Matt Yglesias has written a handful of very smart posts on barber shop regulations which are a pretty good examination of public choice theory. Today he goes a step further and discusses the problems with healthcare cartelization, riffing off this post by Adam Ozimek on why liberals should care about occupational licensing. Here’s Ozemik:
For instance, many states have regulations preventing dental hygienists from practicing without the supervision of a dentist. Dentists have an average of six years more schooling than a hygienists, who on average have 2.6 years of post high-school education. In addition, dentists make on average $100 an hour, and are 80% male, whereas hygiensts are 97% female and make around $37 an hour. Kleiner and Park find that these regulations transfer $1.5 billion dollars a year from hygiensts to dentists. This is a highly regressive transfer to a male dominated, higher educated, higher paid job from a female dominated, lower educated, lower paid job. In a very similar vein with likely similar impacts, many states restrict the ability of nurses to practice without the supervision of doctors. In fact these regulations are currently growing as regulators rush to restrict the number nurses working in retail health clinics in a variety of ways to prevent them from competing with doctors.
Yglesias points out that not only does this raise the overall cost of healthcare by creating artificial scarcity in dental services, it also stifles innovation in the medical field:
The bigger issue—though harder to estimate—is the way that these rules stifle potentially enormous gains from organizational innovation. Imagine a world in which in order to make clothes you needed a license from the State Board of Tailors, and the tailor lobby manages to persuade the state to extend the tailor’s monopoly by saying that to sell clothing you need to be under the supervision of a tailor. This set of rules doesn’t just reduce competition in the fields of clothing manufacturing and retailing. It prevents the technological and organizational innovations that have brought us mass-produced clothing, and retail chains. The cartel would justify its existence in the name of high-quality and consumer protection. And it’s even true that if we all went to work in handmade shirts and bespoke suits that we’d be wearing higher-quality clothing. But the impact on overall living standards would be devastating. There’s no H&M or Ikea of the health care sector, and there never will be without some relaxation of the rules governing who’s allowed to be a provider of health care services.
This is absolutely correct, and one reason why no matter how we reform the health insurance industry, without reforms to the healthcare supply-side we’ll continue to face an artificial scarcity of health services and providers, decreased access to healthcare and higher costs. Allowing low-cost clinics to set up shop and perform basic medical services without the supervision of a doctor is one step. There are many others as well, including allowing dental hygienists to perform routine cleanings without a dentist present. But organizations like the AMA create all sorts of artificial barriers to entry, including caps on medical and nursing school slots available and rules which require high-cost doctors and dentists to oversee relatively low-skill procedures. Getting around the medical cartels is no easy task, either, especially since it’s more likely that any reforms to the system will benefit the entrenched power structure rather than the competition.
For a somewhat more radical take on the cartelization of healthcare services, see Kevin Carson’s excellent discussion of ‘open-source heatlhcare’.
This also reminds me of Brad DeLong’s healthcare reform proposal from way-back-when – something of a knock-off of the Singaporean model. So-called ‘barefoot nurses’ or ‘barefoot doctors’ were part of that proposal. Essentially these are low-cost, service-specific providers of very basic healthcare services, the idea being that not all our problems need to be handled by a doctor who comes with a very expensive medical school pricetag. Midwives also function this way, providing homebirth services at a fraction of the cost of hospital births.
Of course, many insurance companies won’t cover midwifery and I imagine the same would be true of many of these other low-cost providers. This makes expensive hospital births with insurance competitive with the price of hiring a midwife with no insurance, all of which artificially lowers the cost of hospital births to consumers on the front end, but drastically raises the costs on the back end in the form of higher premiums, deductibles, and so forth.
In other words, our healthcare system is a disaster and we haven’t even begun to fix it yet. Reform to insurance coverage – which is basically what the Affordable Care Act was – is only one step down a very long road.
El Tiburon
You Firebagging, Grover Norquist loving Homocon!
But But But This This This is THE crown jewel (or is it Lily Ledbetter?) in Obama’s Amazing Technicolor List of Historical Achievements.
Let’s see: Afghanistan ramping up, Wall Street Living Large, Home Foreclosure skyrocketing, unemployment surging, wages continue to fall…
atlliberal
The difference is, that the worst that can happen from bad tailoring is an embarrassing wardrobe failure.
With bad medical care you can die.
The regulations are there for good reason. you may have a point that the regulations need to be rethought to allow more low cost practitioners, (although you are already seeing more and more nurse practitioners where you used to see doctors) but to allow the free market to cull out the bad guys in medicine is a very bad idea.
Steve
In addition, dentists make on average $100 an hour, and are 80% male, whereas hygiensts are 97% female and make around $37 an hour.
My toddler has a female dentist. It occurred to me that I had never, ever met a female dentist before. I asked her what percentage of her class in dental school was female, and she said 50/50. Of course it takes a while for the real-world profession to catch up (most law schools are 50/50 too). She mentioned that a disproportionate number of the female students go into pediatric dentistry, though.
Brachiator
Make it stop!
I don’t know; $37 a hour seems like a damn good wage to me. And, true story, the last time I went to my hygienist, a decision had to me made whether I needed antibiotics as pre-medication. The hygienist could not make this decision alone.
If you are trying to make a case for deregulation, especially with respect to medical practice, you have got to bring better stuff.
And this stuff about male dominated vs female dominated professions is extremely weak.
And we already have significant problems with low cost/high volume dental clinics performing substandard work, and overcharging insurance companies for it or gouging low income patients when they pay out of pocket. And of course, adding insult to injury, it is often difficult for the proper corrective procedure to be done afterwards.
What’s a basic medical service?
Yeah, there are big problems with health care, but trying to simplistically fit standard issue free markets and deregulation on it just doesn’t work.
Perry Como
I just got a deep cleaning at the dentist and they shot my mouth full of novocaine. Not sure if hygienists are trained for that (dentist did the shots).
curious
the number of practicing physicians is also restricted by the number of funded (largely via medicare) residency slots available.
T.R. Donoghue
Despite Chunky Megan McArdle’s best efforts to trivialize this the issue with licensing “barbers” isn’t about scissors and razors.
Go read the comments at Matt’s place and you’ll see why this is a more serious issue than what Matt portrays it as.
beltane
Most insurance companies do cover midwifery if the midwife in question is an RN with additional training and certification in obstetrics. This training is expensive, of course, so perhaps the issue of exorbitant tuitions should be addressed before we simply throw up our hands and entrust our health care to untrained practitioners. I am looking at an Ikea dresser as I write this. It is in the hall, awaiting a trip to the town dump. It is a flimsy, shoddy piece of crap. I shudder to think of what an Ikea filling would feel like.
And if I had chosen to have my last child delivered at home by the nice Reiki lady down the road, I would not be here right now.
Maybe the answer should be increased access to dental & medical school, which would presumably drive down salaries for doctors.
ornery curmudgeon
Yes, loud and proud Conservative E.D. Kain, “our healthcare system is a disaster and we haven’t even begun to fix it yet.”
And why haven’t we been able to begin to fix it, Mr. Conservative? Hmmm.
Guess which political movement has been responsible for blocking all attempts at reform … you only get two tries. Think ‘hillary-care’ if you need a hint.
Zifnab
Keep in mind, dentists also tend to own their own practices. Is that $100 / hour up front, or take home? Because I know IT guys that take home $30 – $50 / hour while billing out at $300+ and tossing the rest at overhead. If the hygenist is being paid by the doctor, that rejiggers the math significantly.
All that said, there is a big question of what a doctor’s license brings to the table. Are you really safer with a first year dentist than a tenth year hygienist? Is there any reason a nurse shouldn’t be able to cut you a proscription for a higher grade pain reliever or anti-inflammatory drug?
If it’s just a matter of training, is there a better way to organize certifications / degrees such that a nurse doesn’t have to spend 4 years full time and six figures of interest accruing debt just to go through med school?
beltane
@Steve: The dental practice we go to is headed by a woman and the staff ratio is about 50/50. If there really is a gender disparity, it should be addressed by encouraging more women to dental school.
Maxwell James
I completely agree that cartelization is a big part of the problem in healthcare. But: Dental hygienists are not a great example of that, because to a large extent they have held down cost growth by performing services that otherwise would be performed by a dentist at a much greater cost. This is actually a rare example of healthcare providers agreeing to managethe provision of services rather than provide the services directly. The amount saved by doing this far exceeds the amount that would be saved if hygienists were completely independent.
Really, we need more models like the dental hygienist-dentist partnership, with lower (not low) paid workers taking on more direct responsibility for patient care, and doctors performing more and more of a management role. All while maintaining or (ideally) increasing quality. The Robert Woods Johnson Foundation’s Green House Project is a good example of this kind of model.
arguingwithsignposts
My last dentist was a female, and my next will be as well. The male who took over the past dentist’s practice was a douchebag.
And a helluva lot of the dental problem *might* be solved if dentistry was considered a part of medical care, covered by medical insurance, instead of a separate way for insurance cos. to fuck over their patrons.
morzer
@ornery curmudgeon:
I believe ED Kain identifies as a classical liberal. Whether he feels loud and proud about it is something you might ask him. Of course, you could always read his post from yesterday where he talked about all of this.
wmsheppa
@E.D. Kain I’m not sure that I like your dentist example, but for the health care system writ large it makes more sense.
Dental Hygenists can do a cleaning just fine, but I don’t know too many people who go to get their teeth cleaned and don’t need a filling or some other additional work. I think dental problems that need a dentists attention are a lot more common than a doctor’s visit that ends in needing medication, at least for younger folks.
I’m all for having more loosely regulated low cost clinics for health check ups though. That part of the discussion makes a lot of sense to me.
Zifnab
@ornery curmudgeon:
Last I checked, it was the Republican Party that was throwing a hissy fit in Congress, not Kaine. Please try to distinguish between an individual arguing for deregulation and a party intent on playing partisan games to win elections.
matt
This is no good reason for the quotas set on the number of doctors schooled each year, but plenty of bad side effects: Doctors are overpaid, overworked and underslept.
The newly graduated/indebted enter a system that treats them poorly, so by the time they get to be attendings, they are invested in the status quo.
Anonymous At Work
Matt’s main thrust with this, and one I would press ED Kain on, and am pressing some self-proclaimed libertarian friends on, is that of state/local regulation that cuts at economic opportunities. This is, for libertarians, very low-hanging fruit. Dismantle the local/state regulatory system, piece-by-piece, by getting rid of such parochial, protectionist provisions; then, use the credibility you have established there to go after the bigger fruit, like drug legalization.
Why that doesn’t happen, I don’t understand, except for cynical reasons about corporate-sponsorship of astro-turf libertarians.
arguingwithsignposts
BTW, Planet Money did a really good series about health care costs earlier this year. Want to cut down on some cartelization? Give doctors a fucking salary and stop treating them like damned free-agent pro athletes. (on the hospital side of things, at least).
mafisto
Isn’t E.D. talking about Minute Clinics (and the like) when talking about basic medical services? I personally think they’re great, and save an enormous amount of money in reduced overhead.
As for the lame, “but this one time at the dentist!” anecdotes – yeah, geniuses, those are situations when a dentist would be used. The referenced article refers to supervision by a doctor or dentist, not hygienists and nurses operating in some doctor-free zone.
Disclaimer: two of my children were delivered by nice, highly trained midwives at home. Neither birth was covered by insurance, but the total bill in both cases was about 20% of what would have been charged to the insurance company if done in a hospital. So this makes me biased, I suppose.
That's Master of Accountancy to You, Pal
@Brachiator:
Yes, it is. That’s why the point being made is that we should allow the person, typically female, who makes $37/hour do more of the work, and thus have more openings for $37/hour hygienists. If the if the gender ratios in the two professions remained the same (a big if, of course), then the CHANGE would produce a significant transfer of wealth from the $100/hour dentists to the $37/hour hygienists.
I’m not sure what it is about Erik’s posts that cause otherwise sensible people to take perfectly clear statements and think that they mean exactly the opposite of what they plainly say.
someguy
You know, I buy comparable worth theories of discrimination just as much as the next guy but until you can explain to me how the hygenist with the community college degree is getting shafted by only getting $37/hour, and by not being able to dig around in my gums with sharp pointy metal things and do freelance diagnostics on an independent basis, I’m not going to buy this particular example.
At the same time I also have a problem thinking we oughtta deregulate medicine so that state boards can’t ban bad physicians.
Oh wait a minute, the market will sort it out. If your Liberian-flagged doctor inadvertently eviscerates you and leaves you dead, you are free to pick a better one next time, without that pesky state licensing board interference and cartelization. See? Teh Marketplace Godz work!
Mnemosyne
@beltane:
Yep. As long as doctors (and, increasingly, nurses) are graduating from school with six-figure debt, salaries will stay high, which translates into high healthcare costs. If we could waive or forgive that debt for, say, people who agree to practice primary care medicine for 5 years after graduation at a salary of $50K a year, we’d go a long way towards solving a lot of our problems.
People can scream about teh evull insurance companies all they want, but even if we shut the doors of every health insurance company tomorrow, we’d still have skyrocketing costs, because our problem is that we have a for-profit system where everyone has their hand out for a slice of the pie. Taking insurance companies out of it would increase everyone else’s slice of the pie without shrinking the pie itself.
