The hero tax
Why do we make it so expensive to be a doctor or a nurse?
Just before Christmas, the Biden administration announced an extension of the pause on federal student loan repayments, “as we manage the ongoing pandemic and further strengthen our economic recovery.” The subtext of this was that the “ongoing” pandemic was about to get much worse, as the Omicron variant spread; six weeks later, new cases have fallen from their peak, but daily deaths continue to rise. We’ll likely hit a million dead before the repayments start again on May 1.
Though Joe Biden promised to cancel at least $10,000 per person of student debt, his administration has… not done that. The Daily Poster reported this week that Biden’s administration even appealed a ruling in Delaware that eliminated the $100,000 student debt of an epileptic man, who the judge found would never be able to pay back his debt—a move that “could preclude even the most beleaguered student debtors from getting relief through bankruptcy courts.”
A large majority of doctors and nurses need loans to get their degrees. Becoming a doctor is usually even more expensive than becoming a lawyer, and like with law school, those debts push doctors away from serving poorer populations. Nursing school isn’t as expensive, but the eventual pay is also much lower, and the shortage of nurses across the country speaks to the dire conditions and pay pushing people out of the profession, or into travel nursing.
Starting up loan repayments just as we started to trend towards closures and shutdowns again (however limited and uneven this may have been) would have been difficult for anyone with student debt. For healthcare workers, though, it would have been just obscene. Once again our country asked them to work tirelessly and thanklessly as thousands died, to watch helplessly as their ability to care for patients withered away. The extended pause is good; the question is, what will have changed by May? Will we have Returned To Normal? Will healthcare workers no longer be heroes?
I talked to five healthcare workers about their loans—how the pause has affected them and their finances, what they owe, and how they feel about the prospect of paying up again. Most of their names have been changed to allow them to speak freely.
If you’re a healthcare worker with loans, I’d love to hear from you, too. You can reach me at sicknote@substack.com. I might share some excerpts in my Sunday post this weekend; just let me know if you want me to keep your name, or any other details you want to share, private.
Sandra is a registered nurse in Pennsylvania. (Full disclosure: Sandra is a friend of mine. I changed her name.) Her training took about four years in total and cost around $55,000, but with living expenses, “it was closer to $75,000.” Federal loans only paid for a portion of that—around $7000 per semester—because she already had a degree, so the rest had to come from private loans. Her minimum monthly payment for the federal loans was around $400; for her private loans, which was never paused, the minimum is around $700 per month. Since the pause has been in effect, Sandra paid off “a good portion” of the private loans, since she’s had a little more money to spare. But those federal loans are “still there, just waiting.”
She currently earns about $33 per hour, after a four dollar per hour boost for working nights—so it takes about 20 hours each month to earn enough to pay the minimum on her debt, though that’s before tax. She also earns a bonus for picking up a mandatory extra shift, which takes her to 48 hours of night shifts per week. She finds these hours exhausting, and wishes she could work less. She works on a cardiothoracic surgery floor; she’s only supposed to have five patients, but she usually has six or seven because of nursing shortages.
Sandra told me she wished she did travel nursing, but for now, she’s stuck in her job in Pennsylvania. When she moved there from Michigan last summer, she was offered a $15,000 sign-on bonus, in exchange for a two year contract. That went down to about $10,000 after taxes, she said—but if she wanted to end her contract early, she’d have to pay the full $15,000 back. She shared the contract for her bonus with me, and it’s stacked with clauses explaining how her employer could claw back their money if she quit early, or even went part-time. They can take her unused paid time off, or withhold her final paycheck. Even with all those threats, travel nursing could be a better proposition; she could make that back in a month, depending on where she went. No wonder so many nurses are doing it.
Those nurses include Ashlyn, who recently left her job in Colorado for a stint doing travel nursing in Brooklyn. Why the move? “Just the pay, honestly,” she said: “I was getting paid much, much less there—for how much work it was, I just didn't feel it was worth it.” She said she cared for a lot of COVID patients, including the “overflow” units—the patients without actual rooms, who are “just kind of in a hallway.”
The pause in federal loan repayment “definitely” helped her pay off her private loans, which were about $900 a month. She graduated with $45,000 in debt, which is now down to just the $22,000 in federal loans. Knowing that these loans were starting up again “definitely” affected her decision to move to travel nursing, she said:
“The past couple years, working so much, just having to add that onto my monthly bills just feels super demoralizing. All the work that especially fellow nurses have done on the COVID units just doesn't really feel appreciated in that way, with the loans beginning again. It just feels like we have had not even a single ounce of relief or even anything offered to us.”
