“If you don’t [fight], this program, I promise you, will pass just as surely as the sun will come up tomorrow. And behind it will come other federal programs that will invade every area of freedom as we have known it in this country… until one day as Norman Thomas said, we will awake to find that we have socialism. And if you don’t do this and if I don’t do it, one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.”

-Ronald Reagan

Patient Protection and Affordable Care Act, Incorporating the Manager’s Amendment

I want the job of naming bills that completely fool the stupid, ignorant electorate that elect people like Boxer, Waters, Feinstein, my Senator Feinstein et al.

It is the Repub’s responsibility to educate the public, for better or worse, that we are and have been committing fiscal suicide.
patrick neid on December 19, 2009 at 8:02 PM

Your point is well taken.

There’s plenty of blame to go around. When the D’s pursue exactly what they said they would — vastly expanded health care coverage — who is to blame for the fiscal consequences? The voters who voted for “universal coverage” without bothering to discern what that would entail, or the politicians who promised it without being up front about the cost? Neither is blameless.

In the 2000 campaigns, both R’s and D’s, and both presidential candidates, promised that a prescription drug benefit would be passed. Once elected, they set about doing it. Again, plenty of culpability to go around — to politicians for promising benefits without outlining the full costs, and also to voters for demanding an obviously costly benefit and then being surprised by the results. I get particularly irritated with R voters who screamed “betrayal” at President Bush when he was doing exactly what he campaigned on, fought to keep costs lower in the face of congressional pressure, and then brought in costs even under that. If they didn’t want the drug benefit at all, why did they vote for him? It’s pretty hypocritical to vote for a person or a party and then get angry when they do exactly what they promised to do.

Allow me to define myself. I am a 3rd year subspecialty medicine “fellow”. This means that I have completed 4 years of medical school, 3 years of internal medicine training, and currently am in my last year of subspecialty training. I was already $180,000 in debt, of which 75% is unsubsidized principal before even buying a house. I worked well over 80-hrs/week during the 3 years of internal medicine residency and made about the same hourly wage as a person behind the counter at McDonalds. The last 3 years have not been much better.

Those of you who think that this type of health care reform is a good thing, where many of the cuts proposed will come from reimbursements to physicians and hospitals, are sadly mistaken. I would propose that these people have little, or no knowledge as how the system works.

Here are some statistics, and scenarios for you. Because in context of this debate – I fear will damage the medical profession for a long time – if not irreparably. The data speaks for itself, though I can’t keep myself from adding comments.

Some terms:
‘Resident’ = medical student who lives in the same state as the medical school
‘NonResident’ = aka ‘out-of-state’ medical student
‘Public Medical Schools’ = “state” schools (e.g. University of California)
‘Private Medical Schools’ = non-“state” schools (e.g. Harvard)

The costs for ‘resident’ medical students are usually less (with few exceptions) because medical schools prefer to make it easier for ‘local’ applicants, in part to encourage graduates to remain in the same state after they have completed training. (Many schools also receive state funding.)

The following has been taken from the the Association of American Medical Colleges (AAMC) – http://www.aamc.org:

Note: NONE of the cited dollar values below include cost of living, etc.

(1)
Table 1, U.S. Medical Schools Tuition and Student Fees – First Year Students
2009- 2010 and 2008- 2009

Average Cost for Tuition, Fees, & Health Insurance – Public Medical Schools
2008-2009 & 2009-2010
Resident – $23,608 & $25,204
NonResident – $43,686 & $45,853

Average Cost for Tuition, Fees, & Health Insurance – Private Medical Schools
2008-2009 & 2009-2010
Resident – $41,246 & $42,906
NonResident – $41,690 & $43,431

For a breakdown of these values, see the data listed for individual public & private medical schools.

Tuition, Fees, & Health Insurance – First Year Medical Students 2009-2010

Range of Cost for Tuition, Fees, & Health Insurance – Public Medical Schools
Low & High
Resident – $11,394 & $38,684
NonResident – $20,309 & $75,238

Range of Cost for Tuition, Fees, & Health Insurance – Private Medical Schools
Low & High
Resident – $17,512 & $54,244
NonResident – $23,475 & $54,244

Again, these values do NOT include cost of living.

