Doctor shortages and medical-school loan payoffs

The LA Times reports, "California doesn’t have enough doctors. To recruit them, the state is paying off medical school debt."

Federal, state and local governments have increasingly turned to loan forgiveness programs as the competition for doctors has become more aggressive nationwide. Two-thirds of physicians finishing their training said they’d been contacted more than 50 times by job recruiters, according to a 2019 survey by physician staffing firm Merritt Hawkins.

California will spend $340 million paying off doctors’ debts using Proposition 56 tobacco tax revenue. This month, the state offered its first awards — 40 dentists received $10.5 million in debt relief while 247 physicians received $58.6 million.

California’s program is aimed at increasing the number of doctors who see Medi-Cal patients in a state experiencing a shortage of healthcare providers. The number of physicians who accept Medi-Cal patients — and the low reimbursement rate that comes with them — hasn’t kept pace with the rapid expansion of the state’s healthcare program for the poor, which covers 1 in 3 residents in the state.

One of my son's medical degree was paid by the US Air Force. He owes them years of service for the payoff. He is presently an Air Force surgeon, and by the time his years of payback are done, he will have 13 years on active duty - more if he elects to pursue a medical fellowship certification.

The states' doctor shortage (California is not the only one) was fully predictable. I even predicted it 10 years ago in my essay, "Doctor shortages and health-care price controls." (I have to say, though, that I was far from the only voice saying this.)

However one might describe the economic system of American health care, "full free market" ain't it. Probably the best description of how we get medical care is that it is brokered to us: "Health care does not equal health insurance."

The costliness of health care rests largely on the fact that its provision became brokered long ago by insurance companies. We buy "coverage" from insurance companies instead of medical care from providers. The insurance company is intermediate between the consumer and the provider. Unlike say, stock brokerages, which have to compete with each other for consumers and so lower both costs and price, health insurance companies operate in monopolistic fashion. The competition between health-insurance companies is so low that there are no competitive pressures to reduce price, only internal costs. The result? Lower reimbursements to providers and higher premiums to consumers.

We have almost a doubling effect of price controls in play here. First, the government, command rations medical care by controlling the prices its insurance programs will pay, especially Medicaid but also Medicare. Then we have health-insurance companies effectively price controlling medical care because they often, if not usually, tell doctors that they won't pay more (or much more) than the Medicare rate. As Healthsymphony.com puts it, Medicare is such an important part of the health-care economy "because of the precedence set by its claims payment practices."

The inevitable result of price controls, no matter by what mechanism implemented, is shortage of the price-controlled good or service. That doesn't mean that the service is scarcer, that is, physically rarer. Medicaid's low payments schedules have not reduced the total number of doctors. It has produced a shortage of medical care available to patients by halving the number of doctors who will accept Medicaid payments.

We are in the mess we are in because we make two (at least) critical errors of understanding. The first is that health care is a resource that is simply available for those who need it, or that can be made mostly-equally available through proper legislation and regulation. The second error is that medical care and access to it can be rationed by command more equally, economically and fairly than by demand.

But health care is not a resource to be exploited. Medical facilities and doctors are not phenomena of nature, like water or petroleum are. Hospitals don’t just appear. They are produced. Medical care is not a resource that can be "mined" through more regulation to be more plentiful. Medical care is a contracted, individual service.

Hence, before we uncritically head-nod to the claim that health care is a human right, we might ponder what commentator Philip Niles observed: the real question is not whether health care is a human right, but "How much health care is a human right?" Good question, since health care is finite.

Medical care is always going to depend on these three things:

1. Availability -- Can you see a doctor reasonably quickly and reasonably near?
2. Quality -- Will you receive good, appropriate, and effective medical care?
3. Price -- Can you afford to pay for it, either through insurance or through the massively-higher taxes that, for example, candidate Bernie Sanders said would have to be enacted?

Basically, pick two. Because no matter how medical care is structured, all three will not operating at the same time, and it may not even be two of the three.

The post-2020 UMC

"For now we see through a glass, darkly ... ." 
1 Corinthians 13.12

For those who have heard that two bishops of the UMC have proposed a plan to schism the denomination while trying to maintain some level of connectionalism, here are two good analyses. The plan is the product of Bishops Scott Jones and David Bard. It is proposed for next year's general conference to enacted (or not) by a simple majority vote. The plan envisions “two or three self-governing” denominations being birthed from United Methodism.

First the United Methodist News Service release is here.

Second, "Thoughts on the Bard-Jones Plan," by Chris O'Ritter. 

Third, "The Bard-Jones Plan: 'Cooperative Separation',” by David F. Watson.

The Theology of America

There are certain occasions when events on the secular calendar give us the opportunity to pause and reflect on religion in America. The Fourth of July is an obvious occasion. I want to take this day to reflect on the religious underpinnings of our country and explain why I believe there is an actual theology of America and what it means.

