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Yes, PSLF is really happening

09.27.18 // Finance

People often ask if I personally know anyone who has gotten their loans forgiven via PSLF since the first crop of folks became eligible in October 2017. It’s a reasonable question, but it’s also the wrong one.

Because, despite the legitimacy of the PSLF program, there are very few people who could have actually benefitted in the initial crop. This stems from the fascinating(ly terrible) way the program was rolled out to discourage the older generation of folks who were already in repayment to utilize it.

Nonetheless, the proof that PSLF is real has arrived. The Federal Student Aid office recently released their new student loan report (conveniently summarized here):

The Public Service Loan Forgiveness (PSLF) Program, which was established under the College Cost Reduction and Access Act of 2007, permits Direct Loan (DL) borrowers who make 120 qualifying monthly payments under a qualifying repayment plan, while working full-time for a qualifying employer, to have the remainder of their balance forgiven. October 2017 was the first month that borrowers could potentially qualify for loan forgiveness under this program, provided they met all program requirements since the inception of the program.

As of June 30, 2018, approximately 28,000 borrowers had submitted almost 33,000 applications for loan forgiveness under this program. Of the approximately 29,000 applications that have been processed, more than 70 percent of them have been denied due to not meeting the program requirements (such as having eligible loans, 120 qualifying payments, or qualifying employment). In late May 2018, FSA initiated outreach efforts to those borrowers who may potentially qualify for the Temporary Expanded Public Service Loan Forgiveness (TEPSLF) opportunity, which provides limited, additional conditions under which borrowers may be eligible for loan forgiveness if some or all of the Direct Loan payments were made under a non-qualifying repayment plan for PSLF.

Another 28 percent of PSLF applications were denied due to missing or incomplete information on the form. These borrowers have been advised to submit a complete application so a determination of their eligibility can be made. Almost 300 applications have been approved by the PSLF loan servicer as meeting all program requirements, resulting in $5.52 million in processed discharges for 96 unique borrowers.

99% rejection sounds terrible, but it’s actually exactly what you would expect if the feds were honoring the specifics of the program as advertised. Recent graduates—who essentially all hold qualifying loans—tend to focus on the qualifying employment aspect of the rules. But for the folks who would theoretically have been eligible in 2017, the lynchpin was really qualifying loans and, to a somewhat lesser extent (see below), qualifying repayment plans.

Allow me to explain.

The PSLF formula:

Eligible Loans
+ Qualifying Payments
+ Qualifying Work
x 120 months (10 years)

= Public Service Loan Forgiveness

 

The Loans

“Eligible loans” means Direct Loans. Direct loans are given “directly” by the government, which is what all recent students use who don’t take out additional private loans. Back in 2007, that wasn’t the case. Students received loans from private banks that were “guaranteed” by the government under the FFEL program. During the financial crisis in 2008, the government stepped in and used the Direct Loan program to provide most educational funding. The FFEL program was completely shuttered in 2010.

Anyone in repayment during the late 2000s or finishing school near 2007-8 would not have had eligible loans without taking additional steps to consolidate them into a Direct consolidation loan. No one who didn’t hear about the program back then and read the fine print would have done the right thing. Huge swaths of people who thought they were eligible and applied for PSLF were denied for exactly this reason. They were never eligible.

If any of these folks had filed a single PSLF employment certification form, they would have found out the news and been able to change course accordingly.

Take home point: loan forgiveness is too important to not plan.

 

The Payment Plans

This is the second reason for denial, but at least some of these folks will win out eventually.

“Qualifying payments” are full, on-time, payments while utilizing a qualifying repayment plan: IBR, ICR, PAYE, REPAYE, or Standard. The Extended and Graduated plans do not count. IBR, the first of the new generation of income-driven repayment plans, started in 2009. So again, by definition, the folks making payments toward PSLF back in 2007 and 2008 couldn’t have even been using it yet (the lucky ones were using ICR). Unfortunately, many applicants were on the graduated or extended payment plans, which—again—do not count. 

Luckily, Congress decided this technicality was too cruel and passed a temporary $300 million PSLF expansion to help people denied for this on a first-come-first-served basis.

In order to benefit from the new law, you need to apply to PSLF and also file a TEPSLF request.

Since the government doesn’t actually hold the FFEL loans, there is essentially no chance of them extending anything extra to the folks denied for having the wrong kind of loans.

 

The Future

The initial disappointment and underwhelming numbers from the initial stages of PSLF were an inevitability.

Over the next few years, the numbers of successful applicants will skyrocket. Not accounting for undergraduate borrowing, medical students graduating in 2012, for example, would almost universally have qualifying loans and been using qualifying repayment plans. Lawyers from 2011, some masters degree holders in 2009 and 2010, etc. Folks whose schooling began ten years ago will be part of a cohort that didn’t require the same big steps to have been made correctly early on that these initial failures succumbed to.

