Med Student Debt: Veritas vos liberabit.

Guest post by Howard C. Mandel M.D., FACOG:

The electorate will be bombarded in both the 2018 and 2020 election about the $1.4 trillion in education loans outstanding and the 28% currently in default, though a recent Brookings analysis predicts it will increase up to 40% [https://www.brookings.edu/research/the-looming-student-loan-default-crisis-is-worse-than-we-thought/]

The overwhelming majority of these individuals were either sold a bill of goods by for-profit schools or never graduated the public institutions that they enrolled in. Although medical or dental student debt has been shown to impact career choices it rarely results in default.

Did we ever seriously ask ourselves why medical schools are currently so expensive? Where is all that money going? Do the faculties and administrations of our med schools deserve the salaries and benefits they earn?

Are you aware that many medical schools are now paying hospitals to place their students in 3rd and 4th year clinical rotations… what audacity. These hospitals couldn’t exist without Medicare, Medicaid and DSH federal funding——they should be honored to have students on their wards.

Bad policy and Medicare financing of graduate medical education have created the debt crisis for America’s health care workers. There is a major shortage of doctors and nurses and Congress is ignoring treating this because of the economic costs associated with addressing it.

Yet, the inside the beltway crowd has seen a symptom it can campaign on. The right:  Loan default, and made the wrong diagnosis—–people are not educated with the “right major that’s marketable…”  The left: public college should be free for all. Quoting the late community activist, Mimi West, “Free ain’t Cheap…”

National data is biased by the defaults of mostly students that went to extremely large public institutions [not their state flagships] that either dropped out or took 6+ years to graduate. These students probably were not four year college ready and their loans were compounding all the time that they were finding themselves, experimenting with living on their own and maturing into adulthood. The last few decades have seen ever increasing college costs including tuition, fees, room and board.

http://articles.latimes.com/2011/oct/26/local/la-me-college-costs-20111026
 
http://www.learnliberty.org/videos/how-do-we-break-cycle-higher-t/

Society and government leaders pushed an idealistic desire to have every American attain a college education. This goal was encouraged and supported by government employee unions including most public colleges and universities, unionized workers including in many states, professorship. This led to major impacts on state budgets and college costs.

https://object.cato.org/sites/cato.org/files/serials/files/cato-journal/2010/1/cj30n1-5.pdf
 
https://www.heritage.org/jobs-and-labor/report/how-government-unions-affect-state-and-local-finances-empirical-50-state

It also led to inefficiency as well as difficulties for dedicated students to graduate within four years.

https://www.wsj.com/articles/SB10001424052748704657704576149941061124736

 http://www.hup.harvard.edu/catalog.php?isbn=9780674027886

In 2004, Johns Hopkins professors Robert Balfanz and Nettie Legters published an analysis entitled, “Locating the Dropout Crisis. Which High Schools Produce the Nation’s Dropouts? Where are they Located? Who attends Them?”
https://files.eric.ed.gov/fulltext/ED484525.pdf    These schools and other “Factories of Failure” pushed through students who ended up either going to For-Profit Institutions, over crowded Community Colleges or large state institutions.  At the California State Colleges/Universities——-75% of these students need remedial English or Math.  Is it any wonder that the majority never graduate but have accumulated debt?

LAUSD administration claims that “56% of their graduates” are college ready. They are not—-most go to Cal State and need remedial work to even begin introductory college level classes. This 56% is of the only 70% that make it to high school graduation. Unfortunatel, they have previously manipulated data and created sham’s, like their credit recovery program, that inflate the success of students only on paper. As a society we are letting the students in the LA district down.  https://achieve.lausd.net/cms/lib/CA01000043/Centricity/domain/414/documents/Dropout%20and%20Graduation%20Statistics%20for%202010-2011.pdf    

Unless we honestly look at the results we will never develop programs that educate our students to succeed. Of the cohort of students entering high school in LAUSD, only 12.25% actually graduate with either a two year or four year college degree in a total of 6 years after they graduated LAUSD. When looking at the percentage of kids who graduate with “A’s”, only 52% will even graduate any 4 year college within 6 years. Looking at the last year that national comparisons were available, only 1,071 students (4.6%) were in the top quartile of the SAT/ACT.   https://ucla.app.box.com/s/xd8lth2fgy1qdyphmwuj2i7cgyurdwf5

So lets look at who is getting loans in America—-by the numbers, the vast majority are at Community or 2nd tier state colleges. 48% of straight “A” students from LAUSD will not graduate by 6 years and most of the those never graduate. As the school’s tuition’s are not extremely expensive, the overwhelming majority of their loans were used for living expenses for 6 to 8 years and the majority of their debt directly related to inflated costs of living on or near state college campuses, “special fees” to support athletics and recreational centers, bank fees and compounded interest on their balances.

