Access

HEALTH REFORM: U.S. Nursing Shortage ... and My Mom

Veronica Valdez — Tue, 09 Jun 2009 13:24:00 -0400

I've been reading lately about the persistent nursing shortage in the U.S. that threatens the quality of patient care. I know something about this: I was born in the Philippines—the world's leading donor of nurse labor—and many of my own relatives, including my mother, migrated to the U.S. to help fill this nursing gap. My mother studied at the University of Philippines and was trained at the Philippine General Hospital. She, like thousands of others, was exported to the U.S. and then later to Australia in the '80s where she was guaranteed a higher salary and greater opportunities. This hasn't changed much. The mass exodus of nurses from the Philippines continues today.

But with the current economic crisis, is there still a growing demand for nurses in the U.S.? Some hospitals have laid off nurses. And some senior nurses are remaining in, or rejoining, the workforce as they choose to postpone retirement or come out of retirement because of financial insecurity.

But the American Association of Colleges of Nursing (AACN) assures us that the "U.S. is in the midst of a shortage of registered nurses (RNs) that is expected to intensify as baby boomers age and the need for health care grows." An analysis by the U.S. Department of Health and Human Services projects that the current nursing shortage will continue to grow in severity during the next 20 years if current trends prevail and that some states face a more severe shortage than do others." This is a sobering thought.

The shortage is not because people do not want to be nurses. Demand for nursing careers is high. Last year, AACN reported that almost 50,000 qualified applicants to nursing programs were declined. The underlying problem is the lack of nursing school faculty. The Obama Administration is paying close attention.

President Obama said during his White House Forum on Health Reform that:

Nurses provide extraordinary care. I mean, they are—they are the front lines of the health care system. And they don't get paid very well. Their working conditions aren't as good as they should be. And when it comes to nurse faculty, they get paid even worse than active nurses. So what happens is, is that it is very difficult for a nurse practitioner to go into teaching, because they're losing money.

HealthLeaders Media reports that:

President Barack Obama has requested $125 million for the federal Nursing Education Loan Repayment Program (NELRP). In addition, the president has asked lawmakers to increase federal Nurse Faculty Loan Program (NFLP) resources by 40 percent over 2008 funding levels as part of the $1 billion allocated for health care workforce development in the fiscal year 2010 budget.

Some states are also taking action. In Texas last year, nursing schools turned away some 8,000 qualified applicants, primarily because there weren't enough faculty to teach them. The Texas Legislature recently committed $30 million in new upfront funding for nursing schools to expand starting this fall. The Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce Foundation have announced a $22 million five-year initiative designed to ensure that New Jersey will have the nursing workforce it needs to meet its future health care demands.

Addressing the nursing shortage (as well as larger issues about our primary care work force) is important in the grand scheme of health reform. As we try to get all Americans high quality affordable health care coverage, we will need more nurses to provide high quality health care and take on many of the challenges of care coordination, patient education, disease management and preventive care.

COVERAGE: Medical Mallrats

Tom Emswiler — Thu, 29 Jan 2009 13:03:00 -0500

Although the name might lead you to think of retail clinics, Lola Butcher's new article from HealthLeaders Magazine titled "Medicine at the Mall" actually talks about taking over THE WHOLE mall. Yes, really.

But it's not as crazy as it seems. The article highlights the experience of Vanderbilt University Medical Center, who after watching the costs and headaches rise from expanding its downtown campus, looked at the cost of taking over an aging, half-vacant shopping center. They could get quite a bang for their buck, it turned out.

Cost was only the beginning, as Ms. Butcher writes. Vandy serves the large Nashville metropolitan area but is downtown and can be difficult to reach by car. The new facility, on the other hand, is right off the interstate and near some of the residential areas served by the medical center. Bucking the NIMBY trend, all the property values near the new center have risen. Residents viewed the old mall space as "underdeveloped." It may turn out to very convenient for patients to be able to access a variety of services under one roof. Even parking will be easier. Much of it is already constructed.

