The rising cost of applying to medical school — Lack of cost mitigation and trends in workforce diversity

There are numerous socioeconomic barriers to diversifying the physician workforce including parental education, interpersonal discrimination etc. One of the most significant barriers is medical school application costs, which disincentivizes historically marginalized populations from applying [1]. With the June 2023 United States Supreme Court ruling striking down the use of race-conscious admissions in higher education, medical schools are challenged to improve diversity among matriculating students. There is a moral imperative to do so, primarily due to the fact that patients receive higher quality care when cared for by a more diverse medical workforce. AAMC data reveals a lack of diversity among practicing physicians; in 2021, 63.9 %, 6.9 %, 5.7 % identified as White, Hispanic, and Black, respectively [2]. Compared to 2018 (56.2 %, 5.8 %, and 5.0 %), there has been limited improvement in diversity [3]. One study highlighted that in 2018, only 9 %, 10 %, and 1 % of applicants identified as Black, Hispanic, and American Indian or Alaska Native, respectively [4]. 2022 AAMC applicant data revealed no meaningful improvement (1 % increase, 1 % increase and no change, respectively) among Black, Hispanic, and American Indian or Alaska Native applicants [5].

The AAMC asserts the need for: “investing more in strategies that remove barriers and increase opportunities for all socially and economically disadvantaged applicants.” [6] Notably in 2022, 55.3 % of students responded that the cost of applying to medical school would discourage them from applying (compared to 47.4 % in 2018) [7]. In this manuscript, we highlight the lack of cost mitigation in the medical school application process and advocate for interventions to address financial barriers to provide greater opportunity for diverse applicants.

Between 2019 and 2023 the cost of applying to medical school has steadily increased, intensifying the financial strain on prospective students from socioeconomically disadvantaged backgrounds (Table 1). In 2022, the AAMC added PREview that tests hypothetical scenarios, at $100 per test. In addition, the Medical College Admission Test (MCAT) increased from $315 in 2019 to $330 in 2023 and is likely to continue to rise. Over 40 medical schools require the Computer-Based Assessment for Sampling Personal Characteristics (CASper) exam, which increased its fee to $85 for 8 schools (previously $10 flat fee) and $15 per additional school (previously $10). Finally, the AMCAS primary application flat fee increased by $5 plus $5 per additional school. These marginal increases add up for a prospective student applying to 20 schools; as of 2023, the total required cost of applying to 20 schools is $1725, up from $1455 in 2019. The cost of submitting 20 secondary applications can vary, with individual school charges between $0-$200 per school. Associated in-person interview costs continue to increase, including higher costs for airline tickets, hotels, and transportation.

Table 1.

This table is adapted from Millo et al. (2019), The cost of applying to medical school — a barrier to diversifying the profession with updated costs of applying to medical school.

Prospective students may consider applying to D.O. medical schools (AAMCOMAS), and Texasmedical schools (TMDSAS), with separate application fees, extenuating the application cost. As of 2023, AAMCOMAS charges $198 with an additional $55 for each school. TMDSAS charges $215, compared to $150 in 2019. Given higher fees than the AAMC(and no fee waivers), low-income and underrepresented students may be dissuaded from seeking alternatives to M.D. schools.

Additional resources are required to prepare for the MCAT. Companies like Kaplan,™ Princeton Review,™ and UWorld™ offer MCAT study packages, with prices increasing in tandem with application requirements. For example, Kaplan™ and Princeton Review™ offer packages from $2100-$6900. According to the Post MCAT Questionnaire Summary Report, 39.5 % of students in 2022, responded that they experienced difficulty affording preparation courses and materials (38.7 % in 2020) [7]. Notably, students using free courses rose from 39.3 % in 2020 to 48.9 % in 2022 [7], which indicates a growing interest in free resources. While free MCAT preparation is a potential promising approach to improve reach, it is unclear how they compare to traditional prep resources.

Applying to medical school carries financial risk. Out of 55,188 completed applicants (primary and secondary), who applied to medical school in 2022, only 41.1 % matriculated [5]. Interestingly, 31.5 % of respondents to the Matriculating School Questionnaire, reported they submitted 25 or more secondary applications (26.1 % in 2020) [8]. Notably, one in four medical students are from families in the top 5 % income bracket, demonstrating the risk of “economic segregation” in the application process highlighted by some medical school leaders [9]. With a low matriculation rate, risk of needing to reapply, and skewing of applicants with high parental income, medical school application costs not only pose financial challenges, but also send a message to underserved applicants that becoming a physician may not be attainable. Given the lack of improved diversity among both practicing physicians and medical school applicants and the challenges presented by the US Supreme Court invalidation of race-based admission, there is an imperative to implement strategies to foster applicant and matriculation diversity. We advocate for a multi-faceted approach that addresses the financial cost of applying, including streamlined and expanded AAMC Fee Assistance Program (FAP), elimination of in-person interviews and partnership with organizations supporting application costs.

The AAMC FAP has undergone incremental change over the past few years and offers students, with household members with income less than or equal to 400 % of the national poverty level (previously 300 %), 20 free primary application waivers, 20 free secondary application waivers, reduced cost MCAT and waived AAMC MCAT materials. We advocate for additional key changes such as 1) expansion to 40 schools based on the increased percentage of applicants applying to more than 25 schools; 2) waiving the cost of the MCAT entirely; 3) simplifying the FAP process, currently includes requirements such as providing W2 forms, proof of housing and food assistance, and proof of parental income (if under 26), which can be onerous and intimidating.

During the Covid-19 pandemic, medical schools had to conduct virtual interviews, resulting in cost savings for applicants otherwise needing to travel. The California University of Science and Medicine (CUSM) examined the impact of incorporating a virtual online format during the pandemic [10]. In 2020, when both in-person and virtual interviews were conducted, CUSM noted that 40 % of applicants who interviewed virtually matriculated, compared to 21 % for in-person interviews [10]. Finally, during the pandemic, the number of underrepresented minority students applying to medical schools increased from prior years; the number of Black applicants rose from 5164 to 7331 and Hispanic applicants from 5576 to over 7281 [5]. It is plausible that defrayed travel costs, led to reduced financial burden among applicants from underrepresented backgrounds. Recently, the number of minority applicants has returned to pre-pandemic levels [5]. We propose that medical schools eliminate in-person interviews and solely offer virtual interviews, easing the financial stress associated with travel.

We believe that the AAMC and individual medical schools should strongly consider application “scholarships” for students of limited economic means. This process should be streamlined and cover the majority of associated application costs. Alternatively, institutions could partner with and/or sponsor programs like The Healing Project, a nonprofit designed to help underrepresented students pursue meaningful careers in healthcare serving over 30 students across the US and local community colleges. Organizations like The Healing Project support students who identify as racially, ethnically, and/or socioeconomically disadvantaged minorities by reaching out to undergraduate pre-medical and post-baccalaureate programs across the country to support underrepresented students. We propose that AAMC forge long-lasting partnerships with non-profits with established track records among diverse communities to provide key financial support, application guidance, and create pipeline programs.

Medical schools across the country champion increasing diversity and inclusion of applicants, but it is challenging to point to specific efforts that have impacted the representation of matriculating student bodies. In order to appreciate meaningful change in creating more diversity among physicians, it is imperative to address root causes. Addressing the rising cost of the medical school application process provides a means of expanding opportunity across diverse communities. Now is the time to implement strategies to stem the rising cost of application fees and even the playing field for medical school applicants from underrepresented and low-income communities.

Declaration of competing interest

Bassil Bacare is the Founder and CEO of The Healing Project.

Dr. Mallika L. Mendu has no relevant disclosures or conflicts of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: