Budget and law proposals don’t matter: PSLF will work for people who already have loans

If you took out federal student loans after 2007, the master promissory note—the legal contract between you and the US government—had this buried in it:

A Public Service Loan Forgiveness (PSLF) program is also available. Under this program, we will forgive the remaining balance due on your eligible Direct Loan Program loans after you have made 120 payments on those loans (after October 1, 2007) under certain repayment plans while you are employed full-time in certain public service jobs. The required 120 payments do not have to be consecutive. Qualifying repayment plans include the REPAYE Plan, the PAYE Plan, the IBR Plan, the ICR Plan, and the Standard Repayment Plan with a 10-year repayment period.

That’s the part that makes your loan eligible for PSLF if you meet the requirements. You’ll notice there are no loan amount caps, needs testing, or other caveats. The program is in the fine print.

And this is precisely why every budget proposal from Obama (who wanted to cap the forgiven amount) and Trump (who wants to cancel the program) has specified that any change would affect new borrowers. (This is not to mention the variety of recent Democratic presidential candidate proposals to dramatically expand student loan forgiveness).

Who is a “new” borrower? Basically someone who borrows money after the law is created and doesn’t already have older loans. To illustrate how the feds have used this term in the past, look no further than the language in the MPN regarding the Pay As You Earn (PAYE) repayment plan.

The PAYE Plan is available only to new borrowers. You are a new borrower for the PAYE Plan if:

*(1)* You had no outstanding balance on a Direct Loan or a FFEL Program loan as of October 1, 2007, or you have no outstanding balance on a Direct Loan or a FFEL Program loan when you obtain a new loan on or after October 1, 2007, and

*(2)* You receive a disbursement of a Direct Subsidized Loan, Direct Unsubsidized Loan, or student Direct PLUS Loan (a Direct PLUS Loan made to a graduate or professional student) on or after October 1, 2011, or you receive a Direct Consolidation Loan based on an application received on or after October 1, 2011. However, you are not considered to be a new borrower for the PAYE Plan if the Direct Consolidation Loan you receive repays loans that would make you ineligible under part *(1)* of this definition.

Now, even the legal nuances may all be moot for at least the short term, because democrats have been more interested in expanding loan forgiveness than canceling it, and most of the gazillion of the current presidential candidates have been trying to promote free college. With Democrats controlling the house, the chances of PSLF being destroyed in the short term are pretty low. Congress couldn’t even get this done with republican majorities in the house, senate, and a sitting president.

Now, in a couple more years in when the forgiven amounts balloon, the issue may come to a more heated debate no matter who is in charge. Because the overall student loan situation, PSLF or not, is untenable, unsustainable, and rapidly robbing young Americans (and thus the future of our country) of their chance at economic prosperity. Something has got to give.

But to give you an idea of how not imminent this is, keep in mind the Republican congress passed a temporary expansion of the existing program to help people who didn’t read the fine print.

However, the long-term health of the program is irrelevant if you’re already in school. Because the changes, whenever they come, should not affect you.

Websites and news outlets love to play up PSLF-doom-stories because they make for great clickbait (and also encourage private refinancing referrals from which many of them profit). But the clear take-home message from both the MPN and political proposals is that it does not matter what happens to the program if you’ve already made the decision to borrow money for school based on the program’s existence. When people rely on a program, you can’t pull the rug out from underneath them (not just because it’s unfair, it’s actually illegal).

And, for the hyper-cynical among you, when Trump’s Department of Education tried to do so in a very limited fashion recently (by retroactively denying some lawyers who fell into a gray zone of non-501(c)(3) nonprofits that must be approved on a case-by-case basis), the courts shut them down pretty robustly. You can’t change the rules of the game if people are already playing.

Goals and Consequences of Private Equity

A couple of interesting reads from Matt Stoller’s BIG newsletter about private equity. Given the current flood of PE group buyouts and market consolidation in healthcare, it’s not hard to draw parallels between radiology practices ten years from now and what happened to Toys R Us in 2018 or to identify the obvious issues that arise over the long term when the frontline and c-suite have zero overlap.

