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Taxes and death, as the old joke goes, are the only two certainties in life. But who suspected the two were causally related?
Have you been to an emergency room lately and waited for hours to be seen? Have you waited three months to get an appointment with a specialist? Are you a Medicare patient who cannot find a primary care doctor? Taxation (and its evil sister regulation) discourage physicians from working to capacity, thereby limiting the amount of medical care available.
When all the smoke and mirrors are removed, “health care” is not a system. Stripped to its barest essentials, it is a personal interaction between a doctor and a patient. So, what is bad for doctors is bad for patients. Doctors are the ultimate cottage industry. We begin our careers with huge investments in time (11-15 years after high school) and money ($250,000 to $600,000), then invest in equipment and staff and all the accoutrement of a medical office ($150,000 is not an unreasonable start-up cost). Many of us don’t start making an income until we are 35 years old.
Physicians then produce a product – in this case medical care – by seeing one patient at a time. Physicians cannot mass produce, they can only compensate for increasing overhead costs by increasing their efficiency and their hours worked – and there are limits to the hours one can work. Everything in business involves the choice, “Is it worth it?”
Although TV sitcoms paint a very different picture, physicians live in the real world of small business economics. And, as many in the tea-party movement know – but apparently Congress does not – small businesses do not pay corporate tax, but pass their profits on to their owners, who then pay tax at the individual tax rate. At some point, oppressive taxation leads to inactivity, since a person would rather have free time than work more hours only to give that income to the government.
Recently I met with a colleague who is in practice with his wife. He told me that, as his wife sees more patients, he adjusts his workload to see less (and vice versa) because there is no point working themselves into the higher tax level.
I was once in full-time orthopaedic surgery practice in an underserved area of Arizona. I saw sometimes 50 patients a day, did surgery 20-plus hours a week, and helped care for a rapidly growing retiree population. Although as a spine specialist I was at the top of the educational ladder, and performed a relatively complex task that demanded a unique skill set, I was paid less by the government for spine surgery than I paid to my dentist for a single root canal, or to my plumber for installing a bathtub. In addition to the federal and state taxes, which consumed nearly 40 percent of my income, the State of Arizona allowed ballot initiatives that made it easy for a minority of citizens to vote for bonds that disproportionately taxed businesses.
Knowing that I could not make a living doing spinal surgery forever, my husband and I scrimped and saved to build a medical office complex. We thought we could generate additional income through rental of professional space. In a ten-year period, due to the effect of taxes for local bonds, the business went from slightly revenue positive to revenue neutral. We sold out, with no profit to show for our considerable effort before the project could become revenue negative. For the privilege of investing in the business, we paid more per year in local taxes than my father ever made as a physician in the 1960s.
There is a perception that all doctors are rich, and by the government definition we are. But, unlike the Warren Buffets or George Clooneys of this world, who make zillions of dollars a year, we are the bottom of that “rich bracket.” Unlike they who don’t even have to change champagne brands to afford their taxes, we are significantly diminished by having nearly 50 percent of our income taken from us in the form of federal state and local taxation.
Warren Buffet makes billions by skillfully using his intellect to benefit from other people’s physical labor, and I do not deny him his due. But, if he pays more in taxes next year, he won’t break a sweat or lose an hour of sleep. When I pay my taxes, every dollar comes from my direct hands-on labor – standing in the OR all night long, wearing 35 pounds of lead and protective clothing hammering steel rods down trauma victims’ femurs, patching gaping wounds, saving infected limbs, then working all the next day in clinic – in the process losing time with my children, my spouse and my friends as well as damaging my own health.
Several years ago, after finally digging out of debt, paying off my mortgage, etc., my tax man told me I could either give half of my income to the government in taxation or contribute nearly all of it to my pension plan. In either case I had little to spend. I realized that after all my years of education, training and delayed gratification, the long hours and considerable effort, I still had difficulty paying for my two sons’ college education. But I had paid those college fees 20 times over in taxes.
It was then I decided to move and work part-time. Now, I (and other like-minded middle aged colleagues) take no trauma calls. My former hospital and most around the country are desperate for staffing. I see less than half the patients a week I once did, and no longer do big spine surgery. I once employed seven people, now I have only one employee. I have much more free time to take up woodworking, raise chickens and cook for my family. I have even less disposable income, but the difference is not worth longer hours for marginal gain.
As our population continues to age, we need more, not fewer doctors. But I see no young specialists coming to the hinterlands to fill the need. Medical school graduates are less willing to put in the extra years to become sub-specialists for the ever-diminishing financial benefit. We graduate less than 300 general surgeons a year nationwide. We are filling the physician gap with lesser trained people, but all the mid level “care providers” and administrators in the world will not make up for people who can take out an appendix, fix a bone or save you from a heart attack.
The 16th Amendment does not limit the amount of income tax that can be levied against the American people. The government can legally vote to take 100 percent of our income and then dole it out however the “elite politicos” (who have themselves never produced a consumer product) see fit.
In a monstrous parody of the Founding Fathers’ dream, our system now rewards people not to be productive while taxing productive people into oblivion. The health of our citizens and the health of the nation cannot survive any more of this. Not only are we “taxed enough already” (as the T.E.A. party suggests), we are “taxed way too much already” – T.W.T.M.A. just doesn’t remind us of the patriots and Boston Harbor!