Saturday, July 16, 2011

The Budget "Crisis" and Medical Residencies

Among the more amusing tidbits of news that came out of the state government shutdown in Minnesota were pieces like this in which certain voters expressed outrage over the stalemate and demanded their elected officials to just "get things done". "They could have talked more, but they get their feelings hurt a little bit, and act like a bunch of little kids," said one frustrated citizen. What we witnessed in Minnesota, and what the media is playing up in Washington at this moment, is not merely a bunch of squabbling children, even if there are some childish antics involved. The problem, in Minny as in Washington, is that you have genuinely, truly divided government, with huge blocs of both parties with irreconcilable views about the proper function and structure of government, and to expect them to arrive at agreements on operating costs totally misunderstands the ideology of these blocs. You can't simply expect them to "go and get it done" because there's no consensus on even the most basic roles of government.

Despite what some commentators have said about the current inter-party spats being just more of the same-old same-old, the different visions being fought over today really are much more substantive than any other political fight since the early 20th century. For instance, Richard Nixon and a Democratic-led Congress, while political foils, really did agree on the basics: yes, Nixon presided over some unpleasantries in Vietnam and Cambodia, and obviously sought to limit government in ways that Democrats didn't. But Nixon bought into the concept that government could play a role in preventing drag on the economy, so much so that he proposed a comprehensive health care bill not dramatically unlike the one the current President finally got passed, the hysteria over which led to the election of a House so radically different in philosophy from Nixon (Richard Nixon!) that he would have blushed. Given the budgetary concessions that President Obama has already put on the table, and his breathtaking capitulations since the arrival of the new Congress, the fact that the House "Hell No" caucus won't budge in the current debt-ceiling discussions is evidence enough that this is not just your ordinary political dust-up.

The point here is: if it really does come to pass that the US defaults because of the political stalemate, don't blame them--because the voters were the ones who put Obama into office, and then two years later not only seated an opposition party, but an opposition who would legislate against the sunrise if the President said, "the sun will come out tomorrow" in his increasingly grating Annie-like naiveté. It doesn't make any sense to elect a Democrat like Obama (even one as willing to adopt right-wing talking points as him) and then vote for Republicans further to the right than what even George W. Bush could have dreamed of. At least the voters of my home state of Ohio were consistent when they seated a right-wing executive and legislature in the most recent elections, and now have a new budget crafted by people with a very particular view of the role of government in the lives of its people. Let's see how that one works out for you guys in the years to come; as Chrissie Hynde of The Pretenders once lamented, "Hey, way to go Ohio."

Anyway, this blog is geared toward commenting on such political machinations in relation to the world of medicine (with a jaundiced eye befitting its name), and needless to say the world of medicine is going to undergo serious revisions if the Tea Party really does get its way and something resembling the Ryan medicare proposal (see here if you want to read warm fuzzies about it, and here if you prefer cold pricklies) becomes federal law. (Side note: I think there's a pretty good chance that our "Democratic" President is going to avert this "crisis" by eventually signing legislation that passes with either zero, or very few, Democratic party votes in the House.) And to that end, here are two stories (NYT and Boston radio station WBUR) discussing the huge impact that deep medicare cuts are going to have on teaching hospitals.

To help lay readers understand the structure, Medicare is the government-run health insurance program for senior citizens. While you almost certainly knew this (though obviously some people are not too quick on the uptake), what you may not have realized is that Medicare is also responsible for financing the postgraduate medical training in the US, which costs, give or take, a little over $6 billion per year, although a proposal that even Obama himself endorses would cut that amount by an estimated 60 percent. The feds don't pay residents directly, but rather pay the hospitals running the programs, which tend to be large, academic medical centers. These places may also get hit by a decreasing NIH budget to fund research at those medical centers, as this November 2010 article indicates current House Whip Eric Cantor's philosophy.

While places like New York and Boston are going to be hit disproportionally by major cuts to the residency training budget, you can bet that smaller places like Peoria, Illinois, with its 10 residencies affiliated with two local hospitals, will smart as well. In fact, as residency programs in smaller, more rural communities tend to serve as feeders of physicians who would otherwise not move to such places, the damage to residency training programs is going to reverberate well beyond the hospital parking lots, and have a good chance of doing so well into the future.

Perhaps this will all work itself out and the changes will benefit everyone; perhaps all that extra money from the taxes that nobody seems to be paying will give taxpayers more money to afford...well, afford something. We shall see, though hope (© Senator Barack Obama, 2008) is becoming as thin as gruel. Dickens would appreciate the consistency.


  1. When did Nixon try to "limit government"? He presided over extraordinary growth of government: intrusive environmental laws, expanded federal role in local crime, the idea of an unanswerable executive branch, and, for God's sake, freaking top-down wage and price controls. Nixon may have been a Red-baiter, but he was not a small-government conservative by any stretch of the imagination.

  2. I don't want to make too much of a quibble since I don't think we fundamentally disagree, but I didn't say that Nixon tried to "limit government," I said that he sought "to limit government in ways that Democrats didn't". To the kind of small-government conservatives of the Hell No caucus, such differences may seem laughable (here is VP Nixon's 1960 take on how the economy provides for the federal government's work:, but at that time they didn't regard such disagreements as hair-splitting. I concede that I could have phrased Nixon's differences with Dems better since his bedrock philosophy was not focused on limiting government.

    Anyway, this whole discussion only serves to underscore my point that the showdown taking place in Washington right now really is a fight over fundamentally irreconcilable differences in philosophy of government (although it seems that Obama's only philosophy is that he would like to become a two-term President), which was not really the case between the two parties as recently as a few years ago.

  3. Joseph P Arpaia, MDJuly 16, 2011 at 11:02 PM

    Its the old question: Guns or Butter? You can't have both and neither party is willing to come to terms with that. If we ended the "War on Terror" and the "War on Drugs" we would have plenty of money for health care and lots of other things and we could probably even cut taxes too.

  4. Thanks for the post. For me to explain my qualms with how you've framed the issue would take us far afield from this discussion, but suffice it to say I'd describe the situation differently.

    Please forgive me in advance for quibbling a bit, but the "War on Drugs," while obviously important from a policy standpoint, isn't really a major drag on the budget. As seen here ( the federal budget consists mainly of Medicare, Social Security, and defense spending, which accounts for two-thirds of the federal budget (and there's additional defense spending in the "discretionary" category, so the percentage is higher still). So in terms of the War on Drugs, or any other social programs outside of Medicare or Social Security, we're talking peanuts. Even the entire budget of the NIH, which is about $33 billion annually, is a drop in the bucket of the ~3.5 trillion budget of FY 2010.

    I do agree that the misadventures in Iraq (I'm less clear on what should have been done in Afghanistan) were incredibly costly and that the US would do well to curtail its military spending, which last time I checked accounted for more than the rest of the world's spending combined.