From “Why Private Equity Should Not Exist

The goal in PE isn’t to create or to make a company more efficient, it is to find legal loopholes that allow the organizers of the fund to maximize their return and shift the risk to someone else, as quickly as possible.

From “WeWork and Counterfeit Capitalism

Across the West, the basic problem of a corrupted productive process is becoming a quiet crisis. The reason is simple. The people that do the work in organizations are increasingly excluded from the decision-making about the work. That is why Boeing is losing its ability to build planes, why we can’t build infrastructure, and why New York City is on the verge of disaster.

ABR OLA MOC: The First-Year Experience

2019 was the initial offering of ABR’s MOC of the future: Online Longitudinal Assessment (OLA). I wrote about it earlier this year, but to recap: All Diagnostic Radiology ABR diplomates including those fresh off their Certifying Exam victory lap were immediately thrust into the new paradigm. This amounts to answering a whopping 52 multiple choice questions over the course of the calendar year in whatever subspecialty composition you prefer. Questions are released 2 per week and expire after a month.

It’s…fine? Sorta I guess?

The website works (mostly), and the questions are questions (undeniable). Some are pretty good, some certainly less so. People on the internet grumble about content relevance more than I personally would, but then again the minute I got a lame low-yield Core-style GI fluoro question I switched to 100% neuroradiology.

The ABR hasn’t released the passing thresholds yet, which is the most interesting facet of the whole ordeal: recall that the Core and Certifying Exams are “criterion-referenced” by magical Angoff committees that can infallibly determine what a “minimally component” radiologist can do. The ABR just doesn’t seem to have that same confidence when it comes to MOC, presumably because they have no idea how many people would fail if they had logically employed that exact same Angoff method, and failing an unknown number of already dissenting practicing radiologists is a much bigger deal than embarrassing some more trainees.

Now before you say that each diplomate needs to hit 200+ questions to hit the psychometric validity threshold, the ABR could still tell people if they were on track to pass or fail based on their current performance. There are apparently plans to release preliminary feedback soon (which may do just that now that there is some real-world data to calibrate with), but all of us will need to do another few years of OLA to learn if we’re truly maintaining the magic.

In case you were wondering, I did get one question wrong (the software buries additional images in tabs you have to click through; I kept forgetting, though it only burned me the one time).

Drip-Feeding

There are no secrets as to why the ABR chose to release two questions per week that subsequently expire a month later. I finished my required questions in August, less than a year from when I took (and presumably destroyed) the Certifying Exam (but we’ll never know because they don’t release scores for that exam).

What I can tell you is that I spent approximately one hour satisfying the OLA requirements for the year. Without the forced drip-feeding, I could’ve accomplished the entire process during a single generous lunch break.

Some of you reading may be thinking, hey, that’s not so bad. And you’re right, the process is relatively painless. I didn’t learn anything, but at least it didn’t take a lot of my time.

Ultimately, that’s also what makes MOC a meaningless box-checking endeavor and blatant money grab.

The argument that something isn’t stupid, bad, useless, or wrongheaded as long as it doesn’t suck is spurious. Just because it could be worse doesn’t mean that it shouldn’t be better.

And the fact that many doctors are scared that these unelected unaccountable pseudo-governing organizations will punish any dissent by making tests harder and MOC more arduous is toxic and should not be accepted. We shouldn’t treat the relative ease of a profit-seeking exercise as a thrown bone from the shadow lords that can be taken away at any time or a secret to keep quiet so the “public” doesn’t find out.

The Anti-MOC Wave

I am actually not really part of the large and growing cohort of physicians adamantly opposed to any third-party validation of demonstrable skill or the mere idea of a certification-granting organization that can reliably establish minimal competence. In fact, if board certification wasn’t a de facto requirement in many contexts (and thus akin to licensure itself), I wouldn’t even mind if the supposed threshold was greater than minimal competence.

The ABMS was founded in 1933. The ABR was founded in 1934. We’re still waiting on evidence that anything these people do means anything. If the intellectual underpinnings of initial certification are up for debate, then the “maintenance” of said certification is doubly so (hence the lawsuit).

