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The AMA is a tax-exempt hedge fund and licensing corporation (epsilontheory.com)
277 points by erentz 64 days ago | hide | past | favorite | 115 comments



When we ask ourselves why healthcare is so expensive in the US, we never seem to point out that it's the health care that's so expensive. As many others have already said, the AMA puts an artificial cap on the number of medical school graduates each year at around 20,000.

Anecdotally, I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I'm cynical, but there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers.

I'm glad this article has the chutzpah to call the AMA what it really is-- a protectionist guild. These doctors make me sick.


I have a lot of doctors in my family, and while it's not surprising that they've fully swallowed the bizarre fetishization of doctors we have in this country[0], it's really shocking to me the degree to which almost _everyone_ I know has, including those with no ties to the medical field whatsoever.

To be extremely clear, I don't think there's anything wrong with appreciating doctors for the hard work they do, nor the special feelings that people have historically always had towards healers[1]. If someone said they respected a person more for choosing medicine as a career, I can't say I'd disagree. But for some reason, most people seem to model doctors as incorruptible angels, incapable of making decisions that are suboptimal for others or for society. This makes it uniquely difficult to have a conversation about the problems of the devilishly complex healthcare system, since it's impossible to talk about one of the most important groups of stakeholders and their role in healthcare economics.

I remember talking to my sister shortly after her med school graduation about a topic that involved influences , and she said with a straight face "doctors don't do things that aren't in the patient's best interest". My (Ivy-League educated, MD-holding) sister isn't the sharpest tool in the shed, but even for her, the idea that an entire industry full of people are immune to incentives is an especially pants-on-head stupid model of the world. She's since unlearned much of the creepy indoctrination that med school drilled into her (and that her much-smarter doctor husband was never fully taken by), but the same messages have trickled down to many of the friends and family I have that are unconnected with the medical field, without any of the ego-protective incentives that my doctor acquaintances have.

[0] And most countries; if anything, it's way worse in the other countries I'm familiar with, as the US tends to be (on average) more dynamic and less worshiping of formal credentials than the average country

[1] Though I do think it's irrational; I distinctly remember my mom trying to communicate this feeling to me when trying to get me to be a doctor, and my high-decoupling teenage self telling her that she should also be appreciating the engineers whose work powers the hospital and the economists whose work was critical to building the hospital and paying doctor's salaries.


Thanks for sharing this! I went to med school for two years in my home country, married to a doctor who is in her residency training in the US and couldn't agree more.

If you look at my HN comment history, you'll see that I've tried to mention that part of the problem of exorbitant healthcare expenses in the US is the artificial scarcity of doctors. It starts with this inflated/unnecessary requirement to have a bachelor's degree before going to med school. Other nations in the world (e.g., India) do fine with training their doctors for five years (even that, I think is too much; the first year of med school training in my country is pretty much an extended high school curriculum not essential to medicine).

An internal medicine (generalist) doctor in the US can earn $250K right after finishing the residency. Elsewhere in the world (e.g., in the UK), the doctors earn about $90-150K.

I also have to agree with you that contrary to the popular belief in the US, doctors can be fairly un-intellectual. The main requirement to do well in their career is to rely on rote memorization (go check out on YouTube how Anki is so important/popular among med school people).


> contrary to the popular belief in the US, doctors can be fairly un-intellectual. The main requirement to do well in their career is to rely on rote memorization (go check out on YouTube how Anki is so important/popular among med school people).

I agree with everything in your comment, but this is one of the most important ones. This is actually the basis upon which my cocky little 17-year-old self decided he wanted to study math instead of medicine, contrary to the pressure my family was exerting: the idea of turning my brain into a file drawer was somewhere between horrifying and nauseating. I point-blank asked my brother-in-law at one point (he was around ~30 at the time) how someone as intelligent as him was satisfied with going into a field as unchallenging as medicine, and he was on exactly the same page as me: over the course of his medical education (started the same year as my sister), he also got an MBA and has started on a PhD, because being a GP would be immensely dissatisfying to his intellect. If you have a sense of yourself as fairly intelligent, it is _absolutely crucial_ for your health as a patient interacting with the healthcare world that you internalize that doctors aren't necessarily that smart (though of course, some are!).

This isn't an insult! Most professions are filled with people that aren't that smart. But putting yourself blindly in the hands of an imagined omniscient without being an informed and opinionated advocate for yourself as a patient is foolhardy and dangerous, and you'll quickly discover the costs, if you're self-aware enough. If you have a doctor who buys into the God Complex and scoffs at the notion of a patient having an opinion, then you're double-fucked, and should definitely get a new doctor.

