Are the PAs really the ones causing a problem?

[Elisabeth Kate]

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Probably protectionism from the PA standpoint as their licensing requires graduation from an accredited PA school and liability concerns (ie, being held to a physician standard even if not practicing in that capacity).

That's the only thing that really makes sense to me. It's a shame.

 

[primadonna22274]

A limited physician license makes a little bit of sense, but the days are looooonnnnngggg gone when a "PA" could "apprentice" under a supervising physician and work under the SP's license without completing a formal PA program, passing PANCE and maintaining ongoing NCCPA certification, and holding state licensure as a PA.
Used to be in the 70s and through the very late 80s that "grandfathered" PAs as described above (never attended an accredited PA program or obtained any license to practice medicine) could exist. But no more.
Perhaps there is a role for medical boards to offer a limited license to med school grads who haven't attended residency, but my guess is there are few enough of these folks that it isn't worthwhile or compelling enough to the boards. Short of completing a PA program, getting the PA-C, and obtaining and maintaining their own PA license, there is no opportunity for these folks to work as PAs.
Protectionism? You betcha. Hard won and well earned.

 

[Winged Scapula]

A limited physician license makes a little bit of sense, but the days are looooonnnnngggg gone when a "PA" could "apprentice" under a supervising physician and work under the SP's license without completing a formal PA program, passing PANCE and maintaining ongoing NCCPA certification, and holding state licensure as a PA.
Used to be in the 70s and through the very late 80s that "grandfathered" PAs as described above (never attended an accredited PA program or obtained any license to practice medicine) could exist. But no more.
Perhaps there is a role for medical boards to offer a limited license to med school grads who haven't attended residency, but my guess is there are few enough of these folks that it isn't worthwhile or compelling enough to the boards. Short of completing a PA program, getting the PA-C, and obtaining and maintaining their own PA license, there is no opportunity for these folks to work as PAs.
Protectionism? You betcha. Hard own and well earned.

Agreed.

I would also venture that in addition to the small numbers that this would apply to, medical licensing boards tend to be made up of older physicians and community members who are probably not up to date on recent difficulties in matching and would tend to view the unmatched physician as someone who is sub-par and not worth going to the trouble of creating a new license entity.

 

[Makati2008]

I was addressing your subtle condescension towards midlevel providers of which you may not feel that way overtly but your comments give it away.
"I asked why he was wasting time with a PA when he should see a proper doctor."
"Are we the ones creating this NP/PA problem?"
My comment is coming from a place of experience whereas yours is coming from conjecture. You are not even a graduate yet you're already creating a mental barricade between your prospective profession and someone else's. Access to quality care is a problem that has to be addressed but it is hardly a contentious issue like it's been made out to be here. Just trying to get you to see that and evaluate your own biases.

Agreed.
A

 

[Makati2008]

A limited physician license makes a little bit of sense, but the days are looooonnnnngggg gone when a "PA" could "apprentice" under a supervising physician and work under the SP's license without completing a formal PA program, passing PANCE and maintaining ongoing NCCPA certification, and holding state licensure as a PA.
Used to be in the 70s and through the very late 80s that "grandfathered" PAs as described above (never attended an accredited PA program or obtained any license to practice medicine) could exist. But no more.
Perhaps there is a role for medical boards to offer a limited license to med school grads who haven't attended residency, but my guess is there are few enough of these folks that it isn't worthwhile or compelling enough to the boards. Short of completing a PA program, getting the PA-C, and obtaining and maintaining their own PA license, there is no opportunity for these folks to work as PAs.
Protectionism? You betcha. Hard won and well earned.

Totally agree. Also I wouldn't want to be the Physician to supervise this hybrid Physician-PA person. Too many issues such as what caused this person to not pursue a residency(whether it is academic struggles from failed steps or folks with personal issues such as addiction or mental health problems.) as well as could I trust this person to know his or her limits. With a true PA I can honestly saying that you don't know and avoiding practicing outside of my scope was preached from day 1 and was ingrained into how I practiced.

This hybrid PA wouldn't have this same training.

 

[BestDoctorEver]

Some states like FL have limited license for physicians... In FL, these physicians can work in prisons, county department of health etc... One of these physicians that I worked with told me that this license is for FMG who were practicing in their homeland (country) for at least 5 years. They have to pass step I, II and III and they have to go in front of the medical board to make their case.