Our philosophical desire to be egalitarian and support college education for all has been manipulated by a public college industrial complex that accepts kids that are not college material at the point they enter. If those students went to community college and lived at home, the billions saved could be given to support smaller but higher quality state colleges and make tuition lower for all who attend. Additionally, extra funds would be left over that could actually provide free housing for academically qualified students that are currently homeless, larger graduate student stipends, medical student scholarships and funding for post docs as well.

Until we truly address the problem, we’ll waste time, money and energy on snake oil that will not cure the disease. The government wants to force physicians to be paid for “performance”, yet the public schools from K through University just want Carte Blanche funding sponsored by taxes or at the college level, loans that often get written off.

Howard C. Mandel M.D., FACOG
Dr. Mandel is an advocate and philanthropist for indigent health care, inner city educational opportunity and a smaller, more efficient government
Los Angeles

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The solution to healthcare is…

Most agree that we need a healthcare system that encourages people to take care of themselves and covers catastrophic injuries and disease for all people.

I trust the free-market more than government, and some trust the government more than the free market.

MACRA, ACA, HIPAA, HMO act, Medicare and Medicaid were supposed to reduce costs and expenditures. Obviously government only makes it all worse. Looks like a job for the freemarket!

Either way, whichever philosophical system is selected by the people, individuals must freedom of choice and bear their own responsibility to the extent that is humanly possible.

Craig M. Wax DO

CNBC reports:

Medical emergency: ER costs skyrocket, leaving patients in shock

  • Americans are being overcharged by more than $3 billion a year for ER services, according to data from Johns Hopkins School of Medicine.
  • Bills can be nearly 13 times the rates paid by Medicare for the same services.
  • Americans in the Southeast and Midwest, and poor and minority patients, are the most exploited by emergency-room billing practices, especially at for-profit hospitals.

Read full story:

https://www.cnbc.com/2017/08/10/medical-emergency-er-costs-skyrocket-leaving-patients-in-shock.html

Tell CMS to Protect Patients and Physicians from Harmful Red Tape

CMS has released the proposed 2018 regulations for MACRA and is asking for comments.  The new changes don’t go far enough to protect independent physicians and their patients from harmful red tape.

CMS has a fact sheet about the proposed rule available here:

Comments are dues August 21 and can be submitted here:
https://www.regulations.gov/document?D=CMS-2017-0082-0002

Dr. Marcy Zwelling had put together sample comments to help everyone get the correct message to CMS.

Below are comments that you can cut and paste –

Medicare Administrators: 

We appreciate the sentiment of the new MIPS regulations, but it does not get the job done for many physicians struggling to go to work and NOT sit behind a computer all day. America’s physicians need to be able to just do our job and struggling with computers does not help us get it done.  It is not about micro-managing the regulations; it’s about our professionalism. 

We understand the statutory constraints, and we think we have the answer.  If the regulations could be edited to read 

Exemptions permitted:

Clinicians below the low-volume threshold – Medicare Part B allowed charges per physician less than or equal to $90,000 OR 200 or fewer Medicare Part B patients per physician up to a 6 person practice. 

Thank you for your serious consideration.  While this change does not save all small practices, we feel that this minor change will send the right message to American physicians and will encourage physicians to work with CMS and keep their offices open. 

 Further, we encourage CMS to follow thru with Dr. Price’s commitment to allow physicians to balance bill as a means of enhancing our patients’ options and keeping physicians’ doors open. 

A Conversation: Can Free Markets Save American Medicine?

A recent article from the Mises Institute. “Under Socialized Medicine, The State Owns You,” sparked a conversation between Mr. Bob Wells and IP4PI founder Dr. Craig M. Wax.

Bob

I appreciate your assessment of the solutions presented like VA, Medicare and Medicaid being awkward, too expensive, and failing in large demonstrable ways. We haven’t had true market based medicine since World War II. Prior to that, it was relatively inexpensive cash and Barter based services. I argue this is the most efficient as it cuts out insurance, pharmacy benefits managers, all levels of administration, and last but not least, all aspects of government regulation compliance and taxation.

In the last six years there have been at least 12 plans on the table to repeal Obamacare. And, there have been six in the last 12 months. There was no sparsity of plans, just no palpable consensus.

I assert that inexpensive primary care, labs, low-end studies, cheap generic medications, will allow for most needs to be met by most people. And expanded health savings account HSA would be used for each citizen to use pretax dollars to buy anything health related from gym memberships to over the counter medications to actual care necessities. Further, inexpensive catastrophic insurance for the big ticket items would be also affordable by most. There could be community, charity, and state programs to provide for the neediest, while keeping the federal government taxation hands to itself.

Unless the Congress and President act soon to repeal Obamacare, just rearranging the deck chairs, will not prevent its fate. Already 19 out of 23 taxpayer-funded co-ops have gone bankrupt taking billions of taxpayer dollars with it. And for the phony federal mandates state exchanges, many have only one high price insurer participating, while still others have none. Leave it to the government to mandate you buy something very expensive and then there’s no opportunity to even comply!

