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Medscape
23-05-2025
- Health
- Medscape
Changes in Public Service Loan Forgiveness Worry Doctors
For most American medical students, graduating doesn't just mean starting the job they dedicated years of training to — it also means paying off student loans. Physicians hold the highest student debt of any profession, with an average of over $230,000 for medical school alone. About a third of medical students say they plan to use the US Public Service Loan Forgiveness (PSLF) Program to pay off federal loans. If they work in a qualifying hospital or clinic for 10 years and make 120 monthly loan repayments, the rest of their debt will be erased. The amount forgiven depends on salary and the amount of loan repayments. Some students and physicians are alarmed by language tucked into the Republican budget bill, now being debated in Congress, that would exclude residency years from counting toward PSLF. Residencies can range from 3 to 7 years depending on specialty. 'At a time when our country urgently needs more doctors, especially in underserved areas, this bill would create new financial and logistical barriers that disproportionately harm low-income students,' warned Shannon Udovic-Constant, president of the California Medical Association. At the same time, the Department of Education is holding public hearings on student loan program rules with the possibility of limiting which hospitals and clinics are eligible for PSLF. The agency did not respond to Medscape's request for comment. Today, rural and community hospitals, Veteran Affairs health services, and most nonprofit and academic medical institutions qualify for PSLF. Graduates can start their 10-year countdown at the beginning of their residency. Critics of the proposed changes say that making it harder for new doctors to use PSLF will discourage them from choosing lower-paid specialties like primary care or pediatrics and could reduce access to care in rural or underserved regions. 'I went into pediatric endocrinology knowing that I would work for an academic non-profit hospital, and as such, would qualify for Public Service Loan Forgiveness,' wrote Brittany Bruggerman, a pediatric endocrinologist at the University of Florida, on Facebook. 'If I thought I would have to pay back my $200k of loans on my own… I may have made a different choice.' Limiting Options for Physicians These aren't the first attempts to reform the PSLF. While an important lifeline for many students, the program is far from perfect and suffers from bureaucratic hurdles and an overall lack of clarity, said Dimitri Koustas, an assistant professor at the Harris school of Public Policy, University of Chicago. Some of the rules of the program, including income thresholds and which employers qualify, can seem arbitrary, he said. The proposed PSLF changes reduce rather than expand eligibility. The intent is to address what is referred to as the 'doctors' loophole,' explained Audra McGeorge, communications director of the Republican-controlled House Committee on Education & the Workforce. Doctors who begin repaying their student loans during residency do so on a low salary which rises significantly once they become attendings; so for those years, they benefit from a high discount on their loan repayment. Supporters of PSLF changes say residency years should be considered part of doctors' education, not employment. To that end, the budget bill would allow physicians and dentists to defer loan payments during their residency years without accruing interest, based on the premise that residency is education, not employment. That would benefit residents earning lower salaries, said McGeorge. Currently, federal loan payment can be deferred during residency, but in some cases interest continues to accrue. Broader Repercussions for Healthcare Medical organizations and students worry that the proposed PSLF changes could have long-lasting repercussions for doctors' careers and for healthcare more broadly. Reducing PSLF's benefits for medical students 'could have the effect of pushing indebted medical students away from academic practice and away from lower paying specialties,' said Jim Dahle, an emergency physician and the founder of The White Coat Investor, a personal finance site for doctors. Some low-income students, worried about decades of debt, may decide not to pursue medicine at all. For medical students, having residency years no longer qualify for PSLF 'would be a major blow,' said Santoshi Billakota, a neurologist and epileptologist at Wyckoff Heights in Brooklyn, NY, and the co-host of Be Empowered, a podcast offering financial advice for doctors. 