Regular readers of this blog know I sometime stray from the topic of healthcare to passionate issues of mine. One of those is school choice. School choice represents the solution to the problem of poor education, especially in low-income families who can’t afford better. School choice is the path to upward mobility for these children who need a good education to get ahead in this world.

We tend to think of this problem as an inner-city phenomenon, where poor public city schools trap low-income minority children in a never-ending spiral that keeps them impoverished – and that’s certainly often the case. But this problem also is experienced in rural America, where good public schools are often rare, too.

Republicans are correctly associated with favoring school choice in most states, while Democrats usually oppose school choice in deference to their teachers unions supporters. But in rural America, even the Republicans have often opposed school choice, encouraged by teachers unions. But now that pattern may be changing.

Corey DeAngelis, writing for The Wall Street Journal, tells us the Wyoming Senate passed a broad school-choice bill Thursday by a vote of 28-3. The bill would establish Wyoming’s first education savings account program, allowing families with preschool- to high-school-age children earning up to five times the federal poverty level—$156,000 for a family of four—to take their children’s state-funded education dollars to the public, private, charter or home-based providers of their choosing. The grant would start at $6,000 for children in the lowest income category and decline with rising family income. The bill has already passed in the House, so it now heads to Governor Mark Gordon for his signature.

This breaks the trend for Republicans to oppose school choice, backed by the teachers unions. They say their constituents don’t want it because there aren’t many private schools in their districts.

Yet the nine most rural states in the country (as measured by population share) now have some form of private school choice. Maine and Vermont have the oldest private-school voucher programs in the U.S., both enacted in the late 19th century for students who live in rural districts without public schools. Both programs allow state funding to follow the child to the public or private school his family chooses.

In 2021 West Virginia became the first state to make school choice available to all families, regardless of income. And in Alabama last Thursday, Gov. Kay Ivey signed a universal school choice bill into law. That is notable because the state teachers union, the Alabama Education Association, has contributed more than $3 million to Republican legislative campaigns since 2018. A report by the Alabama Policy Institute last year found the union “was the single largest contributor to Republicans in the last election cycle.”

Mr. DeAngelis is a senior fellow at the American Federation for Children. He says, “In Texas my organization’s super PAC, the American Federation for Children Victory Fund, targeted 13 antichoice Republican incumbents for defeat in last week’s primaries. Ten either lost outright or were forced into runoffs. Rural Republican resistance to school choice is crumbling. Now if only Democrats would get on board.”

Former U.S. Secretary of State Condoleezza Rice has called it “the civil-rights movement of our times.” School choice is the freight train coming that can’t be stopped. It’s time for all Americans to “get on board!” The education of our future generation is at stake.

Socialized medicine has been the goal of Progressives for over 100 years. Yes, since the days of President Teddy Roosevelt, the first Progressive president, there has been a move to socialize all medical care. That means government control of healthcare.

ObamaCare was passed in 2010 without a single Republican vote, but it represented a major step forward in this process of socializing medicine. At the time, Vice President Joe Biden was caught on a hot mike telling President Barack Obama “This is a big f______ing deal!”  Yes, Joe, it is.

Recognizing it was politically impossible to come right out and say they wanted socialized medicine, the Obama Administration pushed through the Affordable Care Act with a provision that forced all states to accept expansion of Medicaid to previously ineligible Americans. However, the Supreme Court struck down this provision of the bill and left it up to the states to decide if they wanted to expand their Medicaid.

The expansion of Medicaid in the ACA (ObamaCare) called for no cost to the states for three years, but thereafter they would have to pick up the tab. This bargain with the devil has had severe consequences for many states who accepted the deal.

The AP says that California expected 800,000 new enrollees after the state’s 2013 Medicaid expansion. The real number was 2.3 million. In New Mexico, new enrollment exceeded estimates by 44%. In Oregon actual enrollment exceeded expectations by 73% and in the state of Washington by more than 100%. Needless to say this has crushed the budgets of these states. Illinois once projected that its Medicaid expansion would cost the state $573 million for 2017 through 2020. But enrollment has exceeded expectations by 200,000, leading to a new price tag of about $2 billion, according to the Chicago Tribune.

Alas, many more states have given in to pressure to accept the Medicaid expansion and now we are learning of other severe consequences. In addition to blowing up the budget of many states, many hospitals are closing their doors.

Hayden Dublois and Michael Greibrok, writing in The Wall Street Journal, says there are only 10 states left that have resisted the Medicaid expansion. They are the lucky ones!

They reported their new research which looked at 4,000 hospitals nationwide, examining their federal filings to see how they fared financially. In 2013, the final year before ObamaCare’s implementation, hospitals in expansion states reported just over $10 billion in losses due to Medicaid. The most recent data, from 2021, show the shortfalls ballooning more than 115%, to $22.3 billion. By comparison, the shortfalls in states that didn’t expand Medicaid grew by only 6%. When the data from 2022 and 2023 become available, they’ll likely show even bigger losses in expansion states.

Such massive red ink is written into Medicaid’s flawed design. The program reimburses hospitals a mere 78% of what Medicare pays for the same treatments and procedures, and 62% of what private health insurance pays. Expansion pushes far more people off private insurance and onto Medicaid, meaning hospitals make less on the same patients they may have seen before. And they’re seeing far more Medicaid patients than expected. As of last year, nearly 20 million people received Medicaid through expansion nationwide, compared to initial state estimates of less than seven million. All of them are able-bodied adults. Total Medicaid enrollment is more than 90 million.