(2)

Medical School Tuition and Young Physician Indebtedness – An Update to the 2004 Report (2007)

Between 2001 – 2006:

“Tuition and fees—especially for public medical schools—have increased at an astonishing 11.1 percent.4 Data from the same source show that the percentage of students in debt at graduation has increased to 85 percent for private medical school graduates and 86 percent for public medical school graduates.” (p3)

Average Total Debt Increase for Medical Students (Table 1)
2001 & 2006
Public Medical School Student – $86,000 & $120,000
Private Medical School Student – $120,000 & $160,000

Though projections appear to decrease for future years – to be approaching $250K in debt (Figure 1, p4) – before even completing several more years of training for internship & residency (NOT INCLUDING fellowship subspecialty training) – still is daunting. Remember, this is PRINCIPAL. Not including INTEREST. Though subsidized loans accrue interest, this represents a limited percentage ~ 20% of the total debt. The remainder can accrue ~ 3-5% interest. Do the remaining math.

No prospective medical student can enter medical school without the realization that they will become an economic slave to the government. This doesn’t even factor in the cost of owning a home, or having children. Would it be surprising to find resentment of those who can work, or yet who would rather live on welfare?

(3)

The faculty of medical schools in the U.S. is aging. One can postulate several reasons for this – but the most likely reason is the difference in pay between either private practice or industry (e.g. pharmaceutical) and academic health science centers.

During a recent seminar series for career development where I am working, subspecialty fellows were asked to strongly consider pursuing a career in academic medicine. They encourage that we should do this for the “good of the profession”. Yet, they were reticent to provide any specific answer regarding the average salary for faculty member in a clinical department as compared to private practice. It was an obvious appeal to self-sacrifice, yet they offer little in the way of loan relief. There is a Loan Repayment Program (LRP) offered through the NIH – however, this doesn’t forgive all of your loans. This leads to hard decisions needing to be made. Perhaps this is why the next data set is so significant.

Aging of Full-time US Medical School Faculty: 1967-2007

Average Age (% Age >= 55) 1967, 1987, 2007
Clinical Departments
MD or Equivalent 41.4 (8), 44.1 (18), 47.8 (26)
(number) – (8,577), (37,836), (74,116)

PhD or Equivalent 39.9 (6), 43.4 (13), 48.7 (30)
(number) – (1,375), (7,964), (16,162)

MD and PhD or Equivalent 43.1 (10), 45.6 (20), 49.5 (27)
(number) – (748), (3,025), (7,540)

Basic Sciences
MD or Equivalent 42.3 (10), 49.6 (36), 52.9 (41)
(number) – (1,247), (1,981), (2,193)

PhD or Equivalent 41.3 (10), 45.5 (19), 51.1 (38)
(number) – (2,779), (8,983), (12,445)

MD and PhD or Equivalent 43.5 (14), 48.0 (28), 51.3 (31)
(number) – (444), (832), (1,414)

First-time Assistant Professors
Pursuing Research 33.6 (0), 36.0 (1), 39.3 (4)
(number) – (423), (1,234), (1,739)

The average age for medical and science research faculty is increasing.
Physician scientists, by comparison, are a minority in medical centers.
First time Assistant Professors pursuing research has minimally changed 1987-2007 (1,414 -> 1,739).

Although we are constantly told about the need for more primary care physicians, there is very little encouragement, or significant support, by comparison, to develop new clinician-scientists. New clinician scientists are expected to generate their salary in significant part, though research grant awards (e.g. NIH). The average age for a scientist to receive their 1st RO1 grant award from the NIH is ~ 40 years old. Applications for NIH research awards are competitive – with a range of 20 – 30% actually being funded.

