Parallel Universes: Will Higher Education Follow Medicine? (Part II)

The University

 The Cost of a University Education

As with medicine, the cost of a university education looms large in the public mind. The increase in tuition and fees over the past decades—at a time when the buying power of the middle and lower classes has been decreasing—has cast a serious pall over the value of higher education. It has caused former United States President Barack Obama to wonder aloud if it might not be better for people to get two-year degrees and then a job rather than pay the costs of a four-year college education. This equates education with jobs and ignores the real value of higher education. The burden of student loans plays a large role in generating this concern. The public now considers only the immediate cost, and has dismissed the intangible value of higher education.

This is reminiscent of the 1980s and the alteration in health care payment schemes to make health care more affordable. The value of medicine—it could save your life—judged against its aggregate costs caused the public to ignore the potential short- and long-term value and focus only on the immediate costs. This was for good reason; they were out of control. Families were bankrupted by health care costs, and that immediacy overshadowed potential benefits. The result was the takeover of healthcare by corporate businesses to bring costs under control (1).

 When considering the cost of higher education, the argument quickly comes down to tuition and fees, a portly administration, and tenure. It also includes the increasing amenities offered to entice students to a particular university (6–8). Government aid that once came as grants has transitioned to student loans. The government decided that providing grants for education was not good fiscal policy. According to Best Value Schools and Bloomberg Business, the cost of higher education has surged more than 538 percent since 1985. In comparison, medical costs have gone up 286 percent, and the consumer price index has increased 121 percent.

 Higher education is about 4.5 times as expensive as it was 30 years ago. In current dollars, the average cost for all institutions in 1981–1982 was $3,489; in 2011–2012 it was $19,339. Four-year institutions over the same time went from $3,951 to $23,066; two-year institutions increased from $2,476 to $9,308, and the yearly increases in college tuition and fees often doubled, tripled, or quadrupled the price increases for other goods. These cost increases will, over time, exacerbate income inequality by depriving those of lesser means of the education they need. An undereducated population is a dangerous and unpredictable thing.

 Universities often respond to questions about disproportionate cost increases by pointing out that few people pay the full amount of tuition and fees because they receive financial aid. This argument is disingenuous. Someone pays the full amount of tuition and fees: it may be the student; alumni donations; government grants to the institution; or some other combination of sources. Financial aid actually is cost shifting, not cost reduction. There appears to be no association between aid packaging (federal and state grants and loans) and changes in tuition in either public or private not-for-profit sectors.

 If a service or product is subsidized, people or programs within those organizations will siphon off some of the subsidies. Examples include the military-industrial complex where much of the Pentagon’s increased budget goes to contractors. In medicine, health care provider organizations designed to capture Medicare and Medicaid funds have persuaded the federal government to eliminate negotiations over prices for Medicare Part D medications. Universities are high fixed cost businesses with a lower marginal cost, much like the airlines and the hospitality industries. The fixed costs are the buildings, faculty, administration, overhead, and ever-improving facilities for students. The marginal cost to add students over and above those needed to validate the existence of the school is relatively small. Since the marginal cost of full tuition for extra students is low, and outside sources of funding exist for students, there is little incentive to contain tuition and fees.

 The demand for higher education is sustained by both its perceived and real values. This is a situation guaranteed to drive increases in tuition and fees, expand middle management, and cause private business (for-profit universities) to enter and capture their own piece of a subsidized industry. A surprising, and pertinent, manifestation of this is the appearance of for-profit medical education. As reviewed by Adashi, et al.(9). these are not pre-Flexnerian private ventures, but tuition-dependent business models. The admission requirements are strict, and the curricula similar to those of university-affiliated medical schools. With lower cost structures, they may be able to decrease student loan debt, and perhaps adapt more quickly to the changing health care system. They also may ameliorate the projected physician shortage. A continuing reaccrediting process will be needed to maintain public confidence and guard against loss of quality in the face of demands for more tuition-paying students to sustain profits. There will be a maturation process, but these institutions will probably have an increasing presence in medical education.

 As the realization spreads that many jobs of the future will not require a college education but rather training, and the costs continue to rise, the edifice could fail for lack of students. Higher education must cut costs to survive. Consider the parallel in medicine: nurse practitioners and physician assistants are replacing physicians, and in Colorado there recently was a legislative initiative to allow pharmacists to prescribe for “simple” diseases. This is not necessarily bad medicine; it can be a more efficient use of facilities, but it requires good supervision. Tuition and fee increases within university systems must return to inflation-driven increases if a university education is not priced out of reach of much of the population. The risk is a two-tiered educational system, and a resultant two-tiered intellectual population.

Tenure in The University System

 Tenure was designed to protect academicians from arbitrary dismissal. It had its inception in the tradition of free intellectual exploration in Plato’s Academy, and then in Cicero’s Academy in Rome. This tradition was adopted in the Middle Ages in Oxford, Cambridge, Paris, and Bologna with the recognition that free thinking and expression, save in theology and philosophy, was important in maintaining a comprehensive intellectual life. This, in the age of absolute monarchs and rigid social castes, was a powerful message.