Surprisingly, this idea is nearly 15 years old:

One of the nation's most successful medical malls was started in the mid-1990s when a Jackson, MS, physician recruited University of Mississippi Medical Center to convert a desolate shopping center into a healthcare hub for the city's urban poor. Today, the Jackson Medical Mall houses more than 30 clinics and other medical services, along with restaurants, educational institutions, and human services organizations.

Since then, at least 50 medical malls have emerged across the country, Hunter (a developer) says, with more on the way. On behalf of Prince George's County in Maryland [nearv Washington, DC], Hunter's firm studied the feasibility of converting four underperforming shopping centers into medical malls to increase access to healthcare services for inner-city residents. Such projects might reduce the burden on the county-owned hospital, which is overtaxed by patients using its emergency department for services that could be providing in an outpatient setting.

With 440,000 square feet of leased space to be completed in April, "Vanderbilt Health at One Hundred Oaks" will house nearly 20 clinical programs and nearly 750 Vanderbilt employees. With health care one of very few sectors weathering our recession better than most other industries, it is excellent to see so many health systems revitalizing old space near the residents they seek to serve.

Don't Table Endowments

Ben Miller — Tue, 09 Sep 2008 16:52:00 -0400

Speaking at a Congressional roundtable on college endowment spending on Monday, college leaders and lobbyists offered a multitude of reasons why requiring institutions of higher education to spend a minimum amount of their endowments each year is bad policy and fundamentally unworkable. Among their arguments, they claim that a mandatory payout of endowment funds would be overly burdensome on institutions; would harm future generations of students on their campuses by depleting present resources; and would serve no public good.

We respectfully disagree. At Higher Ed Watch, we have offered a proposal for a mandatory payout that renders most of these objections moot. Our plan would require the wealthiest colleges to spend a specific percentage of the market value of their endowment funds each year, with the difference between their current spending rate and the new threshold going to concrete, measurable projects aimed at improving socioeconomic diversity among students and applicants.

Co-hosted by Sen. Charles Grassley (R-Iowa), the ranking member of the Senate Finance Committee, and Rep. Peter Welch (D-Vt.), who moderated the discussion, yesterday's event featured experts on college endowment practices, higher education leaders and lobbyists, and watchdog groups [Disclosure: the author of this post participated in the roundtable.] Ostensibly, the event's three major goals were to (1) provide a better understanding of the link between college costs and tuition, (2) define and classify university endowments, and (3) debate whether institutional endowments should be subject to a mandatory annual payout. Ultimately, the discussion largely focused on reasons that colleges believe requiring a minimum spending rate would be inadvisable.

Let's take a closer look at the arguments advanced by participants yesterday and show how our proposal addresses them.

Argument: A mandatory spending rate is too burdensome for colleges with small endowments

Most colleges do not have large endowments. According to Molly Broad, the president of the American Council of Education, the vast majority of postsecondary endowment funds (about 70 percent) are controlled by 75 universities. The rest is divvied up among the thousands of other colleges nationwide.

It is true that many schools with smaller endowments would be unable to meet an annual spending requirement. That's why Higher Ed Watch's proposal would leave these institutions alone. Our plan would require a mandatory payout level only from colleges with endowments over $500 million or some other agreed upon metric.

The 75 schools or so that would be affected represent a fraction of national postsecondary enrollment, but they are also among the premier colleges and universities in the world. As a result of their reputation, these institutions confer substantial benefits to their graduates. We believe that colleges should be doing more to ensure that those benefits are accessible to students across all socioeconomic brackets.

Unfortunately, that largely doesn't appear to be the case. Apart from isolated shining examples, such as Amherst and Smith colleges, where 20 percent or more of the student body is Pell eligible, America's wealthiest schools enroll a small and apparently decreasing number of low-income students. According to an analysis published this May by the Chronicle of Higher Education, only 13.1 percent of students at the 75 wealthiest private institutions in the 2006-07 school year received Pell Grants. Moreover, the Chronicle found that the number of Pell Grant recipients at these institutions actually decreased from 14.3 percent in the 2004-05 school year.

Argument: Forced endowment spending on tuition reduction wouldn't serve the public good

College leaders were very clear at Monday's roundtable that there is at best a tenuous link between endowment spending and a further lowering of tuition because institutions already use endowment funds to subsidize tuition and fees. They argued that mandating higher spending rates would lead to nothing more than a small decrease in tuition -- at best.

