The Moratorium on US Medical School Enrollment from 1980 to 2005 (2008)
amjmed.com
amjmed.com
I don't accept the mea culpa for stuff like this. The author even acknowledges that there were obvious signs that they were wrong, and yet they persisted for over 20 years.
Who can imagine what incentive structure possibly led them to make this mistake? I guess it'll be one of life's persisting mysteries.
They make vague statements about quality of work, safety, keeping "bad guys" out, etc. and YouPeople(TM) eat it up without the slightest thought about the tradeoffs because you like the face value of what you here.
Feel free to cite otherwise.
Why cite anything to you when you cite nothing? You are absolutely wrong in all of your assertions.
Ok, I'll provide you citations and solid evidence:
> It is mystifying how one could think the legal definition of a labor union is a monopoly on labor in the United States.
The Sherman Antitrust Act was passsed in 1890 (15 USC 1-38), stating "every contract, combination of trust or otherwise, or consipracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal." [1]. It was then, for a decade, used to declare unions as illegal monopolies by the courts [2]. Here is a review paper from the era listing many, many cases [3].
For example, in United States v. Workingmen's Amalgated Council of New Orleans (1893) [4], the courts ruled that the Sherman Antitrust Act did apply to unions. Here is a good summary quote: "The act declaring illegal “every contract or combination in the form of trust, or otherwise in restraint of trade or commerce among the several states or with foreign nations,” (26 St. at Large, p. 209,) applies to combinations of laborers as well as of capitalists."
So, in order to allow unions, which are monopolies under the law, the Clayton Antitrust Law was passed in 1914, which explicitly allows unions to exist despite being monopolies [4]. Read section 6 of the Act, as 15 USC 17. Section 15 is the federal laws on antitrust and monopolies. Section 17, titled "Antitrust laws not applicable to labor organizations" was required because labor organizations are monopolies on labor.
By the way, I've looked quite a bit at these angles, and I have never found a single country with unions and with antitrust that has not needed this specific exemption - feel free to cite otherwise if you can find it.
Since then there is also a century of legal cases resolving the edges of what parts of union monopoly are allowed and which are not.
Even recently court cases refine the monopoly power of unions, such as this 2019 Supreme Court ruling [10].
Now, you might ask since the law is explicitly clear that unions are legal monopolies, with exemptions, why are they monopolies. Because, under the economic definitions, they are monopolies.
Some examples: From The Concise Encyclopedia of Economics [5]: "Economists who study unions–including some who are avowedly prounion–analyze them as cartels that raise wages above competitive levels by restricting the supply of labor to various firms and industries."
From the textbook, Principles of Microeconomics [6]: "This labor market situation resembles what a monopoly firm does in selling a product, but in this case a union is a monopoly selling labor to firms." Many textbooks have the same explanation because it is correct - a union is a monopoly on labor.
Economists even use the term "monopoly wage" to refer to the wage premiums union workers get [7]: "Is a term used by economists to refer to the higher average wages enjoyed by unionized workers compared to their non-union equivalents. It expresses the idea that unions act as coercive monopolies within the labour market that control the supply of labour and therefore raise wages above the level that they would otherwise reach."
So far I have given clear evidence and citations that unions are legally monopolies, have specific exemptions from US antitrust law because of that, and are analyzed as monopolies by economists.
You claimed "In the United States a union’s legal definition is not a monopoly on labor. This is not the economic definition or practical definition either." These are all wrong, as I just showed.
As you wrote: "You should read up on..." Indeed.
Now as to the questions about do unions on average obtain higher wages? That is also true, and I can cite if you really need it. Then the question is where does that extra wage come from, and again you can track the evidence it comes from cost to the company and higher prices and lower employment (). Then you can think so what if the company pays, but then you learn that the majority of public company value is held by the public in pension funds, in public pensions, in large shareholder groups. Then you can learn that over half of Americans hold stock in some form, and as people near retirement, this ratio increases significantly. Then you can ask when a company loses a dollar to a union wage, how much value is lost in the stock capitalization, and you will find a one to one match. All of this can be read through appropriate academic literature.
So yes, these captured wages significantly fall onto society, whether or not you believe it, in forms of prices, in forms of excluding workers that don't get picked by the union, and in costs more subtly hidden in retirement funds and other financial places. The money is not free.
As to the () about unions lowering employment, this follows both basic economic theory (the more something costs, the less of it gets purchased) and from ample empirical academic literature. [8] : "Union strength, which reflects both union coverage and the union wage differential, is found to decrease employment and increase unemployment by a small but significant amount." [9] "More union involvement in wage setting significantly decreases the employment rate of young and older individuals relative to the prime-aged group." There's plenty more.