Given the average debt the average graduating medical student will carry immediately after finishing 4 years of medical school, often deferring payment for an additional 3-4+ years of internship + residency (and, in some cases, an additional 3-4+ years of subspecialty training) what makes it appealing for new trainees to pursue a job at an academic health sciences center? It simply would be a lot easier to endure 3 years of law school.

When the current generation of clinician scientists begins to retire (in approximately 10 years), who will replace them? What does this imply for innovation originating at medical centers?

(4)

It is not new that may graduating medical students, in addition to foreign physicians, come to the US every year to enter medicine residency. A surrogate for these people, aka Foreign or International Medical Graduates (FMG/IMG), who train in the US, is reflected in those who enter the residency “match” (National Residency Matching Program) and who are successfully matched. (I am not talking about US citizens who go to medical schools outside of the US, and return after graduation.) These IMGs – who primarily come from India and Pakistan – have J-1 visas.

The following data is from the Educational Commission for Foreign Medical Graduates (ECFMG) – http://www.ecfmg.org.

ECFMG Fact Card Summary Data 2007 – 2009

2007, 2008, 2009
Applications for J-1 Visa – 6,825, 7,235, NR

Non-US Citizen IMG Participants – 6,999, 7,335, 7,484
Number Matched – 3,180, 3,108, 3,112
Percent Matched – 46%, 42%, 42%

Perhaps liberals believe that the US healthcare system can weather losses of new US trained physicians by recruiting more IMGs. However, considering the simple sacrifice that these people need to make simply to come here, even they are weighing the costs, because they often are obligated to work in underserved areas in the US, trying to care for HUGE numbers of patients.

This is supported by the attached article “Jinx of the J-1 visa: IMGs finding other paths to residency” by Myrle Croasdale American Medical News (amednews.com) March 10, 2008 – http://www.ama-assn.org/amednews/2008/03/10/prsa0310.htm:

“The J-1 visa requires physicians to return to their home country for two years after residency. Physicians can stay if they agree to work in an underserved area for three years. Physicians on J-1 waivers are particularly important to isolated, rural clinics, which have the hardest time recruiting physicians.”

“The J-1 visa is declining, in part, because the H1-B visa is more attractive.
Physicians with H1-B visas do not need to return home for two years, and they do not need to work in an underserved area if they stay in the U.S. The government does not track how many IMGs have H1-B visas. Practices affiliated with universities and nonprofit or government research groups are not subject to any caps on the number of H1-B visas issued.”

“Carl Heard, MD, chief medical officer and interim CEO for Nevada Health Centers, said that three years ago, the state hired 30 J-1 waiver physicians for underserved communities in what is called the Conrad 30 program. This year, only one J-1 waiver doctor has been hired, a sign of the shrinking supply of such doctors.”

Many of the J-1 Visa physicians are Family Medicine physicians – which are needed in rural, underserved areas. More of these physicians are simply returning to their home country, rather than stay in the US to practice in an underserved area. Also, more and more IMGs with J-1 Visas, or H1-B Visas, are pursuing subspecialty training, then either remaining in an academic medical center, or simply returning to their home country to practice.

Less US medical graduates are choosing to serve in underserved areas despite loan forgiveness offers – because only few such physicians are left to take care of huge numbers of patients – leading to increasing risk of burnout. Additionally, Medicare reimbursements are a travesty by comparison, often being much less than 50% of what is billed. Unfortunately, physicians do not have the luxury to be so snobbish to cite a significant hourly billing rate. Is it a real surprise that more medical school graduates opt to pursue subspecialty training or enter private practice – where reimbursement is better?

(5)

The culture in academic medical centers is profoundly liberal. Some faculty, are even extreme enough to call those trainees heading into private practice “greedy”. This doesn’t even approach the distaste they have for the pharmaceutical industry. Interestingly, these same people who fear becoming ‘biased’ and feel that we cannot make decisions based upon the available evidence in the literature, are the same people who will not hesitate to ask a pharmaceutical company for money when it suits their purposes… This ideology also happens to be prevalent among those who vote Democrat – and often provides the “expert” input for the current Democratic health care proposals. Many of these “experts” simply would not be able to compete in a private practice environment – because they have the mentality of a salaried employee, rather than a private practice physician, who generate an income based upon their productivity seeing greater numbers of patients. The latter group of physicians works HARD to earn their living. This is the same population that takes care of the vast majority of patients in the US.