'PSLF was one of the few incentives encouraging new doctors to work in underserved or rural areas that often pay significantly less.' Doctors and students also noted that, due to the structure of the residency matching process, they have limited control over where they end up in residency, and those who ended up in lower-paying positions would be penalized if they couldn't offset the loss of income by participating in PSLF. The National Resident Matching Program, which places medical students in residency, did not respond to Medscape's request for comment. A Threat to the Healthcare System The intent behind the PSLF program, said Koustas, is to encourage professionals — in this case doctors — to take on roles they would otherwise remain unfulfilled because of the incentive of seeing their debt forgiven. Once that incentive is gone, his research found, people tend to leave their posts and gravitate toward higher paying positions. This, said Koustas, was the unexpected part of forgiveness that happened during the Biden administration, which granted borrowers a one-time adjustment that would include payments made outside of qualifying employment to count toward debt forgiveness. 'We did see that people switched out of public service and the not-for-profit sectors when they got forgiveness,' he said. 'I am a physician who is currently enrolled in PSLF. Neither of my parents were college educated nor did they have the funds to pay for my education,' said Mary Flaherty, a neurologist. 'It saddens me that other people from my background will not be able to access higher education to make our country better. I would not be where I am today if it were not for federal student loans.' Koustas' research confirms that first-generation students and those from lower income tend to be more debt averse and may be more likely not to choose an expensive educational path if it didn't come with an early opportunity of debt relief. 'I entered medicine not for personal financial gain, but out of a sincere desire to serve our nation's military veterans,' wrote Austin Miller, an incoming resident in Physical Medicine and Rehabilitation at Sinai Hospital of Baltimore, in a comment to the Department of Education. 'The PSLF program has been the only realistic path forward to both manage [my] debt and serve in a lower-paying but essential public sector role, such as practicing at the VA after residency.'
Politico
17-05-2025
- Business
- Politico
Bleak budgets shadow Newsom's 2028 ambitions
SACRAMENTO, California — Gavin Newsom's final years of overseeing a massive state budget will be lonely ones. The California governor, who has less than two years left in his last term and is widely considered a potential 2028 presidential contender, is facing intense backlash from close political allies over his plan to close a $12 billion shortfall — which included deep cuts to Planned Parenthood and health care for undocumented immigrants. Next year could be even worse as forecasters project deficits for years to come. In a bitter twist, his nemesis in the White House is forcing many of these painful choices, ensuring months of brutal headlines for the ambitious Democrat. Economic upheaval from President Donald Trump's trade policies, on top of yet-undetermined federal funding cuts, will likely drag state spending talks into the fall — a connection Newsom made clear as he released his plan with a reference to the 'Trump slump.' The governor will now spend his final stretch in Sacramento paring back some of those accomplishments, muddling his record and straining his relationships with supporters who cheered him during the flush years — many of whom he'd turn to for a presidential run. 'Through no fault of his own, the governor's going to have to navigate through a very difficult time,' said Democratic political consultant Darry Sragow. 'He's going to have to make very hard decisions and be prepared to take a lot of heat. He may lose friends, he may lose political standing.' The gloomy finale — which will shadow his next political move — is a stark reversal from years of booming surpluses that allowed Newsom to enshrine legacy projects like universal health care and early childhood education, send voters rebate checks, and deliver for influential players like organized labor. Longstanding allies in the California Medical Association and Planned Parenthood lambasted the governor for cutting reproductive health dollars and Medicaid services. Immigration advocates and Democratic lawmakers excoriated him for seeking to cap health insurance enrollment for undocumented immigrants. Unions blasted his proposals to cut money for long-term caregivers and childcare workers. The broadsides came with a biting message: Newsom is shirking the kind of leadership he champions to counter Trump, cutting Medi-Cal in the midst of federal efforts to shrink Medicaid. 'The proposed budget is catastrophically misguided given where we are as a country,' said Assemblymember Alex Lee, head of the Legislature's progressive caucus. SEIU California Executive Director Tia Orr — who's typically reserved in criticizing a governor who has helped her union group secure major wins — warned the budget fundamentally misreads a political moment in which Democrats are struggling to connect with many voters. 