A moral imperative to address the costs of training our doctors

by Andrew M. Ibrahim and John A. Brockman

Despite the landmark progress of recent healthcare reform, it missed the mark on long term cost control by failing to address medical education.

Radical changes are needed in the way we finance tuition and how we teach our students.

While last month a new graduating class of medical students celebrated their Match into training programs for their specialty, the news wasn’t all good. Following concerning trends of the last few years, US students opted for high-paying specialty careers over primary care. Family medicine, pediatric and internal medicine relied on foreign graduates to fill spots while plastic surgery and dermatology turned down many US applicants.

This pattern is not without reason, and tuition expenses are largely to blame.  This years graduating class was characterized by taking on enormous debt. More than a quarter of graduates have greater than $200,000 in loans. Research continues to show that the level of debt influences students to choose higher paying careers.  More concerning, higher debt has also been associated with poorer quality of life, likelihood of burnout and increased thoughts about suicide.

The negative impact of high tuition on physicians has not influenced medical school administration. In the last decade, the costs of a medical education increased at twice the rate of inflation without justified cause. This leaves graduates anxious to increase their salary and feeling justified to enforce co-pays in their practice, overbill and avoid low-paying insurances, including Medicaid patients. Moreover, they often are paying off this debt well into their 50’s at variable interest rates well above those paid by home owners.

National level intervention is needed to address the unsustainable costs of medical education. At minimum investigation is needed to understand why it has risen at a rate far outpacing similar institutions. While it is unlikely that all of medical education would be subsidized, it could be done for less than 1% of our Medicare budget. Even a partial investment in this direction could represent a common sense strategy to address workforce shortages to care for an aging baby boomer generation.

If we are serious about reducing healthcare costs long term, we have a moral imperative to address the costs of training our doctors. Using capitalist theory to put students in debt and then expect them not to use the same principles for their own interests that drive up utilization costs is unrealistic and unfair.

Andrew M. Ibrahim is the Doris Duke Fellow in Clinical Research in the School of Medicine at Johns Hopkins University in Baltimore, Maryland.  John A. Brockman is national President of the American Medical Student Association in Washington DC.

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  • PhD

    Sure, this will happen, and seems fair… when all physicians agree to flat salaries ($200K sounds fair, to pick an arbitrary number; maybe $250K for those with longer residencies and more on-call), and a single-payer system. But no student loan debt – that will make it worthwhile, right?

    Physicians are so far-removed from the reality in which most Americans live – even other highly educated, well-paid Americans – it’s not even funny.

    • Fam Med Doc

      Physicians are so far-removed from the reality in which most Americans live – even other highly educated, well-paid Americans – it’s not even funny.

      Ok, tell us please: how am I and my collegues “so-far removed from reality”?

    • Jimmy Peanut

      I am a medical student who left another lucrative professional career to go back to medical school because I want to work with patients. I can’t tell how far from reality your statement really is. Here’s the reality of what we as medical students are thinking when we go to med-school:
      1) We’re all pretty smart, so you I feel that is safe to assume that most of us could have succeeded in other professions. Many would eventually make just as much, if not more, in other professions, so you have to compensate us as such. I’m willing to bet that there aren’t too many MD students who couldn’t have gotten into law school, and I know quite a few established lawyers who make more than $200K (and they went to less school, not to mention residency).
      2) We sacrifice more than money. We spend countless hours studying in med-school, and, as the old saying goes, time is money. We spend 7 years in school and residency at minimum, more if we specialize. We give up time with our families and friends. We delay starting families. That has to be worth something.
      3) If you don’t compensate doctors well, today’s students aren’t going to put themselves through the hell of med-school and residency. I’m not talking about the monetary cost; I’m referring to the lifestyle. Students are smart, and most people would prefer their physician to be the best and brightest. Smart people weigh the costs and the benefits and the benefits at the end of the tunnel don’t outweigh the costs, you’ll soon have less qualified applicants. Remember, you get what you pay for.
      4) And just in case you’re under the illusion that treating patients is reward enough, just go work a day in hospital. Patients are rarely the grateful people we imagined before getting to med-school. Some are, but most aren’t, and some are, quite frankly, more trouble than they’re worth. I know that sounds mean, but if you’ve ever been threatened and attacked by a drunk it the ED, you’ll know it’s true.
      5) Paying for our tuition would be a start, and most of us in school would consider it, but it’s not enough. If you consider sweetening the deal with real medical malpractice reform, then we’d think a little harder. But you’re still going to have to compensate us well enough to even get us to the negotiating table. Remember, we’re smart, and smart people know that education is a long-term investment. A small payment up-front with greatly reduced long-term payout is a bad investment compared to a larger investment upfront with bigger payouts over the long term.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        When you say “smart”, do you mean “business savvy”?