(Oh, Lord, I think I’m starting to channel W. Make the pie higher!)
arguingwithsignposts
The comments on Yglesias’ post are too funny:
someguy
And FWIW, all my dentist does is read x-rays, drill, do 90% of the work with the fillings, and prescribe medicine. He doesn’t do *any* hygienist work and has a fleet of about 5 hygienists doing everything state law permits him to delegate. He also employs an oral surgeon and an endodontist (root canal specialist). Personally, I’d rather not have the girl (or the dude with tats) with the community college degree drilling my teeth, or signing off on a treatment plan for my rotted molars. And I really don’t want the bubble gum snapper burning my tooth nerves out or doing jaw surgery on me. Yeah, I’m sure they’re all getting screwed, but I’m somehow comforted that the guy with $200k in student loans is responsible for that part, and with the nice house and the nice car he’s not judgment proof if he screws it up.
But that’s just me. I’m sure Ayn Rand’s disciples would prefer to have Korean barbershops pulling teeth and doing orthodontics… just like in the good old days.
That's Master of Accountancy to You, Pal
@wmsheppa:
In my experience, that typically means having your teeth cleaned and then making another appointment to come back on a different day and have the additional procedures done. I don’t see any reason you can’t have the hygienist do the cleaning, find the cavity (or whatever) that needs more serious work, and have you schedule an appointment with a dentist.
Disclaimer: My experience on this is entirely vicarious, primarily the dental tribulations of my ex-wife. I haven’t been to see a dentist in a decade and don’t have any problems with my teeth. It’s an instance where I came up a winner in the genetic lottery.
Mnemosyne
Our dentist is a man, but he took over the practice from a woman dentist who was retiring.
He’s really good, too — nice man from Russia who trained here and is never reluctant to give you as much Novocaine as you need.
someguy
@arguingwithsignposts:
Um, so they can pull teeth when dentistry gets de-cartel-ized?
Belafon (formerly anonevent)
My dentist is a female.
I have a friend who is a physician’s assistant, who had to go find a doctor to set up her own office. The “doctor” she has currently lives in the Bahama’s and freaked out when her own child got sick. I do agree at some level that some of the requirements need to be relaxed and that would allow us to control some costs.
I am curious though, how does France keep their costs down? I have heard they still have doctors that make house calls.
Batocchio
To the Point covered some of these issues recently:
http://www.kcrw.com/news/programs/tp/tp100818healthcare_reform_in
cleek
my dentist and his wife share a practice. also, my orthodontist (and everyone on her staff) was female (braces @ 36!).
on the other hand, i haven’t seen my primary care doctor (a man) in many years. i always get a P.A., these days. most of whom are women.
Zifnab
@Anonymous At Work:
That’s a big “except”.
And as Kaine himself has mentioned once or twice, some Congressmen enjoy running out “deregulation” platforms that don’t deregulate so much as they shift where the regulations lay. For instance, the HB-1 visa let corporations import cheap professionals from overseas. But the process for securing the visa was set up such that smaller companies could take advantage of it. The visa helped deregulate the labor market, but only to the advantage of the moneyed few.
jl
I agree that outmoded business regulations and professional codes are a problem in health care. But doubt that they are one of the most important issues in the short run in health care reform.
I also agree with the commenter above who points out that mistakes in haberdashery are cheap, and mistakes in medicine are often very expensive.
I also doubt very much that any kind of unregulated market magic will spur low cost innovation in patient care in medicine. The reason is simply the large numbers of patients, and the long time horizon for observation of the results of many innovations are needed to observe the unintended consequences of innovations in health care. It is very unlikely that innovation by small scale practices will produce anything reliable. The difficult problem here is that many innovations that appear to be purely managerial have real effects on the delivery of clinical care.
It is also important to recognize that the anti social restriction of supply by organizations like the AMA are probably not the principal reason for current restrictions in supply. A big immediate problem is finding the funding for training health professional students: public funding has been limited for training slots that do exist, health care organizations under competitive pressure do not want to expend any resources for training (either high skill or low) unless they can profit from it during the real time training experience, and students are bearing unsustainable debt, and would find it hard to get more loans anyway.
Many health professional schools would like to expand, and public ones have been asked to expand by state governments, but there is no money.
Many states are innovating their way out of the kind of regulatory mess described in this post. For example, in California, in many nurse practioner and pharmacist run clinics ‘supervision by an MD’ means that one is available with X minutes via a pager. ‘Pharmacist review’ almost always means that a pharmacist tech does all the work, and pharmacist looks at computer screen at certain Rx that require review and presses a button if everything is A-OK.
There is an argument for requiring access to advanced expertise even in basic care. One of the ways increased preventive medicine is supposed to restrain costs is that serious conditions are discovered earlier, and expensive and dangerous noncompliance or treatment failure is discovered before a disaster (as in, a diabetic not taking meds properly gets the problem corrected before a heart attack). The problem is, it is very difficult to tell beforehand what will turn up, and what level of expertise is needed.
So, I say, yes, get rid of as many needless regulations as necessary. They cause big problems. But I think that it is misleading to suggest that simple deregulation will make major changes that will reliably reduce costs and improve population health in our current system, or the one is promised to come with the recent health care bill.
beltane
@That’s Master of Accountancy to You, Pal: Is there some particular reason that women shouldn’t be making the $100 an hour jobs? As blue-collar jobs for men are in decline, wouldn’t more men be working as dental Hygienists ? (I have seen this happening) Framing the issue in this way, along with the ill-informed reference to amateur midwifery (let’s save money by having the womenfolk drop their babies at home) is rather condescending IMO.
Anne Laurie
@Perry Como:
Do NOT let someone without specialised training stick a needle in your face! Dentists are incredibly fussy about injections for a reason — there are so many nerves & tiny vessels running through the front of the human head that even a tiny poke a quarter-inch in the wrong direction can leave you with long-term pain and/or disfigurement.
There is plenty of room in the American health-care system for “gateway” health/dental providers. But talking about letting hygienists give injections, or ‘barefoot doctors’ handle ‘routine’ medical care, usually breaks down to setting up a two-tier system where those without spare cash, or good insurance, are diverted to the Luzer Track so that the “deserving” C.R.E.A.M. patients don’t have to wait for an appointment or an elective surgery slot. Remember all the ‘Keep Government Out of My Medicare’ yappers? We got a shiteload of those around here when the Masscare semi-sorta-full-care coverage was passed. Some of the smartest people of my acquaintance were wringing their hands over the horrible, horrible prospect that bringing too many people into the system would just make things terribly, terribly inconvenient… for them.
Relaxing the licensing rules and then talking about making good care more accessible is arse-backwards. Deliberately or not (usually deliberately, in my experience), it’s not about getting any care to all Americans — it’s about delivering enough substandard care as cheaply as possible to keep Those People from cluttering up the ERs, or making a nuisance of themselves at the ballot box.
beltane
@Belafon (formerly anonevent): The cost of medical school is considerably less in France and, yes, the doctors always make house calls.
jl
@Belafon (formerly anonevent):
“I am curious though, how does France keep their costs down? I have heard they still have doctors that make house calls.”
IMO, it is not clear that France is really keeping costs down. Their costs have skyrocketed over last few years. Presumably most of the recent increase is due to the recession, but it will be a few years before anyone knows for sure.
As for docs and house calls, France does not have a nationalized service like the UK. Most doctors work in private, single or small group practices, and are reimbursed by the French health insurance system. So, docs have an incentive to keep their clientele.
Jeff
@Perry Como:
In NYS dental hygenists can give the local anesthetic ( if they have been trained) and there is an dentist supervising ( that is in the office and not just at home sipping a martini)
The problem with alot of this is — yes, it’s true that a DH ( or an NP or PA for that matter(full disclosure– I’m a PA )) can take over alot of the “basic dental ” procedures that a dentist used to do for a lot more money, and 99% of the time that works fine– but there is that sticky 1% with a horrendously complicated problem that only a dentist can solve, or a anaphylactic reaction that requires resuscitation, etc.
That is why even I, with 20 years of experience am only too happy to have a physician present to take the heat for that.
b-psycho
I’m just surprised that someone posts here now that would link to Kevin Carson, or even know who he is…
Yeah, cartelization is a huge problem. Kain is right that the health reform bill didn’t address this — IMO it actually made it worse by introducing the mandate+subsidies into the equation. Thanks to there being no “public”-option safety valve, without hard caps on premiums they’ll just keep going up in order to vacuum up tax money, because to the insurance companies it’ll be “fuck em, they’re getting help for it anyway!”.
tfitzaz
Out here in Arizona, dentists are the only medical staff that routinely do not work on Friday.
Dental health insurance does not pay for many procedures, especially implants and dental prices continue at their highly inflated rates. Many people cannot afford any kind of dental care which is routinely eliminated from any kind of government program, except the very poor. Many Americans have to now to another country to get reasonably priced dental care.
taylormattd
Oh god, more free market bullshit. Matt’s posts about how stylist regulations are unnecessary were absolute gargabe. Just junk.
He pulled a slight of hand by pretending no licensing or training is necessary to, for example, shave one’s head. When in fact, a lot of these people are dying hair, giving perms, straightening hair, using tools that need to be sterilized.
I for one, have no fucking problem with States establishing a very bare minimum in licensing and training for people that put dangerous chemicals on people’s heads.
Matt’s posts, and your fluffing of them is just a bunch of warmed-over wingnut bullshit.
Joel
Hygenists make $37 an hour?
Mogden
Absolutely. The so-called reform got it 100% ass-backwards (ok, maybe 95% to be charitable), leaving us with a more cartelized, expensive, inefficient, and politicized health care system.
The only bright side? An upcoming electoral drubbing of the technocrats and meddlers that they so richly deserve.
Brachiator
@That’s Master of Accountancy to You, Pal:
RE: I don’t know; $37 a hour seems like a damn good wage to me.
There is nothing offered as to what other work the $37/hour hygienist might be able to do, or what additional training might be required or how that might in turn raise the wage level of the dental hygienist.
And the major thrust of this part of the argument was that the hygienist should be allowed to work unsupervised in the name of deregulation and free markets. Here, the negatives outweigh the positives since there are common situations that require intervention or input from the dentist.
And the gender crap is a tired dodge that is ultimately irrelevant to the point. The transfer of wealth stuff is weak, too, if you think it through.
Steve
Dental school is ridiculously expensive – I don’t know if there’s any other professional school that costs more.
Bringing the income of dentists closer to the income of hygenienists is something I support in theory, but will people still be interested in making that huge investment in dental school without the prospect of a huge payoff?
beltane
@Brachiator: It would seem that the first line of attack in lowering costs is to reduce consumer protections and quality. Under this plan, health care would become a cheap pair of Wal-Mart flip-flops. Unfortunately, our bodies are not disposable and cannot be replaced on a whim.
That's Master of Accountancy to You, Pal
@beltane:
No, and nowhere do either Erik or I suggest otherwise; that’s just your imagination talking. It is simply an observation that, as of RIGHT NOW, there is a large gender skew between the two professions. Because of that RIGHT NOW there is a lot of money that could be going to primarily female hygienists that is instead going to male dentists who aren’t any better qualified to do the job, just better credentialed.
Notice also that there is an implicit consequence to what Erik is advocating. He didn’t say it explicitly, but it’s still there. If you increase the amount of work going to the hygienists, this means that the demand for hygienists will go up, and lead to higher wages for them. In fact, they might even get to own their own practice and collect profits as well as a wage. Even if there is no change in the gender ratios of the two professions, it will lead to the people currently making $37/hour to make more than that.
If your goal is to feel like you are being condescended to, you are likely to succeed. Of course, you have to create meaning in what people write that wasn’t there.
Omnes Omnibus
@taylormattd: It is one of Yglesias’ major blind spots. The fact that is addressed in the comments again and again without notice amazes me. There are reasons that many professions have licensing requirements, most of them health and safety related. Are all of the regulations perfect? No.
I am willing to bet that a lot of people who want unsupervised hygenists to be able to do basic services would be among the first to sue if that hygenist misses something he was not trained to see and the patient ends up having oral surgery. YMMV.
John Cole
@Steve: All of my doctors are female. Only doctor I’ve seen in the last ten years who was not female was the surgeon who pieced me back together in January.
That's Master of Accountancy to You, Pal
@taylormattd:
No, he didn’t. A perfectly reasonable response to argument is to point out these tasks and say that they should require a license. However, that does not answer the question Matt actually asked, which is, “Why do you need a license to cut hair?” Saying that there are these other things that many beauticians and barbers do that need regulation is true, but off-point.
Tell me, if his posts are so stupid, why does someone need a license to cut hair?
Ethan Epstein
zzzzzzzzzzzzzzzzzzzz
beltane
@That’s Master of Accountancy to You, Pal: Please, there are other commenters who took exception to the gender disparity argument.
A typical dental hygienist has a two-year degree from a community college. They are qualified to clean teeth and assist the dentist with more complex procedures. If you would like one to administer anesthesia and perform a root canal without a dentist present, be my guest.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
Because hair can carry little beasties that need to be killed off between customers so you don’t end up spreading fungal infections or other nasties to everyone who goes to that salon. That big jar of blue stuff that they soak the brushes and combs in after they use them? It’s not for show.