Feel free to cite your evidence about laws and economics.
[1] https://www.law.cornell.edu/wex/sherman_antitrust_act
[2] https://www.shrm.org/resourcesandtools/legal-and-compliance/....
[3] https://www.jstor.org/stable/pdf/1829777.pdf
[4] https://cite.case.law/f/54/994/
[4] https://www.law.cornell.edu/wex/clayton_antitrust_act
[5] https://www.econlib.org/library/Topics/College/laborcosts.ht...
[6] https://pressbooks.oer.hawaii.edu/principlesofmicroeconomics...
[7] https://www.oxfordreference.com/display/10.1093/oi/authority...
[8] https://www.journals.uchicago.edu/doi/abs/10.1086/298204?jou...
[9] https://www.nber.org/digest/dec02/whose-employment-affected-...
[10] https://unlockhighered.com/case-challenges-the-monopoly-powe...
Here we have the AMA / profession of doctor restricting the supply for absolutely no good reason. Complicit in this? How many of the medical schools are state universities and receive federal funding for education AND via payment for services? Outrageous.
I've personally worked for an insurance company, a device maker, and had a roommate that was a specialist doctor, so I have some familiarity of each of those three pigs.
Insurance companies present low profitability to the stock market, but have GIGANTIC executive classes and executive compensation. The MBA class controls the profits there.
Medical device/drug makers have both a gigantic MBA vampire caste, and device monopolies via patents and other tricks that produce their huge profitability and cost. Many of those companies were started by pure engineer/bioscience people in the beginning but long have been taken over by the MBA finance people and basically perform rent seeking and cartel economics.
Medical providers in the US are so strongly incentivized towards specialization. Would you rather make 100,000$ as a vanilla doc, or 500-700,000 a year as a specialist? Yeah.
The fourth, trial lawyers, seem to be the most hated, but I suspect it is the smallest of the four, but it is the one I have the least direct experience with.
Of course, who's fault is the high cost of medical care? Point at the other three pigs at the trough.
The only good news, and this is true of almost all policy in the US, is that there is opposition between the insurance providers to control costs, and the providers/drug companies to increase revenue.
But insurance companies are on the forefront of denial of service to its customers (DEATH PANELS!!!!), as well as monopolization of local hospitals/facilities to increase their margins as well.
The impact that these people have had on primary and specialty care disciplines in the United States is huge, with both good and bad implications for cost control and quality of care.
One could argue that the explosion of nurse practitioners has had a greater recent impact in these fields than the near tripling of osteopathic medicine graduates over the 25 years covered in the article.
On the other hand, generalist midlevels have no explicit residency and even long-time midlevels who never really got any proper oversight can be nightmares. On internal medicine hospital call we used to groan when the urgent care paged us because we were always cleaning up their messes. I can't see how that saved any money or yielded equivalent outcomes.
Seems like in the US we just brought in NPs to fill the gaps instead.
Edit: why disagree? It seems to me the parent doesn't understand this topic as their argument does not make sense.
He was most certainly physically inside one at points ;-)
Edit: I guess a form of a joke, but more of a funny fact
Ultimately, it's the government that makes it difficult to practice medicine without the correct credentials, for more or less good reason, which means that the government better make damn sure they don't screw it up.
It's probably not particularly possible to force one of the private entities to do anything. It should be plenty possible to empower an additional private entity (or substitute a public one).
Seriously, try arguing against time consuming and expensive professional license requirements, let alone for relaxation of current requirements around here and see where it gets you. Your comments will be unwelcome if applied to any trade other than software. People very much buy into the various trade organization's marketing.
It's probably reasonable that the government is involved in funding the training of doctors (it's a huge payor), but it's certainly not the only potential mechanism.
It seems to be the primary mechanism currently. They've failed to significantly increase this funding and have earmarked a percentage of slots for foreign students.
The VA is also a big funder of residencies.
* https://en.wikipedia.org/wiki/Comparison_of_MD_and_DO_in_the...
My takeaway is that they are essentially the same today, but there was a much larger difference decades ago, centering around the patient as a focus of medicine vs the treatment of illnesses. Corrections and clarifications welcome.
Solve the problem with abundance.
I suspect the same problem exists among elite-tier university enrollment sizes.
Who cares if MDs are restricted if you can still graduate DOs? The bigger issue would be funding for residency and the new competition (if you can call it that when a % are earmarked for foreign students) of foreign students for the already tight budget.
I realize it's not exactly what the article is discussing, but it's certainly relevant for all the same reasons.
This is during the Q&A of his lecture "The Economics of Medical Care", given to the very people who would most object to his ideas:
/s
That's never evidence and a well-labeled gateway to our own fallacy. There's a reason serious examination of an issue requires factual evidence in any field, from medicine to law to science, etc.