 

[Elisabeth Kate]

A limited physician license makes a little bit of sense, but the days are looooonnnnngggg gone when a "PA" could "apprentice" under a supervising physician and work under the SP's license without completing a formal PA program, passing PANCE and maintaining ongoing NCCPA certification, and holding state licensure as a PA.
Used to be in the 70s and through the very late 80s that "grandfathered" PAs as described above (never attended an accredited PA program or obtained any license to practice medicine) could exist. But no more.
Perhaps there is a role for medical boards to offer a limited license to med school grads who haven't attended residency, but my guess is there are few enough of these folks that it isn't worthwhile or compelling enough to the boards. Short of completing a PA program, getting the PA-C, and obtaining and maintaining their own PA license, there is no opportunity for these folks to work as PAs.
Protectionism? You betcha. Hard won and well earned.

No one is saying they should be called PAs. I don't know what they could be called that won't cause a lot of confusion. I just think that after four years of med school, a graduate is as qualified as a mid-level to provide care and yet, without residency, there's no mechanism under which they could do that without having to go BACK for more education. It's ridiculous, in my opinion.

 

[Elisabeth Kate]

Totally agree. Also I wouldn't want to be the Physician to supervise this hybrid Physician-PA person. Too many issues such as what caused this person to not pursue a residency(whether it is academic struggles from failed steps or folks with personal issues such as addiction or mental health problems.) as well as could I trust this person to know his or her limits. With a true PA I can honestly saying that you don't know and avoiding practicing outside of my scope was preached from day 1 and was ingrained into how I practiced.

This hybrid PA wouldn't have this same training.

Most U.S. grads who don't match aren't incompetent.

 

[Makati2008]

Most U.S. grads who don't match aren't incompetent.

So then give me your reasons why they don't match?
(Let's not count those who applied to a competitive speciality without a backup they usually go onto to do just fine in the end)

What mechanisms would you propose to prevent this hybrid from harming patients ?

Also you say most US grads that dont match are not incompetent but you will still have plenty that are so how do we keep this group from treating patients?

Also you may say that there are incompetent doctors but fortunately residency as well as the steps/ medical school helps to get rid a good chunk of these folks.

Lastly would you let this group treat your family? Be honest.


This is probably jumbled but typing on the go.

 

[Elisabeth Kate]

So then give me your reasons why they don't match? (Let's not count those who applied to a competitive speciality without a backup they usually go onto to do just fine in the end)

I do think the majority of U.S. MD students who don't match are ones who applied to competitive specialties. I think the other problem is that some over-estimate their competitiveness, even in moderately competitive specialties and don't interview enough/rank enough places.

What mechanisms would you propose to prevent this hybrid from harming patients?

How are patients any safer with a newly graduated PA than a newly graduated med student? If a U.S. med school graduate passes Step 1, Step 2 (both parts), and Step 3, what makes them any less qualified/any more of a danger to patients than a PA who just graduated? No one's saying give them a scalpel and let them loose in the OR.

Also you say most US grads that dont match are not incompetent but you will still have plenty that are so how do we keep this group from treating patients

I disagree that "plenty" of U.S. grads are incompetent, especially when it comes to U.S. MD students since their clinical education is standardized. If a person can get into and graduate from a U.S. MD school, pass all three steps of the USMLE, and do well on clinical rotations, I fail to see how they're incompetent.

Also you may say that there are incompetent doctors but fortunately residency as well as the steps/ medical school helps to get rid a good chunk of these folks

Lastly would you let this group treat your family? Be honest

Again, how are they any different than a newly graduated PA? I think they're MORE qualified than a newly graduated PA to work in a midlevel capacity because they've been through med school and passed Step 1, Step 2, and (ideally) Step 3 before ever setting foot in a clinic where they work under an attending physician. Yes, I would let them treat my family. You're acting like anyone who doesn't match isn't fit to be a doctor and that simply isn't true. Not matching is not an indication of incompetence.

 

[Brain Bucket]

Where can I get an assistant?

 

[Makati2008]

I do think the majority of U.S. MD students who don't match are ones who applied to competitive specialties. I think the other problem is that some over-estimate their competitiveness, even in moderately competitive specialties and don't interview enough/rank enough places.



How are patients any safer with a newly graduated PA than a newly graduated med student? If a U.S. med school graduate passes Step 1, Step 2 (both parts), and Step 3, what makes them any less qualified/any more of a danger to patients than a PA who just graduated? No one's saying give them a scalpel and let them loose in the OR.