We’ll see a small uptick this year and then big rises thereafter. This is only the beginning.

Resident Refinance: Laurel Road vs LinkCapital vs SoFi vs Splash vs REPAYE

09.17.18 // Finance

[2020 Update: Since this post was written, but LinkCapital and Splash have shuttered their resident-specific programs and LinkCapital subsequently shut down completely.]

 

Let’s assume that you are a graduating medical student or resident and plan to actually pay off your loans (i.e. not attempt to qualify for PSLF.)

But before we assume that, let’s remember that PSLF makes the most sense for people destined for academic or government (city/county/state/federal) or with long residencies and big loans.

So, assuming you need to pay off this debt yourself, your goal is to get the lowest interest rate possible to reduce the growth on your loans while having a monthly payment that is feasible as a resident.

Low-debt residents can refinance with any company. If you owe less than you’ll make as a resident, you won’t need a special program. If you’re a resident who owes somewhere near $200k while making $55k/year, then your options are likely limited to the federal government options and the four private companies who offer medical resident programs with reduced monthly payments during training: Laurel Road, Splash Financial, SoFi, and LinkCapital.

Unfortunately, all special resident programs offer less good rates (at least during the training period) than refinancing as an attending, but for some borrowers, you can still save some real money. On the plus side, via the referral links on this page, most offer welcome bonuses.

 

Laurel Road

Laurel Road gets it. Back in 2015 when the company was just called DRB, they were the first to create a student loan refinancing program for medical residents. The deal hasn’t changed much since then.

Post-match MS4s and all residents are eligible for Laurel Road refinancing. The monthly payment is set at $100/month regardless of your income during residency/fellowship, and then switches when you finish training.

There is no maximum number of training years, and you can continue the reduced payment up to 6 months after finishing training to help get you through the fresh start.

The welcome bonus is $300.

 

Splash

Splash Financial is unique among the four programs as being a true forbearance alternative. The required monthly payment is exactly $1 for up to 84 months (7 years) of training. While most residents should not be forbearing and should hopefully be able to find $100 of flexibility in their monthly budget, many feel pinched and forbear anyway. While a lifestyle that requires forbearance is far from ideal, Splash is the only company that makes forbearance completely unnecessary in your quest to get a better rate.

Note, however, one sneaky wrinkle: while Splash offers the same 0.25% autopay discount as everyone else, the discount doesn’t apply to the $1 trainee payment period. So you’ll need to add that back on to compare apples to apples during residency.

Splash offers a $500 bonus for loans above $100k.

 

SoFi

SoFi is the biggest player in the student loan refinancing market, and they’ve grown and grown into a big corporate entity that offers all varieties of personal loans, mortgages, etc. Without that personal touch and scrappiness of the new companies, it took SoFi a long time to make a resident product, and they didn’t do anything creative.

SoFi offers residents $100/month payments for up to 4 years of training. You are eligible as a post-match MS4, but only if your training is 4 years or less in duration. The total reduced payment period is actually up to 54 months (with the final 6 months for the transition to becoming an attending).

If you apply to SoFi in your final year with a signed contract, you’ll automatically get the attending rate instead of the resident rate. Oddly, you will be placed in a mandatory forbearance during that year so that you won’t be able to get an autopay discount during that time.

The welcome bonus is $100.

 

LinkCapital

LinkCapital was the second company to join Laurel Road in offering a resident-friendly program. Link’s program is only available to PGY2’s and above, so graduating students and interns are not eligible. The required monthly payment is a bit lower at $75/month.

Unlike Laurel Road (but like SoFi), Link offers trainees in their final year to qualify for the attending rate with a signed employment contract. Unlike the other companies, Link also tells you your training and attending rates, and when you finish training, your rate automatically goes down. With other companies, you’d likely be on the lookout to refinance again.

As of August 2017, LinkCapital is no longer offering welcome bonuses.

 

IDR: REPAYE & PAYE

I’ve discussed REPAYE and even compared REPAYE/PAYE more at length previously.

With PAYE, your rate is your rate unless you have subsidized loans from college, and so comparing what you currently have to what the refinancing industry can offer is easy.

With REPAYE, there is the 50% unpaid interest subsidy to complicate (but improve!) matters. In short, the government forgives half of the interest that accrues each month that remains unpaid after applying your scheduled calculated payment. This effectively reduces your interest rate, in many cases substantially (especially if you’re single or married with a non-working spouse).

An example:

Loan: $200,000 at 6.8%
REPAYE payment as a single resident making $50,000: $270/month
Annual interest accrued: $13,600
Annual interest paid: $3,240
Annual interest unpaid: $10,360
Amount forgiven: $5,180
Effective interest rate: 4.2%

The more you borrowed and the less you make, the bigger your subsidy will be and the more it will lower your rate

If you’re married and your spouse earns income, the less your subsidy will be and the less it will lower your rate.