        • Vox Rusticus

          Why be obtuse? If you read the reply, you would understand it meant academically high-achieving, and enough so to enjoy considering competitive graduate and professional training opportunities leading to well-paid careers outside of medicine.

          Being business savvy is something else, which some smart doctors are as well, and others, not so much.

  • anonymous

    “Using capitalist theory to put students in debt and then expect them not to use the same principles for their own interests that drive up utilization costs is unrealistic and unfair.”

    This is the heart of the matter. All the humanistic, duty to society, social contract talk (which, btw, is near exclusively directed towards the physician duty to society and not the reciprocal) registers at a faint whisper compared to the jet engine roar of the money squeeze on physicians from all sides, of which student loan debt is just one aspect.

  • http://www.andrewibrahim.com Andrew M Ibrahim

    Look forward to your feedback —
    On Twitter:

  • GaiFella

    Sure, this will happen, and seems fair… when all physicians agree to flat salaries ($200K sounds fair, to pick an arbitrary number; maybe $250K for those with longer residencies and more on-call), and a single-payer system. But no student loan debt – that will make it worthwhile, right?

    I’m glad our PhD colleagues will allow us to have this salary. Can I have a 15 minute nap break every 40 hours for call too?

    There are multiple reasons why people become doctors and financial security has to be one of them. Thank you PhD master, thank you. What else will you allow me to have?

    • Apurva Bhatt

      An excess of government involvement is largely responsible for many of the woe’s that physicians (especially PCP’s) find themselves in today. Are we really delusional enough to believe that the government somehow regulating a lower cost for our education will come without huge strings attached?

  • soloFP

    $200,000 is a lot of money. That said, living conservatily and frugally has allowed me to pay off all my debts and loans. The biggest mistakes my colleauges made included buying $50,000 cars and $500,000 homes the minute they got the guaranteed salary and sign on bonuses. Taking excessive vacations and expensive vacations also does not help pay off debt. It should not take more than a few years to pay off education debt to to doc who stays frugal.
    Most physicians do well financially. Even so, many of my colleagues are living paycheck to paycheck. The more one makes, the more one spends. The more flashy items in the parking lot, the more resentful the population becomes.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    How about 100% loan forgiveness if the student chooses primary care? Would this change anything?

    • Vox Rusticus

      I doubt it. The people who would have taken primary care in the first place will take the loan forgiveness. But why not just pay them better, instead? That would be far more likely to result in more people who are starting out in medicine continuing in general internal medicine (assuming they were happy) rather than going on to fellowships to specialize.

      I am not in primary care, never had any desire to be, and I financed my medical education largely through a military scholarship. Repayment was four years service.
      I would not have accepted a lifetime of rat-wheel financial stress and underpayment as an alternative.

  • http://www.hopestreetgroup.org/index.jspa Joy Twesigye

    Balancing debt and future income is difficult in the medical field. During our conversations about the matter, people seemed to be torn about building in the incentives before vs after graduation. Some felt that if the debt amount incurred while in school could be reduced (via accelerated programs, grants for primary care students) then this would gear more people into primary care while others felt as though building in long term incentives after the fact like longer repayment programs was key–this would provide a benefit for people who are already doing what they want to do….the only consensus we found was to include everything in the report! I imagine similar discussions make it difficult to be decisive about choosing a course of action to solve the problem. http://www.hopestreetgroup.org/docs/DOC-2477

    • pj

      longer repayment programs????

      30 yrs (in my case anyway) isn’t enough????

  • http://www.andrewibrahim.com Andrew M Ibrahim

    So there is interesting data that most docs can pay off their loans within 15 yrs by putting away 10% of their income …. that said, debt still CLEARLY influences students into choosing higher paying careers.