I disagree that "plenty" of U.S. grads are incompetent, especially when it comes to U.S. MD students since their clinical education is standardized. If a person can get into and graduate from a U.S. MD school, pass all three steps of the USMLE, and do well on clinical rotations, I fail to see how they're incompetent.



Again, how are they any different than a newly graduated PA? I think they're MORE qualified than a newly graduated PA to work in a midlevel capacity because they've been through med school and passed Step 1, Step 2, and (ideally) Step 3 before ever setting foot in a clinic where they work under an attending physician. Yes, I would let them treat my family. You're acting like anyone who doesn't match isn't fit to be a doctor and that simply isn't true. Not matching is not an indication of incompetence.

1.)Your first point I agree somewhat.

2.)Go see the previous point about how PAs are trained to know when to say hey doc I don't know. Tell me what is stopping this person from saying you know what I am a doctor and they start practicing outside of their scope. Also let's be honest the majority of medical students are very Type A (myself included which explains why I didn't want to be a PA anymore among other reasons) which would make this problem even more likely to occur..

And to your last point, I never said they aren't fit to be docs what I am saying they are unfit to be a PA. But failing to ever to match or soap into some type of spot makes you unfit to be a Physician due to the rules and regs put into place for us to practice medicine independently.

 

[didymus]

Why not open 20 centers and stock them all with PAs with your name on them all? You can visit each one day a month.

I totally see the point you are shooting for here, but, for sake of clarity, in my home state a physician can only oversee (supervise) two PA's max. It isn't as out of hand as you are making it out to seem.

 

[Elisabeth Kate]

1.)Your first point I agree somewhat.

2.)Go see the previous point about how PAs are trained to know when to say hey doc I don't know. Tell me what is stopping this person from saying you know what I am a doctor and they start practicing outside of their scope. Also let's be honest the majority of medical students are very Type A (myself included which explains why I didn't want to be a PA anymore among other reasons) which would make this problem even more likely to occur

This makes no sense to me whatsoever. What's stopping them from practicing outside their scope? The same thing that stops everyone from practicing outside their scope. They lose their job/license. Do you really think there aren't Type A PAs out there who think they know better? You think there aren't residents out there who think they know better than their attending? This argument is very weak, in my opinion.

And to your last point, I never said they aren't fit to be docs what I am saying they are unfit to be a PA. But failing to ever to match or soap into some type of spot makes you unfit to be a Physician due to the rules and regs put into place for us to practice medicine independently.

No one is saying they should be a PA or a physician practicing independently. I'm saying they should have some role as a midlevel, the same as PAs and NPs. To say that it isn't worth it to create a whole new job for them because there aren't enough of them is a valid point. But the above doesn't make sense because you're arguing something I never said.

 

[primadonna22274]

You're going to have to campaign with each state's medical board to come up with some pathway for these folks. It won't be as a PA as the licensing rules are very, very specific. Other states with high need could try to model the Florida system, but as I've said before I think the desire to do so is very, very low when there are already established and regulated "midlevels" (btw we universally abhor this term!)

 

[Makati2008]

This makes no sense to me whatsoever. What's stopping them from practicing outside their scope? The same thing that stops everyone from practicing outside their scope. They lose their job/license. Do you really think there aren't Type A PAs out there who think they know better? You think there aren't residents out there who think they know better than their attending? This argument is very weak, in my opinion.



No one is saying they should be a PA or a physician practicing independently. I'm saying they should have some role as a midlevel, the same as PAs and NPs. To say that it isn't worth it to create a whole new job for them because there aren't enough of them is a valid point. But the above doesn't make sense because you're arguing something I never said.

1.) no headway will be made with that argument so I'm done beating the horse....luckily it's already dead.

2.)You wouldn't be creating a new profession for these people they would just be a PA. Luckily these unmatched Physicians won't be allowed to practice. End of story.

Prima- I'm a bad PA( rather lazy) I just say MLP.

 

[didymus]

***n=1***

I worked for several years at an executive level in a health clinic in my home city. In this role I observed interactions among a large, and diverse healthcare team, comprised of physicians, PA's, and NP's. In my personal experience, the physicians loved the PA's without exception. The same could not be said about the NP's, however.

