High doctor pay keeps American health-care costs high. Without debt relief, it will be hard to get doctors on board for lower pay.

American health care, per an old aphorism, is a "pay more, get less" system. Studies have shown that the United States pays about twice as much as other high-income nations for health care. Despite higher spending, U.S. life expectancies have declined for the third consecutive year, while the infant mortality rate remains among the highest in the industrialized world. Some 28 million people are uninsured, while another 85 million with insurance don't seek care due to prohibitive out-of-pocket costs.

And so, it is little surprise that health care is again shaping up to be a predominant issue in the 2020 election cycle, much as it was in 2018, and 2012, and 2010—and nearly every recent U.S. voting year. Both sides of the aisle argue that the status quo is insufficient. Republicans have again taken up the fight against Obamacare, with the Department of Justice now arguing that the entire bill should be thrown out. Democrats, on the other hand, especially the presidential hopefuls—Bernie Sanders, Elizabeth Warren, Cory Booker, and Kamala Harris—have begun to coalesce around some version of a Medicare for All proposal—including a bill introduced in the House of Representatives.

Where Medicare for All was once denigrated for being too expensive to implement, advocates have begun to point out that it might be cost-effective. Recent studies have shown that a Medicare for All program, like the bill recently introduced in the House, would expand coverage to those uninsured, cut out-of-pocket expenses, and save somewhere between $2 trillion and $5 trillion over the course of 10 years. Even a study from the Koch-funded Mercatus Center seemingly concurred on this data point. 

Some of the savings would come from curtailing the profits of insurance and pharmaceutical companies, which have parlayed lax regulations and absent price controls into runaway gains. The price of private insurance premiums increased at nearly twice the rate of Medicare costs from 1969 to 2009; removing profit-generating private insurers would create instant savings. But saving may also come from cuts to another expensive sector of the health-care market: doctor pay.

While doctors' wages don't get nearly as much air time in the health-care debate, they, too, are inordinately high when compared to peer nations. American physicians "make roughly twice as much on average as their counterparts in other wealthy countries," says Dean Baker, senior economist of the Center for Economic and Policy Research. With average annual pay for American doctors close to $300,000 (even after malpractice insurance), Baker points out that we "pay an extra $100 billion a year in doctor salaries" over comparable nations across the 900,000 doctors in the U.S. That breaks down to more than $700 per household per year.

As Medicare for All makes its way through debate in the House and inches closer to legislative viability, the prospect of cuts in wages is likely to turn some doctors off. As one study from the University of Massachusetts–Amherst has shown, the plan would require cuts to doctor pay of between 10 and 13 percent, with highly paid specialists shouldering the bulk it, as higher reimbursements from certain private insurers would disappear with the insurers themselves. "If it were up to me," says Baker, "the cuts would be much larger." (Some alarmist accounts have alleged that pay cuts could be as high as 40 percent).

According to Dr. Gary Price, president of the Physicians Foundation, that prospect could be daunting for doctors. Already, "physicians get reimbursed less for the things they do under Medicare," he says, and can rely on cost shifting to make up the difference. If their wages were to be cut substantially, that could keep young doctors from joining the profession altogether.

Part of the justification for American doctor's high wages is the debt burden that young doctors graduate with. According to the Association of American Medical Colleges, 76 percent of medical students graduate with debt. In 2018, the median debt was $192,000. At private medical schools, 21 percent of prospective doctors have debt in excess of $300,000.

"I know from talking to people all over the country, that debt burden is a factor," Price says. His statement echoes a recent article in Stat News about Medicare for all, which notes the "supply of physicians may be constrained as premed students may adjust career plans in response to anticipated cuts in reimbursement and rising student loan debt."

Though it may not seem so on its face, the student debt crisis, now $1.5 trillion and climbing, may well play a central role as Medicare for All becomes an increasingly attainable policy option. The salience of student debt in appeasing both physicians and patients may hold the key to brokering a solution that satisfies all parties. Even with a majority of doctors now saying they support a Medicare for All program, a debt relief program could prove essential in getting those doctors and various physicians groups on board. It may not be the most animating of policy proposals, but that little bit could well be the difference that gets such a bill across the finish line.

"My gut feeling is that it would help a little bit," Price says.

As public sentiment has warmed to Medicare for All—some 70 percent of Americans now support it—health care has been couched as a public good (a "human right" in the words of Bernie Sanders) in the same vein as education. A Medicare for All proposal with a significant student debt relief provision would allow progressives to not only effectuate a more egalitarian health-care system, but also to begin to implement a progressive vision for education, and a way out of the student debt crisis, after years of conservative reforms and charterization. Perhaps, if we're going to emulate other countries' medical system—the single-payer apparatus popular across the industrialized world, including Australia, Canada, and Britain's National Health Service—it would be wise to emulate those countries' education systems, which provide free or low-cost medical education as well.

It's not a notion without precedent. Medicare, perhaps the flagship legislation of Lyndon Johnson's Great Society campaign, helped galvanize an array of successful anti-poverty reforms throughout the 1960s. Already, Sanders has identified student debt as a major policy priority, introducing a bill aimed at student debt reduction that is now endorsed by Warren, Booker, Harris, and Kirsten Gillibrand as well. Making student debt relief part of a Medicare for All program wouldn't simply be wise and perhaps necessary politicking, it would present a way into an programmatic, progressive agenda and reignite the conversation about how best to provide public services.

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