And that’s leaving aside the whole part where they’re using sharp instruments around your head and should probably have some training so they don’t injure the customers.
demo woman
Decades ago when I lived in Texas, I was trained to give my son allergy shots. When we moved to GA due to regulations that was prevented. You had to drive to the doctors office and wait until a nurse could see you to give the shot.
What a waste of insurance money.
arguingwithsignposts
@That’s Master of Accountancy to You, Pal:
Well, as Matt shows, you don’t, if you want to cut your own damned hair. But barbers and cosmeticians don’t just cut their own hair, or the hair of their own families.
And they don’t just cut hair. I have gone to the barbershop several times just to get a straight-razor shave. Some people get their hair dyed, or permed.
It’s the same stupid question as asking “why do you need a license to drive a nail into a piece of wood?”
Omnes Omnibus
@That’s Master of Accountancy to You, Pal: You know, some guy down the block who is good at math can do your taxes, right?
beltane
@Mnemosyne: You don’t need a license to cut your friend’s hair in your own home. You need a license to operate a hair cutting business that serves the public. For all the reasons you mentioned, there is a big difference.
That's Master of Accountancy to You, Pal
@Brachiator:
And the point, very similar to the one Matt Yglesias keeps making, is that, if this is the way you view it, you will have a very difficult time reining in health care costs. The number one driver is that we not only make error prevention A priority, we tend to make it THE ONLY priority.
This approach will mean that the system goes critical. It is more certain to lead to a two tier health system than making some changes to the priorities, and making cost one of them. Somewhere, you are going to have to cut costs, and those costs are going to lead to a greater chance of error. The choice we face is that we can decide to accept a small increase in error rate across a variety of basic procedures, or we can default into a system in which there are very large increases in error rates across a smaller set of the population.
Just digging in your heels and saying that we don’t want to make any changes that increase the risk of something going wrong isn’t an option. If we don’t sit down and decide where we are prepared to accept that increase, then they will happen in places that we consider to be less than optimal.
There may not have been any of this information received, but that’s not because it wasn’t offered. Erik made it perfectly clear what he meant: dental hygienists can continue to do the work they already do, for which they already have the training, but that they can do it without a dentist in charge. He isn’t saying that they will do different work than they do now. He is saying that, by changing the rules under which they do the work they are currently doing, we can simultaneously raise their wages while cutting overall costs.
Omnes Omnibus
@arguingwithsignposts:
You are a braver man (?) than I am.
That's Master of Accountancy to You, Pal
@beltane:
I can’t help it that there are a lot of readers of this blog who lose their ability to read when E.D. posts.
Then it’s a good thing that no one has suggested that they do so. Again, this is an argument that exists nowhere but (using the collective ‘you’) in your imagination and the posts that you make. The question is why they need to have a dentist watching over them when they clean teeth. Why can’t they have their own teeth cleaning business? If they find a more serious problem, refer the patient to a dentist. You can also have separate, and likely less frequent, appointments with a dentist to look for problems, if you like, but you don’t need to pay the dentist for teeth cleaning.
Brachiator
@That’s Master of Accountancy to You, Pal:
And so? What does this have to do with health care reform? And as another poster noted, more women than men appear to go into pediatric dentistry. And then there is this:
Also, some researchers think that there may soon be a shortage of dentists. The male/female thing may be a solution looking for a problem.
Hmmm. Shifting the money isn’t necessarily the same thing as reducing costs to the patient. And you’re shifting the terms of your argument here. At first it was about requirements that a hygienist work in a dentist’s office. Now it’s about tasks done by a dentist that could be done by a hygienist.
Mnemosyne
@arguingwithsignposts:
@beltane:
Yep. It’s not that having scissors and using them on someone’s hair is a crime — it’s that if you’re going to go out and set up shop inviting strangers to come by and let you do it, there are enough public health dangers to make it worthwhile for the state to demand you have some rudimentary knowledge of hygiene.
And am I the first one to bring up Sweeney Todd? There’s a story of the failure of regulation if ever I saw one. If only they’d had a health department to inspect Mrs. Lovett’s shop, it never would have happened.
Wag
I’ve got to say that this post is the biggest pile of BS that I’ve read, mostly becasue the proposed remedy does NOTHING to address why we have the highest health care costs in the world.
We have crappy access to Primary Care. I’m a Primary Care doctor in an academic setting. I work every day with Internal Medicine residents, the majority of whom are paying off massive school debt. Mnay of them would love to become Primary Care doctors, but the allure of a specialist salary (double to triple my salary) coupled with thier debt makes is difficult if not impossible for them to justify a life in Primary Care.
Our current medical system excessively rewards doctors for doing procedures to patients, and poorly rewards a physician for traditional office care.
When we as a society decide to stop paying a Dermatologist the same amount of money to freeze a skin lesion (one minute with the patient) as I’m paid to spend 40 minutes with a complex patient with heart disease, diabetes and kidney failure, only then we will begin to make inroads in our health care costs. Freeing up Advanced Practice Nurses to care for patients with sore throats and sinus infections (the target market for the drug store based clinics in Wal-Marts and Walgreens drug stores), while a it is a goal I support, is a small drop in very deep bucket.
Ripley
Speaking as someone in a license-required & highly regulated profession, licensure at the very least implies the adequate-or-better meeting of defined standards, as well as continued education toward up-to-date understanding of and adherence to those standards. While I’ve received some pretty shitty haircuts from licensed practitoners, I’ve never lost an ear-tip, got an infection, or been chemically damaged by one. Is this due to regulation & licensure for stylists & barbers (there’s a difference in licensing of the two, by the way)? Not sure, but it certainly couldn’t hurt.
I’m with @taylormattd: I think Yglesias is being a free-market shill and an ass on this one.
DougJ
@T.R. Donoghue:
God that is brutal. I like it, though.
That's Master of Accountancy to You, Pal
@Omnes Omnibus:
Sure. And for most people, that’s probably a smarter idea than paying a CPA to do it, though probably not as smart as just doing them yourself. Most people don’t have a financial situation that requires four years or more of education to figure out. Pretty much the only benefit most people would get from having a CPA do their taxes is that there is a shift in liability from the tax payer to the tax preparer if you do, and that’s not worth it for most people.
The idea that you need to pay a trained accountant to do your taxes is a combination of the marketing from the industry and the fact that too many people are afraid of numbers. Just fill out your own tax forms; unless you own a business or have some uncommon deductions, an ability follow basic instructions and do arithmetic is all you need.
Much like with dental procedures or hair styling, you need to have licensed professionals to do the tricky stuff. For the basic stuff, you really don’t. That’s as true of taxes as the rest.
Just Some Fuckhead
Maybe E.D. Kain can enlighten us all on how to truly fix health care.
Martin
One of the best ways to start bringing down the costs of health care is for the govt to provide full loans to cover the cost of medical, dental, nursing school, and to forgive those loans over time as those individuals participate in controlled cost programs such as Medicare, etc. and in specialities that the public needs (GP over many surgical areas, for example.) Medical, dental, and nursing schools would need to significantly expand the size of their programs as the limited number of doctors graduating each year is a big part of the reasons why salaries are so high. Simply increasing the number of licensed physicians (even on the taxpayers dime) would have a positive impact on costs, would encourage more physicians to get into less lucrative fields, and would help ensure there were a steady set of physicians participating in the entitlement programs. Right now Medicare pays for the nations medical internship program, so it’s not unprecedented.
The problem isn’t the licensure requirements, rather it’s the ability of the educational system to crank out enough qualified people. Take away the licensure, and you’ll have no more qualified doctors than you do today simply because there aren’t seats in medical schools, which is a requirement nobody is going to forgive. Unfortunately, the majority of medical school programs are run by public universities that are dependent on public hospital and state support to run the programs. The public hospitals struggle to bring money in because they are treating more and more patients that lack insurance and get less from insurers, which limits their ability to expand, and the states are hardly in a position to fund larger programs themselves.
A necessary solution to the problem is going to be to find an incentive/funding model that will allow money to be dumped into educating more and more medical providers in exchange for them participating in care programs that are designed to control costs. If you can reach a point that you have a surplus of medical licenses out there, particularly that are incentivized to managed care, costs will naturally come down and service will go up.
beltane
@That’s Master of Accountancy to You, Pal: They are not necessarily qualified to find more serious problems. I really do not see the cost savings in going to a teeth cleaning store only to have to pay for a separate visit to the dentist a few months later. The check-up part of the cleaning and check-up is more important the the cleaning itself. If hygienists are paid $37 an hour, I don’t see how this would be cheaper than the $85 I spend for a cleaning and check-up.
You can get cheap teeth-cleaning done at the community colleges that train the hygienists. They do not have the education to diagnose much more than obvious problems like a gaping cavity which you could diagnose yourself.
arguingwithsignposts
@That’s Master of Accountancy to You, Pal:
I don’t think it’s merely a fear of numbers. It’s also a very non-basic tax code, and the fact that those numbers could end up costing you a shit-ton of extra time and money if you don’t do them right. And a lot of those tax-preparers aren’t trained accountants, either.
But until I started doing consulting and had to deal with other itemization, I used tax prep software. (now use a CPA, and I’m happy he’s licensed)
That's Master of Accountancy to You, Pal
@Mnemosyne:
The problem is that there isn’t a service occupation where you can’t make this argument. Pretty much all of them have physical things change hands. And, as you point out, that’s why barbers put their instruments in a cleaning solution between customers. The things necessary to deal with the basic situations aren’t that complicated.
DougJ
@That’s Master of Accountancy to You, Pal:
Do you think they (dental hygienists) should be licensed if they operate independently outside of a full dental practice?
This is an interesting debate and I don’t quite see how licensing plays out the way MY says it does.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
Again, you seem to be glossing over the potential public health issues here. No one is going to get a fungus infection from their accountant’s calculator, but they’re pretty likely to get one from their nail salon if the salon doesn’t take proper precautions.
As Anne Laurie said, the head is a tricksy area full of nerves. My sister-in-law has a dead nerve in her tongue because her properly trained dentist hit the wrong spot when giving her novocaine, and they’re not sure if it’s ever going to come back.
Now, you do have something of a range of training for dental hygenists, as you do with nurses. I would have no problem with freeing up the dental equivalent of RNs a bit more. It’s giving the dental equivalent of LPNs the same freedom that’s worrisome.
Martin
@That’s Master of Accountancy to You, Pal: Actually, the real question is why the IRS, who requires filing tax returns, doesn’t develop the equivalent of online-TurboTax for every taxpayer to fill out. Surely the reduction in paperwork would outweigh the cost of developing the system by a factor of about 9 billion, even with TurboTax already out there gouging everyone for $25 each year.
arguingwithsignposts
@Martin:
I believe it’s $49/year. The extra I pay my CPA is well worth it.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
That’s true. That’s why, say, restaurants are regulated so they don’t poison their customers. Pretty much every service occupation requires a license for this exact reason. You’re going to have to present a pretty compelling excuse to endanger the public health in the name of “deregulation.”
Barbers put their instruments in cleaning solution between customers because it is required by law that they do so and will lose their license if they don’t.
You’re advocating to remove that licensing requirement, so that requirement to clean brushes between customers goes away, too. Sure, some people will keep doing it, but when untrained people open up shop who never learned it, how are they magically going to pick up the idea?
And if barbers don’t need regulation, why do restaurants have to follow all of those onerous health codes, too?
DougJ
What I mean is that while licensing can serve as barrier to entry, it can also serve as a means of legitimization. Maybe this is irrational of me, but I would go to an independent dental hygienist (operating outside of a full dental office) if he/she was licensed, but I might be leery of a wild west of non-intrusive dental procedures.
Brachiator
@That’s Master of Accountancy to You, Pal:
Oh man, you are on my turf now. In addition to CPAs there are EAs (probably better at individual taxation than CPAs). And the IRS is about to bring the hammer down on the tax preparation industry by the imposition of a huge new set of requirements.
And you are just flat out wrong about the benefits of a competent preparer, even a good HR Block preparer (who also are often better than CPAs)
I spend a fair amount of time reviewing returns that have been self-prepared by people using good tax software. But the last few years have seen a lot of new deductions and credits which people miss even when they are using wizards and questionnaires.
That's Master of Accountancy to You, Pal
@beltane:
As I said, in my experience, if you have a more serious problem, you already have to pay for a separate visit to the dentist at a later date. Also in my experience, the hygienist is already being counted upon to find problems; the inspection provided by the dentist is best described by the word ‘cursory.’
I also find the idea that most people need more serious work done every time they get their teeth cleaned pretty silly. If that’s the case, you’re going to run out of teeth by middle age.
But, fine, let’s say I even accept your argument. Please explain where it is that you intend to produce the savings in health care that we need to find without increasing the risk.
Brachiator
@Martin:
They do, as do some states.
Doesn’t work for complicated situations.
That's Master of Accountancy to You, Pal
@DougJ:
Probably. However, I simply don’t believe that they need the supervision, and the cost, of a dentist to do so.
It varies from one occupation to another.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
As Martin said in #67, we’re probably better off lowering salaries by subsidizing medical and dental educations than by telling people who just went $200,000 into debt that they really shouldn’t charge so much.
Wag
Why is my comment in moderation?
DougJ
@That’s Master of Accountancy to You, Pal:
I agree. I think the anti-licensing stuff is a bit barking up the wrong tree. The real issue is requiring supervision from a very expensive, highly trained dentist etc.