What I observed was a truly collegial relationship between docs and PA's. The PA's never exhibited self-consciousness about their role and limitations. The docs demonstrated a high level of trust for them, and always spoke well of them. I never once had to resolve a conflict between a physician and a PA. These things cannot be said for the NP's. All of the nurses I worked with were very nice people outside of the clinic, but, man--while in clinic, they were mostly territorial, contentious, and looked down on the doctors. Several bad outcomes with patients arose due to the NP's refusing to ask a physician for help on a difficult case, despite it being over their heads. One time I had to intervene in a dispute where an NP was telling a physician-colleague "how things were going to be," and actually attempted to act as his supervisor with the case.

All that said to say I have personally noticed a remarkable difference clinically between PA's and NP's, and their respective interactions with physicians. The PA's I have known were quite humble clinically, highly professional, and content with their limitations. The NP's were not; they, as a group, approached practice with a chip on their shoulders, determined to show the doctors up, and prove they were clinical equals.

 

[Elisabeth Kate]

1.) no headway will be made with that argument so I'm done beating the horse....luckily it's already dead.

2.)You wouldn't be creating a new profession for these people they would just be a PA. Luckily these unmatched Physicians won't be allowed to practice. End of story.

Prima- I'm a bad PA( rather lazy) I just say MLP.

Then we'll just agree to disagree. I don't think there's anything "lucky" about an unmatched physician not being allowed to practice when they're just as qualified as any other midlevel just starting out.

 

[Anastomoses]

I totally see the point you are shooting for here, but, for sake of clarity, in my home state a physician can only oversee (supervise) two PA's max. It isn't as out of hand as you are making it out to seem.

Then your state is sensible. I don't think all states have such a rule.

 

[Sephiroth]

Totally agree. Also I wouldn't want to be the Physician to supervise this hybrid Physician-PA person. Too many issues such as what caused this person to not pursue a residency(whether it is academic struggles from failed steps or folks with personal issues such as addiction or mental health problems.) as well as could I trust this person to know his or her limits.

Wow, way to demonize anyone who's dealt with addiction or mental health problems. And as was said here and by many students and professors in my school at least, people only applying to competitive specialties and/or people who only rank a few places. And saying that these end up just fine could use some clarification.

That said, I agree that this quasi-PA approach isn't the way to go. If these people want to practice, they are best off trying to find a research fellowship and a prelim/transitional year if they can. If not, next year apply to every program possible, particularly ones in less desirable places, and ones that have tended to go unfilled, and apply to prelim/transitional years, after which you can still practice as a GP, and to primary care specialties at less competitive programs where you have a better shot. It would seem the best option then would be to try to get more prelim/TY spots opened up (dunno how common it is, but I've heard some rough stories about people matching solid PGY-2 residencies but not getting a prelim spot, so this would help with that problem as well).

You're going to have to campaign with each state's medical board to come up with some pathway for these folks. It won't be as a PA as the licensing rules are very, very specific. Other states with high need could try to model the Florida system, but as I've said before I think the desire to do so is very, very low when there are already established and regulated "midlevels" (btw we universally abhor this term!)

o so is very, very low when there are already established and regulated "midlevels" (btw we universally abhor this term!)[/QUOTE]
What exactly is this Florida program you're referring to? I can't find anything on it. Surprised I had't heard of it given I'd lived in Florida for a while.

 

[primadonna22274]

Actually it was my quote, and I don't know specifics either--a previous poster mentioned it back on page 2 or 3 of this thread.

 

[sakata8242]

A family friend hits me up online (knowing full well I'm not a doctor) to ask if I know anything about eye pus during a cold because it's hard to get doctor.

Him: they gave me amox for my ear infection; in my eye it's not like sinusitus puss
but sort of a whiter version of zit puss, but way stringier and the area above my upper tear duct is REALLY inflamed

Him: it was just a PA. not a real doctor. she just said go to an opthomologist for steroid drops
she just thought it was excessive tearing

LOL 🤣🤣🤣
At least she got the going to the ophthalmologist part right.

 

[DrBodacious]

Why are you talking like a pirate? 😛



What is the educational/training difference between a PA and a NP?

Why are we allowing PA's to see patients without a doctor even in the vicinity of the office? Is there a justification for this other than just money?

Justification = improved access.