    As I’m learning through this great book — Social Animal, David Brooks — our decisions are mostly emotional and we just logic to justify it, not that other way around.

    Great comments, keep them coming!

    • http://www.twitter.com/alicearobertson Alice

      What am I missing? My son has a huge amount of student debt. Maybe as much as a doctor without the earning capacity. He did make the mistake of attending a private college at about $50,000 a year? We took on half and he took on half. I have been paying this back for forever, and he took two extra part time jobs this summer to try to dig his way out. He wants to get out from under for grad school.

      He earns about $40,000 a year. Really I don’t get the conversation when so many others are wading through the same debt without the prestige and earning capabilities of physicians.

      I am very grateful for the sacrifice you make to become a doctor. But I am grateful to nurses, I am grateful for teachers (even though I have homeschooled and paid for private school for a lifetime), soldiers…….etc. The dedication is phenomenal.

      I think the real problem is in your earning power, not the colleges (which is a scam…but we gotta play with the cards on the table..although some doctors keep costs down). Your earning power is clearly going to go down…sure some will hit the jack pot…but overall the more government involvement will mean not only your earning power will be less lucrative, but the peripherals are going to be more constraining.

  • Dave

    How about containing costs some? Medical schools have to waste tons of money. As a student, I honestly don’t know where all the money goes. Well I kind of do, the amount of support staff is somewhat ridiculous and there are other austerity measures that could be taken.

    • http://www.andrewibrahim.com Andrew M Ibrahim

      Great point — how could we make medical schools more accountable? Should we require transparency?

  • http://fertilityfile.com IVF-MD

    Regarding your observation “In the last decade, the costs of a medical education increased at twice the rate of inflation without justified cause.”….

    Whenever price movements on something appear to defy normal market forces, there is usually some sort of artificial subsidy or barrier to entry at work. In this case, it’s a barrier to entry of competition. If a group of innovative educators and doctors got together and figured out a super cost-efficient way to train doctors by harnessing the power of the the internet, efficient ways of skills training and smart ways to slash bloated overhead, they would not be allowed to just get out there and compete. There are all sorts of bureaucratic hurdles to jump before the more affordable school would be allowed to operate. Many of these hurdles are totally unrelated to quality of education.

    So the solution is clear. But politically, there is a lot of opposition to this from the current educational system, because they stand to benefit from preservation of their monopoly. It makes sense.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      Also take into consideration that most medical students paying with loans are borrowing from Federal Direct Loans. The government has no problem lending this money to medical students at relatively low interest rates because in the end, they are making money on us. The more money that is available for them to provide for medical education to medical students, the more tuition will rise as schools know that this money is available for students to borrow. Of course this is not the only factor, but it definitely plays a role.

      • http://fertilityfile.com IVF-MD

        Good point. Subsidized education makes it easier for administrators to pass high tuition costs to the students. It’s less painful to endure high costs if you can defer payments and if some of the money is paid by taxpayers.

        I’m on faculty at two medical schools. One is a state of California M.D. school. For the other one, I’m not totally sure of the financial structure to be honest. A quick web search reveals it to be “a non-profit, private, graduate school for the health professions”. It is a D.O. school.

        In agreement with your observation on ancillary staffing, things have changed lately and my gut feeling is that there were a lot more secretaries and admin workers in the past as compared to now. I don’t have access to the actual payroll data of course, but I sense that staffing has been efficiently trimmed. The current staff seem to be working more, getting more done with less manpower. So that’s a good thing, right? Now if only that were enough to generate savings that could be passed on to the students.

      • http://Www.twitter.com/alicearobertson Alice

        Should teachers get the same perks? Nurses? Where would the line be drawn? The standard? Would it be based on your contribution to society? Right now the government payments to healthcare and via the states Medicaid and schools, teachers, nurses, social workers are all contributing….all have student debt. Why are doctors in a special category?

        Seems to me some think entitlements are only wrong when they go in a direction away from you?


    @Jimmy Peanut

    There is iron in your words.

    It is refreshing to find “smart” folks who understand the issues at hand so early in the process of becoming a physician.

    Please find more medical students that are like minded and get them involved in the new reality before they become mere victims of the new reality.

