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Obamacare's Med-School Debt Problem

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

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.

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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