternmed.2017.1394