I asked her about one frequent criticism of proposals to cancel student debt—what about people who already paid off a lot of their loans, like she has? Is that unfair? She doesn’t feel that way: “I don't want anybody else to go through that so I would have no problem giving people the opportunity to not have any student debt ever again.”
Luke* is a pediatric resident in Georgia, at a large, for-profit hospital chain. His med school training ended up costing about “$400,000 and some change.” He graduated just as the pandemic started, so he hasn’t had to make payments yet.
Pediatricians are the lowest paid physicians: They make an average of $220,000, which is $120,000 less than the average for all physicians, according to a survey last year. Their median pay is even lower, at $177,000. That’s obviously still a lot of money compared to most Americans, but it makes it harder to pay back debt that’s higher than the price of the average house, especially when that keeps growing with interest.
And for residents like Luke, it’s hard to make a dent in those debts at all. He makes around $55,000, a little lower than the national average for pediatric residents. Worse still, he said, “there's not really a lot of ways to increase your earning potential while as a resident.” He works around 60 hours a week, and he’s prevented from picking up many moonlighting shifts by restrictions on his working hours. He could sub-specialize and add on a fellowship, but even that would only add “$2000 or $3000” to his salary, in exchange for an extra three years of training.
Luke said he didn’t go into pediatrics for the money; in general, he says, medicine is “a stupid way to go about having that level of income,” because of the debt and the level of training involved. He’s always wanted to work with kids, and feels that’s how he can have the most impact. But he’s irritated by the “empty gestures” towards healthcare workers in the pandemic.
“We're doing what we signed up to do for the most part; granted, this is a little bit of an extra that a lot of people didn't anticipate. But at its core, this is what we signed up to do is to take care of people in these vulnerable moments, and in these difficult times. To see the whole, we owe you this incredible debt, and then it's like, ‘okay, how about, we collect our money now?’ And then it's like, okay, do you really think you owe us anything? I just feel it's a lot of empty gestures.”
Thomas* is a licensed therapist in California. Like Luke, he hadn’t had to pay back any of his loans yet when the pandemic started. His debt is “relatively mild” compared to some of his peers, he said—“probably $50,000 to $60,000”—but “of course, that'll grow, if it turns back on.” Thomas serves patients who are diagnosed with severe mental illness—mainly psychotic disorders, he told me, but he specializes in substance use disorders. All his patients are on Medi-Cal, the Medicaid program in California. Serving this population usually comes with lower pay; after all, Medicaid generally reimburses providers less than Medicare, let alone private insurance.
Now that he’s been working for a couple years, he’s fully licensed, meaning his “opportunities to make money have opened.” Once he has to start making repayments on his loans, “that will weigh heavier; some of those offers that are not in this underserved population might be more attractive.” A private practice psychotherapist makes twice as much as he does, he told me:
“This isn't totally due to the debt situation, but I started as very committed to that—like, ‘oh, I'm never gonna go to private practice ever. I'm a public mental health worker for life, this is what I'm going to do.’ And I've started a small private practice, I see a handful of people privately for private pay, I charge a very low fee, and try to reach people that are not on Medicaid, not on private insurance—or rather, maybe they are on private insurance, but that doesn't cover it—but charging a modest fee. But today, total 180 of where I was two years ago, like ‘I could do private practice, and maybe I'll just go feed the homeless on the weekend or something.’”
I asked him how he feels about the prospect of having his loans turned on; “angry,” for sure. But he also said he still believes they’ll cancel it. “Maybe that's just delusional,” he said, but he’s not yet fully convinced he’s going to have to pay them back. If he did, he said, that would be the line that was crossed—he would “never, ever” vote for Democrats again, though he hasn’t voted for them since 2008 anyway. Many of his colleagues are already pretty disengaged from politics, he said, so “it wouldn’t turn them off if it didn't get canceled because they're already turned off in many senses.” But, on the other hand, he suspects that ”the relief that would come” from having their debt canceled would turn them into “lifelong Democrats.”
Mark* is a neuropsychologist in Michigan. Most of his work is inpatient care at the hospital, where he performs cognitive assessments of patients, often to determine if they’re capable of making decisions about their own care. He has had some Covid patients, but the pandemic has mainly affected his work in how he deals with other physicians. Before the pandemic, he “would have followed up with them quite a bit and had some long conversations about some of the issues” and “really nail it down a little finer,” but since Covid hit, he has “tried to minimize how much we're asking them to clarify, do a little bit more of the legwork, because they're stretched so thin already.”