I think that the theology of America was best summarized by Thomas Jefferson in his 1774 essay, "A Summary View of the Rights of British America." There he stated, "The God who gave us life gave us liberty at the same time. The hand of force may destroy but cannot disjoin them."

Editorialist James Freeman wrote that based on the standards of our day, “Thomas Jefferson was a religious nut.”

   Jefferson was a big believer in religious liberty, but he certainly wasn't shy about mentioning God in official proceedings. In the final paragraph of the Declaration of Independence, Jefferson asks twice for God's help in creating the country. And the Declaration was not the only work of Jefferson's in which he gave credit to a higher power. . . .

   In his Notes on Virginia of 1782, Jefferson writes: "Can the liberties of a nation be thought secure when we have removed their only firm basis, a conviction in the minds of the people that these liberties are of the gift of God?"

If we disregard the Founders’ religious faith, we have no answer to the question, Where do our rights come from? Jefferson's religious ideas, shared by representatives from the thirteen colonies, are the reason we have a United States and the reason that We the People are in charge.

However much it is claimed that Jefferson and most of the other Founders were more secular than religious, there is no escaping that Jefferson's writings are permeated with God consciousness. It's true that Christ does not figure into his political writings, but God does, and frequently. What gave Jefferson and his fellow revolutionaries the right to be so, well, revolutionary? Whence came their idea that the people should rule instead of a king or a parliament of nobles? How could they claim that the right to life, liberty and the pursuit of happiness was "unalienable," meaning beyond the rightful power of any government either to grant or deny? Why did they talk about human rights to begin with and where do rights come from?

According to Thomas Jefferson and his fellows, the ultimate answer to all those questions was simple: God. Only cynics say that the religious convictions of the Founders were not central to their determination to risk their lives, their fortunes and their sacred honor for a single claim: that all human beings are created equal and that they are endowed by their Creator with certain rights that may not be rightfully denied them. And yes, the Founders did exclude African-Americans from this claim, but let us also acknowledge that Jefferson, among others, said explicitly that God's righteous day of reckoning and judgment upon slave-owning America would come. And it did.

The whole justification for the American revolution was that the divine rights of the people trumped the divine rights of kings that European monarchs claimed to have. Human rights come from God, not government. When the British government usurped them, it was the God‑given right of the people of America to cast off the that government and form their own. That is what the Declaration of Independence says, and that is what the Founders did. Freeman wrote, "If you could sum up Jefferson's political views in one sentence, you would say: He believed that God and reason allow people to rule themselves."

One of the genius things our Founders did was create a civil society in which enormous numbers of different Christian denominations and nowadays, different religions, find a home. Our history has seen times of sectarian strife, but it never descended to open combat as it has in, say, Northern Ireland. A lot of Protestants were suspicious of whether Catholic John F. Kennedy would cleave to the Vatican rather than the Constitution, but their fears were unfounded. In 2004, orthodox Jew Joe Lieberman ran for president and then was the nominated candidate for vice president and no one worried whether he would cleave to Jerusalem rather than the Constitution.

The American ideas of freedom and liberty are drawn from religion. Jefferson was saying that human liberty is inherent in the creative acts of God in bringing forth humankind to begin with. Creation was not a static event, it is a dynamic process of bringing forth the image of God in humankind and the world at large. The creation stories in the book of Genesis show that the realms of the divine and creation overlap. God is powerful, but creation has power too; a certain degree of independence and freedom is built into creation by God's very acts of creating.

In the original paradise, the Garden of Eden, Adam and Eve were given the run of the garden and meaningful work to do. They were free agents of their own will. Yet there were limits. God commanded them that they could eat the fruit of any tree except one. Their freedom had its limits. When they crossed that limit, they were less free, and Genesis relates that as generations passed, humankind became steadily even less free.

Eventually the story leads to Egypt, where the Hebrews found themselves in chattel slavery to Pharaoh. They had no freedom at all.

The twin images of slavery and freedom shape the entire theology of both Jews and Christians. Always God is a liberator. The central story of the Jews is that of Moses leading the children of Israel from slavery in Egypt to freedom in the Promised Land. At their start, slavery. At their ending, freedom. But neither the slavery nor their freedom is the high point of the story. The high point is what happened at Sinai. The high point, the defining moment, was when God gave them the Law.

The Law of Moses defined freedom in two ways. On the one hand, the law defined what was forbidden. On the other, it stated what was obligatory.

There is always a tension between the forbidden and the mandatory. But the Bible seems clear that human freedom is found somewhere between the limits of what may not be done and what must be done. With no limits there is no freedom because there is no orientation on God. Without obligations there is no justice, without prohibitions there is no community. The surest way for persons or societies to fall into bondage is to ignore prohibitions and obligations. Falling into slavery is easy, staying free is hard.