Best wishes for good health,
Craig M. Wax, DO

—————

Dr. Wax,

The deficiencies of state-sponsored health care are widely known. What is difficult to figure out is an alternative — market-based — that is universally accessible and affordable (with affordability being as elastic as elastic can be), while still offering high quality. If there is a model in this world, I am unaware of it.

All efforts America has made to provide public support for health care since World War II, from the VA system to Medicare and Medicaid to Obamacare, have been awkward and grossly inefficient (if somewhat effective, overall). Unfortunately, blowing these systems up and starting a new system based solely on market forces would be catastrophic in the short term. And since politicians think in the short term, such a radical transformation is impossible.

Today’s Republicans realize there is reward in trashing Obamacare, but they also know that they do not have a better plan to replace it. If they really had a better plan they would have introduced it by now, and it would be on President Donald Trump’s desk for signature. The fact that they cannot agree among themselves on a replacement is testimony to how difficult a problem this is. (This does not excuse the Democrats, either.  They’d rather let the Republicans look foolish than offer their own “solutions.”)

Regards,

Bob Wells

Even a Seventh Grader Can Understand the Root Failure of Government-Run Care

From Steven Dailey FACHE:

The first term paper that I ever wrote was titled “Should Medicare and Medicaid Survive?” and was handed in to my seventh grade teach in the spring of 1967. She gave me a “B” because she did not believe that I had interviewed the local hospital administrator whom I quoted extensively in the term paper.

She also marked me down because in her mind, “our government never takes something away that they have already given away. That is just too hard to do.” Maybe she was right about never taking something away -. She was wrong about the interview with the hospital administrator – he was my Dad…. He ran a 500 bed hospital and he absolutely railed against the involvement of government in healthcare.

Many, many hospital administrators did not want Medicare and Medicaid back then. They knew all too well what would happen – regulation and cost increases year after year…. Isn’t it amazing that our public trusted our physicians and hospitals back in the 1960’s and after decades of increasing governmental regulation and trillions of government expenditures healthcare suddenly fails to meet public expectations? It isn’t amazing that when you add insurance coverage to tens of millions that costs will increase? Not really….

Real Patient Lives vs. Corporatized/Government Healthcare, Part IV

The insurance and government dominated system is failing our patients. A physician friend of IP4PI shares this shocking example about the system claiming another victim:

A 59 y/o man presented to my last employed practice, with an almost elephantiasis swelling bilateral legs.  He had pinpoint marks on the skin of his legs.  He held up a jar with what looked like a couple of tiny maggots.  He said, these come out of those holes every so often.  I said how long has this been going on??  He said 1.5 years.  “I’ve mentioned to several doctors, they just shrug and don’t do anything.”  I said we would do something, and called the hospitalist immediately to admit for workup and treatment.  I was directed to the nurse gatekeeper for approval for admission.  What’s wrong, she asked.  “4+ edema in both legs, which are also full of maggots.”  Hmmm, she said.  There is no medicare admissible diagnosis of ‘maggots in legs’.  What about his rising creatinine of 1.7?  Not bad enough to qualify under guidelines.  Call us back if it gets worse.  I did try to do some outpatient workup, but I think the man was disgusted.  He never followed up.  He was dead within the year.

Real Stories of the ACA nightmare #9 – A Tale of Two Patients

“Whereas Mr. Clinton has accurately diagnosed Obamacare’s fundamental problem, Mrs. Clinton has spent the past year either defending it or calling for even greater intervention in health care. Now momentum is building among her supporters and allies for a full-blown, single-payer system in which the government, using tax dollars, pays for all medical care of its choosing. Medicaid, Medicare and the Veterans Affairs hospital system operate on this model, and each provides sub-par care to their intended beneficiaries in many key ways…I have patients who show the dangers of going in this direction.

One patient comes from the VA. He requires very high doses of concentrated insulin to control his blood sugars. At my practice, we provided him with treatment quite effectively until he retired. Now the VA has been giving him the runaround for over six months. It has yet to even accept his application for the concentrated insulin he needs, which has driven his blood sugar to dangerous levels. It’s unclear when, or even if, the agency will get him the treatment he needs. His health is failing fast under the single-payer system.

The second patient is on Medicare. He has had type-1 diabetes for over 40 years, but thanks to advances in medicine he has been able to continue working on a consistent basis. When he turned 65 and went under Medicare, however, he lost his coverage for the specific treatment he needs. He has appealed this all the way up to a federal administrative law judge, but six months after the hearing he still hasn’t heard of a decision. His health, too, is failing fast.

Wouldn’t it have been better for these two men to keep their private insurance plans, which fit their needs and improved their health…My patients experience shows the danger of heading toward even greater government intervention in our health care system. If we empower bureaucrats to wield ever more power over patients’ health and well-being, the end result will be higher costs, fewer choices, worse care and even lost lives….For the sake of my patients, to say nothing of millions of other Americans, it’s critical that we get this one right.”