Private Equity Gloats Over A Doctor Glut

[Taurus]

Private Equity Gloats Over A Doctor Glut

Health care vultures helped create an oversupply of ER physicians — now they want to use the surplus to cut wages and limit care.

www.levernews.com

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[DeadCactus]

Being discussed in the Denver $20/hour thread.

 

[southerndoc]

Probably deserving of its own thread. Love how the article posted a reference to SDN.

 

[betamale]

not so sure. i have 3 jobs

 

[bravotwozero]

big FU to PE.

what I don’t understand is, why CMGs see it as a financially sound idea to have PE backed them with debt equity to be paid at obscene amounts of interest

 

[Arcan57]

big FU to PE.

what I don’t understand is, why CMGs see it as a financially sound idea to have PE backed them with debt equity to be paid at obscene amounts of interest

The short answer is they don't feel like they have a choice. To be a CMG you either have to be massive or growing at a meteoric rate. If you're not, you're going to get swallowed by a bigger entity. Loosely paraphrased from a Kevin Klauer presentation to Team FMDs back in the 2010s: Banks won't lend the kind of money you need to buy out existing groups or even to float the 3-6 months before what you're billing starts being collected due to lack of collateral. Angel investors are going to want a seat on the board and too much control of the operation ( one could argue that now applies to PE too, but slowly boiling water v. frog, etc.). You can rely on using your own collections, but it's too slow and you'll get eaten.

PE was fine when visits where ticking up 10-15% per year in a lot of the country and there where still a lot of big independent groups with great contracts to snatch up. Now that the herd has been thinned, the apex predator CMGs are starting to feel the effects of the deals they made to get where they are.

 

[Birdstrike]

There's a special place in Hell for vulture capitalists in private equity who use Emergency Physicians and their patients as sacrificial lambs to score points in their reckless war of profit worship.

 

[EctopicFetus]

The short answer is they don't feel like they have a choice. To be a CMG you either have to be massive or growing at a meteoric rate. If you're not, you're going to get swallowed by a bigger entity. Loosely paraphrased from a Kevin Klauer presentation to Team FMDs back in the 2010s: Banks won't lend the kind of money you need to buy out existing groups or even to float the 3-6 months before what you're billing starts being collected due to lack of collateral. Angel investors are going to want a seat on the board and too much control of the operation ( one could argue that now applies to PE too, but slowly boiling water v. frog, etc.). You can rely on using your own collections, but it's too slow and you'll get eaten.

PE was fine when visits where ticking up 10-15% per year in a lot of the country and there where still a lot of big independent groups with great contracts to snatch up. Now that the herd has been thinned, the apex predator CMGs are starting to feel the effects of the deals they made to get where they are.

100% yes.
Dom bagnoli thinks USACS will keep growing. NFW. Their only hope to increase profits is to cut doctor pay which is coming. I believe pay will be slashed a lot and the difference between the haves (good SDGs) and have nots (CMG /employed) jobs will be much more than the 60k a year medscape has been quoting. I would expect 3x that by 2030. For anyone in an SDG keep in mind that as that gap grows so does the value of your group.
for those who don’t understand here is the simple math. SDG group makes $250/doc hr current market is $200/hr in the area. Value of group is roughly $50/hr * number of staffed doc hours. then You get a “multiple” on that number 7-13 in EM. Change the $50 to $150. Even with the lower end of the multiple your group will be worth more in the future than today. Fwiw I’m not condoning selling out. I. Don’t believe in PE in EM.
on that note F Kevin Klauer Dom Bagnoli Lynn Massingale tony briningstool James Augustine etc for all the turds who screw over their colleagues or those who did.

 

[hundreddaysoff]

You can rely on using your own collections, but it's too slow and you'll get eaten.

This fact right here makes me real sad. It suggests that, despite 8+ years of specialized training, I would never be able to turn a profit running, eg, a SDG or urgent care of my own creation.

The old wisdom of "use what you know to start a business and turn a profit" does not seem to apply to ER docs. Unless, possibly, we want to become the types of dingusholes who are good at attracting Big PE and other Sith Lords to give them cash, and thus who already run things.

