The need for health care reform and new health care policies keeps making the news almost every day. Better access to health care includes better access to the knowledge and services of physicians. That would imply new health care graduates should grow as the population grows, but medical school degree data published by the National Center for Education Statistics shows no growth at all. For the academic year 1985-86, they report 15,938 Medical School Degrees. They have not reported a number as high as that since, although MD degrees reached 15,730 for the year ending June 2007.
In that same period the resident population reported by the Bureau of Census increased 66.2 million. It was 237.9 million in 1985 but reached 304.1 million in 2008. Despite continuous growth in America’s population it does not train more physicians.
Becoming a physician is a long and expensive process that takes four years of college prior to 4 years of medical school. Medical school tuition reported by the American Association of Medical Colleges in 2008 averaged $23,593 for the 75 public university medical schools; $41,235 for the 50 private university medical schools.
In some states a medical school graduate can get a license to practice medicine after completing a one year internship, but most states require two years in a medical residency program. During residency programs hospitals typically define pay as a stipend, apparently to save money paying low wages, so the residency period continues to be a period of financial drain on medical students.
Those admitted to America’s service academies at Annapolis, Maryland and West Point, New York pay no tuition. America trains its military officers at public expense. For medicine though America puts the burden to pay for at least 10 years of training on the individual. Much of this medical expense comes during a time in life when people usually begin to support themselves and pay their own living expenses. For many in medical training living expenses are a burden that generates even more debt to pay off later.
Some of the strain in the current system shows up in physician employment reported by the Bureau of Labor Statistics. Family and General Practitioner jobs are in decline. There were 135 thousand reported as recently as 2001, but 106 thousand reported for 2008. It also has the lowest entry pay of reported physician specialties, $73 thousand.
An entry wage of $73 thousand dollars will not be sufficient to support a family and pay the debt from 10 years of medical education. It is time to recognize that a major component in health care reform needs to be more physicians. They need to grow at least as fast as the population. That is not happening with the current system and we have to doubt it ever will. It’s time to train our physicians like we train our generals: at public expense.
Tuesday, September 29, 2009
Wednesday, September 16, 2009
Taxes and Health Care Reform
The headline in the Washington Post reads “Tax on Health Benefits Weighed: Senate Calls Levy ‘Perhaps the Best Way’ to pay for Overhaul.” [June 10, 2009] Actually it was Senator Max Baucus who is drafting the legislation for the Senate who said that, but we can be sure he discussed it with his Senate colleagues.
The qualifier “perhaps” in front of best should be translated into the best we can do given that a majority in Congress wants to avoid raising income tax rates at the top of the Federal income tax scale. The top rate continues to be 35 percent, which began in 2003.
The Internal Revenue Service publishes detailed income and tax data on its website. The latest detail is for 2006, a year in which 940,384 returns had taxable income over $500,000. Suppose Congress declared a one percent increase in the tax rate for just the taxable incomes over $500,000. Having a 36 percent top marginal rate instead of 35 percent for tax year 2006 comes to $9.5 billion dollars of additional revenue.
Higher incomes in 2009 would make it more than 9.5 billion. Raising the top marginal rate 4.6 percent to 39.6 percent will bring in more than $40 billion. A top marginal rate of 39.6 was the top marginal tax rate from 1993 to 2000.
Congress knows taxing employer health benefits is a regressive tax because employer health care benefits do not go up in proportion to income. Taxing health benefits when benefits decline as a percent of higher income guarantees those with higher incomes will pay a lower percentage of income in tax. Ignoring dividends and capital gains only makes their proposal more regressive.
Senator Baucus is already retreating and offering moderating qualifications like phasing in, and a “grandfather” clause for union negotiated health plans. Maybe he is anxious making proposals for regressive taxes, but others in Congress are making other proposals.
Other proposals include, higher alcohol taxes, a new tax on flexible savings accounts and health reimbursement accounts, taxing half of all employer provided health premiums, eliminating tax deductions for high medical expenses, and a “3-cent tax” on sugary drinks. Many proposals, but all regressive and none to raise marginal tax rates.
America’s health care is too expensive for millions. To have health care for everyone some will have to pay more to finance health care for others who can only pay less or America will continue to exclude millions.
American’s need to feel concern for their fellow citizens to help pay subsidies, but the regressive finance proposals reflect the attitudes and political strength of the well placed and the well to do. If a family of four in 2008 used the standard deduction, a 39.6 marginal tax rate instead of the current 35 percent rate, increases taxes by $5,615.13 on $500,000 of gross income. Those high earners do not want to pay and Congress continues to go along. It makes it hard to feel optimism for extending health care to all.
The qualifier “perhaps” in front of best should be translated into the best we can do given that a majority in Congress wants to avoid raising income tax rates at the top of the Federal income tax scale. The top rate continues to be 35 percent, which began in 2003.
The Internal Revenue Service publishes detailed income and tax data on its website. The latest detail is for 2006, a year in which 940,384 returns had taxable income over $500,000. Suppose Congress declared a one percent increase in the tax rate for just the taxable incomes over $500,000. Having a 36 percent top marginal rate instead of 35 percent for tax year 2006 comes to $9.5 billion dollars of additional revenue.
Higher incomes in 2009 would make it more than 9.5 billion. Raising the top marginal rate 4.6 percent to 39.6 percent will bring in more than $40 billion. A top marginal rate of 39.6 was the top marginal tax rate from 1993 to 2000.
Congress knows taxing employer health benefits is a regressive tax because employer health care benefits do not go up in proportion to income. Taxing health benefits when benefits decline as a percent of higher income guarantees those with higher incomes will pay a lower percentage of income in tax. Ignoring dividends and capital gains only makes their proposal more regressive.
Senator Baucus is already retreating and offering moderating qualifications like phasing in, and a “grandfather” clause for union negotiated health plans. Maybe he is anxious making proposals for regressive taxes, but others in Congress are making other proposals.
Other proposals include, higher alcohol taxes, a new tax on flexible savings accounts and health reimbursement accounts, taxing half of all employer provided health premiums, eliminating tax deductions for high medical expenses, and a “3-cent tax” on sugary drinks. Many proposals, but all regressive and none to raise marginal tax rates.
America’s health care is too expensive for millions. To have health care for everyone some will have to pay more to finance health care for others who can only pay less or America will continue to exclude millions.
American’s need to feel concern for their fellow citizens to help pay subsidies, but the regressive finance proposals reflect the attitudes and political strength of the well placed and the well to do. If a family of four in 2008 used the standard deduction, a 39.6 marginal tax rate instead of the current 35 percent rate, increases taxes by $5,615.13 on $500,000 of gross income. Those high earners do not want to pay and Congress continues to go along. It makes it hard to feel optimism for extending health care to all.
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