Can Medical Students Afford to Choose Primary Care?
Table 2 and Table 3 summarize the repayment scenarios across the three career tracks that we modeled for Dr. Median's household.
In Scenario 1 ($150,000 borrowed), Dr. Median chose forbearance during residency, followed by a standard 10-year repayment plan, requiring her household to make the maximum monthly payment after she completed her residency. In this scenario, while living in Boston with a $145,000 primary care starting salary, her household would have $1,100 per month in discretionary income two years into practice at age 32. In Denver, her household would have $1,500 per month (see Table 2 , Scenario 1). Because this scenario requires the largest monthly loan repayment and our model suggests that her household could manage it, we did not include the results of the other repayment plans at this borrowing level in this report as these would allow even more monthly discretionary income.
Scenario 1 would result in an even higher level of monthly discretionary income if Dr. Median pursued a non-primary-care specialty. For example, psychiatry or obstetrics–gynecology would afford her $3,200 per month with a $195,000 starting salary, and general surgery would afford her $5,100 per month with a $245,000 starting salary (see Table 3 and Table 4 , Scenario 1).
In Scenario 2 ($200,000 borrowed, forbearance during residency, standard 10-year repayment plan), her household would have much less discretionary income if Dr. Median chose primary care: just $200 per month at age 32 living in Boston. To repay this level of borrowing without falling into debt or reducing spending in other areas, Dr. Median's household might need to consider other repayment options, such as living in a more moderate-cost area like Denver, where the same scenario would result in $600 per month in household discretionary income (see Table 2 , Scenario 2). Alternatively, if Dr. Median were to make a two-year commitment to the NHSC loan repayment program while living in Boston, her household would also have $600 per month (see Table 2 , Scenario 3). If she chose an extended 25-year repayment plan living in Boston, her household would have $1,500 per month ( Table 2 , Scenario 5). They would have roughly $1,000 per month if she chose IBR in that scenario ( Table 2 , Scenario 8), although IBR would require them to make an $800 monthly loan repayment during her residency. At this level of borrowing, even if Dr. Median pursued primary care while living in Boston—the specialty choice and living combination that generates the most economic challenges among all the models—many repayment plans would be economically feasible. However, extended repayment would result in a hefty interest payment over its 25 years.
Examining the scenarios at the level of $250,000 borrowed showed a different story. The only scenarios where a standard 10-year repayment plan seems economically realistic involve at least a four-year commitment to the NHSC loan repayment program, whether living in Boston or Denver ( Table 2 , Scenario 12). Using the extended 25-year repayment plan living in Boston at this level of borrowing does result in $900 in monthly discretionary income at age 32, although full repayment for this scenario totals over three-quarters of a million dollars ( Table 2 , Scenario 13). If Dr. Median chose IBR at this borrowing level, which requires repayment during residency, her household would also have $900 in monthly discretionary income at age 32 ( Table 2 , Scenario 16).
Fewer than 1 in 20 indebted medical school graduates face the final borrowing level that we modeled—$300,000. This borrowing level would be difficult for Dr. Median to comfortably repay if she were a Boston-area primary care physician. The few repayment scenarios in which her household discretionary income would be above $300 a month involved either IBR ( Table 2 , Scenario 24), PSLF ( Table 2 , Scenario 25), or a four-year NHSC commitment while on an extended 25-year repayment plan ( Table 2 , Scenario 23). If Dr. Median pursued primary care in Denver at this borrowing level with an extended 25-year repayment plan, her household would have $700 in monthly discretionary income and over $920,000 in total repayment ( Table 2 , Scenario 21).
The considerable economic benefits to pursuing the higher-paying specialties are apparent when comparing scenarios across Table 2 , Table 3 , and Table 4 . For example, Scenario 18 ($300,000 borrowed) seems economically infeasible if Dr. Median were a primary care physician living in Boston, as it results in −$1,300 per month in discretionary income ( Table 2 , Scenario 18). However, if Dr. Median had a starting salary of $195,000, this same scenario would result in $400 per month in discretionary income, and, with a starting salary of $245,000, her household would have $2,200 per month( Table 3 and Table 4 , Scenario 18). In Table 3 and Table 4 , we show only selected Boston scenarios for comparison purposes because these higher-income households seem economically capable of living in an expensive city and managing the most financially challenging repayment option that we modeled—$300,000 borrowed and repaid via a standard 10-year repayment plan.