One reason among many for all the threads around here about side gigs and retiring and the like, I guess.

 

[EctopicFetus]

This fact right here makes me real sad. It suggests that, despite 8+ years of specialized training, I would never be able to turn a profit running, eg, a SDG or urgent care of my own creation.

The old wisdom of "use what you know to start a business and turn a profit" does not seem to apply to ER docs. Unless, possibly, we want to become the types of dingusholes who are good at attracting Big PE and other Sith Lords to give them cash, and thus who already run things.

One reason among many for all the threads around here about side gigs and retiring and the like, I guess.

I think that’s false. new groups are starting but they are few and far between. Need someone who knows what they are doing to be on the team. Em isnt complicated but running a group isn’t exactly ever taught to us.

 

[Birdstrike]

You’re not going to be able to teach enough ER doctors to be CEOs. The better way is to unionize and leverage your collective power. Unified, you can bend the world to your will, in a matter of hours. Acting as individuals, you’re nothing but high cost, replaceable hourly help.

 

[EctopicFetus]

You’re not going to be able to teach enough ER doctors to be CEOs. The better way is to unionize and leverage your collective power. Unified, you can bend the world to your will, in a matter of hours. Acting as individuals, you’re nothing but high cost, replaceable hourly help.

No chance til things get real bad. People still finding $300/hr locums. If it happens it won’t be anytime soon. The new residencies and a large number of attendings have the mindset of replaceable hourly help.

 

[Arcan57]

This fact right here makes me real sad. It suggests that, despite 8+ years of specialized training, I would never be able to turn a profit running, eg, a SDG or urgent care of my own creation.

The old wisdom of "use what you know to start a business and turn a profit" does not seem to apply to ER docs. Unless, possibly, we want to become the types of dingusholes who are good at attracting Big PE and other Sith Lords to give them cash, and thus who already run things.

One reason among many for all the threads around here about side gigs and retiring and the like, I guess.

If you want to do capitalism, you can still do capitalism. Find inefficiencies in the markets, exploit those inefficiencies for profit, repeat until you’re big enough that someone offers you a big check to walk away. It’s harder then it used to be but it’s still possible. The guy that owned the contract at my old hospital is rich af after selling to APP. It’s stupidly difficult but if you play your cards right the mid 5th to early 6th decade of your life can be amazing. Instead of hanging out on a fishing boat in the Gulf Coast, you can be hanging out on a yacht in the Mediterranean.

 

[WilcoWorld]

Instead of hanging out on a fishing boat in the Gulf Coast, you can be hanging out on a yacht in the Mediterranean.

Both of these sound entirely OK to me! I'll take the option where I get to keep my soul, please.

 

[EctopicFetus]

If you want to do capitalism, you can still do capitalism. Find inefficiencies in the markets, exploit those inefficiencies for profit, repeat until you’re big enough that someone offers you a big check to walk away. It’s harder then it used to be but it’s still possible. The guy that owned the contract at my old hospital is rich af after selling to APP. It’s stupidly difficult but if you play your cards right the mid 5th to early 6th decade of your life can be amazing. Instead of hanging out on a fishing boat in the Gulf Coast, you can be hanging out on a yacht in the Mediterranean.

You mean mark green?

 

[Arcan57]

You mean mark green?

The character Anthony Edwards played on ER? No.

 

[EctopicFetus]

The character Anthony Edwards played on ER? No.

This dude. Sen. Mark Green takes CEO, chairman roles at Align MD

now deep in politics.

 

[southerndoc]

You know, the more I think about this, the more I realize that the CMGs and HCA have colluded to drive down market forces by increasing supply above demand. Many corporations in the US would face legal action if they were caught doing this.

I think there might truly be a case for the Department of Justice to investigate the large CMGs and HCAs that have supported the proliferation of emergency medicine residency training programs with the sole purpose of increasing supply so much that it drives down market prices.

 

[Franzd'Epinay]

I think there might truly be a case for the Department of Justice to investigate the large CMGs and HCAs that have supported the proliferation of emergency medicine residency training programs with the sole purpose of increasing supply so much that it drives down market prices.