The new system may be no worse than the 10-year exam it replaced; it would seem to me that it’s likely significantly less hassle. Less studying, less travel, less time, less effort, and more relevant (in that you can exclude broad categories of radiology irrelevant to your practice). However, cumbersomeness (or lack thereof) is not a component of psychometric validity.

A lack of rigor may serve as a salve for diplomates injured by losing out on years of rightfully-earned respite after a recently passed 10-year exam, but it doesn’t change the fact that gradually adding strata of multiple-choice questions on a foundation of more multiple-choice questions creates a weak structure that teeters in the winds of change.

PSLF is also a partial federal match for pretax retirement contributions

For those who qualify, PSLF can make an incredible difference in your long-term financial health by wiping away your student loans well before and for less money then you may be able to accomplish for yourself.

Due to the way income-driven repayment plan monthly payments are calculated, PSLF also acts as a government subsidy on your pretax retirement contributions. If you are currently using an income-driven repayment plan, every dollar you contribute this year to a pretax account will not only save you money on taxes this year (at your marginal tax rate) but will also “lower” your income for the year and then save you ten cents the following year.

Why?

Because IDR loan payments are calculated according to your discretionary income. Less income, smaller payments. For the two most common plans for recent borrowers, PAYE and REPAYE, it’s 10% (for borrowers on the old version of IBR, 15%).

For loans eventually forgiven via the PSLF program, every single dollar less you spend on your loans during the 10 years of repayment is another dollar that you save. This amounts to a partial federal match on your 401(k)/403(b)/traditional IRA contributions and an automatic 10% return on your investment.

Theoretically, the relatively low income of a resident is generally ideal for making post-tax Roth contributions (either to a Roth 401(k)/403(b) or Roth IRA). This is because doctors are felt to likely want to retire on more annual “income” than they earn as a resident, so that paying taxes now in a lower bracket is better than paying taxes later when in a higher bracket (not to mention the possibility that tax brackets may be higher across the board in the future). That said, a life in retirement without constant car payments, a mortgage, or student loans would cost far less than a similar lifestyle as a young professional. The bonus “match” is a reason to consider making pretax contributions against the more conventional wisdom.

Note that even without PSLF, pretax contributions still reduce monthly payments. For people actually paying off their loans, lower payments generally aren’t a good thing (just more money spent in the long term on interest), but in the setting of REPAYE and negative amortization, the lower payments would also mean more unpaid interest and thus more unpaid interest waived via the 50% unpaid interest subsidy and a lower effective interest rate.

For example, if you were somehow able to max out your personal contribution ($19,000 in 2019), then you would reduce your payments by $1,900 the following year in PAYE/REPAYE (or $2850 in IBR). That’s $158 per month. And that kind of savings over 10 years definitely adds up.

Extending $0 payments

Things can get really creative. If you were lucky enough to have a working spouse who earns enough to pay for your family’s living expenses (or are so hyper frugal that you live in the call room and eat saltine crackers pilfered from the ER for the majority of your meals), you could even pull a clever trick and zero out your loan payments for your first two years of residency. How?

Well, if you read my beloved (free) book, this helpful post about consolidating your loans after graduation, or remember the bit about this from a few paragraphs ago, you’d recall that payments under an IDR plan are calculated as 10% of your discretionary income based on last year‘s taxes under PAYE/REPAYE. A graduating medical student / new intern generally made little to no money the prior year and can secure zero dollar monthly payments for their intern year that nonetheless still qualify for PSLF.

Now here is where the retirement contribution component comes in. Normally, a second-year resident who consolidated after graduation will make payments based on a tax return that combines the last half of their fourth year of medical school and the first half of their internship. This means that it essentially based on a half year of income, say $25-30k instead of $50-60k.

Discretionary income takes your adjusted gross income and subtracts 150% of the poverty line. So PAYE = 10% (AGI – 150% x Poverty Line) / 12. For example, in the contiguous 48 states in 2019, the poverty line for a single person is $12,490. As a practical matter, this means that a single borrower must make around $19k per year in order to have a non-zero payment. Therefore, if you can put away enough money in the first half of your intern year to reduce your gross income to the poverty line, then your payments the following year will also be zero dollars.