But reducing college prices is not a cure-all for college access problems. Ironically, the reduction in the proportion of Pell Grant recipients at wealthy schools occurred after several took steps to substantially reduce their tuition burden for financially needy applicants. This suggests that colleges need to do more than lower tuition costs to improve socioeconomic diversity on campus.

This is where mandating a minimum payout rate for endowments could be useful. Rather than just requiring colleges to spend more of their endowments on the nebulous, seemingly catch-all category of "student aid," colleges under our plan would be required to use additional funds to take proactive measures to attract more low-and moderate income students to their campuses, and help them succeed and graduate once there.

With such a mandate, colleges would not be able to use the increased endowment spending to supplant, rather than supplement, existing student aid dollars, or use them in a fungible way to finance extravagant capitol projects, such as dormitory amenities or new fitness centers for athletes.

Instead, the newly tapped endowment money could go to projects such as:

Centers of Excellence for Low-Income Student Success
Under the recently-passed Higher Education Act reauthorization legislation, colleges can apply for grants to create centers of excellence for veteran students. These centers are to consist of full-time staff members whose job will be to coordinate all aspects of veteran student life, running the gamut from academic and career advising, access and persistence monitoring, outreach, housing support, and tutoring assistance. We would like to see colleges use the additional endowment funds to create similar centers for low- and moderate-income students.

Improved High School Outreach
In Creating a Class: College Admissions and the Education of Elites (Harvard University Press, 2007), Mitchell Stevens, an associate professor of educational sociology at New York University, documents the mutually beneficial nature of close relationships between admissions officers at an elite New England liberal arts college and guidance counselors at prestigious public and private high schools. Admissions officials who are familiar with specific schools and counselors end up devoting more time to these schools, which aids their efforts to locate talented students. Under our plan, colleges could use additional endowment funds to buttress their efforts to build stronger relationships with officials at high schools that predominantly serve lower-income students.

Local Outreach
Increased endowment spending on preparing low-income students for a college education need not solely target individuals guaranteed to attend one of these wealthy institutions. Many colleges with large endowments are located in economically depressed cities and counties where an influx of money could have substantial effects on improving the educational outcomes of students in local school districts. For example, my alma mater Brown University, promised in February of 2007 to create a $10 million endowment for the Providence School District. This fund could be an important source of support for a district where 38 percent of its students are impoverished and just 28 percent of its fourth grade students scored proficient or higher on state mathematics tests.

Argument: Spending too much from endowments now would harm future generations

Many wealthy colleges claim that spending more endowment funds today would be unfair to future classes of students because it would deplete available resources -- a concept known as intergenerational equity. There are two problems with this argument. First, most colleges already are spending over 4 percent of their endowment funds each year, meaning they would likely be forced to contribute only a few tenths of a percentage point more. Surely this is not enough to drain what are extremely well-managed funds.

Second, the schools are adopting a notion of intergenerational equity that is far too narrow. Rather than thinking solely about the potential harm to future classes of students on a given campus, colleges should be thinking about the societal implications of continuing our current policies. According to the Advisory Committee on Student Financial Assistance, an estimated 170,000 otherwise qualified low- and moderate-income students do not attend college each year. These individuals are put at a significant disadvantage in the workplace and are likely to generate much less income over their lifetimes. Failing to attend college also has implications for individuals' children. The National Center for Education Statistics found that students whose parents had a bachelor's degree or higher enrolled in college at a rate 22 percentage points higher than students whose parents had no more than a high school diploma. Enrolling a low-income student today increases both their expected lifetime earnings and the likelihood that their children will go to college, having a positive impact on the college access of future generations.

Obviously the endowment issue is far more complex than just requiring a blanket payout rate for all institutions. But for the wealthiest colleges there should be fundamental questions raised about whether their lack of socioeconomic diversity is hindering them from fulfilling their greater educational mission. This also has implications for taxpayers, who forgo the billions of dollars the government loses by not taxing donations to, and earnings from, endowments. For these reasons, we believe that a mandatory endowment payout rate for higher education is an issue worthy of further debate and negotiation.