'In this past election, we saw so many questions about what electeds are going to bring to working-class individuals,' Orr said. His budget, she added, 'is one that I'd call more centered on the wealthy, protecting CEOs and those with vast wealth.' Newsom has pinned much of the blame on Trump, estimating tariffs would bleed some $16 billion from state coffers by undercutting core industries and convulsing the stock market. But the governor oversaw a costly and politically combustible state spending initiative — the expansion of a program offering free health insurance to undocumented immigrants — even as Republican foes warned about the price tag. Newsom called the program both fiscally prudent and morally laudable. Now he is retrenching. His proposal would cap the enrollment of undocumented adults and charge them a monthly premium. The governor has insisted he is stabilizing the program, not walking away from it. But in doing so, he has managed to both infuriate the program's liberal supporters and reinvigorate Republican attacks about excessive government spending — fodder for rivals to his left and right in a national campaign. 'He's trying to blame Trump and tariffs for his budget deficit when it's been very clear this deficit was coming, it was just a matter of how big it was going to be,' said Assembly Minority Leader James Gallagher. 'We're continuing to fund healthcare for illegal immigrants, and it's not sustainable.' The budget proposal preserves some of Newsom's biggest legacy projects, like universal pre-kindergarten for 4-year-olds, that he built across multiple budget cycles. During his budget presentation, he touted the state's booming GDP as a sign of its continued economic dynamism — a goal that former and current aides describe as a central part of Newsom's fiscal vision. 'What the governor believes is that California is the example of progressive pluralism that is also economically dominant,' said former administration official Jason Elliott. 'In order for the right-wing ideology to be correct, California can't succeed.' But despite the pace of new patents and initial public offerings, voters living in the world's fourth-largest economy are still feeling profoundly pessimistic about the economy — and the polling shows it. Newsom's approval ratings have dipped underwater, and voters have overwhelmingly concluded he's more focused on his national prospects than on fixing his state's problems. A drumbeat of headlines about deficits and cuts is unlikely to turn that around, noted Berkeley Institute of Governmental Studies poll director Mark DiCamillo. 'The last two years could be consequential,' DiCamillo said. 'If things turn negative for California, which looks likely to happen, I don't think he'll end up with positive job approval ratings.'
Politico
15-05-2025
- Health
- Politico
There are no best friends on budget day
MEDICAL DEBT: For a man who came into office calling himself the 'health care governor,' filled his office with health industry insiders and enjoyed massive financial and campaign support from the health care sector, Gavin Newsom made some surprising moves to close the state's budget shortfall. The budget plan Newsom unveiled yesterday not only includes deep cuts to Medi-Cal and Planned Parenthood — it also sweeps billions of dollars from a health care ballot measure championed by a who's who of health care interests into the state's general fund, sparking intense and personal backlash. Newsom has had an exceedingly close relationship with prominent players in health care, especially organizations like the California Medical Association and Planned Parenthood. Leaders from Planned Parenthood, a major force in Democratic politics, handed out 'WE LOVE GAVIN + JEN' T-shirts on election night in 2018, and helped Newsom fend off a recall attempt in 2021. The governor's inner circle is full of people who have notched time in the industry — either in-house or as consultants — like Jim DeBoo, Erin Mellon, Stuart Thompson, Anthony York, Brandon Richards, Dana Williamson, Dustin Corcoran and Jason Kinney. The ties are personal, not just political. For those who don't remember: Proposition 35 was an effort from the most powerful health care interests in the state to lock up the proceeds of a tax on some health insurance plans. Instead of letting the governor move all of it into the general fund (as all previous governors had done), the doctors, hospitals, health plans and others hammered out a statewide ballot measure that directed the money to specific pay increases for Medi-Cal providers. The measure passed with an overwhelming 68 percent of the vote back in November, designating rate hikes for certain medical specialties to strengthen the Medi-Cal safety net. But, but, but: Newsom hated Prop 35. He complained that it tied his hands budgetarily, overly prescribing the funds and not giving him enough flexibility to spend. The governor never formally opposed it but made his feelings known whenever he was asked. The rift between Newsom and his longtime allies only deepened after the election, when they bemoaned that he was dragging his feet implementing the measure. Now, it's clear he wants to go back on it entirely. The rage-filled backlash to Newsom's budget announcement was almost instant. 