Also, note that REPAYE can be a particularly good deal for your intern year if you play your cards right. Even if refinancing is a generally good choice for your situation, unless you had substantial income as a family during your final year of school, private companies are going to have a really hard time beating the feds if you consolidate and apply for REPAYE right after graduating.

 

Summary & Verdict

All of these companies offer no-cost refinancing with zero fees. Picking a shorter term will result in lower rates (note: the term doesn’t kick in until you become an attending and start true repayment). A couple things to keep in mind: if you pay the minimum every month, you will definitely be in a negative amortization situation, likely even more than you would be using a federal plan (with their higher monthly payments). Second, unpaid interest will also capitalize at the end of the training period, so it would behoove you to try and reduce some of this accrued interest prior to graduation.

Most companies also offer referral bonuses where you can get some cash back with your refinance. This means that while you can never go back to a federal repayment plan after refinancing, there is literally nothing stopping you from refinancing multiple times, rate hunting, and even collecting multiple referral bonuses.

Assuming you have the financial flexibility to afford all four plans, the only reason to completely exclude a company is if their plan doesn’t conform to your current PGY status and training duration. Getting preliminary rates is a quick 2-minute process that is a soft credit check that won’t affect your credit. It’s only once you move forward with getting a final rate and the formal (but still short) application process that involves a real (“hard) credit check; even then, multiple checks for the same thing within a short period of time are considered rate shopping and should function as a single temporary hit. Applying to all of the options that are feasible is the best way to guarantee a good rate. Even the complete applications don’t take more than half an hour or so.

Most importantly, however, is to make sure that your effective REPAYE rate isn’t as good if not better than what the private industry can offer you. Be aware that advertised rates almost universally contain a 0.25% autopay discount, so make sure to account for that when comparing your federal rate. In many cases, REPAYE offers the straight up best rate for someone in training (particularly if single and not moonlighting substantially). Most residents should be in REPAYE in training and then refinance after training or only once they’ve signed a contract for a job that is not PSLF-eligible.

A few docs talk about early career financial mistakes

09.12.18 // Finance

A bunch of physician finance bloggers (and me) were asked to weigh in on early career financial mistakes for MDLinx’s relatively new PhysicianSense blog.

Everyone else said don’t buy a house and don’t try to beat the market. I largely agree with both of those sentiments.

I’m not exactly a finance blogger, even though I write about money with some frequency. My answer was instead largely about being purposeful with your time.

Many of us spend our lives reacting. We spend our days constantly reacting to crises, patients, and bureaucracy at work. We react to short bursts of free time or moments of boredom with our phones and social media. We consume media and television like we’re hardwired.

And when faced with financial troubles like student loans or other financial goals, we often react by either shutting down and ignoring our problems or by becoming obsessed with dollars and cents. There’s nothing wrong with moonlighting or trying to carve out some side income—I still do both routinely. But it’s also important to step back and see if and how your efforts are affecting your mood, health, and family.

The need to be cognizant of how you spend your money should be self-evident. The need to be cognizant of how you earn it is less obvious.

Explanations for the 2017 Official Step 3 Practice Questions

09.09.18 // Medicine

Here are my explanations for the 2017 version of the official USMLE Step 3 free question pdf. This is a constant reader request, so enjoy my take on these 137 questions.

You can find my thoughts on preparing for Step 3 here. In short, I think the free materials and UWorld should be enough for most folks. If you want books recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taking under test-day conditions.

(more…)

NYU and the slow coming wave of “free” school

08.30.18 // Finance, Medicine

A couple of weeks ago, NYU announced that they were making medical school tuition free for every student. Dean Robert Grossman stated, “This decision recognizes a moral imperative that must be addressed, as institutions place an increasing debt burden on young people who aspire to become physicians.”

My first thought on this news was, Man, Harvard is going to be so pissed that they weren’t first.

The idea of free tuition has been discussed and debated in multiple contexts across Ivy-type schools for years. These institutions are not immune to the burgeoning reality that their educations are financially untenable for most people and crippling for others. With many such schools fostering endowments numbering in the tens of billions of dollars, actual tuition dollars are no longer the bedrock of a healthy world-class institution. Over the past ten or so years, Harvard has often led the way on increasingly generous undergraduate financial aid, and many similar schools have made corresponding efforts to make undergraduate education more affordable, but until now, no one has taken meaningful steps to fix graduate schools, many of which are now considered mandatory for advancement across many industries. Even this move is largely a token effort, as every other extremely expensive NYU school will still keep its top-dollar cost in the shadow of this brilliant PR stunt.