(Click here for more materials from the roundtable and here for comments prepared by this post's author for the roundtable.)

UPDATE: Video of the roundtable is now available here.

Guaranty Agencies: A Middleman in College Access Clothing

Ben Miller — Wed, 16 Jul 2008 21:59:00 -0400

What do an appendix, plica semilunaris, and student-loan guaranty agency all have in common? They're all vestigial structures whose original purpose is no longer necessary. But unlike the first two examples, guaranty agencies are desperate to show -- despite all evidence to the contrary -- that they are still relevant.

As parts of a system known for its complexity and confusion (the Federal Family Education Loan Program, otherwise known as FFEL), guaranty agencies are the ultimate amorphous entity, branching out into numerous roles that are completely unrelated to their original purposes.

Soon after Congress created the FFEL program in 1965, it authorized the involvement of guaranty agencies (many of which were already in existence in the states), to encourage lenders to offer student loans by providing default insurance. Congress also gave the guarantors important oversight responsibilities, such as ensuring that only eligible students obtain federal loans, and that lenders make a concerted effort to keep delinquent borrowers from defaulting.

While it made sense for guaranty agencies to occupy these roles at a time when technological limitations made it difficult for solely the federal government to oversee FFEL, the program's current setup and recent oversight failures make it clear that guaranty agencies should not be the ones to carry out these functions.

Consider loan guarantees. Currently, all FFEL loans must be certified by one of the 35 guaranty agencies. If a loan defaults, the guaranty agency reimburses the lender for 97 percent of its loss. The agency then takes control of the loan and attempts to either get the borrower to begin making payments or start collection proceedings -- both of which result in compensation for the guarantor. But if neither effort is successful, the guaranty agency is reimbursed for nearly all of its losses by the U.S. Department of Education. Guaranty agencies can thus serve as little more than a pass-through of federal funds from the Department to the lender -- a middleman at its finest.

The oversight role, meanwhile, has been completely undermined by overly close ties between lenders and guaranty agencies. Take the relationship between Sallie Mae and USA Funds, the nation's largest guarantor. As The Chronicle of Higher Education outlined in a recent article, the two companies have a contractual relationship, in which USA Funds pays the lending giant a quarter of a billion dollars each year to handle nearly all of its guarantor functions - essentially putting Sallie Mae in charge of monitoring itself.

This problem of incestuous lender/guarantor relationships is far from novel. In 1993, for instance, the U.S. General Accounting Office (GAO) raised red flags about these types of relationships, warning that "many guarantee agencies have expanded their operations to activities that create serious conflicts of interest with their stewardship responsibilities in the program."

Given the superfluity of their guarantees and the ineffectiveness of their oversight, it's not surprising to see guaranty agencies stretching into other areas to show their relevance. In fact, guaranty agencies successfully lobbied Congress to insert a provision into a 2006 budget reconciliation bill that explicitly required them to take steps to promote college access -- a role completely unrelated to loan guarantees. Under that law, guarantors are to "promote and publicize information" for low-income students and those from traditionally underserved populations "on how to plan, prepare, and pay for college."

Now, guaranty agencies are using these college access activities to justify their continued existence -- and at least some members of Congress seem to be buying it. In June, caucuses representing black, Hispanic, and Asian American lawmakers sponsored a briefing touting guaranty agencies for their role in "enhancing higher education access and success for minority students."

In a letter to lawmakers announcing the briefing, the leaders of these groups praised guarantors for "support[ing] programs that promote higher education preparedness, access and success for students who are members of ethnic minority groups, including scholarships, early awareness programs, symposiums for minority-serving institutions, research to promote college access for minority students and Spanish-language college planning materials."

The real purpose of the event, which was co-hosted by USA Funds and Texas-based guarantor TG, was to show the damage that would occur to college access efforts if the FFEL program was eliminated, as the presumptive Democratic presidential nominee Barack Obama has proposed. Speaking at the briefing, Marshall Grigsby, a USA Funds board member and former top aide to Rep. William Clay (D-MO), warned that if FFEL is abolished, guaranty agencies "will disappear" and take all the positive college access benefits with them.