(6)

Just an exercise: a Google search of “Parkland Medical Center” and losses in reimbursement for illegal aliens. Then imagine this over the whole Southern US. Is it a wonder why so many medical centers are financially running in the red? You will never hear a liberal address this. I have plenty of anecdotes where money is lost, but imagine this scenario that is NOT uncommon. An illegal alien from Mexico comes into the US and develops active pulmonary tuberculosis. He/she is evaluated in the emergency room and admitted to a negative pressure room that increases costs. He stays there, providing sputum to confirm the working diagnosis, and remains there until he has no more detectable sputum after starting therapy. The hospital loses all of this money. Because hospitals are evil, as are doctors who make so much money, liberals could care less. But hospitals pass on the cost to the hard working, insurance carrying patients, by charging $5 per tab of Tylenol. This will get worse when millions of illegal aliens are covered by this plan. There cannot be any health care reform without immigration laws being firmly and coldly enforced.

(7)

No tort reform. Really? That makes no sense. Do a Google search of “AMA News” and comparative malpractice insurance costs for physicians between southeastern and western Michigan. One example – ~ 1998, obstetrician and gynecology physicians would each pay $100,000/YEAR in Detroit versus $40,000/year in western Michigan. $40,000 versus $10,000 for internal medicine physicians. The difference? Demographics, liberal politics, and malpractice awards.

(8)

It is not true that a patient who needs medical attention does not get care. I have never seen a single patient turned away who needed medical attention. If they do not have insurance, a social worker will enroll them in a state funded plan. Anyone who says otherwise is intellectually dishonest.

(9)

Anyone who states that an individual should not pay ANYTHING for his/her medical care is a communist. Why should tax paying, working citizens who have insurance, be forced to shoulder all of the financial risk for: a drug addict with infective endocarditis needing several weeks of IV antibiotic therapy; an “unemployed” drug-dealer who requires a long hospital stay to recover from gunshot wounds; an elderly woman with dementia who has been dropped off in the emergency department by her daughter who is unemployed, yet collects unemployment checks, disability, and social security support not only for herself and children, but also for her mother who resides in the hospital? These are NOT uncommon occurrences.

(10)

Sadly, Medicare/Medicaid already rations medical care to the elderly by either limiting reimbursement, or refusing reimbursement. Why do many elderly carry additional supplemental insurance? And making cuts is supposed to be better?

(11)

The “non-medical” proponents of the current health care overhaul either are ignorant regarding the sacrifice (personal & financial – that it already takes to become a physician), or malicious. By malicious, I mean that whenever one of these people state that doctors will simply “take” another cut in pay because they are dedicated to their patients, simply ignores economic reality that physicians face. As a result, physicians already are limiting how many Medicare patients they will take in their practice. It will only get worse.

Most people, like myself, who become physicians do what they do because they love medicine, science, and being able to help people. After paying such a price to reach a career goal, we are being told that we do not DESERVE the fruits of our labor? No other profession has to endure such training to be able to work and earn a living. No other profession has to pay such a steep price. No other profession can say it would be UNETHICAL to form a union – can you imagine what would happen in an intensive care unit if physicians walked out? Or if surgeons walked out?

As this bill passes – some physicians, who are in a position to do so, will retire. Some may attempt to obtain reimbursement on a cash-only basis. Some may lay off office workers to make ends meet. Others may change careers. Bright college students savvy about the costs involved to become a physician will pursue other careers. There are even less incentives for US medical graduates to pursue a career in primary care and preventive medicine. (Why be saddled with excessive debt, and forced to see more Medicare patients, working more hours, to make less?) We will also be less likely find a safety net by recruiting foreign physicians.