That's Master of Accountancy to You, Pal
@Brachiator:
How often do they miss them? To justify it in the aggregate, in a case where all we are talking about is saving money, the amount saved by the ones who get an extra credit or deduction has to cover not only their costs, but also those of all the people who don’t get any benefit.
Unless you have some way to predict which people are going to benefit, such that you serve only them, and only bill them, then the expected value of using a tax preparer is a fraction of the savings some payers get. Which is exactly what I was saying: there are people out there who need a trained tax preparer.
Cain
@Steve:
My wife is a dentist and I would concur that her class was about 50/50. I only know female dentists and not many male dentists.
And boy, we can tell you stories about dental assistants.. who are all female. In fact a lot of dental offices are almost all female and that is looking at all the places my wife has worked. From what my wife goes through it seems to me that an all female office seems to have more politics than in a mixed office. Certainly emotions runs high.
That said, I don’t understand the observation regarding gender in the post.
cain
That's Master of Accountancy to You, Pal
@DougJ:
Which is the point of the post. I don’t think anyone made a claim that dental hygienists don’t need to be licensed. Erik certainly didn’t make that argument, and I don’t think I did. If I’m wrong, and I did make it, that’s my fault. It’s not what I meant.
The licensing thing came in talking about other professions, where I think the need for licensing is much less pressing.
Mnemosyne
@Cain:
It’s weird, but the RNs I know well are both men even though the field is still heavily female.
mclaren
I’ve been hammering away at the cartelization of American medical care for years. The kooks and cranks and crackpots on this forum scream that the Obama health care non-reform bill has fixed our problems. It’s nonsense.
For the latest example of out-of-control health care costs, see <A HREF="http://theeconomiccollapseblog.com/archives/kicked-in-the-groin-health-insurance-companies-are-dramatically-increasing-premiums-due-to-the-new-health-care-law-and-there-is-not-much-we-can-do-about-it“Kicked in the groin: Health insurance companies are dramatically increasing premiums due to the new law and there is not much we can do about it”
As I predicted, health insurance premiums are once again skyrocketing — but not because of Obamacare. Health insurance premiums are shooting up because the underlying cost of American medical continues to skyrocket. The Obama non-reform HCR bill did nothing to control health care costs…and without cost controls, health care costs (and insurance premiums) will go up and up and up and up forever, without limit.
No one seems to recognize this. But as health insurance premiums relentless climb to the moon, even the dullest among you will eventually begin to get a clue. There is no health care reform without tackling the cost structure of American medicine. MRI’s that cost $1500 in America cost $150 in Japan. Blood tests that cost $25 in France cost $350 in America. Exact same tests, exact same equipment. That kind of insane 10-to-1 cost ratio isn’t due to health insurance overhead…it’s due to the greed and corruption and cartelization of gigantic monopolies of medical devicemakers and doctors and hospitals and insurers who all collude to fix prices and block competition.
“Soaring costs laid to growing power of medical cartels,” San Francisco Chronicle, 21 February 2010.
“The hidden public-private cartel that sets health care prices,” Slate magazine online.
For more, see the excellent New Yorker article “McAllen Texas and the High Cost of Health Care.” Health costs skyrocket because doctors set up their own imaging clinics and blood test labs and charge hospitals 40x what those tests actually cost, raking in vast profits. The hospitals sign sweetheart contracts with the doctor-owned labs that lock them in as suppliers and prevent disclosure of prices. The health insurers lock in customers as regional monopolies, prevented people with insurance from getting insurance anywhere else. All along the line you have bribery, collusion, sweetheart contracts, non-disclosure agreements, price-fixing, massive monopolies that collude corruptly to raise prices and prevent competition.
For a discussion of the massive bribery that goes on when medical devicemakers pay off hospitals to use their brand rather than someone else’s (massively raising prices in the process), google “Medical device maker kickback allegations keep coming” at fiercehealthcare dot com, July 16 2009.
Also see the Rolling Stone article “Take two kickbacks” from December 2009.
For details on doctor monopolies, google the article “The Medical Cartel: Why are MD Salaries so High?” Because the AMA artificially restricts the number of doctors to keep doctors’ income sky-high.
For details on the grossly corrupt cartelization of the health insurance industry, google the article “Insurers set to raise prices, walk away from consumers” in the huffington post, March 5, 2010.
For more on the gross failure of Obama’s HCR bill to tackle these cartelization issues, google “Obama Points to the Lack of Insurance Competition, a Problem His Plan No Longer Solves” at commondreams dot org, March 8 2010.
For a general overview on the insanely high cost of American health care, where costs are typically 10x to 40x what they run in Germany or France or Spain for the exact same procedure or test or image using the exact same equipment, see the article “An insurance industry CEO explains why American health care is so expensive,” in Ezra Klein’s blog at The Washington Post, December 2009.
That's Master of Accountancy to You, Pal
@Mnemosyne:
I’m not sure how this actually lowers how much the doctor will charge. It contains an implicit argument I don’t think holds. It means that doctors, as business people, deliberately either charge less than the revenue maximizing price now, or would do so after such a change in tuition. I don’t see anything in the overall behavior of doctors to think that this is true.
For most goods or services, the price charged converges to the marginal cost absent regulation that keeps it from doing so. Lowering the cost of tuition does nothing to change that. What regulations are you planning to take to force doctors to charge less?
Violet
@That’s Master of Accountancy to You, Pal:
Most of them don’t have a dentist standing over them watching their every teeth-cleaning move. But the dentist is there if needed.
That would be a hassle. Why would someone want to go to the teeth cleaning shop and then have to make a second appointment to get their teeth examined for problems? Why not just get it done all at once during one appointment?
slightly_peeved
I think the whole discussion of hygenists and dentists is a bad analogy for healthcare costs in general, because this same artificial scarcity occurs in every first-world system. And a significant reason other systems are cheaper is because they control this cost better.
The main problem that’s particuarly bad in the US is that doctors in many parts of the country are rewarded for recommending unnecessary procedures and tests. And this is addressed in the Affordable Care Act, through a pilot program for payment bundling. Payment bundling pays for getting the patient well, as opposed to for each individual treatment the patient has.
Get more doctors to work for a salary, rather than as an independent business, and you can significantly cut healthcare costs while maintaining high and accredited levels of care. It’s already used at the Mayo Clinic, and it leads to them spending far less medicare money as well as private money.
Again, it seems people are discussing how the Affordable Care Act doesn’t do enough to cut costs without showing any knowledge of what it does do in that area.
Mike E
My daughter got her wisdom teeth removed a week ago, but it almost didn’t happen. All 4 were impacted and she needed general anesthesia for the hour-long procedure, but BC dropped coverage for this last year. They wouldn’t even pay for the GA, saying it wasn’t necessary for this operation. Fuckers. Try getting a jackhammer to your jaws for an hour without GA, what assholes.
Her dental coverage has a yearly spending limit of $1,250, which goes toward her regular cleanings and xrays, so only $780 was left to go towards this $2,200 procedure. Only after the med ins rejected the claim would the dental ins okay this amount. So I had to ‘borrow’ $1,435 from my siblings to get this done in time before she goes back to school. We’ll pay out of pocket again if she needs a trip to her dentist this year, for whatever reason. Her 1st trip ‘under’ went without complications, and 7 days later she’s doing well. We’re lucky for family; others might easily forgo this if there are more pressing financial needs (which I have, but no way was I making her wait until it was worse).
This whole healthcare business is such an ordeal: You must fight these bastards tooth and nail the entire time, it’s like another part time job just to keep up with this shit. The staff at the oral surgeon’s did what they could, but they too couldn’t help but shake their heads at the reluctance of the ins cos to intervene in any positive way. This notion of reform seems like a mirage on the horizon right now.
Joel
@That’s Master of Accountancy to You, Pal: I would argue that even if you relax the “regulations” on barbers, you wouldn’t see a dramatic change in the landscape of barbers. Because if you suck at something, you’re not going to stay in business (see: restaurants). That said, I’m in favor of maintaining basic public health regulations because 1) they maintain basic hygeine standards 2) I don’t see how they impede the normal practice of business.
In the case of the medical profession, unlicensed professionals are actually fairly common, especially in rural areas. Unsurprisingly, their malpractice rates are significantly higher.
DougJ
@That’s Master of Accountancy to You, Pal:
I think it’s because it was the point of one of the Yglesias posts that he linked to. That’s throwing people off.
I know what you and Kain are getting at, but the Yglesias link is a bit of a red herring.
DougJ
What I mean is that the barber post is about why barbers shouldn’t be licensed. The debate is about dysfunctional licensing. They aren’t the same issue.
Jack Newhouse
Someone’s probably already pointed this out, but you aren’t likely to die or become disabled if your tailor makes a mistake. There are some very good reasons for regulating the practice of medicine.
Cain
@Steve:
Exactly, my wife makes this point a lot.
cain
Wag
I’ve got to say that this post is the biggest pile of bull that I’ve read, mostly becasue the proposed remedy does NOTHING to address why we have the highest health care costs in the world.
We have crappy access to Primary Care. I’m a Primary Care doctor in an academic setting. I work every day with Internal Medicine residents, the majority of whom are paying off massive school debt. Mnay of them would love to become Primary Care doctors, but the allure of a specialist salary (double to triple my salary) coupled with thier debt makes is difficult if not impossible for them to justify a life in Primary Care.
Our current medical system excessively rewards doctors for doing procedures to patients, and poorly rewards a physician for traditional office care.
When we as a society decide to stop paying a Dermatologist the same amount of money to freeze a skin lesion (one minute with the patient) as I’m paid to spend 40 minutes with a complex patient with heart disease, diabetes and kidney failure, only then we will begin to make inroads in our health care costs. Freeing up Advanced Practice Nurses to care for patients with sore throats and sinus infections (the target market for the drug store based clinics in Wal-Marts and Walgreens drug stores), while a it is a goal I support, is a small drop in very deep bucket.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
That’s because you’re assuming we continue the model of doctors as independent businesspeople, which is a model that’s already dying out. As we move further into managed care, more and more doctors are in group practices anyway, so putting them on salary is perfectly feasible.
It won’t do much to help with doctors who are already established in their own practices, but it will gradually help both our severe shortage of primary care physicians and part of the high cost of healthcare as it is offered to new medical students as an option.
mclaren
@slightly_peeved:
You’re wrong. It’s an excellent analogy. The AMA artificially restricts the number of doctors who can enter medical school each year. This maintains a shortage of doctors and keeps doctors’ income sky-high.
To fix our broken health care system, we have to start by disbanding the AMA and letting 120% or 150% of the number of doctors required in a given year enter medical school. The income of doctors would plummet to what it is in the rest of the developed world — 50% to 25% of the income of the typical doctor in America. Yes, in France or Germany or Switzerland, doctors make between half and one fourth what they make in America. That’s usual in the rest of the world. America is a wild outlier in doctor income.
No, that’s one problem. It’s not the main one. Individual medical procedures cost 10x in America what they cost in France or Germany. A typical appendectomy costs $75,000 in America — it costs $8000 in France. An MRI costs $1500 in America — it costs $150 in Japan. That has nothing to do with unnecessary procedures or tests, and everything to do with ridiculously out of control medical costs caused by a variety of corruptions and collusions and price fixing scams and cartels all along the line, from the medical devicemakers who bribe hospitals to use their overpriced surgical equipment, to doctors who set up indpendent imaging lab and charge outrageous fees to hospitals, which collude with doctors to do unnecessary surgeries and unnecessary tests and pad doctors’ bills and enter into sweetheart contracts that lock the hospitals into using particular overpriced imaging labs and overpriced doctors’ specialty clinics and specific brands of overpriced medical equipment, to monopoly insurance cartels that collude to fix prices and lock customers into a giant health insurance monopoly in their geographic region.
All those problems contribute to sky-high medical costs in America. There isn’t just one cause. It’s a multitude of causes.
There is no one “magic bullet” to reduce health care costs in America. We need massive structural reforms in many different areas. We need to reform medical schools and reduce tuition. We need to eliminate fee-for-service medical care. We need to break up the giant health insurance monopolies. We need to unleash the hounds of antitrust hell on the AMA and hospitals and medical devicemakers and doctors groups that specialize in high-margin procedures. We need to break up the AMA and allow a lot more people to enter medical school each year. We need to legalize RNs to perform a lot more basic procedures that don’t need a doctor. We need to eliminate independent imaging labs and blood workup labs and group together all reimbursements under a single payer system, so if the labs and imaging suites try to charge $1500 for an MRI, the single payer tells them, “No, that’s too high. If you charge that much you get nothing.” Then the cost of an MRI in America will come down from $1500 to $150, because that’s what they did in Japan and Germany and France. We need to break up giant health insurance cartels — in fact, health insurers provide no social service and should be eliminated. They’re pure parasites, serving no social function. Single-payer does a better job of distributing costs and reducing payouts to greedy doctors and hospitals and devicemakers.
Americans have this simple-minded foolish belief that there’s one single simple solution to every problem. Sometimes there is. But in many cases, the problems are complex, and require many different adjustments and fixes and alterations in the system. This is one of those cases. There is no magical “single solution” to reducing health care costs in America. But one thing is for damn sure — a health care non-reform bill that does nothing to control costs sure as hell won’t fix America’s broken medical-industrial complex.