(Note: it’s actually probably better to have a token payment of a few dollars so that there is an easier paper trail of payments for PSLF as well as no chance of your servicer not applying the 0.25% interest rate reduction for setting up auto-pay).

Roth conversions can be a useful hedge

Consider a Roth conversion to be a hedge. Now if a light bulb just went off and you’re thinking you could place money in a pretax 403b/401k to get the income-lowering benefits for IDR/PSLF purposes and then immediately convert that money to Roth in order to take long-term advantage of their low current income bracket, that’s not how it works. The IRS treats the Roth conversion amount as income for your taxes, so it undoes the income lowering.

But while in REPAYE, you could make pretax contributions during your early residency years as we discussed to get the lowest effective rate possible. Then, during your final training year—if you now know you’re not going for PSLF and have enough money saved up—do a Roth conversion and pay the taxes at your low resident income bracket before you become an attending. A senior resident and an intern are in the same tax bracket unless a lot of moonlighting is taking place, so you don’t lose money that way due to higher marginal taxes. In this setting, you’d likely follow this with a student loan private refinance, so the increased AGI for the following year wouldn’t matter.

Take Home

So, in addition to providing uncapped tax-free loan forgiveness, don’t forget that PSLF also functions as a government subsidy on your retirement accounts as well.

Academic Medicine and the Peter Principle

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

The Three-legged Stool

Academic medicine is sometimes described as a three-legged stool, where the department/institution is balanced on the three pillars of clinical care, research, and education. There is a pervasive myth that academic physicians can do it all: be an outstanding clinician, an excellent teacher, and a prodigious researcher. The reality is that most people don’t have all three skills in sufficient measure, and even those that do are not given the requisite time to perform meaningfully in all three categories.

While polymaths exist, the idea of the physician-scientist is increasingly intractable in modern medicine. The demands of clinical work have increased substantially with increasingly advanced medicine, increased productivity/RVU expectations, often overwhelming documentation burdens, and greater trainee oversight. Meanwhile, research has gotten more complex at the same time that the grant money has dried up. More and more of the funding pie goes to fewer and fewer people. And, lastly, education is typically taken for granted as something that should just take care of itself, something we expect “clinician educators” to do without faculty development, dedicated time, or even credit.

It’s very easy to have an unbalanced stool. Departments tend to lean in one direction or another precisely because they are aligned to do so and are staffed accordingly. As Arthur Jones of Proctor & Gamble famously remarked, “All organizations are perfectly designed to get the results they get.”

Putting pressure on individuals to do everything—deliver excellent clinical care, teach/mentor students/trainees, and contribute to high-impact research—fails to acknowledge the reality on the ground that doing high-end work in any of these dimensions is hard. Without dedicated time and sufficient support, doing anything successfully for very long is a challenge. Trying to work toward impossible expectations (even self-imposed ones) is a big contributor to burnout. At least a veneer of control, self-determination, and respect are prerequisites–not luxuries–for a successful “knowledge worker”-type career. We could more reasonably expect people in every role to excel at one role, be competent at another, and largely ignore the third.

Hospitals and large academic institutions are not filled by flat teams of equals working on a common mission, they are occupied by layers of committees and bureaucracy. Rising stars often contribute more to their superior’s careers than their own. Progress, change, and new initiatives are choked by a spinning-wheels-grind of proposals, SOPs, committees (and subcommittees), amassing nebulous “stakeholders,” and every other trick in the large organization toolbox that isn’t bad in theory but should never be implemented universally and thoughtlessly. It’s all leadership in the I-attended-a-leadership-conference sense without any true leadership.

Physicians who focus on producing excellent care are derided as “worker bees” while those who believe in education are labeled “doesn’t like research.” And the managers rise to the level of their incompetence and perpetuate the hierarchy.

Meanwhile, the consultants and nonphysician leadership consolidate power outside of the traditional hierarchy. And how can we stop them, when we do such a bad job ourselves?