Obamacare's Med-School Debt Problem

Would-be primary care doctors could take a financial hit from health care reform, but most students say it's worth it to fix a broken system

If Barack Obama wanted an ideal agent to sell America on the future of medicine under his Patient Protection and Affordable Care Act—a/k/a "Obamacare"—he could do worse than to pick Sarah Griffin.

A second-year medical student at SUNY Downstate, the 28-year-old Griffin not only supports the new law but is also on track to become a primary care physician. That would put her on the front lines facing the wave of new patients who are expected to arrive when the law kicks in next year. By the time Griffin graduates in 2015, an estimated 32 million more people will be insured.

The floodgates will open just as warnings of a long-expected doctor shortage reach a critical point. Nearly a third of all U.S. physicians are set to retire over the next decade, according to the Association of American Medical Colleges, which estimates the nation will need more than 90,000 new doctors by 2020, at least half of them in primary care, as the population grows and ages. Currently, just 20 percent of medical students become primary care physicians, something that Obamacare tries to remedy by increasing funding for the National Health Service Corps, which extends scholarships and forgives loans to new doctors in underserved areas. The new law also establishes teaching health centers, where primary care residencies can take place in smaller clinical settings, not just hospitals.

President Obama and his staff were 
all smiles as they watched the House of Representatives vote to approve the Affordable Care Act in March 2010.
Pete Souza/Wikipedia
President Obama and his staff were all smiles as they watched the House of Representatives vote to approve the Affordable Care Act in March 2010.
NYU’s Siegel worries that reform will mean fewer students entering grad school.
Courtesy doctorsiegel.com
NYU’s Siegel worries that reform will mean fewer students entering grad school.

Yet even as the new law tries to remake the health care landscape, debt is shaping the next generation of doctors, and Griffin believes Obamacare doesn't do enough to lift that burden. "People are taking on a huge amount of debt, and primary care doesn't pay as well as other specialties," she says. "We're being asked to choose a profession that may not compensate us in a way that will allow us to pay off our debts and to provide for a family and live a comfortable life after, what, 10 years of hard work."

More work for less pay was the battle cry of practicing physicians opposed to Obamacare, but medical students were surprisingly big supporters of the law, according to a survey published last year in the online science journal Plos One. Of the students polled at 10 medical schools, almost 95 percent believed the health care system needed to be reformed, and 80 percent supported the law, though an equal measure "did not feel that reform efforts had gone far enough." This professional generation gap points to the difficulties facing Obamacare, as it grafts new ideas onto a well-entrenched system. That's why Obamacare's best hope might now rest with medical students.

"Younger physicians think much differently than the older generation," says Kristin Huntoon, a Bronx medical student who authored the Plos One study while at the New York College of Osteopathic Medicine. "Once we're out there and they're not, we can shake things up—hopefully for the good of our patients."

Most of the medical students interviewed by the Voice view the current system as unsustainable. Both public and private medical schools have hiked their four-year tabs by more than $100,000 over the past decade. Average debt upon graduation now ranges from about $162,000 to $205,000. "And this is interest-bearing debt that we aren't able to pay during our residencies, so it continues to grow as we continue training," says Dr. Elizabeth Wiley, president of the American Medical Students Association, which represents 35,000 physicians-in-training.

The average primary care physician makes less than $200,000 a year, while an orthopedic surgeon, for example, earns $420,000 a year. "These salaries are large, but the reality is, we make some pretty significant financial sacrifices—and the indebtedness issue is huge," Wiley says. "Me, I have more than $300,000 in debt. It makes no financial sense, honestly, for me to choose primary care."

One big reason primary care physicians are at a disadvantage is that the health care business is built on billing per procedure. A family doctor doesn't get reimbursed for listening to your heart, for example, or taking your reflexes—these procedures are all part of a general physical examination, and they don't have billable codes for insurance purposes. But if a doctor draws your blood or dilates your eyes, he or she can enter a code to get paid.

Obamacare aims to lower costs by shifting from the current fee-for-service model to a system that would group primary care physicians into what are called accountable care organizations, large outfits emphasizing team-provided care, in which doctors will be paid a salary or for each treatment session and have no financial incentive to do more than necessary.

For some doctors, this prospect represents a threat to their way of doing business. "We're already starting to move away from fee-for-service," says Dr. Marc Siegel, a professor at the NYU School of Medicine and frequent contributor to Fox News. "A lot of people are in favor of that, but at least under fee-for-service you knew if you performed a procedure, you'd get paid for it."

Siegel notes that medical care has been moving away from independent practitioners toward the larger group- or hospital-based practices. "Obamacare will accelerate that," he predicts. "Fewer doctors will do fee-for-service, and more will be on salary. There also will be more nurse practitioners, who are excellent, but it's not the same as seeing a doctor."

Huntoon has found resistance to the new law while interviewing for residency positions. "I'm encountering attending after attending who's not supportive of the Affordable Care Act, not supportive of branching out health care—that's bizarre to me," she says. "It's incredibly frustrating to be on rounds and hear, 'This patient has this infection, and this is the ideal treatment for them, but they don't have insurance, so I can't give them the ideal treatment.'"