While we strongly support efforts to increase college access, we aren't convinced that guaranty agencies are the most appropriate entities to fulfill this purpose. For one, there is no accountability for how taxpayer dollars are spent on these efforts. Congress has put in place no standards for measuring success or effectiveness. And, there is no way to gauge how much federal money guaranty agencies are spending on this purpose.

If, however, guarantors really want to move in this direction, then perhaps it's time to shift the agencies' reimbursement and incentive structure accordingly. Rather than funneling billions of dollars through them as middlemen, Congress should provide guaranty agencies with a simple block grant to help run counseling and education services. In exchange, the Department would take on the reimbursement and oversight roles, functions it already handles or should handle. Collection activities, meanwhile, could be handed over to the same agencies that have already won the competitive bidding on the Direct Student Loan servicing contract. Using a block grant over the current haphazard system would also allow provide a way for overseeing the effectiveness of these efforts.

While these changes might decrease the number of guaranty agencies, that's not a bad thing, particularly for taxpayers. Like the appendix, these agencies have served their purpose, and are unlikely to be missed.

Guest Post: Integrating Student Aid and Tax Benefits

Ed Policy — Tue, 20 May 2008 14:42:00 -0400

By Art Hauptman

Both Sens. Barack Obama (D-IL) and Hillary Clinton (D-NY) have made achieving greater college affordability a high profile issue in their Presidential campaigns. To reach this goal, the two Democratic candidates have proposed expanding Pell Grants and consolidating the current set of tax breaks for college into a single refundable tuition tax credit. Sen. John McCain (R-AZ) has thus far been strangely silent on the topic, despite its importance to so many millions of Americans.

The reach of the Democratic contenders' proposals does not match their rhetoric, however. To truly make college more affordable, the next President will need to push for a much fuller integration of student aid and tax provisions for higher education, as I suggested in my guest post last week.

Any effort to change the current system (or non-system) of student financial assistance should first recognize that federal higher education policy has two distinct goals. The first is to eliminate the chronic gaps in the rates at which students from low-income and high-income families (and between minority students and white students) enroll in and graduate from college. Call this the accessibility problem. The second big goal is to make college more affordable for millions of students from middle class and upper middle class families who have found the ever growing price of college to be a real strain on their budgets. Call this the affordability problem.

The differences in these goals can be readily seen in looking at the history and current array of student aid and tuition tax benefits. The federal student aid programs were created primarily to help improve accessibility for low income students, although over time, they have been used to address affordability issues as well. Starting in the 1990s, policymakers began creating tuition tax credits and various tax incentives for savings principally to address concerns about affordability for the middle and upper middle class, as well as for older students already in the work force going back to school to further their education.

In proposing to consolidate the existing tax breaks for college, and make them refundable for students whose families do not pay taxes, the Obama and Clinton campaigns are seeking to address the accessibility and affordability issues simultaneously. But in taking this approach, they will probably fall short of achieving either goal.

I make this prediction for a couple of important reasons. First, these proposals would undo key tax reforms of the last several decades by requiring millions of low-income Americans who don't now have to file tax returns to reenter the tax rolls in order to quality for the benefit.

More importantly, making tuition tax credits refundable will only make the current structure of student financial support in this country more redundant and less well targeted. By providing an overlap in benefits for some students, it would raise the government's costs significantly without solving the basic underlying problem that college tuition and other charges are going up much faster than many families' ability to pay them.

A Better Approach

A better approach would be to more fully integrate the tax system with student aid in several key ways. One form of integration would be to allow the government to use information from families' income tax forms to determine their eligibility for student aid. Both Obama and Clinton have endorsed this proposal, and it looks like Congress will adopt this change if and when it finally reauthorizes the Higher Education Act. This would be a welcome beginning of the end to the FAFSA and would greatly simplify the much too complex student aid application process.

What is also needed, however, is for Congress to permit students from families who are eligible for welfare, Medicaid, food stamps, and/or the Earned Income Tax Credit (EITC) to be fully eligible for federal student aid. This would be in sharp contrast to the current system in which nontaxable forms of income such as welfare are used as a means to reduce student aid eligibility.