'We believe the Administration's proposal to swipe Proposition 35 funds in order to backfill the state's budget is not only a direct violation of state law, but also a snub to the millions of California voters — 68% — who supported this ballot measure last fall,' said California Hospital Association President Carmela Coyle in a statement excoriating the 'smoke and mirrors budget.' California Medical Association President Shannon Udovic-Constant said Newsom was breaking promises in order to fill a budget hole of his own making. Meanwhile, the governor's office is still blaming Prop 35 for the state's budget woes. A spokesperson pointed to it as the reason why the latest budget proposal cut over $500 million from Planned Parenthood's budget, saying the ballot measure left the state with an 'unfunded mandate' to contend with. Planned Parenthood Affiliates of California President Jodi Hicks — who glowingly live-tweeted Newsom's 2023 debate performance against Florida Gov. Ron DeSantis on Fox — delivered one of the most blistering critiques. 'With this May Budget Revision, Governor Newsom is effectively defunding Planned Parenthood in the state of California,' Hicks said. 'Make no mistake: this crushing proposal — the same morning Congress debated whether or not to defund Planned Parenthood nationwide — would immensely harm patients in California.' These funding decisions are not yet final and must be negotiated with Democratic lawmakers. But if nothing changes, there's a chance some of Newsom's longtime friends and allies take him to court. A statement from Molly Weedn of the Prop 35 coalition said the proposal 'raises serious legal concerns and disregards the will of California voters.' IT'S THURSDAY AFTERNOON. This is California Playbook PM, a POLITICO newsletter that serves as an afternoon temperature check on California politics and a look at what our policy reporters are watching. Got tips or suggestions? Shoot an email to lholden@ WHAT YOU NEED TO KNOW TODAY MILES TO GO: The Assembly's embattled sex trafficking bill advanced off the floor today — but author Nick Schultz's respite likely won't last for very long. Schultz and Assembly Speaker Robert Rivas negotiated amendments to AB 379 that would make it easier for prosecutors to charge felonies for soliciting 16- and 17-year-olds for sex — with exceptions for those within three years of a victim's age. (That agreement only came after original author Maggy Krell, a Sacramento Democrat, dragged her caucus through an embarrassing debate over sex trafficking.) Democrats mostly fell in line to move the bill out of the Assembly today, with the exception of Oakland Assemblymember Mia Bonta, who declined to vote on it. LaShae Sharp-Collins, a San Diego Democrat, previewed a possible fight to come in the Senate over another portion of the bill that adds penalties for loitering with the intent to solicit sex workers. 'History has shown that these types of crimes are disproportionately used against people of color and those experiencing poverty,' she said on the Assembly floor. 'When laws are vague, they are ripe for profiling.' Sharp-Collins said her future support for the bill would be contingent on amending that section of the legislation. She's likely to get her wish. Schultz on Monday acknowledged the loitering provision 'is another piece that will change.' IN OTHER NEWS PROP 36 BUDGET WOES: Opponents and proponents of tough-on-crime ballot measure Proposition 36 aren't giving up on their push for state money — even after Newsom's revised budget largely hung them out to dry. The Senate Public Safety Committee and Budget Subcommittee on Corrections, Public Safety, Judiciary, Labor and Transportation met today for an informational hearing on the initiative, which increased penalties for some theft and drug crimes. In particular, local officials continue to lobby lawmakers for resources to implement a portion of the ballot measure that requires drug treatment in exchange for dropping felony penalties. County behavioral health agencies will need $95 million to $213 million annually for evaluations, court-related activities and treatment, said Michelle Cabrera of the County Behavioral Health Directors Association of California. 