Amanda in the South Bay
As someone who is currently in college (computer science, not anything health related) I think the biggest problem is expanding allied health programs, as well as medical school.
The supply of health care professionals certainly does not equal the demand, and as anyone who has been to college recently can attest, there are wait lists a mile long to get into nursing and other allied health programs, not to mention the fierce competition (I’m sure biology and chemistry TAs would love having students who want to be there and learn the subjects rather than simply caring about getting straight As). Medical schools are even worse-some states don’t even have them.
I guess I don’t see that changing anytime soon, because its not in the best interests of doctors or nurses to massively increase supply-not to mention the obvious financial costs of doing so. There’s a reason why programs like nursing are so popular, its because of job security and pretty damn good pay for only a two year degree. There are lots of people who don’t want to rock that boat.
RE dentistry-maybe dentistry needs people who are the equivalent of nurse practitioners or physical assistants to fill the gap between hygenists and dentists?
That's Master of Accountancy to You, Pal
@Mnemosyne:
That may be true, but what does it have to do with charging less tuition? I don’t doubt that there are changes coming in how health care is charged. It’s the linkage between lower tuition and lower service prices that I’m asking about.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
I will walk you through this very slowly:
Medical school tuition is very high.
Because medical school tuition is very high, medical students choose to go into specialties that will pay them higher salaries. They choose not to go into primary care because the salaries for those specialties are quite a bit lower: a general practitioner will make less than half as much as a radiologist ($130K vs. $350K).
Because medical students are choosing to go into specialties that pay them higher salaries, we have a shortage of primary care doctors.
If we can reduce the cost of medical school so that primary care is a more rational choice for future doctors, we will be paying them lower salaries than if they had become thoracic surgeons.
People in lower-salary jobs = paying less in salaries.
Mnemosyne
@Amanda in the South Bay:
Another problem is that nursing schools are very expensive to run relative to how much you’ll get in donations from your graduates, so a lot of universities closed their nursing schools for not being cost-effective.
It’s not (necessarily) that nurses didn’t want the competition — it’s also because colleges and universities decided they weren’t donating enough back to make it worth their while to educate them.
slightly_peeved
@mclaren:
Most of the countries with lower health costs that you cite don’t have most of the reforms you describe in your second-to-last paragraph. Australia has an AMA. And private insurers. And private pathology laboratories. Those reforms are great, but they’re not necessary to solve the US’s problems.
The entire point of the exchanges is to break state-based insurance company monopolies; the exchanges require multiple entrants in each state, or the states don’t get the funding. The ban on pre-existing conditions allows portability; the reforms combined create an actual market for private insurance with consumer choice, which hasn’t existed for ages in US insurance.
The Act also increased the role of the government through a massive increase in medicaid funding at the lower end.
I’d like it if the US could have pushed through all the reforms you describe, but you’d be destroying two for-profit industries in the US at one go. For it to be possible, a large number of people and organisations on the US left would need to publicise and push these issues, as a coherent and organised whole. It would also need to develop a long-term plan for insituting these reforms rather than expecting them to occur in one election cycle. As you say, there’s no “magic bullet”. The flip-side of that is that it won’t be solved in any one law, but in an ongoing process of lawmaking. The fact that the US left doesn’t do coherent and organised, and has no long-term plan for doing these kind of projects (and the left movement in many other countries does) is part of the reason that we’re where we are, and you’re where you are.
That's Master of Accountancy to You, Pal
@Mnemosyne: So what? I’d like to see some evidence that eliminating the debt problem will actually lead medical school graduates to choose much lower paying jobs in significant numbers. As I said, my experience indicates that doctors aren’t any more likely to voluntarily choose to have much lower salaries, particularly for jobs that the article that you cited are considered to be more frustrating as well as lower paying.
My contention is that the important element in which field doctors choose to practice in, for the most part, is the discrepancy in income, not the amount of debt carried. The latter may make it impossible to choose the lower paying field, but that’s not even close to the same thing as saying that they will start voluntarily choosing that field without it.
So, you can repeat this as slowly as you like, but I’m still waiting for an actual answer to my question as to why you think doctors are significantly less revenue maximizing than other people are. The entry costs to the profession are not relevant to that question. Continuing to cite them constitutes avoiding the question, not answering it.
Mnemosyne
@That’s Master of Accountancy to You, Pal:
Oh, fer chrissakes. Do you really have to ignore the pieces of my argument that you find inconvenient and zero in on the eensy-weensy piece that of course makes no sense once you’ve ripped it out of context?
You remove the crippling debt from the medical students who choose the lower-paying primary care positions. You do not remove it from the students who choose the higher-paying specialty positions. That evens the playing field.
Now, are you still going to have some people choose to go into plastic surgery even if it means they’ll start off $200,000 in debt? Of course. Does that mean that every medical student will continue to take that path once it’s no longer rational? That seems to be your argument: that even if the barrier to choosing a lower-paying primary care practice is lowered, the vast majority of medical students will still choose crippling debt because it comes with a higher salary.
Please present your evidence to prove that. Here’s mine to the contrary.
kay
Dental cleaning is a poor example.
It costs between 40 and 110 dollars. Any added costs come from once a year x-rays.
I don’t think it would cost less with a stand-alone dental hygiene office, particularly if the allied profession makes 37 dollars an hour, because a cleaning takes an hour.
One dentist supervising a larger group of allied professionals is actually the place we want to go with medical care. Dentists are far ahead of physicians, in that model.
Still, even if we were to extend the approach to physicians (and I think we should) I don’t know that one salaried physician supervising a group of allied health care professionals (the community health center model) is going to cost less than, say, one hundred dollars for a routine visit. I don’t know how paying a nurse 40 dollars an hour and paying the overhead on a medical facility comes in under 100 dollars, and that’s about what it costs now. I know community health centers cost patients less than that, but that’s because they’re subsidized.
We spend too much on health care not because of dental cleaning and routine office visits and healthy women giving birth in hospitals rather than at home. That stuff isn’t where the problem is.
Ailuridae
@Mnemosyne:
Every time this comes up you conveniently dodge the issue of why US medical schools only graduate 3/4 of the needed doctors every year in this country. Of the 1/4 that are educated at medical schools outside the country 80% are foreign nationals and 20% are US citizens who know they can go to medical school in Costa Rica or Israel of what have you and know they can return to the US and have a job for life. This has been going on for four decades in this country at a minimum; I’m 35 and have know many South Asians who were born in the US who are my age who either one or both of their parents were born, raised and educated in India and then came here to practice (at salaries they couldn’t even fathom). There are whole pockets of the western suburbs of Chicago that are nothing but people who meet this description. How can that be going on for four fucking decades and then have the rest of the country have to listen to doctors bleat on and on about free markets in health care?
The argument that doctors if lessened with lighter loan burdens would choose primary care over specialties is specious at best and presumes doctors are some uniquely benevolent actors. My close friends include all manners of doctors and, mercifully, none of them pull this woe is me shit that doctors at large pull. There’s a pathologist, a knock out doctor, a high-risk Ob/GYN and a cardiothoracic surgeon and they’re pretty honest about why they do the work they do. It is reasonably challenging, it pays well its interesting etc. But none of them bleets on that they would be a doctor waiting on Medicaid patients of working at the VA if it only weren’t for their fucking loans. If you lessen the debt for all medical graduates but keep the outrageous pay for specialists most doctors will still become specialists – it pays better! That’s how people choose what they do for a living on the macro scale.
So yeah, I’m all in favor of making med school (and even college) free for any doctor that wants to be a primary care physician as long as, like a school teacher, their wage is determined by central planning. But this nonsense where doctors enter a manipulated market with comparable debt to lawyers and then has medicare pay for their residencies* (a convenient fact left out by all these whining doctors and their free market bull shit) and then complain that they deserve outrageous salaries arrived at through a gamed market is beyond the fucking pale. And none of this gets addressed until we start producing as many medical school graduates as there are doctor openings every year.
* A whole lot of people are totally unaware of this fact Its about 80% of the way down the page.
Re: dentists and their essential pimping of dental hygienists. Yeah, sorry, that’s exactly what it is. It is absurd to have dentists supervise teeth cleanings. Hygienists are already certified to do the cleanings. Its perfectly reasonable to me to have the patient decide when to visit an actual dentist or to be asked to do so as a condition of his dental insurance and to go get my cleaning without the additional overhead of paying a dentist. Additionally if a dental hygienist sees something of note they can recommend a patient see a dentist .
mclaren
@slightly_peeved:
That is flatly false.
I never mentioned Australia. Switzerland also has a different system that is more privatized. But the majority of the world’s developed nations have the reforms I described: nationalized single-payer health care systems with strict regulation of medical devicemakers, doctors, hospitals and insurers (if the insurers exist at all).
France and Germany and the Netherlands and Britain and Japan and most of the rest of the developed world does not use a fee-for-service model. (In Britain they do if you have a private insurer instead of NIH, but very few people choose that option. So it might as well not exist.)
France and Germany and the Netherlands and Britain allow private imaging clinics and testing labs, but they have to pay what the single-payer system will reimburse them for tests. That’s totally different from the American system, where the sky’s the limit and doctors and hospitals merely tack on zeroes to the end of their imaging and lab costs and the insurers simply add 10% and pass the cost on the patient, no matter how outrageous. Japan and Germany and Britain and France don’t do that at all. In Japan, if some private company wants to charge $1500 for an MRI, the Japanese single-payer health insurance system says, “Fine, but we’ll only pay you $150.” That’s totally different than in America.
Other developed nations do not have the chronic shortages of doctors and nurses that America has. The reason is that while organizations like the American AMA may exist in other developed nations, they aren’t corrupt cartels that collude with medical schools to keep tuitions sky-high and restrict the number of people allowed in.
Other developed nations not not have doctors setting themselves as private businessmen owning imaging labs and testing labs and then charging hospitals whatever the sweetheart contract with a price nondisclosure agreements says they can charge. That happens only in America, because in other countries hospitals aren’t allowed to bill $10 for an aspirin or $20 for a cotton ball or $1500 for an MRI test. The single-payer national health care system won’t reimburse hospitals for those kind of wild overcharges, so they don’t happen.
Health exchanges are a worthless band-aid on a gangrenous limb. Health exchanges will only work if they’re big enough to provide serious competition with private insurers. But once that happens, you’re most of the way toward single-payer. If exchanges are limited in size as they were in Obama non-reform HCR bill, you get the catastrophic breakdown in health care we’ve got now — states slashing their medicaid budgets to throw people off the medicaid rolls, and doctors who refuse to accept medicare patients.
California is talking about shutting down its entire medicaid program. States across the nation are drowning in red ink. They don’t have the money for existing patients, much less the 15 million new patients this non-reform HCR bill dumped on them by setting up the exchanges. So it’s easy to see what will happen — those 15 million new patients will wind up on the street dying without medical care because the states are too broke to fund medicaid treatments for them, and the exchanges are so small that they have no negotiating power with the giant insurance and hospital-doctor cartels. So exchange insurance costs at least as much as private insurance, sick people with chronic illnesses can’t afford so they cascade onto the state medicaid programs, the state medicaid programs go broke and throw the sick people onto the street to die slow screaming, and the entire system keeps getting worse and worse and worse and worse.
You can’t fix America’s broken medical-industrial complex with half-measures like exchanges. Ruthless massive regulation is the only answer. Stripping the profit out of the system is the only thing that will work in a greedy corrupt society like America (in Switzerland, where there’s no such ting as a Texas or a Tom DeLay, private insurers strictly regulated work; but that won’t work in a greedy decadent corrupt country like America). Unleashing antitrust hell on doctors and hospitals and the AMA and nurses and medical devicemakers is the only way to fix our broken system.
We can’t reform a broken system by patching bits and pieces. Obama tried that. People are robbing banks to get into prison so they can get decent health care. People in America are shooting themselves to get into the E.R. so doctors can fix their old injuries that their insurance won’t cover. The system is catastrophically broken. It keeps getting worse. Band-aids like health insurance exchanges are worthless, we need real reform.
kay
E.D., this is essentially a community health center. It’s not a radical idea at all. It’s not even an “idea”. It’s a reality. Bernie Sanders will be amused when he finds out some blogger is claiming credit.
Community health center capacity doubles under health care reform.
I wish people who comment on the health care reform act would carefully read the health care reform act.
I agree with you about medical schools, though.
Martin
@Brachiator: Cool. I didn’t realize that. I’ll have to check into it next round. Thanks.
kay
Here’s your barefoot doctor, in Vermont:
What are Community Health Centers?
Community, Migrant, and Homeless Health Centers are non-profit, community-directed providers that remove common barriers to care by serving communities who otherwise confront financial, geographic, language, cultural and other barriers. Also known as Federally-Qualified Health Centers (FQHCs), they: are located in high-need areas identified as having elevated poverty, higher than average infant mortality, and where few physicians practice;are open to all residents, regardless of insurance status or ability to pay: tailor services to fit the special needs and priorities of their communities, and provide services in a
linguistically and culturally appropriate manner; provide comprehensive primary and other health care services, including services that help their patients
access care, such as transportation, translation, and case management; provide high quality care, reducing health disparities and improving patient outcomes;1 and are cost effective, reducing costly emergency, hospital, and specialty care, and saving the health care system $24 billion a year nationally.
kay
Correction: He’s probably not barefoot if he’s in Vermont.
