One morning late last month, the financial futures of hundreds of medical students in the Bronx changed forever. A gift of $1 billion from Ruth Gottesman, a former professor at the Albert Einstein College of Medicine and chair of its board of trustees, will make the school tuition-free in perpetuity.

The donation, one of the largest in U.S. higher education history, is an act of generosity that will undoubtedly improve life for Einstein’s students and potentially benefit the surrounding community, one of the nation’s poorest.

It also highlights how much U.S. colleges and universities rely on wealthy donors — and raises the question of whether more systemic changes would better serve students and society.