There is bitter irony to the medical predicament of the unemployed, especially the newly unemployed. They helped put a whole generation of doctors through medical school. But now considerable numbers of them can no longer afford to go to those doctors.
That is not the way things were supposed to work out when American taxpayers were handed the bill in perpetuity for medical students' tuition 20 years ago.
The figures were set out in the Dec. 26, 1980, issue of the Journal of the American Medical Association:
Tuition paid by medical students covers only 6 percent of the cost (excluding room and board) of a medical school education. Another 4 percent of that cost is paid by philanthropic gifts to the medical schools, and 5 percent is listed in the Journal as coming from unspecified sources. The remaining 85 percent of a medical school education is paid for by the public. It pays directly in federal and state subsidies to medical schools, and indirectly in the fees charged to patients by doctors who serve on the medical schools' full-time faculties.
Few people know how their own visits to the doctor put medical students through school. A faculty member at a medical school draws a salary of $60,000 for teaching. On top of that, he is allowed to pursue a private practice and is provided with offices within his teaching hospital and all the equipment he needs. In return, the medical school takes a portion of the income from his practice to subsidize tuition costs. That portion is included in every bill the doctor sends his patients.
The same faculty doctor who treats private patients also treats clinic patients, for whom he bills Medicaid. As with his private fees, a portion of what Medicaid pays goes to the medical school to pay for students' education.
Nor is medical school tuition the only medical education item that the public pays for. It also pays for residency training, the program after medical school in which the doctor learns his or her specialty. And the yearly salaries of hospital residents, which range from $20,000 to $30,000, are calculated (as are their teachers' salaries) into all our medical insurance premiums.
The insurance premium represents the total cost of medical care for the group being insured, divided by the number of people in the group. The major part of that cost is hospitalization. The cost of a hospital day is arrived at by adding up all of a hospital's costs--including equipment, laundry, heating and salaries of staff, including residents-- then dividing by 365 days. The cost of a hospital day chiefly determines our insurance premiums, whether or not we are ever hospitalized. The residents' share of this cost has been conservatively estimated by the Department of Health and Human Services at $2 billion.
All in all, the public pays approximately 92 percent of the cost of educating its physicians. This flow of public money to the nation's medical schools began in the 1960s as a preliminary to providing all Americans with equal access to medical care. President Kennedy believed this goal could best be achieved through a national health insurance plan. But once embarked on the design of such a program, Kennedy and his advisers were alarmed to discover that not enough doctors were being trained to provide medical care for the entire population.
In fact, this shortage had first been noticed in the 1950s, when more and more people began to receive major medical insurance as a fringe benefit on the job, yet medical schools were turning out no more doctors than before. Several bills giving grants to medical schools to increase the nation's supply of physicians were then introduced into Congress. The first of many such bills was passed in 1963.
Two years later, with the passage of the Medicare and Medicaid legislation, the second step toward equality of access to medical care was taken, and with it came public subsidy of postgraduate medical training--the residency program. Prior to Medicaid and Medicare, residents had been taught by working with charity patients, who paid no fee. Residents received a stipend of a few thousand dollars a year and room and board in the hospital, while the faculty who taught them took no salary for teaching or for the care they themselves provided charity patients in the course of teaching. True, the residents' subsidies and board were included in the hospital's bills to its private patients, but the additional cost was negligible.
With the passage of Medicaid and Medicare, money began flowing into the hospitals to pay for a large number of patients who used to be treated free. Residents in turn argued that they should be paid salaries proportionate to what the government was paying the hospital for the care they were providing. The residents won that round and are now paid (although they do not themselves think so) about what the hospital would have to pay other health professionals to do what they do. As I noted, faculty doctors make $60,000 a year for teaching.
But the goal of all this legislated money--equality of access--was never achieved. That is what is disquieting about the economics reported in the Journal of the American Medical Association. It reminds us that many of the 12 million unemployed who have paid for other people's training as doctors for 20 years might just need a doctor now. But without an employer's medical insurance, they are not only out of pocket but out of luck. For what they were also supposed to be paying for-- equal access to medical care for all Americans -- never came to pass.