IME, in areas I lack expertise, the truth is usually intuitive but an unexpected intuition. The only solution, the only source of truth, is evidence.
Do I need to say this on HN? Sadly, it seems like it.
But now I see the name of your throwaway account. It's sad that you can't talk to other people respectfully.
The very sad and dangerous issue is, they don't seem to care or grasp the fallibility of their subjective judgment. Some even turn to ridicule as an argument, which of course is irrelevant and obstructs the search for truth.
Without truth, we are doomed. We only spin our wheels, sometimes excitedly, sometimes frantically, sometimes confidently - but it's all a waste of time and labor. We go nowhere; we gain nothing; we are in the same place tomorrow as today (or we may go backward). We don't even know what problems there are or how to solve them.
(The claim that existing members benefit also needs evidence: Existing members express feeling very overworked, which doesn't corroborate the claim, and most analyses I see say the the money is going to the insurance companies and the hospital owners and managment.)
At least the prediction of surplus of VCs in all other countries except US seems to be working well.
/s
I know how insulting this is, but asking this question implies either the one asking shouldn't participate in discussions of any kind, or is involved in the corruption
That way the funding is scaled to the size of the industry without reevaluating it year to year.
I suppose it would end up in healthcare organizations working to have care classified as non-hospital to avoid the tax.
Meanwhile, there's no cap on law admissions, leading to malignant narcissists who couldn't make it in the humanities doubling down on chasing losses and feeling entitled to grift the vulerable at the barrel of a gun because they made they are too ornery to get good tips if they work customer service and can't figure out a terminal prompt to save their life.
Somehow productivity among medical professionals - also taking into account increased demand - didn't increase fast enough to get to similar decreases of doctors per capita.
There's also stuff like figuring out that bacterial infections are a big contributing factor in ulcers. Once doctors believed it was true, interventions got a lot more effective.
Well, when a large number of patients are effectively outbidding each other over an insufficient pool of medical professionals, then yes, it really can cost that much, not necessarily by making doctors absurdly rich (probably some of that too), but in the sense that price gouging structures will surely emerge to capture that surplus.
Most of the money is going to private insurance companies and their non-med staff, as well as hospital administrators.
"Absurdly rich" is too vague to be meaningful. But on average, in the United States, doctors are better-paid than those in the tech industry. And it is not a close call. See https://news.ycombinator.com/item?id=30047116 for links to tables from the Bureau of Labor Statistics.
At Hacker News, we may overestimate tech salaries (thinking too much of FAANG salaries, for example). And like most Americans, we may underestimate doctors' wages.
4 years of undergrad, 4 years of med school, 2-3 years of residency, maybe a chief resident year, 2-4 years of fellowship.
So after 10-15 years of training, doctors get their first big paycheck. Meanwhile, smart high school graduates can start making tech salaries in their early 20s.
Median lifetime earnings would perhaps be a more useful metric.
The SV numbers tossed around roughly compare to the percentage of doctors making over 1 million per year which is very real, but again small percentage of the total.
The money goes all over the place, everybody gets their cut, prices are almost never lowered because competition doesn’t properly exist, and things get more expensive.
Most of it doesn’t need to exist but almost nobody’s interests are aligned properly to want to lower prices and raise efficiency.
no quibble with the theme of your post overall, but to clarify: US physician wages have been decreasing in real terms since the 1980s.
So, prices go up, but the dollars go elsewhere.
https://en.wikipedia.org/wiki/Comparison_of_MD_and_DO_in_the...
https://www.bmj.com/company/newsroom/promising-evidence-that...
That’s how I knew they were mentioned.
I have never know anyone who has been treated by an osteopath rather than a medical doctor (or whatever you call the conventional training). They are not equivalent in any of the medical systems I have been involved with.
https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_Un...
https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_Un...
Historically these were very different approaches to medicine. In some countries osteopathy shrank and essentially went away, in the US instead it morphed until it's not different.
I don't know about the US medical system, but I'm a bit surprised about comments saying an osteopath is roughly the same thing an MD.
Edit: there's a dedicated page on wikipedia https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_Un...
> US DO graduates have historically applied for medical licensure in 87 countries outside of the United States, 85 of which provided them with the full scope of medical and surgical practice. The field is distinct from osteopathic practices offered in nations outside of the U.S., whose practitioners are generally not considered part of core medical staff nor of medicine itself.
If there was a significant difference in the degree program, they'd need different residency programs prior to practice, and that's not the case, AFAIK.
In real life, there is some correlation, plus other uncorrelated items and just plain luck ;)