I'll admit that I don't know the first thing about law, but this seems unrealistic.

Colluding to directly depress wages is obviously a no-no.

Even if you could prove it, colluding to increase labor supply (to in turn depress wages) seems like exactly the sort of technicality that a court would say is above board.

 

[grt398]

You know, the more I think about this, the more I realize that the CMGs and HCA have colluded to drive down market forces by increasing supply above demand. Many corporations in the US would face legal action if they were caught doing this.

I think there might truly be a case for the Department of Justice to investigate the large CMGs and HCAs that have supported the proliferation of emergency medicine residency training programs with the sole purpose of increasing supply so much that it drives down market prices.

Also, there's an argument to be made that this result is exactly what the government wanted. It's a lot easier to "influence" a dozen large corporations to get on board with your agenda than it is to corral 10k independent physician practices. Throughout history as markets consolidate into a handful of large entities those entities tend to be more plugged into the government to build legal "moats" around their kingdom so they can establish a pseudo-oligopoly type of status. It takes a LOT of anger and disastrous economic circumstances in society at large before they get broken up.

For some historical perspective, here's a simplified chart on some of the derivative companies of Standard Oil, which controlled ~90-95% of all oil refining in the United States at its peak when it was owned/run by the original John D. Rockefeller:

Chart: The Evolution of Standard Oil

In 1911, John D. Rockefeller's Standard Oil was broken up into 34 pieces by the Supreme Court. Today, the remnants form the base of the U.S. oil industry.

www.visualcapitalist.com

TLDR: Standard Oil was broken up into 34 companies and the resulting companies today have since undergone massive consolidation to include most names you're familiar with. It's worth a look if you have a few minutes. I'd argue healthcare is going in the same direction and this is what the govt wants since it can heavily influence healthcare without having to transition to an official "single payer" type system.

Oh and one more reference, which I can't fully vouch for but I think is relevant: Approximately 70% of physicians now work for corporate/hospital-employed practices:

Nearly 70% of U.S. physicians are employed by hospitals or corporate entities

The acquisition of private physician practices across the U.S. accelerated after the onset of the pandemic.

www.healthcarefinancenews.com

 

[turkeyjerky]

Also, there's an argument to be made that this result is exactly what the government wanted. It's a lot easier to "influence" a dozen large corporations to get on board with your agenda than it is to corral 10k independent physician practices. Throughout history as markets consolidate into a handful of large entities those entities tend to be more plugged into the government to build legal "moats" around their kingdom so they can establish a pseudo-oligopoly type of status. It takes a LOT of anger and disastrous economic circumstances in society at large before they get broken up.

For some historical perspective, here's a simplified chart on some of the derivative companies of Standard Oil, which controlled ~90-95% of all oil refining in the United States at its peak when it was owned/run by the original John D. Rockefeller:

Chart: The Evolution of Standard Oil

In 1911, John D. Rockefeller's Standard Oil was broken up into 34 pieces by the Supreme Court. Today, the remnants form the base of the U.S. oil industry.

www.visualcapitalist.com

TLDR: Standard Oil was broken up into 34 companies and the resulting companies today have since undergone massive consolidation to include most names you're familiar with. It's worth a look if you have a few minutes. I'd argue healthcare is going in the same direction and this is what the govt wants since it can heavily influence healthcare without having to transition to an official "single payer" type system.

Oh and one more reference, which I can't fully vouch for but I think is relevant: Approximately 70% of physicians now work for corporate/hospital-employed practices:

Nearly 70% of U.S. physicians are employed by hospitals or corporate entities

The acquisition of private physician practices across the U.S. accelerated after the onset of the pandemic.

www.healthcarefinancenews.com

You do know that the ACA was basically written by lobbyists for the AHA, PhRMA, etc., right?

Love the constant invocation of a government boogeyman for the sins of the corporatocracy.

 

[southerndoc]

I'll admit that I don't know the first thing about law, but this seems unrealistic.

Colluding to directly depress wages is obviously a no-no.