  • Muddy Waters

    Doctors are like highly paid corporate CEOs. Supporters justify the exorbitant bonuses given to CEOs as necessary to keep their invaluable expertise and experience from jumping ship to another endeavor. As has been illustrated by others on this post, medical students ARE the best and brightest. It goes without saying that we CAN be successful and well-paid in other professions. If you don’t pay us, we will just go elsewhere. Think it’s hard finding a good doctor now – just wait. Without doctors, there is NO HEALTHCARE. Insurance companies, Pharma, and malpractice attorneys would be well-advised to make sure we get ours…because their survival is dependent on us, and not vice-versa.

    • http://Www.twitter.com/alicearobertson Alice

      They maybe be bright…but not the best overall. If they were Mensa would be crawling with them.

      Are applications to med schools down?

      • Vox Rusticus

        Mensa is crawling with people who want to be members of Mensa.

        • http://Www.twitter.com/alicearobertson Alice

          LOL. I take it back….you are bright…..but the best? Best comeback of the day?


    @ Muddy….

    What you said.

  • http://Www.twitter.com/alicearobertson Alice

    It is not just doctors struggling with student debt. Universities charge what they can get away with. Read insider tales about this, or the delightful, new book Crazy U.

    If the government gets involved anymore with doctors you will become pawns. They may even choose your specialty. More government…less freedom.

  • http://www.edwinleap.com/blog Edwin Leap

    This is an excellent column, and one that resonates with me. I am an emergency physician, and have at least one child who suggests he is interested in medical school. The debt problem is compounded by college debt as well. Too many in our society believe that the only good college education comes from an expensive private school, which leaves the student possibly 100-150K in debt before medical school. So they might graduate medical school owing 300-350K! A modest house is 100K. Cars are not cheap. Food isn’t cheap! But all too often, the response physicians get is this: ‘so what, you’ll be a rich doctor!’ As if, with our academic hooding, we receive a pirate’s treasure chest of gold! In point of fact, medicine involves more than making gobs of money and eating caviar. It involves paying one’s own health, disability and malpractice insurance; one’s own CME, the costs of insurance for one’s employees. It’s not the same as being employed and having someone else pick up the tab. After all this, how many physicians can afford to go into lower paying specialties and see the poor? We need to cut the educational cost at several levels, starting with college. And realize, nationally, that the practice of medicine is lucrative but also costly.

  • http://www.andrewibrahim.com Andrew M Ibrahim

    @Edwin: great points, you’re right the same scandal of education rising in cost is happening at the undergraduate level too.

    @soloFP: yes, we need to get better about spending in general. That is a broad problem well beyond just docs — its most Americans.

    @IVF-MD: I have yet to see ANY medical school show any kind of transparency in how they spend their students tuition $. My sense is that is goes into a big “central pot” of money…

    @Alice: thanks for joining in — you’re right, education is being used to manipulate a lot of people in many professions… but I think why some feel that medicine stands out is because of the amount of $$ that is followed by long training afterwards at a lower salary (i.e. Its hard to pay off $250k of debt accruing interest when youre salary is $50,000 the first 4-6 years out), you know? Truth is eventually we pay it off — its just something different to plan for.

    I did not meant to say doctors don’t make enough money … I only meant to say that when early in training, being placed in a lot of a debt (often 200k + ) changes your view of medicine. It may appropriate or inappropriate, but debt clearly shapes our career plans ahead. Most of us (people in general) think in 2 yr and 5 yr plans, not 30 year plans.

    • http://Www.twitter.com/alicearobertson Alice

      I think doctors are paid fairly…now the good ones…not enough. But the debate ends when you have a teacher owing over six figures earning less than $30,000 annually.

      I think our soldiers are underpaid. But our neighbor’s son did the Peace Corp and got 70% of his student loans paid off. They were over six figures. My friend’s daughter is getting pre med paid off this way, and a huge part of medical school.

      Wouldn’t doctors do well to serve in this manner to get student debt paid off….rather than an entitlement? This seems more fair. I am sure you have read about doctors who were offered student loan pay offs if they would work a few years in either inner cities or the boondocks. They could not get enough doctors to do it. Why? The pay wasn’t very good. But that mindset is changing.

      • pj

        Alice (and the other poster who mentioned loan forgiveness for practicing in underserved areas)-

        There are barriers to entry into these programs- yes, they are competitive. As a preventive medicine physician, I am ineligible for many of these depsite extensive primary care experience.