As an illustration of the numbers involved in making one small school free:

The annual NYU med tuition was an exorbitant $55k per year, and there are 442 total active medical students, which gives a total cost of $24 million per year. “Paying” this requires (according to NYU) an endowment of $600 million because the school is utilizing the famous 4% rule that would make this massive endowment essentially guaranteed to last forever based on historical stock market returns.

Numbers aside, I do agree with the words of the dean (though I would expand them). There is a moral imperative to fix the cost as well as the delivery of medical education. The length, cost, and inefficiency are all otherwise mutable strong arms that are breaking healthcare and squeezing the joy out of young doctors in training from coast to coast.

NYU will not be the only school to offer free tuition. Other rich schools in and outside of medicine likely have been and certainly will be shoring up their endowments to join the club as is feasible. I anticipate this is the first in a salvo of private schools slowly making various programs free, and this will speed up if/when PSLF is eventually canceled, as the program is basically the only justification for charging otherwise unmanageable amounts of money to students who are destined to never be able to actually service their debt. Beleaguered state schools with their chronically strapped budgets will struggle.

My second thought is that free tuition will now make NYU about as affordable as the best-priced state schools (because the cost of living in New York is otherwise so high). Four years of living expenses will never be cheap, and it’s much harder to scrounge time to be gainfully employed during medical school compared with college. Clinical rotations are inflexible more-than-full-time jobs.

This will also result in, I imagine, a huge increase in applications to NYU. When my wife and I applied to medical school, we only applied to state institutions back in Texas where we were still residents while away for college. We were not keen to spend as much in a single year as we could on the whole package. People like me may now decide to add NYU to the list, especially since NYC is glamorous.

So, good on NYU for being the first to pull the trigger. I hope more schools join their ranks, and I hope most of all that this well-publicized confrontation of medical training costs will lead to a paradigm shift that allows schools and hospitals to rethink the whole process. We can do so much better, for our doctors and for our patients

Student loan books now on iBooks

08.24.18 // Finance, Writing

I’ve been a bit slow on expanding the availability of my two books on student loans, but as of today, Medical Student Loans and Dealing with Student Loans are now available on Apple iTunes/iBooks as well as from Amazon.

Get them here:

  • Medical Student Loans (iBooks, Amazon)
  • Dealing with Student Loans (iBooks, Amazon)

The Med Ed Trifecta

08.20.18 // Medicine

Akhilesh Pathipati, writing “Our doctors are too educated” in the Washington Post (emphasis mine):

U.S. physicians average 14 years of higher education (four years of college, four years of medical school and three to eight years to specialize in a residency or fellowship). That’s much longer than in other developed countries, where students typically study for 10 years. It also translates to millions of dollars and hours spent by U.S. medical students listening to lectures on topics they already know, doing clinical electives in fields they will not pursue and publishing papers no one will read.

We’ve done an amazing job in medicine findings way to fill years with reasonable-sounding and potentially useful activities and then pretending they are not only worthwhile but necessary.

The Hit Points

08.13.18 // Miscellany

Starting in 2003, my secret work/study music has mostly been comprised of hundreds of wonderfully creative arrangements of video game music, largely thanks to a website called OverClocked Remix, which has been steadily curating a massive collection of high-quality pieces for almost 20 years.

Which brings me to this stellar bluegrass rendition of a theme from a Kirby game (that I haven’t played):

My son wants to listen to this song on repeat in the car on the way to school literally every day.

Check out The Hit Points’ complete new album CD for free on their bandcamp. Every piece isn’t a standout, but the overall effort is still just delightful. If you can recognize Guile’s theme from Street Fighter II from your childhood, you’ll immediately agree that it was meant to be played this way.

Workflowy redesign

08.04.18 // Miscellany, Writing

This is some niche dorky stuff for a Saturday night, but I’m excited: My digital brain, Workflowy, just got a modern redesign.

For those who don’t know, Workflowy is a totally free (with very optional paid options) outliner/todolist/organizer that allows you to have infinitely nested arbitrarily large outlines/lists. If that doesn’t make sense, just try it. It’s ridiculously simple but very powerful. I even wrote the bulk of my last book in it.

The main downside for me has been that Workflowy’s design has been stuck in yesteryear. I’ve been spoiled by a number of elegant writing environments over the past few years, and I actually do think the extra zen makes a difference. This new design is, as expected, super simple, but the clean lines and font crispen up the experience just enough. Well done!

If you’ve already given Workflowy a try, you can activate the new beta design through the options page here. Now they just need to update the iPhone app!

Burnout may be a misnomer

07.29.18 // Medicine

Simon G. Talbot and Wendy Dean, arguing in STAT that burnout is actually a misdiagnosed consequence of unchecked moral injury:

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Which is why the chorus of hollow wellness outreach efforts for trainees and other physicians are so patronizing and eye-rollingly ineffective:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises.

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