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Comment by jerlam | Hacker News Reader

> Sounds like a doctor?

Not disagreeing, but the US also has a doctor shortage for at least a decade that it is seemingly unable to fix.

There are multiple reasons for the doctor shortage but it's at least partly intentional. The primary bottleneck on producing new physicians is the number of residency program slots: every year some students graduate with an MD but are unable to practice medicine because they can't get matched to a residency slot (some do get matched the following year). Most residency programs are funded through Medicare and Congress has refused to significantly increase that budget for years. But here's the trick. By limiting the number of doctors they also hold down the cost of Medicare claims. If a Medicare beneficiary can't get an appointment because there are no doctors available then no claim will be generated and the federal government doesn't have to pay anything.

https://savegme.org/

This is fucked.

I love how that page is from the AMA, the organization that is largely responsible for pushing Congress to institute the residency caps in the first place because they feared too many physicians would drive down existing physician's incomes.

Crazy how they present as a guild but behave like a cartel.

Unlike a cartel, you're not required to be an AMA member in order to practice medicine. It's completely voluntary and many doctors never join.

Cartels are usually voluntary.

Hmm, guilds were often the institution that controlled a profession, while cartels are usually voluntarily joined. Is that really what you meant?

My simple understanding is that the width of the bottleneck is controlled by existing doctors who are (unfortunately) monetarily motivated to limit the supply of new doctors.

Nope, your understanding is mostly wrong. It's primarily controlled by Congress in the form of Medicare limits on residency funding. And to a lesser extent by the management of teaching hospitals. Most of those people aren't doctors.

At one point the AMA lobbied Congress for those funding limits but they reversed position on that years ago.

https://savegme.org/

Ah damn, looks like my understanding was incorrect. Thanks for the link, that's very illuminating!

The USA restricts the number of positions for medical schools and residencies. It's a problem that money could solve.

There is no restriction on medical school admissions. It's really just residencies.

My understanding is that this is a distinction that doesn't make a difference? Without a residency, can you become a doctor?

That's mostly correct, but there are a few students who enroll in medical school with no intention of becoming practicing physicians. They want to go into some other career like research or technology or hospital administration.

Yes, because you have to be (or be about to be and in time to start) a doctor in order to be apply for residency.

Resident doctors are doctors, exactly as junior SWEs are software engineers.

(UK doctors have for some reason long objected to 'junior' and recently become 'resident doctors' over exactly this. All the more confusing - throughout and still there's been 'Senior House Officers', because 'house' used to be what it was called, like US residency, doing house, there were junior and senior house officers, so why not just revert to that? Who knows, but now they're all resident doctors - and some of which are senior house officers - until they're registrars/consultants, and they're happier with that than junior doctors.)

There are no artificial restrictions on residency slots. The Federal government funds a fixed number of slots, but states and hospitals also fund residencies. The "shortage" has much to do with geography and specialty--the money and interest is working in specialties on the coasts, not as a GP in rural towns. People who are rejected are typically vying for slots in high-demand areas and specialties; they often could have been accepted if they had applied elsewhere.

One answer would be to raise GP salaries, but that's difficult, especially if you're self-funding residencies and already paying out the nose for specialists and other inflated expenses deemed necessary in modern healthcare systems. Kaiser California imports medical school graduates from abroad for their in-house residency programs, which is presumably cheaper than raising salaries to draw more US resident candidates.

Kaiser arguably points the way forward. As an HMO--a vertically integrated healthcare system--there's greater financial incentive to self-fund residencies. When insurers, hospitals, and doctors are all at arms length from each other, the financial incentives don't align very well, thus the "need" for outside funding (i.e. the government) of residencies.

Note that unfunded residencies are also a thing, where the resident is responsible for sourcing the funds for their salary and expenses.

The supply of doctors is limited by the AMA and state MA, to avoid excess doctors = price competition

And part of the problem there is that money and profit got introduced in the healthcare system.

In other countries people become doctors because they want to heal others. Not because they want to become wealthy. In the US doctors spend half of their time haggling with the insurance companies.

I mean going to school for 10 years only to be in debt for 100K-300K+ dollars, and not have a good idea of whether you will be able to pay that back... is a massive problem. Most countries don't have this issue, for example. They have an abundance of doctors and engineers, because people who actually want to do those things, are able to pursue those careers without financial investment. We are snubbing an entire generation of people and then acting surprised when the very obvious consequences of those actions start to come back to bite us. Its the definition of insanity.

> They have an abundance of doctors and engineers

They are usually paid several times less than people doing the same jobs in US.

I don't really see why that would be a problem.

It's fine if you're starting from nothing.

But we wouldn't be starting from nothing. There's a large group of people who would lose income and who will lobby against that.

But in other countries they dont need to pay so much for social system, insurance or healthcare, kindergarden and so on.. You can not always compare everything with money, when there is a lot around it.

Would you rather spend 10% of 50k on healthcare or 15% of 100k?

Also taxes are generally much higher in these countries as well.

Taxes are usually higher, but not incredibly so. Healthcare spending is generally less for better results. Switzerland spends the most, although nowhere near what America spends, and is where Romney/heritage foundation got the mandatory health insurance idea from.

Well yes, Switzerland is pretty much the only place in Europe where income/wages are overall on par with those in the US (of course not in all sectors). Other countries are generally very poor in comparison.

> Taxes are usually higher, but not incredibly so

So again.. would you rather make 60k and pay 45% in taxes or make 100k and pay 35%?

> nowhere near what America spends

Sure, if you are above median higher will likely more than compensate the higher healthcare costs (unless you’re very unlucky of course).

But their cost of life is also lower.

Is it? Housing in Paris, London, Munich, Toronto, Vancouver etc. is extremely expensive relative to income of course other stuff varies.

Apples to apples. If you take the extremes in Europe, you have to take the extremes in the US as well. London and Paris most be compared to New York or San Francisco, not with Cheyenne (Wyoming).

Yes, exactly. Why do you think I meant something else?

Because New York and San Francisco are more expensive than Paris and London.

It's hardly "most countries". The USA is about average for developed countries in terms of physicians per capita. We're higher than France, Belgium, UK, Japan, Canada, etc.

https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?most_rec...

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