        I’m told the military programs are similar. Some years their needs are greater so they accept more applicants.

        For those who worship “free markets,” this is the major downside… less stability. Not a set # of slots each year. Just like many other gov’t sponsored programs, there is less money available and more demand.

  • http://fertilityfile.com IVF-MD

    Well, there is a certain price that students are willing to pay in exchange for what medical school has to offer. Bear in mind there are two very distinct components that they are paying for – knowledge and permission.

    There is the knowledge and skills that one can acquire by attending class and doing rotations. One could argue that there are infinitely better ways to achieve this more efficiently. For the book science part, there is no evidence that sitting in a classroom listening to a virus lecture from a PhD who had never actually seen a patient with any of the discussed diseases before is the best way to learn this material. With the power of computing, there are so many better ways to try.

    If the perceived value of medical school were purely related to how one can acquire knowledge, you can bet there would be many successful competitors that do it better and cheaper.

    However, there is the second component of a medical school’s value and that is the permission aspect. Pretend we have a student whose twin brother is a medical student. The twin could get all the same notes and watch videos of all the same lectures. And let’s say he somehow gets away with sneaking in to all the clinical modules as well. When it’s all said and done, even if they both have the exact same knowledge and skills now embedded in their brains, only one is permitted to interact with patients. The other, even if he was smarter and learned the material better, is banned from practicing medicine. So this “permission” aspect is what commands the high tuition – NOT just the knowledge acquisition part.

  • Alice

    PJ….the law changed…volunteerism helps write off the loans and something about a ten year limit. I am on my cell but I remember reading for some whatever you owe after ten years is wrote off. Grr…..quite frankly, I do not support Pell Grants…I support volunteerism for everyone from high school students (I would make 20 hours a month mandatory for graduation…put all that youthful energy for something better than …ah…..recreational activity that recs havoc on their psyche and ah libido, etc

    I believe this is on table for educational reforms. If you have a doctorate you enter the forces as an Officer with almost complete loan forgiveness.

    • pj

      Alice, I think you refer to this-


      But I fear you miss the point. Before a Doc is eligible for any forgiveness, they must get hired! That’s the rub- that is not as easy or straightfoward as you make it sound. It’s a competitive process.
      Those budgets are getting slashed just like most others. In my state, the board who hands out the money to those who work in underserved areas said they had almost a hundred rural docs apply for a limited amount of money (wouldn’t tell me how much, but their point was, it was less every year, and it was orig. intended to assist a dozen, not hundreds of docs).

      • http://Www.twitter.com/alicearobertson Alice

        Not really missing the point. Your training can be used for so much more than making money. Every angle doctors use becomes moot…high student loans….get in line….long work hours….how does two low paying jobs sound?….stress….try WalMart, UPS, etc. Getting fired quickly with few options. Your problems are not as specific as you try to make them. and public perception that the average doctor earns five times what their average patient does without five times the student debt.

        JP…your point is good….but you are so vastly outnumbered by struggling patients whose standard of living is so much less they view it all as sour grapes:)

        I actually do not know any doctor who volunteers consistently unless they are retired…and they are few and far between. So it is not just few opportunities…it is an unwillingness…it is the desire for respect….and, rightfully, compensation for your own sacrifice.

        • pj

          Alice, you have good perspective, but I think the authors were pointing out first, this trend is just as unsustainable as that of health care cost growth in the US, and second, that the shortage of PCP’s is aggravated by the high tuition since the earning power of specialists is much greater.

          Volunteering is a great thing but another complex issue altogether.

          If there were more certainty of loan forgiveness, more Docs would “volunteer” for underserved areas.

          Also, even if a Doc sees poor pts for free, how will they afford their meds, transportation, lab (and other) tests, xrays, therapy and specialty visits?

          These problems are often overlooked when discussing health care delivery.

          • http://Www.twitter.com/alicearobertson Alice

            Medicaid now covers 70 million people if they want it.

            But the larger point is being missed in defensiveness. Doctors earn so much more…give so much less back for free (granted you have huge impact on lives when your job is done well)…why do you think you should be entitled to anything other than a good living far above the normal (and good on you because you do deserve that). If we only have XXX amount of federal dollars to help out then help the ones who need it the most…like um…maybe a teacher risking their life daily to teach in the ghetto? Soldiers?