Obamacare also seeks to expand Medicaid to cover 15 million Americans just above the poverty line. But many doctors don't accept Medicaid payments because they average just 56 percent of what insurance pays. Huntoon says physicians should suck it up and accept that lower costs for patients will require lower fees for doctors. "Personally, I believe doctors have to look at their own salaries and ask if they're overpaid," she says. "Do I really need to make half a million dollars a year? No. Hospital administrators have been among the worst offenders—does a hospital need 20 administrators? The top end is way too heavy."

Siegel says the views of his NYU students are more diverse: "Some are just optimistic, wet behind the ears, eager, idealistic. Others are concerned that they won't have what their parents had, what the prior generation had, that the golden years are over. A lot of people will continue to go into the field, because of the desire to take care of people, to do science, and to provide health care. That's very exciting. But the fringe won't want to go, the people who did it for the money or for the prestige and privilege."

Good riddance, responds Huntoon, but one of her poll's findings was particularly telling: Almost half of the students said they were "unsure" whether the new law would improve the quality of care. "It's a large-scale experiment," she admits.

Just as Obamacare gets set to go into effect, meanwhile, a new threat has come from the prospect of cutting Medicare to reduce the deficit. Medicare cuts could slash the number of residency and training programs for medical-school graduates. Universities have already been expanding their medical schools in anticipation of the looming physician shortage, and fewer residency slots would send graduates scrambling. Dr. Lisa Mellman, a dean at Columbia University's College of Physicians and Surgeons, notes that she has already seen students trying to improve their chances by obtaining additional degrees, such as a master's in public health, or by working as research fellows. "An additional year of research or an additional degree does mean more debt, however," she says.

For Griffin, the chief administrative officer of the Brooklyn Free Clinic, a student-run facility in Bed-Stuy, the new law presents additional unknowns. "We've been thinking about how Obamacare is going to affect our patient base and if there's going to be a need for us anymore," she says. "And I definitely think there will still be uninsured people who need health care."

Still, Griffin says that she's pleased Obamacare passed. "I'm glad insurance can't reject people with preexisting conditions. I'm glad that young people can stay on their parents' insurance. And it extends access. But I just don't think it's based on the belief that access to health care is a basic human right, and that's what I believe. Hopefully, it's just the beginning."

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6 comments
nix123
nix123

I cannot remember a time when I didn't want to become a doctor, but now with Obamacare everyone is encouraging me to not continue in medicine.  For me, it's never been about the money, and honestly, I would work for free.  I have dreams of working overseas providing free medical care to developing nations and countries in crisis, but now I have years of repaying student loans to think about.  I want to save people and make a difference in their lives.  I do not want to have to worry about the fact that with a program such as Obamacare I will have to pay back loans until I am forty.  I sincerely hope that the government reevaluates this program and looks at it from my perspective, because this bill is changing my long term future and everything that I have ever wanted to do.  

Robert Elder
Robert Elder

Make education free to those with the chops to perform

rberns
rberns

Obamacare Jan 1st, 2012

In the standoff over the fiscal cliff, all the discussion has been about the Bush tax cuts. There has been no discussion about the ObamaCare tax increases. That's a mistake.

Five of the tax increases Americans will face on January 1 are new taxes created under the Affordable Care Act (ObamaCare). And they are not just for the very rich. Three of the five will hit people who are solidly middle class.

The new ObamaCare taxes will hit everything from dividends and capital gains to day care and services for special needs children. They will increase the tax bill for those who have extraordinary medical expenses? at the very time when they can least afford to pay higher taxes. They will hike the tax burden for the chronically ill who have several thousand dollars of out-of-pocket prescription drug expenses every year. The taxes will fall on medical devices ranging from pacemakers and artificial hips to bedpans and stents.

President Obama is the biggest spender of public funds in history, and he has shown absolutely no willingness to make any significant cuts in spending programs. The fiscal cliff, then, offers the GOP the unprecedented opportunity to cut spending, something that is otherwise impossible to do with President Obama through compromise.

No matter how the fall over the cliff develops, the president will successfully use it to blame Republicans. The average American voter has not yet felt the impact of the ObamaCare tax increases that will be enacted Jan. 1, 2013, whether the cliff fall is averted or not. And more importantly, no matter how Mitt Romney tried to explain the negative effects of Obama's fiscal policies, the electorate voted for Obama. So the GOP needs to abandon the idea that they will be able to convince the electorate that Obama's policies will hurt working Americans.

To provide all Americans with health insurance, premiums will have to rise to pay for it, Aetna CEO Mark Bertolini told CNBC's "Closing Bell" on Wednesday. Bertolini said that insurance premiums could double in some places just on the basis of what types of policies people buy today. He also said that when Obamacare is fully implemented, it won't start the way people had hoped and it won't be cheaper.

G1911
G1911

@rberns A lot of wind... but how will the president use this to blame republicans?

 
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