I am an ENT, and I use a PA. It helps patients get in to be seen more quickly. Patients appreciate this, especially for acute issues. If they have acute sinusitis that hasn't been treated before, then they probably don't need to see me, anyway. (My PA has been doing ENT for 15 years, so he is very good with anything basic, and knows when to get me involved). If the patient doesn't improve, then I am going to be seeing them back for the follow up. The alternative is that the patient has to wait longer to get in to my office. If there were a surplus of ENT specialists in my area, then having a PA would be less viable.

Also, if it were just me practicing, I probably wouldn't take medicaid. But with a PA, I can have him help triage, and it makes seeing medicaid somewhat viable, or at least less painful to the bottom line. This way the medicaid population in my area has access to specialty care.

 

[DrBodacious]

3. If PAs can practice in clinics with no doctor in the area, why shouldn't NPs push for autonomy to have their own clinics and they can merely do exactly what PAs are doing...which is refer someone to a specialist if they can't help the individual with their problem?

The difference is that a physician provides quality control of a PA. Md/Do signs all the PA's notes, and therefore is responsible for the PA doing a good job. After seeing the PA, the patient is established in a clinic with the physician and can get follow up care with the PA or physician, as appropriate. Patients can easily request to see the MD.

Individual differences aside, this is a better situation than an independent NP clinic.

 

[Brain Bucket]

a valid message.

 

[Brain Bucket]

a valid message.

 

[KGflyboy]

First of all, when you become an MD you can be part of the "we." Secondly, and related to that, when you start practicing and you have actual interactions with PA's and NP's you'll learn that you have to temper that condescending attitude. These people are professionals and important components to delivering care and seeing many of the cases that you yourself will not want to deal with so you will be happy to have a good number of your patients "wasting their time" with midlevel providers so now is the time for you to get the idea out of your head. They are not "fake doctors" or "doctor wannabes" so have some regard. Besides, not everyone is privileged enough to attend medical school nor do they all want to.

The level of condescension in this post far exceeds any from the OP. You are overestimating any distain for midlevels evident in the OP (I didn't notice any), and at the same time you are speaking down to someone for not being a doctor yet. That is pretty ironic.

 

[CLETUS.the.FETUS]

It does seem that way and if the OP is reading then please accept my apologies for speaking down to you. As far as no condescension towards PAs I feel you're wrong about that. If I assert that someone is part of "a problem" or is a "waste of time" then the implication is fairly clear I feel. My point, and I'll make it again for all the premeds and MS 1s and 2s is that you are simply part of a team, albeit an important one, and we are not in opposition to other providers though often our training affords us greater insight. If you understand your role in the team and encourage others to understand theirs then the team runs smoothly and patients get taken care of.

 

[DermViser]

I do think the majority of U.S. MD students who don't match are ones who applied to competitive specialties. I think the other problem is that some over-estimate their competitiveness, even in moderately competitive specialties and don't interview enough/rank enough places.

How are patients any safer with a newly graduated PA than a newly graduated med student? If a U.S. med school graduate passes Step 1, Step 2 (both parts), and Step 3, what makes them any less qualified/any more of a danger to patients than a PA who just graduated? No one's saying give them a scalpel and let them loose in the OR.

I disagree that "plenty" of U.S. grads are incompetent, especially when it comes to U.S. MD students since their clinical education is standardized. If a person can get into and graduate from a U.S. MD school, pass all three steps of the USMLE, and do well on clinical rotations, I fail to see how they're incompetent.

Again, how are they any different than a newly graduated PA? I think they're MORE qualified than a newly graduated PA to work in a midlevel capacity because they've been through med school and passed Step 1, Step 2, and (ideally) Step 3 before ever setting foot in a clinic where they work under an attending physician. Yes, I would let them treat my family. You're acting like anyone who doesn't match isn't fit to be a doctor and that simply isn't true. Not matching is not an indication of incompetence.

For many old-school doctors, medical students who are unable to accurately gage their competitiveness to match into a specific specialty, are incompetent and calls into question their lack of judgment.

 

[Elisabeth Kate]

For many old-school doctors, medical students who are unable to accurately gage their competitiveness to match into a specific specialty, are incompetent and calls into question their lack of judgment.

Then those old school docs can choose not to hire those students/recent grads who didn't match. Simple enough.

 

[DermViser]

Then those old school docs can choose not to hire those students/recent grads who didn't match. Simple enough.

The jobs of those docs on licensing boards, is to look out for the public. Not just the ones they hire in their own practice.