Everyone has to read the health care act before making suggestions. That’s the rule, goddammit.
That's Master of Accountancy to You, Pal
@Mnemosyne:
Contrary to what? It certainly doesn’t contradict any argument I’ve made, and doesn’t say a thing about debt causing people to choose other specialties. It’s primary contention is:
This is about the structure of specialty, not the amount of debt. If anything, this undercuts your contention that we would get more general practitioners by lowering their debt:
In other words, unless you change the pay and conditions of family practitioners, you are likely to get the students in the program for the mandatory five years, and then many, if not most, of them switch out of the field. If a sixth of practitioners overall switched specialties, and family practice is considered to have the characteristics that are least desirable, that’s where the defections are likely concentrated. What you’ll have accomplished is subsidizing medical students getting into other specialties without debt. I’m having a hard time seeing the value here.
Unless you make changes such that family practice is not considered just about the least desirable specialty to practice, you aren’t going to increase the percentage of medical students who choose it significantly. That’s your driver, not debt. It pays the lowest, and is considered a frustrating specialty.
Ailuridae
@kay:
Everyone has to read the health care act before making suggestions. That’s the rule, goddammit.
Also my data about foreign born and educated doctors from the above post isn’t controversial but was most recently echoed here:
http://www.nytimes.com/2010/08/03/health/03doctors.html
That would have made a lot of those threads in late 09 early 10 awfully brief though ….
kay
@Ailuridae:
I was kidding, but I agree.
I’ll do a post on “bundling” etc, but I can’t now because I have to spend 12 hours a day in Toledo for the rest of the week and it takes me forever to write anything. I do like Toledo, though.
We should do a joint post, like co-counsel.
I’ll do all the cussing, and you can do the math. That’s the general division of duties.
Mnemosyne
@Ailuridae:
It’s very strange to me that you start your reply like that and then say the exact same thing I’ve been saying: we need to lower the debt load on students who agree to go into primary care. Why start so belligerently if you agree with me?
Mnemosyne
@That’s Master of Accountancy to You, Pal:
I give up. Yes, fine, everyone who goes to medical school is a complete asshole who’s only interested in money and there’s no way we can ever change anything in our medical system because all doctors are assholes. You win. Happy now?
Martin
@That’s Master of Accountancy to You, Pal:
Well, you’ve got two competing interests – the law of supply and demand that can drive health costs as high as the market will tolerate, and the need to bend the cost curve.
The problem with relying on the free market to solve certain problems presumes that the public can opt out of the market. If the TV makers try to maximize revenue by raising prices, I have the option to simply not buy a TV. That doesn’t hold in the medical market (along with many others). The freedom to not participate in a market is a key element of market price efficiency.
That means that in order to bend the cost curve, leaving the problem to the free market can fail in a myriad of ways simply because the market isn’t free for patients to exit. But if you look at my proposal, it’s not just a free money drop on doctors. It goes directly at what Wag says in #63 – expand the number of people that can go to medical school (a surplus of medical providers – even a small surplus – is necessary for any market forces to function, and that requires a fairly substantial surplus of medical degrees) and put subsidies out there for doctors to go into needed areas like primary care. If they want to go into dermatology (I have nothing against dermatologists), that’s fine, but they’re going to have to cover their own medical school costs.
And even in that case it’s not just a money drop on primary care doctors, but those loan forgivenesses come in exchange for some direct effect on costs. If we are losing Medicare providers, reward new doctors for being Medicare providers. Further, reward them more if they can bill below Medicare rates. If your compensation is based on what you bill, there’s an incentive in the system to bill more. If your compensation is based on the care you provide, independent of what you bill, there’s an incentive to provide good care at lower cost (because you’ll earn more, and it’ll cost you less to provide the care). Ultimately, that’s what we need to find a way to. There’s simply no alternative.
Ailuridae
@Mnemosyne:
No. I am willing to concede that might be a good option to lessen the debt load on primary care physicians if that’s the only way to get the cartel to stop artificially limiting the supply of all doctors as it has for forty years. I’m not particularly in favor of removing the debt load on primary care physicians if they still average 130K a year in a distorted market. Again for every four openings every year for a doctor US medical schools produce three doctors. And this has been going on for decades.
And, I’m sorry but unless you are going to argue that doctors are unique amongst human beings even if you lessen the overall debt load for doctors coming out of medical school they will still disproportionately flock to the higher paying specialties. Eventually doctors are either going to have to accept government control over pricing or compete in a genuine free market where some of them risk graduating without a cushy job for life and they have to all have to find a non-government source for their residency training. Its just a question of how the country gets their and how much of GDP is ceded to the medical cartel before it happens.
To put this in perspective the noxious (to most Americans) auto bailout is going to end up costing the American people between 18-22B total. The American people pay that every four or five years to the medical establishment for residency training to then be told that its perfectly reasonable for cardiologists to make 750K because of all the years they went without a salary and that they are burdened with 135K in debt.
kay
@Ailuridae:
I think we’re on the wrong track with AMA as “cartel” though. I’m not crazy about them, they almost single-handedly killed Medicare at 50, and they have a long and sordid history of lobbying and dirty-dealing against Medicare going back to the 30’s, but they’re a voluntary association and only 20% of physicians belong. I think they’re over-played as “cartel”. They lobby, but they don’t directly rule-write.
I think you have to look at state medical boards. That’s the governing body.
mclaren
@kay:
Yes, one of the few good things about Obama’s non-reform HCR bill is that it massively cranked up funding for community health clinics.
The problem with all these kinds of half-measures, as with expanding medicaid coverage, is that only the lowest-income people qualify. But more and more middle-class people are dropping off health insurance rolls because they can’t afford the premiums. Yet these people own a home and 2 cars and their total assets are far far far far far far too high to qualify for medicaid or to allow them to go to a community health center and get affordable care. In most states, for example, if you own more than $3000 worth of assets, you can’t get on medicaid. If you’re income is above 150% of poverty level in many states you don’t qualify for the special low prices offered at a community health center. These places are deigned for homeless people, people right at the bottom of society with no income and no jobs and no assets at all. But the people who need community health centers and medicaid increasingly are the middle class families who’ve been priced out of health insurance and have a sick kid and can’t afford to lose their home because they go to the E.R.
Amanda in the South Bay
@Mnemosyne:
I’m seriously not trying to be snarky or anything like that, I guess I’ve always assumed thats why probably 90% or so of doctors, nurses, etc enter their chosen fields. I mean, isn’t medicine one of those careers that middle class families push their bright, straight A high school student kids into (along with law) in order to make it to the upper middle class or higher? Yeah, student loan debt sucks, but for most doctors that’s still enough money for a nice new car and a house in teh burbs.
My primary care MD works at Planned Parenthood, so I know there are idealistic medical workers who work for (relative) squat, but I’ve also spent some involuntary time at both major private and public hospitals to see that those Planned Parenthood workers are not the norm.
mclaren
@Ailuridae:
Exactly correct. A rollback on debt for doctors who agree to become primary care physicians would be nothing more than a giant free giveaway of the public’s tax monies. The doctors who sail through med school without incurring huge debts would become primary care physicians, and then immediately go into business with other doctors who are specialists to open fabulously overpriced imaging clinics and blood test labs. The primary care physician-owned labs would bill out their insanely overpriced tests to the specialist doctors, both the specialists and primary care physicians would make millions per year by gouging middle class people for grotesquely overpriced tests and imaging scans and blood workups, and the specialists and primary care M.D.s would split the profits, laughing all the way to their 300-foot yachts.
You can’t fix America’s broken medical-industrial complex with a single magic bullet. No single “fix” will work. Ultimately the entire system will have to be structurally reformed at a basic level, or it will collapse entirely. And we’re very nearly at the point of collapse because a tipping point will arrive in the foreseeable future at which the average middle class worker can’t afford the government-mandated health insurance premiums and their employers will have cut back on the insurance offered so much that the government-mandated health care insurance doesn’t cover much of anything anyway ($40,000 deductible plans that don’t cover dental or pregnancy are now typical).
kay
@mclaren:
I don’t actually agree with you on that, mclaren, and I work with a lot of people who are on Medicaid.
S-CHIP covers middle income children, and for younger families, that’s huge. Younger parents just don’t have prohibitive medical costs, generally, and if their kids are covered, they do okay. I’m never sure who you mean by this generic “middle class family”. I don’t deal in generics.
Look, I know you wanted radical change, but it wasn’t happening as long as 94% of college educated white people have health insurance and are happy with it.
The reason health care wasn’t tackled all these years is because most of the people who vote have health insurance. Either they’re old and on Medicare, or they’re college educated and insured.
Schumer estimated that 11% of the people who will benefit from health care reform VOTE. 11%. Is it any wonder no one would take the political risk up until now?
kay
@mclaren:
I apologize, but I have to go. We’ll continue this some other time, okay?
Ailuridae
@kay:
I never specified anything about the AMA. There are a series of intertwined interests that artificially limit the number of medical school graduates. Two of the hospitals in Chicago are going through massive, expensive expansions and neither is significantly expanding the number of students per class in their medical schools. There are no shortage of (exceptionally ) qualified people applying to medical schools year after year yet this supply gap in graduates has existed for four decades at a minimum. That can’t be a coincidence. I suspect its some combination of regulatory capture, the AMA’s noxious interest and the self-interest of doctors as whole that constrains the supply of medical graduates but the most basic economics reasoning will lead anyone to conclude that an inefficiency this severe (again three graduates for every four jobs) cannot be organic and in anything resembling a free market or a reasonably built central planner would have already been addressed. So, that leaves us with cartels.
Mnemosyne
@Ailuridae:
Maybe it’s just me, but I really don’t think that $130K a year is a crazy wage for a medical doctor to be making. They’ve had a lot of schooling, they (theoretically) have a lot of knowledge and skills, and I don’t see why we should insist that they take a 50 percent wage cut.
I have friends who make more than that a year to market cars or write software. Are you saying that those jobs are more important than being a physician so naturally they’re going to be better compensated?
Not necessarily, and I have statistics for you. Two related points:
IOW, increasing medical school costs have made medical students more likely to be white and wealthy, which also makes it more likely that they will choose a high-paying specialty, because poorer and minority students are more likely to choose primary care.
Making it easier for less-wealthy students to go to medical school makes it quite likely there will be an increase the supply of primary care physicians. In fact, their absence from medical schools is one of the reasons for the decrease in primary care physicians.
Mnemosyne
Also, too, here’s an interesting article from the NEJM (PDF) about the intertwining problems that have led to the primary care physician shortage.
Ailuridae
@Mnemosyne:
Maybe it’s just me, but I really don’t think that $130K a year is a crazy wage for a medical doctor to be making. They’ve had a lot of schooling, they (theoretically) have a lot of knowledge and skills, and I don’t see why we should insist that they take a 50 percent wage cut.
But that’s for the worst paying specialty right? And absolutely nobody graduates medical school and ends up much worse off than that, right? Let’s focus on the comparable profession by debt load: Lawyering. Its perfectly common for the worst graduates from even high end law schools (Chicago, Northwestern) to not have any work when they graduate and some mid-tier schools (Loyola, depaul, IIT-Kent) to have nearly half its graduates without work. That’s what competition in a highly desirable field should look like. Needless to say the average salary for bottom end legal work isn’t 130K a year.
And on its face and using your numbers taking a job that on average pays 125K (using your data) while carrying a 130-140K in total debt is a pretty enviable situation. Not nearly as enviable as making 350K with the same debt load but far better off than anyone but elite law school graduate walks into.
Making it easier for less-wealthy students to go to medical school makes it quite likely there will be an increase the supply of primary care physicians. In fact, their absence from medical schools is one of the reasons for the decrease in primary care physicians.
You’re confusing correlation with causation. While minorities may be put off by the financial burden and minorities are more likely to do primary care work that doesn’t mean that limiting debt will mean more primary care physicians.
The far more reasonable free market solution to this issue is to stop constraining the supply of doctors thereby inflating wages in the industry. If that seems unfair I’d be willing to back a solution where primary care physicians can graduate with no debt burden and a solidly middle to upper middle class life with the same absurd job security they have now. But, again, as doctor and provider compensation continues to swallow a greater and greater portion of American GDP with each passing year doctors have to stop asking to have their cake and eat it too.
Glen Tomkins
We’ve already tried a quality spiral in primary care
It didn’t work. It’s a large part of why we are where we are today with US health care, lowest quality and highest price tag in the industrialized world, and both by hefty margins.
Right now, today, no need to wish for this as some “reform”, your “medical-school-price-tag” primary care MDs have to see 40 patients a day to survive in the market that we’ve let the insurance industry, aided and abetted by the Medicare fee structure, foist on us. And that 40-a-day doesn’t even include the supposed supervision of the various “physician extenders”, NPs, PAs, etc, that unrestricted price pressure has already worked into primary care. We’ve already got those “barefoot doctors” at work in our system creating all the false economy we’re ever going to see out of the attempt to low-ball primary care.
Our health care non-system is not overpriced because we pay too much for primary care. It’s overpriced because primary care has proven the echelon of care least able to defend itself against downward price pressure, and it has therefore effectively stopped doing the one thing it needs to do to prevent the overuse of high price-tag specialty interventions, controlling the flow of patients to these specialists. In the absence of that control, of any control over the system, of course centrifugal forces send the price of health care spinning out of control into specialist land, as there is no one to supervise the specialists, no one is in charge of providing the patient medical advice that sums up the entire array of options open to him or her in any given health situation.