Results
Table 2 and Table 3 summarize the repayment scenarios across the three career tracks that we modeled for Dr. Median's household.
In Scenario 1 ($150,000 borrowed), Dr. Median chose forbearance during residency, followed by a standard 10-year repayment plan, requiring her household to make the maximum monthly payment after she completed her residency. In this scenario, while living in Boston with a $145,000 primary care starting salary, her household would have $1,100 per month in discretionary income two years into practice at age 32. In Denver, her household would have $1,500 per month (see Table 2 , Scenario 1). Because this scenario requires the largest monthly loan repayment and our model suggests that her household could manage it, we did not include the results of the other repayment plans at this borrowing level in this report as these would allow even more monthly discretionary income.
Scenario 1 would result in an even higher level of monthly discretionary income if Dr. Median pursued a non-primary-care specialty. For example, psychiatry or obstetrics–gynecology would afford her $3,200 per month with a $195,000 starting salary, and general surgery would afford her $5,100 per month with a $245,000 starting salary (see Table 3 and Table 4 , Scenario 1).
In Scenario 2 ($200,000 borrowed, forbearance during residency, standard 10-year repayment plan), her household would have much less discretionary income if Dr. Median chose primary care: just $200 per month at age 32 living in Boston. To repay this level of borrowing without falling into debt or reducing spending in other areas, Dr. Median's household might need to consider other repayment options, such as living in a more moderate-cost area like Denver, where the same scenario would result in $600 per month in household discretionary income (see Table 2 , Scenario 2). Alternatively, if Dr. Median were to make a two-year commitment to the NHSC loan repayment program while living in Boston, her household would also have $600 per month (see Table 2 , Scenario 3). If she chose an extended 25-year repayment plan living in Boston, her household would have $1,500 per month ( Table 2 , Scenario 5). They would have roughly $1,000 per month if she chose IBR in that scenario ( Table 2 , Scenario 8), although IBR would require them to make an $800 monthly loan repayment during her residency. At this level of borrowing, even if Dr. Median pursued primary care while living in Boston—the specialty choice and living combination that generates the most economic challenges among all the models—many repayment plans would be economically feasible. However, extended repayment would result in a hefty interest payment over its 25 years.
Examining the scenarios at the level of $250,000 borrowed showed a different story. The only scenarios where a standard 10-year repayment plan seems economically realistic involve at least a four-year commitment to the NHSC loan repayment program, whether living in Boston or Denver ( Table 2 , Scenario 12). Using the extended 25-year repayment plan living in Boston at this level of borrowing does result in $900 in monthly discretionary income at age 32, although full repayment for this scenario totals over three-quarters of a million dollars ( Table 2 , Scenario 13). If Dr. Median chose IBR at this borrowing level, which requires repayment during residency, her household would also have $900 in monthly discretionary income at age 32 ( Table 2 , Scenario 16).
Fewer than 1 in 20 indebted medical school graduates face the final borrowing level that we modeled—$300,000. This borrowing level would be difficult for Dr. Median to comfortably repay if she were a Boston-area primary care physician. The few repayment scenarios in which her household discretionary income would be above $300 a month involved either IBR ( Table 2 , Scenario 24), PSLF ( Table 2 , Scenario 25), or a four-year NHSC commitment while on an extended 25-year repayment plan ( Table 2 , Scenario 23). If Dr. Median pursued primary care in Denver at this borrowing level with an extended 25-year repayment plan, her household would have $700 in monthly discretionary income and over $920,000 in total repayment ( Table 2 , Scenario 21).
The considerable economic benefits to pursuing the higher-paying specialties are apparent when comparing scenarios across Table 2 , Table 3 , and Table 4 . For example, Scenario 18 ($300,000 borrowed) seems economically infeasible if Dr. Median were a primary care physician living in Boston, as it results in −$1,300 per month in discretionary income ( Table 2 , Scenario 18). However, if Dr. Median had a starting salary of $195,000, this same scenario would result in $400 per month in discretionary income, and, with a starting salary of $245,000, her household would have $2,200 per month( Table 3 and Table 4 , Scenario 18). In Table 3 and Table 4 , we show only selected Boston scenarios for comparison purposes because these higher-income households seem economically capable of living in an expensive city and managing the most financially challenging repayment option that we modeled—$300,000 borrowed and repaid via a standard 10-year repayment plan.