What will Canadian health care systems do, when they can no longer send patients from Windsor across the bridge to Detroit, for an angioplasty – because all of the cardiologists have left to go to the suburbs?

And malpractice lawyers, who bill by the hour, will have less and less numbers of physicians to sue.

How ‘bout them apples? Have fun. Sleep tight.

Garbage in, garbage out.

The manipulation comes from the garbage in phase.

While it is true that folks predicted a certain number for 2008 which we appear to have come under leading to popping the corks the 1.2 trillion originally projected seems a lot closer to the ten year number than a one year total. A chart on page 24 shows that between now and 2014 as more folks become eligible spending will approach almost 100 billion a year.

Truth is, a 100 billion here, a 100 billion there, the Repubs passed what was at the time the largest deficit spending measure in history. Today’s health care bill will certainly surpass it. I do not accept as an excuse, previously offered in Repubs defense, that the Dems wanted or still want an even more egregious raping of the treasury.

It is the Repub’s responsibility to educate the public, for better or worse, that we are and have been committing fiscal suicide. They don’t because they are politicians first and their first cause is to get re-elected. For this reason we have Pelosi, Reid and Obama in office.

Medicare payroll tax increase in the November legislation was 0.5% — this time around it’s 0.9% — they nearly doubled the rate of the increase.

For those under the delusion that middle class tax increases won’t occur. Read it and weep.

See the 2009 Trustees’ report: Table II.B.1 — in 2008, total Part D expenses $49.3 B. http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf

Go back to the 2005 Trustees’ report and see what they predicted for 2008: http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2005.pdf. They predicted $98.5 B. (See Table II.F.1)

Again, this doesn’t by itself make the prescription drug benefit good policy, but there are two irrefutable facts:

1) The D’s alternative plan was far more expensive than the one that passed, and:
2) Costs came in well below the cost estimates that caused such a flap in 2003-2005.

The drug prescription plan came in at 40% under budget, that is the only program of its kind that actually came in less then expected.

Terrye
I don’t know where you get your figures from. The bill to date is the biggest boondoggle ever passed. Originally slated to cost 400 billion over ten years it was changed to 1.2 trillion within 2 years by 2005.
http://www.washingtonpost.com/wp-dyn/articles/A9328-2005Feb8.html

. . . which turned out to be a gross overestimate. If you read any of the Trustees’ reports from 2005 through 2009 inclusive, you’ll see they’ve continually had to revise downward the costs of Medicare Part D relative to the original estimates.

That doesn’t make it good policy, but it DID come in far under the original budget projections.

The drug prescription plan came in at 40% under budget, that is the only program of its kind that actually came in less then expected.

Terrye

I don’t know where you get your figures from. The bill to date is the biggest boondoggle ever passed. Originally slated to cost 400 billion over ten years it was changed to 1.2 trillion within 2 years by 2005.
http://www.washingtonpost.com/wp-dyn/articles/A9328-2005Feb8.html

You continue doing what you have always done, make excuses for pathetic Repubs that led to Dem control of the House, Senate and Presidency.

As a group the Repubs from 2000-2008 are some of the most reprehensible politicians ever assembled. That alone is the reason the Dems are in control. Not the silly idea that folks sat at home. Record turn out should have put that BS to sleep. It has nothing to do with your bullshit moderate vs extreme right canard you trot out every couple of years here and at other sites. The Repubs helped to destroy this country by continuing runaway spending and growth of government under their leadership when they were specifically elected to do the opposite in 1994. They paved the road for Pelosi, Reid and Obama. Independents saw this and threw them out of office starting slowly in 2004 and then accelerating the process in 2006 and 2008.

The facts that these same Independents will throw out the current Dems in 2010 is meaningless. The damage has been done. Health care, cap and trade and amnesty amongst a long list will be permanent by the time Reupbs get some control.
I don’t fault the Dems for any of this. They are being the snakes they always promise to be. It is the Repubs that are the hypocrites. The Tea party is a response to this failure by your moderate Repubs.