Making these students eligible for the maximum amount of federal financial aid available could yield much greater benefits for at-risk students than making tax credits refundable. This would particularly be so if policymakers are willing to make an important tradeoff: eliminating middle class and lifelong learner eligibility for Pell Grants and in-school interest subsidies in the federal student loan programs in exchange for a much expanded tuition tax credit. Congress could use the savings derived from making the eligibility changes in the Pell Grant program to significantly increase the maximum award for the lowest-income students. Meanwhile, the government could use the savings it would get from better targeting in-school interest payments to pay for the expansion in the tuition tax credit.

A further step in the direction of integration would be to use the 1040A income tax rules to calculate eligibility for Pell Grants for students whose families pay taxes. The income tax rules would then be used to calculate eligibility for both Pell Grants and tuition tax credits (as the amount of a nonrefundable tax credit actually received cannot exceed the amount of tax paid). Using the 1040A rules to calculate Pell Grant eligibility would also eliminate the current practice in the federal methodology that allows tax write-offs for business losses and other above-the-line deductions to increase middle class eligibility for Pell Grants.

These changes would clarify the federal role in helping a broad range of families pay for college. Pell Grants and federally subsidized loans would be used to improve accessibility. Unsubsidized loans and expanded tax benefits would be the principal vehicles for addressing affordability concerns.

In my next two blog items, I will discuss how a more aggressive federal early intervention strategy and finally the creation of a seamless student-centered loan system as key steps to achieving a well functioning federal student support system.

Art Hauptman is an independent consultant on higher education finance issues. His guest blog column will continue to appear each Tuesday in the month of May. Views expressed herein are his own and do not necessarily reflect the positions of the New America Foundation.

'Sub Sub Sub Subprime' Borrowers 100 Million Strong Worldwide and Growing

Jamie Zimmerman — Thu, 17 Apr 2008 12:00:00 -0400

It's all we hear about these days: The U.S. subprime mortgage bubble -- created by poor and at times predatory lending practices and lax banking regulation and creative investment products -- has burst. Of the approximately 7.7 million subprime loans outstanding, over 2 million are at risk of foreclosure and 600,000 borrowers are expected to lose their homes this year. The majority of us are left in shock as we watch the devastation unfold, the bubbles aftermath wreaking havoc on the U.S. (and increasingly global) economy, ensuing fears of recession and economic pain to come, and leaving politicians, economists, and regulators all scrambling to pick up the pieces.
However, in the meantime, the 2006 Nobel Peace Prize winner on Tuesday proudly hailed microfinance -- the innovation of providing small loans to poor, traditionally financial excluded individuals, mainly women -- as "sub sub sub subprime" lending. That means that globally, more than 3300 microfinance institutions provide such "super-subprime" loans to over 100 million clients and growing. Just to be clear: I'm a huge fan of microfinance. However, I'm left perplexed by this dichotomy: How can a lending practice that is almost singlehandedly dragging the whole of the U.S. economy in to a hole simultaneously and sustainably end third world poverty?

Well according to Yunus, the answer is simple - the U.S. subprime crisis was fueled by "sloppy business practices" and complex product, which simply don't exist in the microfinance industry. Finding ways to extend access to credit and financial services to those with less than stellar or no credit or financial history, if done properly, can provide asset-building opportunities to those traditionally excluded and economically disadvantaged. In that sense (and this may come as a shock to those who only know of subprime as it related to the current crisis), subprime lending is not inherently a bad thing.

However, when discussing this issue last night at a CGAP cocktail reception, the answer seemed to be about as complicated as a 5/1 balloon ARM disclosure. Expert discussants, considering the similarities and differences between these sub-prime markets, concluded that microfinance products and services are indeed different from the complex mortgages and bundled securities of the U.S. mortgage market. However, they all cautioned the microfinance industry to take a close look at how certain similarities - the perverse incentives for quantity over quality; the potential of similar "irrational exuberance" of both clients and lenders; the growing influx of new players, products and dis-intermediated capital that could lead to predatory products and practices; similarly, competition among providers that could lead to "race to the bottom" practices and products; the risk of information asymmetries and moral hazard created by increase in disintermediation (which creates distance between borrowers and lenders), and finally, the lack of regulation in many markets -- indeed mirrors characteristics of the sub-prime mortgage market in the United States.