Even if you could prove it, colluding to increase labor supply (to in turn depress wages) seems like exactly the sort of technicality that a court would say is above board.

You may be right. It could be a technicality. As @grt398 pointed out, it's easier to have corporations go along with you than individual physicians.

In my haste of writing the above post, I failed to take into consideration that the government also benefits with lowering our market prices: Medicare will spent less on physician reimbursement (provided that CMGs also lower their rates).

We are one of few professions that not only have salaries not keep up with inflation, but even worse, go down as years progress. We are being assaulted from multiple fronts: projected oversupply, insurance reimbursement reductions, etc.

I've said it once, and I'll say it numerous times. If salaries decrease, there is a set margin that I haven't determined yet where I'll just give up my career and find something else to do. I'm sure there are numerous other physicians who feel the same way. To the new graduates, please live within your means and don't take on excessive debt. There is a lot of power in your ability to walk instead of taking sacrificial wages in order to pay your debt. Freedom is a lovely thing!

 

[grt398]

You do know that the ACA was basically written by lobbyists for the AHA, PhRMA, etc., right?

Love the constant invocation of a government boogeyman for the sins of the corporatocracy.

You think there's a difference b/w the govt and corporate interests at this point in healthcare? I would have to strongly disagree. And nothing in the ACA helped small physician practices in any way, shape or form...I'm well aware of who wrote the ACA b/c it also lead to the elimination of physician owned hospitals/practices, which, as it turned out not surprisingly to anyone familiar with consolidation of industry power in almost any other economic field, were cheaper:

Summary: Hospital ownership increases physician spending by 20%, study finds
Source: Patient Expenditures in Hospital-Owned vs Physician-Owned Medical Groups

Doesn't really matter at this point. There's no going back till the system fully breaks. I'm with southerndoc above...live within your means, avoid excessive debt, achieve FIRE or partial FIRE ASAP. And I guess for the med students...if you can get into a field where you can do a cash practice, that's probably best, but if not, at least consider fields where you are a revenue generator for the hospital system, or key source of referrals, and not fields where you're viewed as a cost center. Because much of management doesn't care about your ability to provide better patient outcomes unless it negatively impacts their earnings.

 

[Franzd'Epinay]

Also, there's an argument to be made that this result is exactly what the government wanted. It's a lot easier to "influence" a dozen large corporations to get on board with your agenda than it is to corral 10k independent physician practices. Throughout history as markets consolidate into a handful of large entities those entities tend to be more plugged into the government to build legal "moats" around their kingdom so they can establish a pseudo-oligopoly type of status. It takes a LOT of anger and disastrous economic circumstances in society at large before they get broken up.

I'd argue healthcare is going in the same direction and this is what the govt wants since it can heavily influence healthcare without having to transition to an official "single payer" type system.

How exactly does the government benefit from lower physician salaries if the CMGs are charging insurers the same and pocketing the difference?

This is the exact opposite of single-payer, where the overall goal is to reduce spending on healthcare.

 

[RustedFox]

How exactly does the government benefit from lower physician salaries if the CMGs are charging insurers the same and pocketing the difference?

This is the exact opposite of single-payer, where the overall goal is to reduce spending on healthcare.

CMG gives kickbacks to their elected officials.

 

[Franzd'Epinay]

CMG gives kickbacks to their elected officials.

That's true, donations (kickbacks) can certainly help.

I would argue even that is unnecessary, as a large swath of the population (elected officials included) are of the opinion that gubermint is the root of all evil, and therefore any gubermint involvement in the "free market" is inherently bad.

 

[turkeyjerky]

In my haste of writing the above post, I failed to take into consideration that the government also benefits with lowering our market prices: Medicare will spent less on physician reimbursement (provided that CMGs also lower their rates).

Hahahaha, good one.

You think there's a difference b/w the govt and corporate interests at this point in healthcare?

Yes, I do. I didn't see the feds advising the laying off of large numbers of healthcare workers during covid, for one example. While I agree with you that governmental policy is heavily influenced and beholden to corporate influences, we at least have a possible remedy for that. Whereas short of regulation or mass boycott, there's no remedy to make CMGs and hospital corporations behave better.