If the Repubs had stayed within their mandate of fiscal restraint and a small government bias in all things we would not be faced with today’s horrible situation. A situation that is only going to get worse.

If you read the report, you can see CBO bending over backwards to say that, while they had to score it this way, the numbers shouldn’t really be believed.

Pp 18-19:

“The legislation would maintain and put into effect a number of procedures that might be difficult to sustain over a long period of time. . .”

“payment rates for physicians’ services in Medicare would be reduced by about 21 percent in 2010 and then decline further in subsequent years. . . ”

“The projected longer-term savings for the legislation also assume that the Indpendent Payment Advisory Board is fairly effective in reducing costs beyond the reductions that would be achieved by other aspects of the legislation.”

“Adjusting for inflation, Medicare spending per beneficiary under the legislation would increase at an average annual rate of less than 2 percent during the next two decades — about half of the roughly 4 percent annual growth rate of the past two decades. It is unclear whether such a reduction in the growth rate could be achieved, and if so, whether it would be accomplished through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care.” (Emphasis added)

They have to score what they’re given, but decide for yourself whether they really believe it. They didn’t have to put those caveats in.

Our job for next November just got bigger. Yo, Sen. Nelson of Nebraska, ho of the first order, you’re now on the list.

They also won’t include the Medicaid payments to Nebraska either. They make up all the numbers. They don’t know how much it will cost in subsidies because they don’t know how much the insurance plans will cost. They won’t know how much they will have to charge, and they don’t know if they have to charge too much will people buy it.

Basically they are using federal tax dollars to buy health insurance (to people who may not need health insurance). And they are forcing states to pay more for Medicaid.

The Democrats already defeated every attempt to include citizenship and/or legal residency requirements in the HC bill. If this POS bill passes, illegals will be getting (even more) healthcare at U.S. taxpayer expense. Count on it.

Yes I am afraid you are correct. That will add a big additional cost and potentially another 10 or 20 million people to the trough.

CBO to declare $130 billion in deficit savings over first 10 years?
Update II: Well, on page 10, CBO assumes some pretty
hefty cuts in Medicare compensations. It cuts $186 billion from “most
services” in the first 10 years, reducing……

rockmom on December 19, 2009 at 1:05 PM

Just made me a Bloody Mary in honor of this day–the day America got screwed. I intend to make sure that political blood is spilled in 2010.

Here in Indiana, they sit up a plan that helps people get insurance, it is funded both by the individual and by the state. Only so many people can even be in the program. But to even try and get it, you have to prove citizenship. You have to produce a birth certificate or some other form of ID that proves citizenship. Plus, you have to have a letter from your last employer stating why you lost your job, and you have to prove you can not possibly get insurance any other way.

I wonder if they put anything like that in this bill?

The dirty secret part is that they will be more than happy to administer control over 26% of the US economy. Dem or repub the key is central control. A politician’s first goal is election.

patrick neid on December 19, 2009 at 1:43 PM

Not always. And it could just as easily be said that the first goal of a lot of voters out there is what is in it for me? Where is my cut?

Forecasters said the bill would expand coverage to roughly 94 percent of eligible Americans under age 65, a total that excludes illegal immigrants.

That’s funny, considering that the bill does not actually exclude illegal aliens. Yes, I know it says that it does, but it contains no enforcement mechanisms, so the language about excluding illegals is absolutely meaningless (and was included solely to provide vulnerable Dems with political cover back home).

Representative Guttierrez of Chicago has announced he will introduce immigration reform in February. He plans to make 12 million illegals into permanent residents. So first they pass health care with no coverage for illegals, then they make the illegals legal.

4thQTR on December 19, 2009 at 1:29 PM

They don’t have to pass amnesty in order for illegals to get coverage. They’ve already made that possible — if they can pass the healthcare bill. The Democrats already defeated every attempt to include citizenship and/or legal residency requirements in the HC bill. If this POS bill passes, illegals will be getting (even more) healthcare at U.S. taxpayer expense. Count on it.