So, my original question remains unanswered, but these new insights beg related, and perhaps more pertinent questions. In our haste to extend the power of micro-credit to the millions living in poverty around the world, how much, if at all, should we head the warnings derived from the subprime crisis? Can light-touch regulation and more concerted efforts enhance consumer awareness provide the balance between providing as much access as quickly as possible to as many as possible and quality of products and practices? Would putting such regulatory brakes on this exploding industry help us to avoid the possibility of a global sub-prime bubble or just deprive the needy of access to finance?

If some predictions are right, then the tightening of capital in the global financial markets -- essentially the effect of failing to address these issues U.S. until it was too late - may inadvertently apply those brakes before we get the chance to answer the question. But with others predicting the opposite (even more capital being diverted into more lucrative, global markets (i.e., microfinance investment)) then we may need to look at these issues more closely, ASAP.

PAYMENT: When the Uninsured Become Insured, Who Will Care For Them?

Joanne Kenen — Wed, 26 Mar 2008 16:51:00 -0400

Dr. Benjamin Brewer, in his Wall Street Journal column (subscription, or read a summary in the Wall Street Journal health blog) wonders: who will take care of the 47 million uninsured in a system that already undervalues family medicine and primary care?

We would suggest that the uninsured are getting care – not enough care, too- late care, expensive emergency room care instead of more appropriate and cost-effective primary care. But Dr. Brewer’s central point is correct. Our system gives short shrift to primary care and is chockfull of incentives for fragmented specialization. In the health care system we envision for the future, primary care doctors (internists, family doctors, pediatricians, geriatricians, perhaps for some women OB/GYNs) would play an elevated role in coordinating patient care. And they would be paid for doing it well.

In the short run, though, there’s no doubt that Brewer is right in pointing out that the system undervalues primary care, both in money and status compared with specialists. The demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000 family doctors at work in 2006, as Dr. Brewer notes.

But students aren’t flocking to primary care, which can have worse hours, less status and lower incomes than specialties. “Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field,” Brewer writes. For instance, only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a two percent increase in family practice residents is cause for celebration among family doctors.

One last word -- we were disheartened that Dr. Brewer and several of the readers who commented on his column equate “universal insurance” with a single-payer government-run Medicare system. They aren’t synonyms. There are many ways to cover all Americans, and nearly all of the plans on the table in Washington these days use a mix of public sector and private market options. The presidential candidates are not advocating plunking an additional 47 million people in Medicare. Len Nichols, director of New America’s Health Policy Program, in a detailed post yesterday explained why simply expanding the 40-year old Medicare program is not the silver bullet for the complicated cost, quality and coverage challenges facing our system.

Keep the Eye on Access

Ed Policy — Tue, 21 Aug 2007 01:00:00 -0400

With all the attention paid to student loans of late, there is a risk that policy makers will lose track of an issue of even greater importance for college access for low- and moderate-income students: grants for postsecondary education. Research has long shown that grants, not loans, are the most…

Note: This post pre-dates Higher Ed Watch's shift to a new publishing system. For the complete original post, including any comments, please click here.

Pulling a Bait and Switch on Veterans

Ed Policy — Thu, 16 Aug 2007 01:00:00 -0400

If you've seen an action film this summer, odds are you've also seen a slick advertisement touting the benefits of joining the Army or Marines-including help paying for college. You won't hear the word "Iraq," and as the Washington Post reported last week, it…

Note: This post pre-dates Higher Ed Watch's shift to a new publishing system. For the complete original post, including any comments, please click here.

Making Wealth Work

Ed Policy — Wed, 08 Aug 2007 01:00:00 -0400

Last week, we discussed the paucity of low-income students at the country's wealthiest colleges and universities. We offered a proposal that would require the richest private colleges to devote a portion of their yearly endowment income to help increase the socioeconomic diversity of their students. Some might argue that there aren't enough qualified underprivileged students…

Note: This post pre-dates Higher Ed Watch's shift to a new publishing system. For the complete original post, including any comments, please click here.