Of course, there's your other option of fleeing the system in order to become a service provider to the elite. No shame, I think it's rational at this point.

 

[Brigade4Radiant]

Senators can get kickbacks but if Doctors do it they can go to jail also corporations can do kick backs

 

[hundreddaysoff]

While I agree with you that governmental policy is heavily influenced and beholden to corporate influences, we at least have a possible remedy for that.

What remedy are you thinking?

 

[EctopicFetus]

Any discussion of a “free market“ in healthcare is a joke. It’s highly regulated, lots of rules, one payer (the government) makes most of the rules and sets payment for most to follow.

 

[emergentmd]

Maybe I am jaded but after 20 yrs of EM, doctors take a water pistol trying to fight the CMGs/Hospitals. We will never win. Even when we feel like we won through legislation, they just manipulate the laws in their favor. We are all looking down the path of lower income, more work, more rules/metrics, less workplace control.

The only control docs will ever have is to save enough where you can decide to jump ship on your own terms. Most docs should be able to do this in 10-15yrs of EM. If you don't try, you will be 45 dreading each EM shift.

 

[WilcoWorld]

Any discussion of a “free market“ in healthcare is a joke. It’s highly regulated, lots of rules, one payer (the government) makes most of the rules and sets payment for most to follow.

Not to mention that the "customers" don't really have freedom of choice.

 

[emergentmd]

Any discussion of a “free market“ in healthcare is a joke. It’s highly regulated, lots of rules, one payer (the government) makes most of the rules and sets payment for most to follow.

I was Med director at big receiving hospital, part of our private SDG, now know EM billing quite well and healthcare is likely the most non capitalistic system we have. There is no other business where the consumers are forced to have a middle man (insurance), have no idea what the seller is charging (hospitals), only to wait on a nebulous/overly complicated bill where even the most education will not understand. This system has both the insurers and hospital working against the consumer/healthcare providers to maximize profits.

These barriers allow the buyer and practitioner to have no control over prices with penalties for subverting the barriers.

Imagine wanting to buying a car. You go to a dealer who can just tell you that an SUV is available but can't guarantee the model, price, or when you will get it. The car maker is forced to make a car, sell it, and then hope/fight to get payment.

 

[WilcoWorld]

I was Med director at big receiving hospital, part of our private SDG, now know EM billing quite well and healthcare is likely the most non capitalistic system we have. There is no other business where the consumers are forced to have a middle man (insurance), have no idea what the seller is charging (hospitals), only to wait on a nebulous/overly complicated bill where even the most education will not understand. This system has both the insurers and hospital working against the consumer/healthcare providers to maximize profits.

These barriers allow the buyer and practitioner to have no control over prices with penalties for subverting the barriers.

Imagine wanting to buying a car. You go to a dealer who can just tell you that an SUV is available but can't guarantee the model, price, or when you will get it. The car maker is forced to make a car, sell it, and then hope/fight to get payment.

Also, you have good reason to believe that if you don't get an SUV within the next month you will die, and this is the only dealer in your area, so you don't have the ability to walk away from what looks like a bad deal.

 

[emergentmd]

Also, you have good reason to believe that if you don't get an SUV within the next month you will die, and this is the only dealer in your area, so you don't have the ability to walk away from what looks like a bad deal.

With the added benefit that 90% of the population have no idea what condition they have even if they explained in detail. Atleast a car, most have driven it and have a good understanding of what they want.

Its messed up. I am very pro capitalist. I am pro docs making a great living. But this system is so messed up and the buyer/provider gets screwed at every turn.

 

[Birdstrike]

There’s two types of headphones you can use in the water- standard in ear bud type and bone conduction. I have not tried the bone conduction yet, but will next time I’m in the market. Otherwise, you will need a waterproof buds/mp3 player combo. Some come integrated. I’m not sure that any are great, but I’ve tried swimbuds and they are acceptable.

You may be right. It could be a technicality. As @grt398 pointed out, it's easier to have corporations go along with you than individual physicians.