There isn’t some vast reservoir of interventions our system does that barefoot doctors could take over from the MDs that would have any impact at all on the out of control cost of health care, and the more serious quality spiral, that we have in this country right now. What we need are professionals who literally know everything medicine has to offer (even if, out of the necessity created by the explosive growth of the full array of what medicine has to offer, no one physician could possibly be able to perform all of these interventions his or herself), and whose job it is to look at that array, look at what the patient needs, and do as much as possible of as little as possible of these interventions. The high monetary cost interventions carry a high human cost, and mnimizing those human costs, doing nothing except what will benefit the patient, is the best way to save the system money, even as it aims to maximize quality by avoiding the expensive and invasive in favor of every less invasive alternative.
We need to get someone back in charge of the whole, currently out-of-control, array of interventions. “Barefoot doctors” won’t be able to do that. Medical professionals even further downgraded and beaten down than primary care MDs already are, forced to see even more than 40 patients a day, won’t be able to do that. We need to go the opposite direction with primary care, upgrade the quality, widen the knowledge base, so that medical decision-making for all levels of care can start to happen at the primary care level.
Brachiator
@That’s Master of Accountancy to You, Pal:
RE: But the last few years have seen a lot of new deductions and credits which people miss even when they are using wizards and questionnaires.
I had to step away for a bit. I have no idea why you are trying to construct a zero sum game here.
This is as strange as suggesting that we can’t talk about the value of auto repair shops unless we can predict the number of people who can fix their own cars vs the number of people who need a professional.
No, you suggested that most people don’t need a tax preparer (and even here you seemed to know only about a CPA). Not the same thing. And you don’t know enough about the industry, and instead just threw out some off-the-cuff remarks.
But even here, let’s return to health care. Somebody thinks she might be sick. She can self-diagnose or go to the doctor. If she goes to the doctor and pays out of pocket and is told that she is fine, was there any value obtained?
E.D. Kain
@DougJ: Sure, I’d want them to be certified or trained in some way, too. I wouldn’t want that certification to require that she A) attend a really expensive trade school instead of a community or public college; or B) be required to clean my teeth under supervision of a dentist; or C) fulfill some sort of apprenticeship or on-the-job certification rather than from a school. Obviously there’s room here for some form of certification and training. The question is how that’s structured, who is making the rules, and whether the game is being rigged in an elaborate attempt at rent-seeking.
Brachiator
@Ailuridae:
But isn’t it the case that a significant number of people with law degrees don’t end up practicing law at all, but end up in other professions (such as politics)? But then again, there are more people who go through life without ever needing an attorney than people who go through life without ever needing a doctor. I’m not sure that lawyers provide the best comparison.
Are you suggesting letting in more foreign doctors? Opening up more medical schools? Getting rid of licensing and certification?
And then, what do you do to get doctors to where they are most needed?
mclaren
@Mnemosyne:
Yes, it’s just you. No one else is that stupid.
$130K a year is a crazy wage for the ignorant incompetent fools who work as doctors in America.
Let’s run through some facts to see how allegedly “smart” and “skilled” most doctors are:
Fact #1: 48% of the people who apply to medical school get in.
Compare that with the 16% of applicants who got into CalTech last year. Gee, sounds like 48% is just about…the goddamn cutoff point for a below-average IQ, doesn’t it?
Yet CalTech graduates don’t make a minimumof $130K a year or anything close. But doctors make a minimum of $130K a year.
Who has more skills? Which group is smarter? The PhD engineers and physicists and mathematicians who graduate from CalTech (only 16% of applicants get into that elite institution)…or the schmucks who make it through medical school (48% of the people who apply get in)?
Sounds like something else is going on other than “skills” and “smarts” and “knowledge,” doesn’t it?
C…A…R…T…E…L.
That’s what’s going on. It’s a giant scam. A massive restraint-of-trade ripoff by the AMA.
Fact #2: Now let’s talk about doctors’ actual alleged “skills.” Take a gander at this little piece of documentation about the incompetence and ignorance of your typical doctor in America:
Source: “Believing In Treatments That Don’t Work,” New York Times Well Blog, April 2 2009, David Newman, M.D.
$130,000 dollars a year? For treatments that don’t work? That doctors keep prescribing even though the evidence overwhelmingly shows the treatments don’t work and cause injurious side effects…?
Are you drunk, brain-damaged, or just wacked out on crystal meth?
Ailuridae
@Brachiator:
I’ve been pretty clear here, I feel. In a situation where there are four openings for every three graduates from US medical schools of course wages are going to far out pace inflation and drive costs. But that shortage of doctors is not a bug, its an intended feature. Its a deliberate, persistent supply constraint to maintain artificially high doctor wages. I’m not a free market absolutist by any stretch; doctors can maintain their supply constraint and the effective lifetime guarantee of top 10% wages and their training on the government (at a cost of 4-6B a year to taxpayers) as long as they are willing to accept some cost controls. Barring that (and especially since doctors won’t accept those cost controls) there should stop being medicare paying for doctors training and wages in residency and the market should be flooded with doctors. Additionally, states should start mandating that a far greater number of medical students are admitted every year preferably to state run institutions. Graduate more doctors every year than there are vacancies and watch doctor salaries fall and then health care costs fall and then our long term deficit issues quicklyfade away.
Here’s a really trivial way to know that there isn’t a supply constraint in an industry: you know somebody who is unemployed within that industry. Does anybody know a doctor who is unemployed? It’ll be a long time before you find one.
And the legal comparison does hold. I know some reasonably bright people who went to decent law schools and didn’t do very well in law school who would have been far better off having never gone to law school and accumulated the debt. Some of them took a year to find a job and then had to claim hardship for a long time to be able to even begin paying their loans off. They weren’t choosing to use their degree elsewhere or go into politics; nobody would hire them as lawyers. That simply doesn’t happen in medicine and there is a reason for that: supply constraint designed to artificially inflate wages (and thereby costs).
And every doctor knows it and they almost all benefit from the practice whatever their protestations to the contrary.
Brachiator
@Ailuridae:
Thanks for the clarification. I wasn’t able to follow some of the earlier posts in this thread because of computer hiccups that I had to work around, not because you weren’t clear.
mclaren
@Glen Tomkins:
That statement is explicitly untrue — and I can prove it.
Take a look at the comparison chart here.
Sweet Christ on a minibike, lookah that! America jumps out like a sore thumb! A simple office visit to a primary physician in America COSTS FIVE GODDAMN TIMES WHAT IT COSTS IN ANY OTHER DEVELOPED COUNTRY!
That’s insane.
That’s pure greed.
That’s grotesque out-of-control avarice.
And the stats on the pay of American doctors compared to the pay of doctors in other developed nations bears this out.
Source: New York Times “Week In Review,” July 29, 2007.
So your statement is clearly and provably false
You go on to claim:
But once again, that’s just plain wrong. Obviously and provably wrong. You’ve left out a whole bunch of options — your solution is the conventional Republican non-solution, simply shut off the flow of patients to high-cost medical specialists. This can be done easily enough. Let costs rise, and patients will die in the streets instead of seeing those high-cost medical specialists! Problem solved!
Not.
That’s no solution.
The obvious solutions, the solutions you deliberately ignore in your crazy Randroid manifesto, are:
SOLUTION #1: Reduce the cost of those high-priced American medical specialists. This can easily be done, and has been done in every other developed country, by setting up a single-payer national system that refuses to pay exorbitant fees for common procedures. No matter how much skill required or how specialized an operation like an appendectomy may be, it simply isn’t worth $75,000. Only in America do you get surgeons charging those kinds of insane fees. Everywhere else in the world, single-payer national health system simply refuse to pay that kind of stupid extortion. So that’sthe first solution. Stop overpaying for those specialized procedures.
And if doctors quit en masse? Great. Revoke their license to practice medicine and get foreign students into medical schools, or people who were rejected becuase they had one or two Bs on their college transcript instead of straight As. Reagan busted the PATCO traffic controllers union, it’s time to bust the AMA cartel. But of course, you never even contemplate that possibility, do you?
SOLUTION #2: Let enough people into medical school to put massive downward price pressure on all the specialties. When there are 150% as many specialists as needed, the price of their services will drop. But once again, you never contemplate that option.
SOLUTION #3: Shift resources toward preventive medicine and away from heroic surgical intervention. Huge amounts of heroic procedures are done in America for no good reason. Only in America do you hear about teams of surgeons spending 20 hours on a miracle surgery to separate conjoined Siamese twin babies. Only in America do we encounter premature infants born 13 weeks too early put in incubators on massive 24-hour-a-day life support, using up millions of dollars of medical care, instead of sensibly rationing the available medical resources.
America has a bizarrely twisted “heroic intervention” model of medical care where preventive care gets totally negelected in favor of superstar exotic spectacular surgical procedures by highly trained specialists.
Study after study shows that American doctors systematically neglect preventive medicine. American insurers refuse to pay for preventive treatments. American hospitals systematically refuse to perform preventive procedures instead of high-priced whizzbang spectacular heroic interventions using the latest surgical technology.
If American medicine and American hospitals and American doctors stopped neglecting and refusing to pay for preventive care, and put anywhere near as much money into preventive medicine as we currently put into heroic last-stage intervention surgical procedures (as for instance insane treatments like using a team of world-class surgeons to perform some procedure on a terminally ill cancer patients who’s going to die in 6 weeks anyway), we could save enormous amounts of money in American medicine.
Source: “Health: If we spend so much why don’t we live longer?” Steve Klingman, June 10, 2010, Salon magazine online.
But once again, you never even contemplate this possibility of shifting our resources away from heroic life-saving end-of-life intervention and toward preventive medicine.
No, your “solution” is to brutalize the poor. Rational those high-priced medical specialists. Crush everyone who isn’t rich. Grind ’em into hamburger! If they need some specialized expensive procedure, throw the bastards out on the street and let ’em crawl away and die.
That’s no solution. That’s insane. That’s the roman arena. It’s not just barbaric, it’s unspeakably stupid.
slightly_peeved
Your list of reforms included the removal of all private insurance. France, Germany, Italy, Ireland, the Netherlands and Britain all use private insurance, as does Australia. So your proposed reforms go further than the current systems in these countries.
Oh, and Germany uses fee-for-service. As does Denmark. A number of countries have competitive health care systems while having fee-for-service.
Which, again, you said had to be removed for a healthcare system to be effective. If what you mean that there should be limits on how much they can charge, then say that. Don’t say the private profit motive has to be destroyed when that’s simply not true.
Australia does – it has had a massive ongoing shortage of rural doctors….
… because that’s a pretty good description of our AMA, minus the bit on tuition.
Just south of them there is, however, a Silvio Berlusconi, a man that makes DeLay look like a rank amateur when it comes to government corruption. Yet Italy has a pretty good healthcare system.
So did the rest of the world, and it worked for them. Bismarck took three bites of the apple back when he created the German healthcare system, and it’s received countless refinements since. You’ll never pass a single piece of legislation that’ll close all loopholes and fix all problems; the people you’re trying to thwart adapt and find new loopholes, which you have to address. You point out (correctly) that there’s no single policy to fix healthcare, but there’s no single piece of legislation that can fix it either. That’s looking for magic bullets too.
Amanda in the South Bay
@Ailuridae:
Its easy to find tons of 2nd, 3rd, and lower tier law schools to get into. There simply aren’t nearly as many medical schools. Even if, in some fantasy world where the government decides to massively expand medical education, I’m pretty sure the AMA, etc would oppose it.
Also, lawyers have been hurt pretty hard by the recession, and I’m not talking about 3rd tier grads at obscure law firms.
Yutsano
It does show a huge ignorance of the history of universal health care in the Western world to assume that we would get it all in one single stroke. Canada developed single payer province by province over twenty years until the Canada Health Act was passed. South Korea finally installed theirs after 15 years of when the first law was passed there. And Germany has had a universal health care system for 150 years and it is constantly being changed to reflect the dynamics of their changing population needs. The whole reason why the ACA is so significant is it’s a start not the end. Now we improve and refine the laws until we get a system that best works for us. I think we eventually end up similar to Australia, but that’s just my theory.
Ailuridae
@Amanda in the South Bay:
Its easy to find tons of 2nd, 3rd, and lower tier law schools to get into. There simply aren’t nearly as many medical schools. Even if, in some fantasy world where the government decides to massively expand medical education, I’m pretty sure the AMA, etc would oppose it.
That’s my point. The US medical community is a cartel that is constraining the supply of doctors to enrich themselves at great detriment to the country at large.
E.D. Kain
@beltane: The point isn’t that people shouldn’t get training or that free markets will somehow swoop in and fix everything. The point is that all medical treatment is considered, essentially, the same. We can’t get a routine teeth cleaning (no Novocain) unless we go to the dentist; we can’t get stitches or get our throat looked at unless we see a doctor. There should be some way to separate out routine care, preventative care, etc. from really complicated, dangerous, procedures. Lots of other countries do this.
E.D. Kain
@Maxwell James: That’s a really good point, actually. I agree (mostly) but I think we could have very basic healthcare services done without supervision of an MD or dentist. When I get my teeth cleaned I see my dentist for all of thirty seconds. It would be nice to have options. Then again, you’re totally right, this isn’t the best example.