        • pj

          Also, this may chill the desires of PCP’s to serve the federal gov’t….

          “A new study of medical records at the U.S. military base at Guantánamo Bay, Cuba, has concluded that doctors and psychologists at the prison concealed evidence of intentional harm and torture in apparent violation of the Hippocratic Oath. The study found “the medical doctors and mental health personnel who treated the detainees…failed to inquire and/or document causes of the physical injuries and psychological symptoms they observed.””

          From Amy Goodman, journalist.

  • Tom

    It’s really too simplistic to blame this on the cost of medical tuition or even financial compensation. While I was interested in primary care when I entered medical school there are just too many things that made it seem like a bad career choice. The workload is above average, the work itself is usually not the high end medicine we are used to hear about, there is an immense amount of paperwork in these specialties, and there is a threat of midlevel providers taking over your job. Add in the factor of lower compensation and the problem is magnified exponentially, but even with equal compensation these specialties would still be less desirable to today’s students. As a graduating student, I think it is silly to focus solely on the medical school debt aspect when the problem is multifactorial and incredibly complex.

    Personally, the prevalence of nurse practitioners in primary care was a much more important factor in my shying away from a primary care specialty. They do the same thing a residency trained family physician does in many areas and are quite often seen as equivalent by patients. Why would I enter a specialty where a person with much less training can do a job supposedly equivalent to mine? At the same time, the lack of primary care physician drives an increase in midlevel employment, exacerbating the problem. At the same time this is the elephant in the room nobody seems to want to talk.

  • http://Www.twitter.com/alicearobertson Alice

    PJ..this backs both of us up….

    Kiss Those Student Loans Goodbye
    There are lots of programs that help grads repay their student loans. A few will even wipe the slate clean. But qualifying isn’t easy

  • http://gumption.typepad.com Joe McCarthy

    While reading this article and the comments responding to the article, I kept thinking about Daniel Pink’s book, Drive: The Surprising Truth About What Motivates Us, and many subsequent posts on his blog and Twitter feed (@DanielPink), in which he reports on several studies investigating different professions that show little evidence of any positive correlation between compensation and motivation (or performance).

    Unfortunately, I couldn’t find anything Pink has written about a link between compensation and motivation for doctors … however, I did find references to Pink and the issue of incentives in this post on KevinMD by Kunmi Sobowale that talks about Accountable Care Organizations and the need to innovate.

    As for the moral imperative of addressing the costs of training doctors, I would argue that a moral imperative for the public to support training of experts extends far beyond medical school to many fields. I highly recommend an article I read recently at N+1 magazine, Bad Education, about the disturbing parallels between the housing bubble and the securitization and corporatization of education.

  • richard scottr

    Eggers April 30 article, the high cost of low teacher salaries, discusses the moral obligation for spending on educators and this can be applied to medical education as well. The real costs of medical school are discussed in the recent blog here.


  • Hatari

    With the increased governmental cost controls nearly a sure-bet, physician reimbursement will likely go down, with specialists being the hardest hit (and rightly so). I would be willing to bet that medical education will begin moving to a more heavily subsidized model where decreased compensation is made up for by decreased educational costs.

    I’m concerned about a scenario where people in the middle of their medical training (such as myself) will graduate with $250k in debt, right into a environment that is compensating physicians as if they have little debt to contend with.

    It’s tough to discuss this topic without sounding ungrateful to many for the great education and opportunities presented to those going into medicine. However, it is simple fact that it is NOT a financially sound decision to enter into the field anymore. I’m going to finish my residency at 36 years old with $250K in loan debt. Do the math.

    I do believe that physicians need to be compensated commensurate the the amount of work performed and the number of years spent in training. Primary care sure would look a lot more attractive. It makes zero sense that dermatologists make more than double what PCPs make, working fewer hours with marginally more training.

    The root of the issue is that treating illness (surgery, procedures) is valued more highly in our system than promoting health. Until this problem is sorted, the best and the brightest will continue to run away from primary care at full speed.

  • kozi

    I believe the Medicare should stop funding for residencies. The doctors make way more than any average american. why do the Tax payers have to pay for these people? They should pay for themselves.

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