'On the one hand, we're going to have our local courts and law enforcement partners telling us that we must address the treatment needs of individuals coming through this as a matter of justice and due process,' Cabrera said 'On the other hand, we're going to have Medi-Cal beneficiaries who are competing for those same scarce beds.' OH SNAP: As Newsom and state lawmakers figure out how to close a $12 billion budget gap, federal lawmakers are actively worsening the situation. The House Agriculture Committee on Wednesday night voted along party lines to advance legislation that could cut $300 billion in Supplemental Nutrition Assistance Program funding, kicking the cost down to states, our Grace Yarrow reported. The GOP proposal would create the largest overhaul in decades to the SNAP program — which helps more than 42 million people in the U.S. pay for food — by forcing states to share the cost of food-stamp benefits. The House Budget Committee plans to combine the legislation with other legislation to curb federal spending before a floor vote. But the GOP's plans for the so-called megabill may be hitting a roadblock, our Mia McCarthy and Meredith Lee Hill report today. At least three hard-liners are now pledging to oppose the legislation, calling Speaker Mike Johnson's Memorial Day deadline for a floor vote into question. WHAT WE'RE READING TODAY — The Supreme Court today sounded inclined to rein in the use of national injunctions by judges to halt Trump's policies, including the president's order to end birthright citizenship. (POLITICO) — Sacramento Democratic Rep. Doris Matsui says that a bill approved by the House Energy and Commerce Committee would 'rip massive holes in the states' budgets that are nearly impossible to fill.' (San Francisco Chronicle) — FEMA cuts to the Building Resilient Infrastructure and Communities grants might cause Rancho Palos Verdes to spend nearly its entire annual budget on its worsening landslide zone. (Los Angeles Times) AROUND THE STATE — San Diego may dip into the city's reserves for the first time in years amid budget problems. (San Diego Union-Tribune) — The average San Jose renter needs to make over $130,000 a year to comfortably afford payments. (San Jose Mercury News) — Sacramento Mayor Kevin McCarty will receive a 12-percent raise, bringing his yearly salary to more than $180,000. (Sacramento Bee) — compiled by Nicole Norman
San Francisco Chronicle
14-05-2025
- Health
- San Francisco Chronicle
The worst of avian flu outbreak may be over in California, health officials say
The worst of the H5N1 avian flu outbreak — which began in 2024 and infected thousands of birds and dairy cows and dozens of people in the U.S. — may be over in California, state public health officer Dr. Erica Pan said Tuesday. 'In California, we feel we've gotten through the worst of this,' Pan said during a briefing for medical professionals held by the California Medical Association. 'In fact, we have demobilized the active public health coordination response and will continue to monitor.' The Department of Public Health on Tuesday did not clarify what exactly the demobilization entails. The virus appears to have slowed in California and nationally, though it's unclear if some of that may be related to less surveillance or a scaled-back federal workforce doing less testing and information-sharing with state and local health departments. It may be that the state or nation is in a temporary lull that may pick up again in the fall and winter. This is because wild birds, the source of many infections, migrate north to Alaska and northern Canada to mate in the spring, and return back south in the fall. This may be why there was so much bird flu activity in the U.S. last fall, said UCSF infectious diseases specialist Dr. Peter Chin-Hong. 'We're kind of in a quiet period now,' Chin-Hong said. 'We aren't seeing reports of humans getting infected as much as we did in the earlier part of the year or late part of last year.' As of late last year, California was the epicenter of the U.S. outbreak, with about 70% of cases in dairy cattle and the majority of cases in people. To date, 38 of the total 70 confirmed human cases in the U.S. have been found in California. Most have been among dairy and poultry workers who experienced mild symptoms, with the exception of one Louisiana resident who died, and two young children in the Bay Area who recovered after having mild symptoms and had unknown sources of exposure. In California, the virus among dairy cattle peaked with 766 infected herds in 12 counties as of earlier this month. While avian flu is very deadly in birds, cows usually get milder symptoms and are kept in quarantine for a period of time, tested and released once they test negative. 'The worst thing we can do is forget about it,' Chin-Hong said. 'We need to continue to be vigilant. Just because we're not seeing much now doesn't mean that for the future.'