In my haste of writing the above post, I failed to take into consideration that the government also benefits with lowering our market prices: Medicare will spent less on physician reimbursement (provided that CMGs also lower their rates).

We are one of few professions that not only have salaries not keep up with inflation, but even worse, go down as years progress. We are being assaulted from multiple fronts: projected oversupply, insurance reimbursement reductions, etc.

I've said it once, and I'll say it numerous times. If salaries decrease, there is a set margin that I haven't determined yet where I'll just give up my career and find something else to do. I'm sure there are numerous other physicians who feel the same way. To the new graduates, please live within your means and don't take on excessive debt. There is a lot of power in your ability to walk instead of taking sacrificial wages in order to pay your debt. Freedom is a lovely thing!

CMG gives kickbacks to their elected officials.

Hahahaha, good one.


Yes, I do. I didn't see the feds advising the laying off of large numbers of healthcare workers during covid, for one example. While I agree with you that governmental policy is heavily influenced and beholden to corporate influences, we at least have a possible remedy for that. Whereas short of regulation or mass boycott, there's no remedy to make CMGs and hospital corporations behave better.

Of course, there's your other option of fleeing the system in order to become a service provider to the elite. No shame, I think it's rational at this point.

Senators can get kickbacks but if Doctors do it they can go to jail also corporations can do kick backs

Any discussion of a “free market“ in healthcare is a joke. It’s highly regulated, lots of rules, one payer (the government) makes most of the rules and sets payment for most to follow.

Maybe I am jaded but after 20 yrs of EM, doctors take a water pistol trying to fight the CMGs/Hospitals. We will never win. Even when we feel like we won through legislation, they just manipulate the laws in their favor. We are all looking down the path of lower income, more work, more rules/metrics, less workplace control.

The only control docs will ever have is to save enough where you can decide to jump ship on your own terms. Most docs should be able to do this in 10-15yrs of EM. If you don't try, you will be 45 dreading each EM shift.

Not to mention that the "customers" don't really have freedom of choice.

The older I get the more I'm convinced that the amount of corruption in our society is growing like an out of control cancer. I don't know if I'm just noticing more what's already been there, if I'm getting more jaded and conspiratorial, or if there truly are less and less good guys winning. But it makes me crave the days I can retire with nothing but a fishing pole, a drink and throw my cell phone in the pond, for good.

 

[deleted941485]

The older I get the more I'm convinced that the amount of corruption in our society is growing like an out of control cancer. I don't know if I'm just noticing more what's already been there, if I'm getting more jaded and conspiratorial, or if there truly are less and less good guys winning. But it makes me crave the days I can retire with nothing but a fishing pole, a drink and throw my cell phone in the pond, for good.

Its because the country is probably getting poorer overall for the average person and there just isn’t much productive activity being done so people resort to fraud and theft. I’m too young to retire and too cynical to think I ever will with any dignity. Best I can hope for that I am in the within the initially blast zone when the nukes start flying.

 

[Franzd'Epinay]

Its because the country is probably getting poorer overall for the average person and there just isn’t much productive activity being done so people resort to fraud and theft. I’m too young to retire and too cynical to think I ever will with any dignity. Best I can hope for that I am in the within the initially blast zone when the nukes start flying.

Somehow I get almost the exact opposite impression: the country as a whole is incredibly rich, but there are some very greedy groups doing their utmost to hoard all the gains from that productivity. You're going to have a hard time convincing me that private equity and their ilk are "resorting" to fraud and theft because of their poor situations.

 

[bronx43]

Somehow I get almost the exact opposite impression: the country as a whole is incredibly rich, but there are some very greedy groups doing their utmost to hoard all the gains from that productivity.

Incredibly rich and getting poorer are not mutually exclusive. In fact, I would say that both are very true of the US.

With that said, every country is getting poorer. The US, by comparison, is actually getting relatively richer even if we are becoming poorer in absolute terms.

 

[Franzd'Epinay]

Incredibly rich and getting poorer are not mutually exclusive. In fact, I would say that both are very true of the US.

You're probably alluding to wealth inequality. While this is also a hugely important factor in the country's issues, I think it's important to note if the country as a whole (considering both the haves and the have-nots together) is getting richer or poorer.