Hospitals must cover the shortfalls somehow, but they have no good options. They can lobby state lawmakers for more taxpayer funding, which is a challenge in an era of tight budgets. More likely, they’re raising the costs they charge to private health insurance companies. In other words, they’re forcing some patients to pay more because Medicaid expansion recipients pay less. That necessarily drives up the cost of health insurance, which rose 4% between 2022 and 2023 and another 4% heading into 2024.

The soaring costs persist because Medicaid expansion continually shrinks the number of people on private health insurance. Every year, there are fewer people to stick with higher prices and more people paying less than the cost of the care they receive. There’s a name for that: A death spiral, and it’s already killing hospitals nationwide.

In the South, Arkansas’s Crittenden Regional Hospital had a nearly $7 million surplus before Medicaid expansion. It closed in 2014 after profits turned to losses. In the Midwest, Illinois’s Westlake Hospital managed a surplus before expansion, but by 2019, a nearly $7 million loss pushed it out of business. Rural hospitals appear to be hit the hardest. At least 12 have closed in expansion states despite promises from activists and experts that expansion would not only save rural hospitals but also add hospital jobs.

The facts haven’t stopped ObamaCare’s advocates from demanding that the 10 holdout states embrace this foolishness. The way they tell it, these states are heartless, leaving needy people out in the cold. Yet Medicaid expansion hurts the needy, since it forces some of the most vulnerable patients to compete with able-bodied adults for the same care, making wait times and health outcomes worse.

In summary, Medicaid expansion is bankrupting states and hospitals. Many hospitals are closing their doors because they can’t keep up with the red ink and they can’t pass the losses along to their private patients. The net result; less state money for education and other priorities, fewer hospitals to care for the needy -especially in rural areas, poorer care for more patients, and higher private healthcare insurance policies. It’s clear that 10 years after ObamaCare we’re still seeing the negative impact of this disastrous legislation.

When I started medical school in 1975, the tuition was $8500.  This figure is indelibly imprinted on my brain since I was paying for it myself. I was able to make the payments through accumulated savings from two years of work before beginning school, low-interest loans, and a part-time job in the school emergency room. I finished school with about $25,000 of debt but I was able to pay off these loans in about ten years after graduating.

Inflation has averaged 1.41%/year since 1975 making $1000 in 1975 worth $5591 in 2024. By this metric, medical school today should cost about $47,523. But, alas, many schools are charging $100,000 or more. It’s not unusual for students to complete their studies and have $300,000 or more in debt to pay off.

Some medical schools are trying to address this problem. Thanks to a $1 billion donation, the Albert Einstein College of Medicine in New York recently announced that it would go tuition-free, joining a growing movement to sharply reduce the financial barriers that can deter aspiring doctors.

According to the AMA, it is estimated that more than 83 million people in the U.S. currently live in areas without sufficient access to a primary care physician. The American Association of Medical Colleges projects a national physician shortfall of at least 37,00 – and possible well over 100,000 – over the next decade.

Reasons for the Physician Shortage

The AMA lists the following reasons for the physician shortage:

• An increasingly impersonal and bureaucratic health care system that places enormous administrative hassles and burdens in our lap each day, and leaves us feeling powerless to make any meaningful change.
• Physicians today, on average, spend about two hourson paperwork for every one hour we spend with patients.
• An attack on science that undermines trust in our medical institutions, and too often leads to threats and hostility directed at us and other health care workers.
• Government intrusion into health care decisions and aggressive efforts in many states to criminalize care supported by science and evidence.
• Increasing consolidation across health care that is giving more power to our nation’s largest hospitals, health systems and insurers, and less autonomy and fewer choices to patients and doctors.
• Widening health disparities for historically marginalized communities, by race and by gender, between wealthy and low-income, and people living in urban and rural settings.
• The twin health crises of firearm violence and drug overdose.
• And for the last 20 years, a shrinking Medicare reimbursement rate for physicians that has pushed many small, independent practices to the brink of financial collapse and jeopardized care for millions of America’s seniors.

For all these reasons, the physician shortage is expected to get worse, not better. Therefore, solutions to this dilemma need to be found. Lowering the cost of medical school – even making it free – is an excellent idea. Thanks to the generosity of some donors, this may be possible.

Melissa Korn, writing for The Wall Street Journal, says some medical schools, like New York University, are taking the free-tuition-for-all-approach. Others, such as the medical school of Columbia University, award scholarships specifically for students who demonstrate financial need. Most schools also provide low-interest loans with flexible pay-back plans.

The programs, backed by hundreds of millions of dollars in donations, have led to jumps in applications at several of the schools. School officials say they show promise in attracting more students from underrepresented backgrounds, but critics warn their reach is limited given how selective most of the participating institutions are and how heavily some weigh standardized tests in admissions. But lowering standards for training doctors is not an option.

I am not an advocate of free college tuition, but to serve the growing need for physicians, such programs in medical schools make good sense, especially when they are paid for by generous donors and not the government. I would even support government subsidies if they are tied to commitments to practice in under-served remote areas of the country.

We certainly need to find ways to incentivize young people of all socioeconomic backgrounds to consider medical careers if we’re going to meet the growing need for physicians in our country now and in the future.