He left school with $110,000 debt; in the six years since then, that debt has only grown, due to interest. He does income-based repayment, and he was paying around $700 a month before the pandemic. The pause was a “big weight” off his shoulders, he said. $700 is roughly half his mortgage every month. He knows a number of people who have been working in his field “for 20 plus years, and they're still paying some of those debts.” But he’s hoping that won’t be him: He works for a non-profit hospital, and hopes that will mean he’ll qualify for the public service loan forgiveness program, which Biden did revamp. (Contrast this with Luke, who works for a for-profit hospital chain; he won’t qualify for relief of his $400,000 in debt, even though Luke considers what he does “public service” just as much as any other doctor. He certainly doesn’t have much opportunity to get rich yet, with a $55,000 salary and $400,000 in debt.)
Still, even if Mark’s debt is eventually forgiven, he’s got years of payments to go before he qualifies. His hospital is also switching how it compensates physicians to a system that includes patient survey ratings and RVUs, essentially a measure of doctors’ productivity that we’ve discussed here before; this is causing “anxiety” among his colleagues, he said, because “you don’t actually know what [your] total pay is going to be,” making it hard to budget. And that’s no small thing, since “many of us have children; all of us have debt.” (It didn’t help that the expanded Child Tax Credit expired in January, either.)
The day I spoke to Mark was the day that the administration announced it would extend the pause on repayments to May 1st. I broke the news to him; he said he felt “a little bit relieved,” but also that it was “the bare minimum” given the Omicron wave that was about to hit.
“It could have been worse, and I don't know what that says about my expectations. It seems a bit arbitrary. There's nothing about May, in particular, I think that really makes that an ideal destination.”
This echoes what I heard from everyone I spoke to: Why does any other date to start repayment make much more sense than another? Sure, delaying it beyond the Omicron wave is better than nothing; it would have been truly insulting to restart payments while hospitals are still overflowing with patients. (Of course, it’s hard to predict whether May will be much different on that front.)
It took a pandemic to pause these payments, probably for longer than our leaders ever thought. But like so many policies that were apparently quite firmly within the government’s grasp this whole time, it makes you wonder: What is the value in making healthcare workers pay back debt at all, plus interest, for years and years? Even putting aside the pandemic—the hours and hours worked, the exposure to the virus, the horrors on the wards they staffed, watching their colleagues struggle and burn out and quit; then the reaction of their bosses, using predatory contracts to trap them instead of making conditions better—what do we get out of saddling people who want to go into this difficult and unforgiving field with tens or hundreds of thousands of dollars in debt?
In many ways, it’s a logical extension of our individualized, profit-focused healthcare system. Charge people insane tuition to qualify for these jobs (while letting someone skim interest off the top, of course), so that the only way they can come out ahead is only to look out for themselves. Seek the highest paid specialties, or the best paid regions, or the patients with the biggest insurance payouts—not the areas that need staff the most, or the populations that need the most care—because otherwise they’ll fall behind on payments, or just be paying off interest for the rest of their lives, like a tax on going into healthcare at all. If you think of someone training to be a doctor as a person learning how to run just another type of profitable business, then sure, maybe it doesn’t make sense to you to pay for their schooling.
The term for healthcare workers in the pandemic has always been “heroes,” and they are that, of course. But the government is the one stuffing them in the cape and tights and pushing them onto the train tracks. It doesn’t have to be quite such a sacrifice to work in healthcare, in normal times or even during a pandemic, because there’s more that could be done for them that isn’t being done. That could include better pay, letting them unionize, tighter restrictions on maximum work hours or patient loads, increasing the number of residencies, or many other policies.
But the most basic thing that could be done to make life easier, and just to say ‘thanks,’ is to decouple this important work from debt. Of course, that involves canceling current debts. It also would involve making it free to attend medical school—which would also help make the field more diverse—and nursing school. It should be part of a general reimagining of healthcare as a public service, and not just another business. If we treated healthcare as a universal right—something that we do for each other, as a society—and didn’t pretend that it’s just another way to make money, then it wouldn’t make sense to do anything but subsidize the training of its workers.
It would be awful if the administration made healthcare workers start paying their loans during a wave like Omicron, or during the pandemic at all. But there’s no point at which it makes sense to do it. It never made sense before the pandemic and it certainly won’t after. There’s no state of affairs, ‘normal’ or otherwise, where it would be right to turn around and say that these people owe us money for becoming doctors and nurses. If anything, we owe them.