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Comment by simianwords | Hacker News Reader

My controversial belief is that the barrier to become a doctor is way too high. I think barriers need to be reduced.. I mean think about it - I learned software pretty much by being put into it and forced to learn.

I understand medicine is slightly different but my hunch is that any sufficiently smart person can do well enough as a doctor after 1-2 years of theory.

This might anger a lot of people because there’s a trend where we elevate medicine and doctors to a godly level.

Thankfully with the internet and AI, knowledge is not gatekept as much now.

I wish we allow more people to become doctors and intelligent people to become doctors. The type of people who choose to become doctors are not problem solvers, at least from my experience.

Of course my argument doesn’t work exactly for surgeons but I think we should not artificially reduce their numbers.

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In New York, the moderate Democrats, like their governor and health commissioner, have for years been proposing to join the Interstate Medical Licensure Compact for doctors and the Nurse Licensure Compact for nurses from other states.

The far left Democrats have consistently blocked such proposals, usually without so much as a hearing.

Forget other countries, they won’t even let health professionals from the United States practice. I believe this is true of several large state Democratic parties.

It's not that controversial - it's why you're quite likely to see a nurse practitioner for more routine issues.

Strange because this was not mentioned in the article. Doctor wages contribute way more than silly insurance companies whose margins are lower single digits.

There should be a good career ladder for nurses to become actual doctors if they perform well on the job. No need to gatekeep now that we have AI and internet.

It doesn't matter what the insurance company margins are.

It matters how much they add to the cost.

Typically, "margins" means the profit they make over and above expenses. For insurance companies, the salaries of all the people they employ, and the rent/mortgage/upkeep on their buildings & grounds, would all be classified as expenses that would not generally be included in their margins.

But in a single-payer system, none of that cost would even exist. We have to pay for all of that through our premiums, and we get nothing out of it.

1. In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses. It's called the Medical Loss Ratio if you care to Google it. That stipulation is part of the ACA / "Obamacare". If they spend less than 85%, they are legally required to issue refunds. The 15% that insurance companies get to keep has to cover both administrative costs and their profit.

2. Single-payer systems still have administrative costs. The administrative cost of running England's NHS is not zero. But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.

3. Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.

> But, even if you created a perfect AI robot that had zero cost to operate (in magic fairytale land) to run your single-payer system, you still couldn't reduce premiums by more than 15%.

This is only true if you assume that health insurance companies have no influence on the cost of care. That is, however, patently false.

> In the United States, insurance companies are legally mandated to pay out at least 85% of premiums as medical expenses.

Which means, of course, that their main option to increase profit is to increase overall spending on healthcare. Reducing cost is directly against their interests.

UnitedHealthcare buys up physician practices, and pays theirs higher rates. That's part of the 85% bucket, but they're profiting off it. https://www.statnews.com/2024/11/25/unitedhealth-higher-paym...

> Single-payer systems still have administrative costs.

https://www.healthaffairs.org/do/10.1377/forefront.20110920....

"According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue. Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower."

> Realistically, switching to single-payer and doing nothing else would reduce costs by a single-digit percent.

I mean, that's a start.

If you chart the US against the rest of the OECD, we're doing something bafflingly expensive versus everyone else. It is certain to be multi-factorial, but our insurance setup absolutely plays a role. https://commons.wikimedia.org/wiki/File:OECD_health_expendit...

> Doctor wages contribute way more than silly insurance companies whose margins are lower single digits.

The numbers don't back this up. https://www.cms.gov/files/document/nations-health-dollar-whe...

> There should be a good career ladder for nurses to become actual doctors if they perform well on the job.

Again, that's most frequently called becoming a nurse practitioner.

Those graphs don't really refute the point.

Look at the buckets: Things like Dental Services, Home Health Care, Nursing Care Facilities... This tells you about healthcare spending at the macro level, but doesn't explain why a particular doctor visit cost so much (I don't use any "nursing care facilities" or "dental services" when I visit the doctor for a sprained ankle, for example).

When you go to the doctor for a sprained ankle, where does that money go? By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan). Where does the other 85% go? Certainly some it is the cost of running a clinic (staff, rent, equipment, etc), but what about the rest?

Then look at doctor's income. Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more. Where do you think that money comes from?

> By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan).

That's quite a bit to a middleman.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6179628/

"According to Reinhardt, “doctors’ net take-home pay (that is income minus expenses) amounts to only about 10% of overall health care spending."

It's also a big incentive for the insurer to increase prices. If they want more revenues, and more profits, they have to get overall spending to go up.

> Your basic family care provider living in Podunkville earns as much as a mid-career SWE in the Bay Area, and specialists earn way, way more.

Good. They should.

> By law, no more than 15% is going to the insurance company (which isn't just profit, that covers all the administrative costs of running the plan).

I'm aware of two huge exceptions that are large enough to make this basically not-true.

1) This doesn't apply when they're administering a self-funded plan, like most plans provided by large companies. This represents a giant chunk of US health insurance.