The apostle Paul said that creation itself is in bondage to decay, an amazing statement for a pre‑scientific man to make. Science today confirms that the universe is running down and cosmologists now seem convinced that the universe will keep expanding forever, until the time comes when energy states will be even, and nothing will ever change.

As for we men, women and children, we are born slaves to this decay. At the end lies the grave. We know that. We fear death because our mortality looms over everything we do. Human customs and culture are shaped by the end of life in ways we cannot even uncover, to degrees we do not recognize. Such is our slavery to the fear of death.

Christians have tended to think of Jesus' gift of life as some sort of afterlife, but Christ is concerned about far more of our lives than what happens after they end. Christ frees us not only from the fear of personal death but from our slavery to a death‑shaped culture. With death overcome, the family of God is empowered to inaugurate a new order of living and a new kind of life.

Jesus explained in the Gospel of John (8:34‑36), "Very truly, I tell you, everyone who commits sin is a slave to sin. 35The slave does not have a permanent place in the household; the son has a place there forever. 36So if the Son makes you free, you will be free indeed."

Through Christ, we are freed from sin and from servitude to the things of this world which inhibit godly living: greed, jealousy, anger, resentment, racism, selfishness – all the hundreds of things we put under the general label of sin. We are freed from sin and the fear of death.

So liberated, we should be able to live positively in ways not possible before. Justice, the right ordering of things in human affairs, is the result of this spiritual freedom. So the fuller Law of the Hebrews recognized this fact. Deuteronomy 10:12‑13 and 17‑18 says to the nation of Israel:

12 So now, O Israel, what does the LORD your God require of you? Only to fear the LORD your God, to walk in all his ways, to love him, to serve the LORD your God with all your heart and with all your soul, 13and to keep the commandments of the LORD your God and his decrees that I am commanding you today, for your own well‑being. 17For the LORD your God is God of God's and Lord of lords, the great God, mighty and awesome, who is not partial and takes no bribe, 18who executes justice for the orphan and the widow, and who loves the strangers, providing them food and clothing.

Those are some of the divine obligations people have as they live in community. Yet our nation's founding documents make no mention of the obligations and responsibilities, they seek to ensure only our rights. In fact, Jefferson wrote that the whole purpose of government is to secure the rights that God gave us. He ignored codifying the obligations God lays on us.

I think that is a good thing. I shudder to think what our civil life would be like if our Constitution required things of the people rather than limited the power of government. It is always too easy for the law, whether civil or religious, to cease being a guide and become a slave-master. George Washington warned that even democratic "Government is not reason; ... it is force. Like fire, it is a dangerous servant and a fearful master."

In both our civil and religious life, we would do well to remember Paul's admonition to the Corinthians, 1 Cor 10:23: "‘Everything is permissible' – but not everything is beneficial. ‘Everything is permissible' – but not everything is constructive.'" The absence of limits in America's founding documents is not an oversight. The Founders expected the people to understand the limits of libertine anarchy on the one hand and political slavery on the other.

John Adams wrote in a letter to his wife, "We have no government armed with the power capable of contending with human passions unbridled by morality and religion. . . . Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other."

Justice William O. Douglas wrote in a majority opinion of a Supreme Court case, "We are a religious people whose institutions presuppose a Supreme Being."

The Constitution guarantees our rights, but not our liberty. It is our religion under the providence of the God of the Bible that secures our liberty. Liberty is maintained by faith in powers greater than government, by living out God’s call to know the truth of freedom in God’s way of life. When we make government the object of our faith, when we decide that our liberty depends on government, we will live under political bondage.

Various commentators of the American religious scene point out that America is becoming less and less religious. A lower percentage of Americans regularly attend church or synagogue than in past times.

But the fact is that Americans are still just as religious as before, it's just not Jewish or Christian religion they are practicing. Increasing numbers of people are turning to forms of spirituality that are private and personal, not public and social. These forms of religion are, at their base, selfish and self‑centered. While this is certainly their right, I fear that over time the obligations of freedom will be ignored, and the justice of our freedom will be degraded. Self‑centered persons do not prosper, and neither do self‑centered societies or nations. Paul warned the Galatian Christians (Gal 5:13‑14):

13 For you were called to freedom, brothers and sisters; only do not use your freedom as an opportunity for self‑indulgence . . . For the whole law is summed up in a single commandment, "You shall love your neighbor as yourself."                                                          

Freedom is God's will. Certain rights are God‑given and cannot be rightfully denied by human authority. God's gift of freedom carries the obligation to live godly lives under his guidance and to love our neighbor as ourselves. Our rights and our obligations reinforce one another, guard one another, preserve one another. Together they comprise our freedom.