E.D. Kain
@Zifnab: @morzer: Thanks. Actually I came down on the pro-reform side in the end, though I didn’t like a lot of it. I remain hopeful we can fix the ACA in the future. I have no interest in repealing it, and would rather work to improve it. The status quo is (I hope, I think) worse.
E.D. Kain
@Anonymous At Work: Part of the problem is that it’s very difficult to do this in a meaningful way across the country. Entrenched interests are hard to topple. National networks support the entrenched interests, etc.
E.D. Kain
@That’s Master of Accountancy to You, Pal: Exactly.
Yutsano
@E.D. Kain:
This is not a hope, it’s the whole damn point of the exercise. The ACA is, like every other major social legislation, a starting point that will get constantly refined over the years. In fact, that movement, in both directions, is happening already. And the status quo is unquestionably worse. When families go broke because of a medical bill that’s a drain on our country. When a citizen can’t get any treatment until the situation deteriorates that they end up in the ER that we all end up paying for that’s a bad situation. But we’ll get there. Kicking and screaming the whole damn way, but we will.
BTW welcome home. How’s the wife and little one?
E.D. Kain
@Belafon (formerly anonevent): French doctors make a lot less money than American doctors. Here’s an interesting take on that system. Oh, and Matt Welch has a really interesting bit on why he prefers their system to ours.
E.D. Kain
@Anne Laurie: You have it backwards or else you’re not reading carefully. Nobody is suggesting allowing hygienists to perform injections or drilling.
E.D. Kain
@Omnes Omnibus: Again, nobody is suggesting no training. The point is that a lot of the certification boards are controlled by people who can make a lot of money off these rules; the schools that charge outrageous prices to train students benefit way more than the students themselves; and so forth. I’m sorry but a lot of the hair dying and hair cutting and sterilization stuff could be learned on the job, in an apprenticeship style situation.
E.D. Kain
@Wag: You can honestly read this post, about access to – basically – primary care, and come up with that response? Oh my.
E.D. Kain
@Martin: This would turn into a huge transfer of wealth from taxpayers to doctors who, to be fair, don’t do too badly in the long run.
E.D. Kain
@DougJ: Well that or having your entrenched competition write the rules for you. Both are problematic.
E.D. Kain
@mclaren: That’s all great information, thanks!
Ailuridae
@E.D. Kain:
This would turn into a huge transfer of wealth from taxpayers to doctors who, to be fair, don’t do too badly in the long run.
That’s a pretty good description of the current system, though, right?
E.D. Kain
@Mnemosyne: But we could lower tuition by letting more doctors go to school which would increase supply, lower doctor salaries, thus decreasing the amount people would pay to go to medical school, and so forth. Simply subsidizing ridiculous tuition rates is a waste of many and doesn’t really address the underlying problem. If doctors can still make more doing specialist work they’ll gravitate there subsidies be damned.
E.D. Kain
@kay: No, most community health centers are staffed with expensive doctors, which is exactly what Carson is trying to avoid.
rickstersherpa
I always believe a reference to Dean Baker, the best economist in the world, is a good way to figure out this discussion. http://www.cepr.net/index.php/publications/reports/free-trade-health-care/
Dean and the folks at CEPRs have some wonderful discussions about bringing the benefits to “free trade” to the upper income professions, including medicine and the first place to start is with Medicare and Medicaid so folks can go to Canada, Ireland, the UK, France, India, Thailand, Australia, New Zealand and get great care for half the cost have their co-payments go for the plane ticket and hotel costs.
I don’t know how many you have gone to a hospital for a procedure and gotten the bill, it is marvel. One bill was for $15,000 for a 24 hour stay with tests. Thankfuly we had insurance but I never saw anything less transparent. Talk about an information asymmetry and lack of negotiating power (it was an emergency visit so not much opportunity to shop around).
E.D. Kain
@Ailuridae: Well yes, but no need to exacerbate it further.
mclaren
@slightly_peeved:
I really have to Fisk you in detail because you’re distorting and misrepresenting almost everything I said. But I think it’s unintentional. My sense is that we’re talking past each other, mostly saying the same things without realizing it.
Look: what I tried to say (and think I did say) was that we need to remove private insurance as the only way delivering health care in America to most of the population. If you have more than $2000 to $3000 in assets (which virtually everyone not homeless does), in most states that means you’re excluded from Medicaid, and if you’re not on section 8 disability or over 67 you’re excluded from Medicare, which is also true for the vast majority of the population.
So practically speaking, private insurance is the only method of delivering health care to Americans. That just doesn’t work. You’re nitpicking here and it sounds like you’re playing word games. What I said is substantively true for your examples of Britain etc. They have private insurance, yes, but it’s not the only method of health care delivery. In fact, it’s a distinctly fringe minority health care delivery system in those countries.
It should have been clear that’s what I meant. I think I said that. This is really verbal calisthenics on your part, and it’s unworthy of you.
My proposed reform was to remove private health insurance as the only (and really as the primary) means of delivering health care. I stand by that. Moreover, it’s precisely true for the countries I talked about, except Switzerland and one or two other outliers. And int he case of the Swiss the private insurance is only nominally private — it’s an oddball public-private melange that isn’t anything like a free capitalist market as we have ’em in America, it’s more like the keiretsus in Japan that get guided and partially funded by Japan’s MITI. That has nothing to do with “private enterprise” as we understand and practice it in America.
First, Germany has had socialized public doles since Bismarck, so we can’t possibly compare Germany with America. They’re light-years ahead of us. They were light-years ahead of us in terms of national social services back in the Great Panic of 1906, let alone 1929, let alone today. So you’re comparing apples & oranges.
Second, Germans are very different from Americans culturally. Example: the Germans had zero housing bubble int he recent run-up. None. They just have a totally different culture, Germans don’t go in for massive speculation and getting rich and becoming a zillionaire the way Americans do, it’s been burned out of their consciousness probably because of the hideous hyperinflation of the 1920s, which Americans have never had to live through. So the entire concept of setting up a private business and bending and stretching the rules as a doctor or an insurance CEO or a hospital administrator to become richer than Croesus by gaming the health care system simply never occurs to the Germans. Apples and oranges. The German culture is so totally different from American laissez-faire wild west cowboy capitalism, probably due to the hyperinflationary horros of the 1920s & the aftermath of WW II where msot of the population spent 10 years hauling around the rubble of their former houses in wheelbarrows, that fee-for-service means “charge a decent rate, make a decent living” to a German doctor. Whereas to an American doctor, fee-for-service means “Bugatti Veyron, baby! Rolex presidential watch! Vacation home in Maui!” That’s my fee-for-service works in Germany, but not in America.
Germany has a peculiar culture marked by that hyperinflation and post-WW II privation. Germans save compulsively, they don’t want to get filthy rich, they want to make sure they have 3 months worth of beans in the cupboard just in case. It’s a different culture. We haven’t been through what the Germans have been through. You’re trying to take an element of one unique radically different culture and paste it onto another wildly dissimilar culture and say, “See? Fee for service! It can work!” It can work in Germany. Not here in America. Not when our heroes are Butch Cassidy & the Sundance Kid.
You’re playing word games again. Look, what I said is subtantively true and you know it’s substantively true. Putting sharp limits on private insurers or drastically limiting what a fee-for-service system can charge does effectively extinguish the private profit motive. You can make some money in that kind of system but you can’t get rich. The profit motive means the sky’s the limit, get rich, baby, retire to a penthouse in Manhattan. That has to be destroyed for health care to work. That’s what I said and that’s substantively true.
Scraping along with a 4% per annum profit isn’t “the profit motive,” it’s getting by. When we limit American health care to that kind of system, it effectively destroys the profit motive and turns it into scraping by. Today you’ve got hospital admins and health care CEOs and doctors with chains of private clinics who want to become the Bill Gateses of medicine. We have to destroy that to get a health care system that works. Wellpoint must die along with the philosophy behind it. UCLA medical center must die along with the philosophy behind it. Every chain of private clinics that subsists on non-stop goddamn overpriced drug tests done on prospective employees for employers must die, along with the philosophy behind it. That’s the profit motive all along the line. Scraping by with a regular dull 4% profit every year ain’t the profit motive, it’s surviving.
When I pointed out that “Other developed nations do not have the chronic shortages of doctors and nurses that America has” you responded with the grossly deceptive:
Australia does – it has had a massive ongoing shortage of rural doctors…
You know as well as I do that the Great Red Centre of Australia is a giant outback desert with ridiculously low population density and lots of unique problems (like the world’s worst drought right now). The vast majority of Australia’s population resides around the shoreline, and there’s no shortage of doctors there. So you’re just being deliberately deceptive with this one. Stop it. It’s misleading and silly.
When I pointed out Texas and Tom DeLay (read the New Yorker article “McAllen Texas and the high cost of health care” for details of what I’m talking about) as a horrible example, you countered with:
Now you know that Texas has had a wild west “anything-goes” mentality and laissez faire culture for a century and a half. Houston has no zoning laws at all, which is insane, and Texas deliberately uses a “low taxes + no services” model that the rest of the planet regards as demented, it’s something out of MAD MAX BEYOND THUNDERDOME.
Berllusconi is a recent development. Italy had a huge progressive surge after WW II — in fact, as you no doubt know, the CIA’s first covert op was a disinformation campaign to make sure the Communists didn’t win the first free post-WW II election in Italy. So we’re talking about a country that since WW II has had a massive history of leftist politics. Comparing that in any way to Texas, the home of psychotically far-right wingnuts who wear hats with a picture of an electric chair and the logo REGULAR OR EXTRA CRISPY, and who wear T shirts that read I BELIEVE IN GUN CONTROL – I USE BOTH HANDS! is ridiculous. And you know it.
When I pointed out “We can’t reform a broken system by patching bits and pieces. Obama tried that,” you replied:
That’s just plain dishonest. You know as well as I do that Germany led the world in providing public pensions to its older workers, in effect social security, but back in the 1870s, 60 years before we got around to that in America. And they did it in one fell swoop. They enacted public care much earlier than we did, and they did comprehensively, without this insane private insurance/greedy doctor/millionaire health care CEO crap we’re struggling with.
So that’s just plain opposite to the documented facts. We’re struggling to do this HCR incrementally, one tiny bit at a time, and we’re damn late, 70 to 80 years later than Germany, and we’re fighting like wild animals to make even the tiniest bit of progress. Bismarck didn’t have to fight like that. He ordered, the Germany legislature complied. Kaisers operated just a liiiiiitle bit different than presidents, buckaroo. Know where the word “kaiser” comes from? It’s a transliteration of the ancient Latin word Caesar, which means “dictator.”
Then you went on to whack away with a baseball bat at the memorial plaque for the death of the horse on which a straw man was riding when you said:
I never said we needed to do that. What I said is that we need to close some of the loopholes. Obama’s HCR non-reform hasn’t closed any. Everything his bill does (which was ass-kissed into form by handing over to the giant health care cartels everything they asked before in private conferences before the bill was even drafted) gets thwarted and stymied by the current broken medical-industrial complex. 15 million uninsured people get moved to medicaid, but the states are too broke to cover ’em and there’s a 4-year gap twixt when the states get mandated to cover ’em and when federal funding fully kicks in. Disaster.
Public exchanges are brutally limited to the point where private insurance through the exchanges will cost more through for-profit insurance from regular insurers. Disastrous.
Recission is still allowed, just under another name. Insurers can still use claims of alleged fraud to cut people from the insurance rolls. There’s no teeth in the appeals process. If the private insurers don’t live up to the requirements of Obamacare, the people covered by private insurance have no standing to sue — they have to rely on the state insurance commissions, which are utterly toothless and in most cases the victims of massive regulatory capture. The fines levied by states against insurers who violate the requirements are a joke. And on and on.
We need at least one or two of those goddamn loopholes closed. Not all of ’em, sure, but some. We’re not seeing any with this HCR non-reform. And the evidence of skyrocketing rate hikes (50% rate hikes now for people) and the empty words of mealy-mouthed promises from health care CEOs (“we could technically drop the entire family in order to avoid covering a sick kid with a chronic illness, but we prooooooooomise not to do that” — yeah, until it impacts your bottom line, asshole) show us that it’s all just getting worse.
Health care in America is a slow-motion train wreck and engineer Obama has tried slamming on the brakes. Unfortunately, the train we’re heading for is about 1/4 mile away and we’re goin’ 90 mph, so you can figure for yourself what’s gonna happen.
You went on to say:
Julie
Kay @109, dental cleaning costs a lot more than $40-110 dollars if you don’t have insurance. I recently had my teeth cleaned and two surface fillings and of course the stupid x-rays. The charge for the cleaning alone was $207, but since I had insurance it was only $72. If I had needed no fillings, the actual non-insured price for getting my teeth cleaned would have been $319, as I was informed that they would not clean my teeth or examine them at all w/o performing x-rays. The total bill was $786 (w/o insurance), but since I had insurance I paid $205.
I hadn’t had a dental visit in several years, mostly because of all the extra unknown costs involved and because I didn’t have insurance, so I knew I would have to pay the non-insured penalty. If I had been able to get my teeth cleaned by a hygienist for $100, I would have done it much more frequently. I think that’s E.D.’s point, although I personally blame the problem on insurance more than licensing.