 

[Elisabeth Kate]

The jobs of those docs on licensing boards, is to look out for the public. Not just the ones they hire in their own practice.

Well, considering there is currently no mechanism in place by which the licensing process would even be initiated, it's a moot point.

 

[DermViser]

Well, considering there is currently no mechanism in place by which the licensing process would even be initiated, it's a moot point.

Yes, and I am saying the above reason I listed is the reason it's not in place.

 

[Elisabeth Kate]

Yes, and I am saying the above reason I listed is the reason it's not in place.

It's not in place because no one has taken the initiative to investigate/pursue it, so any reason as to what would happen is conjecture. I don't believe these old-school docs who sit on licensing boards AND think any unmatched student is incompetent are in the majority screaming for this not to happen.

 

[BestDoctorEver]

Wow, way to demonize anyone who's dealt with addiction or mental health problems. And as was said here and by many students and professors in my school at least, people only applying to competitive specialties and/or people who only rank a few places. And saying that these end up just fine could use some clarification.

That said, I agree that this quasi-PA approach isn't the way to go. If these people want to practice, they are best off trying to find a research fellowship and a prelim/transitional year if they can. If not, next year apply to every program possible, particularly ones in less desirable places, and ones that have tended to go unfilled, and apply to prelim/transitional years, after which you can still practice as a GP, and to primary care specialties at less competitive programs where you have a better shot. It would seem the best option then would be to try to get more prelim/TY spots opened up (dunno how common it is, but I've heard some rough stories about people matching solid PGY-2 residencies but not getting a prelim spot, so this would help with that problem as well).


o so is very, very low when there are already established and regulated "midlevels" (btw we universally abhor this term!)

What exactly is this Florida program you're referring to? I can't find anything on it. Surprised I had't heard of it given I'd lived in Florida for a while.[/QUOTE]

Some states like FL have limited license for physicians... In FL, these physicians can work in prisons, county department of health etc... One of these physicians that I worked with told me that this license is for FMG who were practicing in their homeland (country) for at least 5 years. They have to pass step I, II and III and they have to go in front of the medical board to make their case.

 

[cbrons]

Can you clarify when the government will be paying for 95+% of the population? The only time the government pays out of pocket would be medical and medicare, and both of these aren't available to 95+% of the population, nor has it been expanded in many states (on that, we can leave the politics for another thread). Even if it were expanded, 95% of the population wouldn't qualify for either. Furthermore, ACA doesn't provide insurance, it mandates people go out and get it. Was this just supposed to be a hyperbole, and I looked too far into this? If it's the latter explanation, then whoops on me.

When there is no more private insurance, the gubmint will be paying for the vast majority of people. Since insurance companies are mandated to provide insurance regardless of preexisting condition and since the penalty for not having that insurance is less than it costs to obtain a policy, there will at some point in the near future be 0 private insurance companies and we will be forced into a single payer system. Of course the politicians and the super-rich (Jay Z & Beyonce, Warren Buffet, other scumbag hypocrites) will not be participants in this system and will flock to the small minority of physicians practicing so-called concierge medicine. I hope to be on those small minority of physicians btw.

 

[ruedjgtc]

When there is no more private insurance, the gubmint will be paying for the vast majority of people. Since insurance companies are mandated to provide insurance regardless of preexisting condition and since the penalty for not having that insurance is less than it costs to obtain a policy, there will at some point in the near future be 0 private insurance companies and we will be forced into a single payer system. Of course the politicians and the super-rich (Jay Z & Beyonce, Warren Buffet, other scumbag hypocrites) will not be participants in this system and will flock to the small minority of physicians practicing so-called concierge medicine. I hope to be on those small minority of physicians btw.

So, I'll take that as a "just made it up". Use your time machine for more useful purposes. =)

 

[Sephiroth]

So, I'll take that as a "just made it up". Use your time machine for more useful purposes. =)

yeah pretty much. I will agree with him that the penalty being too low is an issue though.

 

[ruedjgtc]

yeah pretty much. I will agree with him that the penalty being too low is an issue though.

This may well be true, but insurance companies in the US have long left the model of making money from premiums within a closed market. Premiums are just forms of equity to use as trade in the open market, so I don't think it's quite the apocalypse for the insurance companies, they have money making down to a MCAT science. They'll figure out a way to "invest" premiums in the tech emerging bubble etc. don't worry =D