2) This doesn't apply to new plans (I believe in the first two years of operation). I admit I've not looked into it, but I'd be shocked if this isn't being gamed such that a fairly high proportion of plans that aren't excluded by #1, are always "new" and so not subject to those limits.

> Again, that's most frequently called becoming a nurse practitioner.

Personally, I would always rather see a physician due to how much more training/experience they have. A physician who's out of residency will have gotten at least 3 years of on the job training (after medical school). A nurse practitioner may have just gotten their BSN and then gone straight into an NP program without ever working a single day as a nurse.

But yes, you're right, this person is absolutely describing NPs.

> Personally, I would always rather see a physician due to how much more training/experience they have.

There's a very good chance, if you're seeing a NP, that the NP has a lot more experience with that sort of condition than the docs. After all, the practice is sending those sorts of issues to the NP. My dad's a radiologist, but they haven't assessed a minor break in decades, because they're very subspecialized.

If it's unusual or complex, the NP is probably the first to say "we'll need to make an appt with Dr. So and So".

Wrong. This is just the money government spends which goes to insurance which is used to pay doctors. Don’t use these figures.

Go on, give us the right figures, then.

The first chart includes "private healthcare insurance" as an input, so I'm pretty sure you're wrong.

The $4.9 trillion detailed in this chart is "the official [estimate] of total health care spending in the United States". https://www.cms.gov/data-research/statistics-trends-and-repo...

Another thing the US could do would be to offer a fast and easy path for foreign medical doctors to immigrate and start practicing medicine with minimal barriers.

Unfortunately, right now, it is difficult for doctors to do so much as move to and start practicing in a different state. But if you want medical costs to actually come down and to ensure availability, you need to multiply the number of doctors available to treat people.

Well, I happen agree with this allegedly controversial opinion, but the fact that we invent legal fictions like "nurse practitioners" and "physicians assistants" I think sort of proves the point that it is controversial in the wider public consciousness.

We create these roles and gradually give them more and more autonomy precisely because we can't agree to produce (or import) more MDs. MDs actually see the writing on the wall, too. Their lobbying organizations are strenuously opposed to expanding NP and PA roles.

> I learned software pretty much by being put into it and forced to learn.

And how many people are at risk of dying if you screw up at your job? My guess is exactly 0.

How many risk dying because of costs? You won’t reduce quality that much if you have a smart person looking at your medical problems. But decreasing the costs may outweigh the benefits.

I can’t prove this but my intuition says that you don’t need this high of a barrier.

> You won’t reduce quality that much if you have a smart person looking at your medical problems.

I think you're vastly underestimating the complexity of the human body and the amount of education necessary to do a good job as a physician.

And I think you're vastly underestimating the silliness of the requirements to get into medical school.

Medical schools care whether you got an A or B in your undergrad physics-for-life-sciences lab (I know this because I had to deal with annoying grade-grubbing pre-meds as a TA for that class). I would feel 100% comfortable with being treated by a physician who "only" earned a B in my undergraduate physics.

Medical schools also care about how many hours of volunteer community service you do. So, I guess all the applicants who had to work a job through undergrad can just go fuck themselves.

You might start by asking why medical schools care about such silly things. It's such a strange metric! The answer is that medical school collude to limit the number of doctors (so that we don't have "too many"!). Since the quota is so low, they have an enormous ratio of qualified applicants to seats. , So, they need objective criteria to pick some people over others. A or B in undergrad physics (or number of hours of community service) is an objective, quantitative way to cull the herd of overqualified applicants.

Personally, I always thought a better solution would be to have med school applicants roll a die. While I would be 100% comfortable being treated by someone who earn a "B" in my physics class, I'm not sure I want an unlucky surgeon operating on me.

So nursing?

Increase nurses, allow them to get promoted to doctors. Reduce barrier for both nurses and doctors.

I don’t think having to study for 10-15 years to become an MD reflects in the marginal benefits. A couple of years is probably all you need.

So one problem with a nurse -> MD career track is that they are just fundamentally different roles. It's not (just) number of years of schooling, but what they study. Nurses don't do diagnoses or prescriptions, and don't receive much if any formal training in those areas. So I'm doubtful you can make up that difference with just on the job training (though doctors who were once nurses might be better doctors).

That said, I think that a RN -> NP career track with some kind of "executive NP" program (analogous to "executive MBA"), followed by supervision under an MD and eventually graduating to full autonomy, is an interesting idea.

> Increase nurses, allow them to get promoted to doctors.

I think this sentence shows that you don't really understand the difference between the two jobs. Nurses and physicians have wildly different training/education. There are things about the body that any first year medical student could tell you, that nurses never learn even after decades of experience (because they don't need to).

You didn’t read my post. I literally wrote training doesn’t matter. An intelligent nurse without a formal medical background but with enough experience can outperform a doctor. Maybe you can give the nurse a year or two of formal medicine theory as a certification that allows them to become a doctor.

What would you define as "a formal medical background?" Schooling? The schooling that nurses and physicians receive is very different.

> Increase nurses, allow them to get promoted to doctors.

We already do this.

https://en.wikipedia.org/wiki/Nurse_practitioner

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