 Tenure became formalized in the late 19th century and early 20th century in the U.S., largely due to pressure from the American Association of University Professors. It is considered to be a powerful enticement to retain faculty. Historically, it has worked relatively well, but now its potential benefits are being overshadowed by too many reports of faculty who lose the motivation to remain current after receiving tenure; remain in their positions for many years after obtaining tenure; and the lack of a mandatory retirement age. The result is the loss of younger, ambitious faculty, and the need to hire non-tenured, adjunct faculty. A university faculty composed of short-term contract workers, and tenured faculty who occupy secure positions, demands change. The public perception of tenure has become one of outrageous job security that no one else in the world enjoys (10,11).

The entry of outside forces to correct this disparity was inevitable. The tenure system is now in question for both public and private institutions. Lawmakers in Missouri, North Dakota, and Iowa have introduced legislation to eliminate, curtail, or periodically reassess tenure. This is effectively a conversion to a long-term contract model. In 2015, the Wisconsin legislature voted to weaken a state tenure law, and the University of Wisconsin instituted five-year reviews of tenured faculty. Faculty hired at the State College of Florida after July 2016 no longer qualify for tenure (12).

The Business of Education

 In medicine, technology and the requirement to treat sick people regardless of ability to pay, drove the cost of medical care to a point where experts were brought in to contain costs. Corporate business failed abjectly at this, but did put together business models that rewarded those who own and manage the business. 

 Two professions that never were designed to be businesses now either are (medicine) or will be (education). Social unrest and protest, coupled with attempts to go outside the system to reform or circumvent it, are early warning signs. When universities undercut themselves by pandering to critics, and attempt to deflect criticism by using the jargon of business, it will be the end of the game. Students are now spoken of as customers; business language is used to describe the mission of the university; businesspeople are brought in to streamline operations (perfectly appropriate as long as they confine themselves to operations and not academics); coursework is made relevant by slowly eliminating liberal arts from the curriculum; science becomes the purview of fewer people; and societal ignorance of the scientific method and critical thinking diminishes to the point where anything promulgated by the media is accepted as true (12,13).

A Draconian picture was presented by David Gelernter who described the slow loss of the intangible values of higher education, exposure to the humanities, and the consequent loss of perspective and judgment that otherwise would have been communicated to students (14). He believes that 90 percent of U.S. colleges will be gone within the next generation. Teaching, especially in technical and scientific subjects increasingly will be done online. Other ways of demonstrating certification in subjects will appear and will be the modern equivalents of the apprentice system. In essence, education will decline as information transfer ascends. Avoiding Gelernter's prognosis requires two things: recognition that a terrible change is in progress, and a willingness to take serious action to reverse it. Generally, vested interests insulate and delude themselves about reality, and in so doing make it impossible to undertake the actions necessary to correct the situation.

Successful reversal of this process must come from within. Change imposed from outside is often disruptive and creates more problems. Medicine is a relevant example. Whether education will maintain its historical intellectual milieu that encouraged exchange and debate of ideas, and welcomed the exploration of novel or even unpopular concepts is open to question. In medicine, changes largely affected physicians, and medical care continues to be provided. Corresponding changes in higher education will bring about a loss of intellectual role models; the abnegation of free inquiry; the development of a culture that does not know how to think; and the conversion of education into a business. Society and subsequent generations will be much the worse for it.

References

1. Marr JJ. Fall from Grace: A Physician’s Retrospective on the Past Fifty Years of Medicine and the Impact of Social

Change. Online: True Directions; 2015.

2. Hannah-Jones N. Conscience of the Nation. A Prescription for More Black Doctors. Collegeland, The New York

Times Magazine; September 13, 2015: 30–8.

3. Ridley, M. The Evolution of Education. In: The Evolution of Everything. New York: HarperCollins Publishers;

2015: 174–92.

4. Stein H. What I Think: Essays on Economics, Politics, and Life. Washington (DC): AEI Press; 1998.

5. Belkin D. Faculty’s New Focus: Don’t Offend. The Wall Street Journal. February 28, 2017: A3.

6. Best Value Schools. http://www.bestvalueschools.com/understanding-the-rising-costs-of-higher-education/.

7. Bloomberg News. College costs surge 500% in US since 1985. http://www.bloomberg.com/news/articles/2013-08-26/

college-costs-surge-500-in-u-s-since-1985-chart-of-the-day.

8. Forbes. The Reason Why College is so Expensive is Actually Dead Obvious. May 9, 2013. http://www.forbes.com/

sites/pascalemmanuelgobry/2013/05/09/the-reason-whycollege-is-so-expensive-is-actually-dead-obvious/.

9. Adashi EY, Krishna GR, Gruppuso PA. For-Profit Medical Schools—A Flexnerian Legacy Upended. JAMA. 2017

Mar 28; 317(12): 1209–10.

10. McNutt M. Whither (wither?) Tenure? Science. 2015; 350(6266): 1295.

11. Loop DR. Academic Tenure: Its Origin, Administration, and Importance. South Carolina Commission on Higher

Education Staff Position Paper. http://files.eric.ed.gov/fulltext/ED382149.pdf.

12. Belkin D. Universities, Facing Cuts, Target Tenure. The Wall Street Journal. February 14, 2017; A3.

13. deBoer F. Why We Should Fear University, Inc. In: Collegeland, The New York Times Magazine; September 13,

2015: 64–8.

14. Gelernter D. A High-Tech Rebirth From Higher Ed’s Ruins. The Wall Street Journal; January 23, 2017: A21.