 

[bronx43]

You're probably alluding to wealth inequality. While this is also a hugely important factor in the country's issues, I think it's important to note if the country as a whole (considering both the haves and the have-nots together) is getting richer or poorer.

I’m not alluding to wealth inequality.
What I’m saying is that the US has been incredibly wealthy relative to others since WW2. We can be incredibly wealthy but still lose ground in terms of standard of living.

 

[deleted941485]

Somehow I get almost the exact opposite impression: the country as a whole is incredibly rich, but there are some very greedy groups doing their utmost to hoard all the gains from that productivity. You're going to have a hard time convincing me that private equity and their ilk are "resorting" to fraud and theft because of their poor situations.

If the value extracted from PE firms and like minded employers were ever returned to the workers who produced it you would see inflation the likes of which would make Weimar Germany look like a stable country. PE is guilty of wage theft and bilking patients. It’s a zero sum game. Workers lose money so PE can have a net positive return.

The real products are services we use are getting crappier. The things we need are getting scarcer. Financial security is pretty much a joke at this point. Credit is what fuels even everyday consumption at this point. The US is also competing with multiple emerging economies which are eating our lunch. And all anyone is doing is focusing on GDP and we’re the Dow is at any given time. It’s a joke. The average American is probably poorer than even they would be willing to admit. So if your not in the correctly appointed economic niche or studying the right kind of engineering, an shrinking proportion of the population. You’re probably paying for that new television with a payment plan.

 

[deleted941485]

I’m not alluding to wealth inequality.
What I’m saying is that the US has been incredibly wealthy relative to others since WW2. We can be incredibly wealthy but still lose ground in terms of standard of living.

It’s all about your wealth reletive to others. The absolute number while large isn’t really the point.

 

[EctopicFetus]

Regarding the poor the easiest metric is looking at percent of population who live below the poverty line.
reAl income is up. Real income by race poverty over time here. Was much higher now bounces between 10 and 15 percent. Poverty rate over time

what we have seen is the super rich become more common but reality is the poor have dropped over time, and more middle class are now wealthier. We worry about income inequality cause it plays well politically but in reality as the real income graph shows everyone is “richer” now than previously in real money.
yes there is corruption but things are pretty darn good in the ole us of a.

 

[GassYous]

Regarding the poor the easiest metric is looking at percent of population who live below the poverty line.
reAl income is up. Real income by race poverty over time here. Was much higher now bounces between 10 and 15 percent. Poverty rate over time

what we have seen is the super rich become more common but reality is the poor have dropped over time, and more middle class are now wealthier. We worry about income inequality cause it plays well politically but in reality as the real income graph shows everyone is “richer” now than previously in real money.
yes there is corruption but things are pretty darn good in the ole us of a.

In 50 years when the world is on fire, crop yields are down and everything is going to **** then we will look back and realize how good we had it

 

[deleted941485]

In 50 years when the world is on fire, crop yields are down and everything is going to **** then we will look back and realize how good we had it

I’ll look back and say. A slow decline is preferable to a sudden fall.

 

[Apollyon]

In 50 years when the world is on fire, crop yields are down and everything is going to **** then we will look back and realize how good we had it

Isn't that part of the plot of Interstellar, Highlander 2, Blade Runner, Judge Dredd, et al?

 

[namethatsmell]

I tell my trainees to step back and evaluate their path to FI at least every 3-4 months. If a resident takes a little bit of time to plan things out and then make some choices with FI in mind (ie first job/house/car/spouse), there are very few scenarios where a doc can't exit the ****show by their 40s or 50s if they chose.

 

[GassYous]

Isn't that part of the plot of Interstellar, Highlander 2, Blade Runner, Judge Dredd, et al?

I just watched blade runner and I've been reading the three body problem

 

[RustedFox]

Isn't that part of the plot of Interstellar, Highlander 2, Blade Runner, Judge Dredd, et al?

We may chuckle at this; but it is in this fashion that a sizable percentage of the millennials and beyond see the future - and with defensible logic.