This can be a delicate balance, and the doctors I know are quite fairly annoyed at the patient who does his own research (often poorly) and argues with them on the basics. "Knowing what you don't know" is an important part of being informed. Just 1) find a doctor who understands his limits and 2) approach the conversation as a meeting of mutually-interested peers logically discussing a problem (your health): one who has substantial headstart on the intimate, sometimes-inarticulable details of the problem, and one who has a substantial headstart on general research that's relevant to the problem.


> over the course of his medical education...he also got an MBA and has started on a PhD, because being a GP would be immensely dissatisfying to his intellect

To put it charitably, it seems unlikely that while in medical school someone can also complete a full-time two-year business program and start a doctorate. But taking the comment at face value...

There are plenty of specialties much more challenging than family med (which is what 99.999% of GPs do for residency). It's one of the least competitive and least well-paid specialties. This is why most of the med students who don't match end up scrambling into family med, because those are the (toxic) programs that have unmatched slots. If you don't own the practice you'll be lucky to break $200k cash comp without a post-residency fellowship. Infectious disease, pathology, and radiology are much more challenging intellectually and any surgical residency, including ones that you don't typically think of surgical like OB/GYN are similarly challenging. Hell, if you're in it for the money gynocologic ongcology and neurosurgery both have median cash comps well over half a million a year.

> Just 1) find a doctor who understands his limits and 2) approach the conversation as a meeting of mutually-interested peers logically discussing a problem (your health): one who has substantial headstart on the intimate, sometimes-inarticulable details of the problem, and one who has a substantial headstart on general research that's relevant to the problem.

I'm not a "peer" with my doctor because whether it's rote memorization or not, they've got at least 7 years of training I don't, and much more if they're a specialist and not a GP. You do not have a "substantial headstart" on any research relevant to your problem unless you've had it for years and are seeing a new GP just to get a referral to a new specialist. In which case, honestly, your old specialist can probably just refer you somewhere else.

This doesn't mean doctors know their limits, I've heard some absolutely boneheaded nonsense out of GPs who got out of their lane - my favorite was a 70 year old, borderline morbidly obese physician telling me not to do back squats below parallel because "it will destroy your knees," and he subsequently groaned when he stood out of the chair. But that's in the same vein as going into a GP because you've had bad headaches for the last two weeks and approaching it as a "meeting of mutually-interested peers."


> it seems unlikely that while in medical school someone can also complete a full-time two-year business program and start a doctorate.

If you're very ignorant about a topic, it's probably a good idea to do thirty seconds of Googling to make sure a claim is actually implausible before you accuse someone of lying.

MD/MBA programs exist that add 1-2 years to one's med school[1]. On top of that, "over the course of his medical education" quite explicitly doesn't simply mean "in med school", unless for some bizarre reason you don't consider one's residency (and possibly fellowship) years to be part of one's education. Lastly, and I can't believe I have to explain this, _starting_ a doctorate doesn't actually take any time. In the limit, it takes one Planck time[2].

> I'm not a "peer" with my doctor because whether it's rote memorization or not, they've got at least 7 years of training I don't, and much more if they're a specialist and not a GP. You do not have a "substantial headstart" on any research relevant to your problem unless you've had it for years and are seeing a new GP just to get a referral to a new specialist. In which case, honestly, your old specialist can probably just refer you somewhere else.

You've entirely missed the point of my comment. You seem to think that doctors are equipped with future-tech Neuralinks to personally feel the day-to-day manifestation of every one of your symptoms and Black Mirror-style grains to review your entire life history and extract the parts which may be relevant to your medical issue. I hate to be the bearer of bad news, but they're not: for any non-trivial medical issue, doctors have the difficult task of compressing the entirety of your life into the data that are relevant to your current condition, and doing so in a very short time. If you think that they're capable of doing this without active participation from you, then I pray you never have any medical issues, because you are going to have a very bad time in the healthcare system.

> There are plenty of specialties much more challenging than family med

Yes, obviously. Part of "know what you don't know" is realizing that the complexity of some medical issues means that the "general technical knowledge" side of the scale is weighted heavier than the "intimate insight into the specific problem" side of the scale. I'm not suggesting that one starts arguing with an oncologist about which course of chemo they should be on. But then, I'm pretty sure that was obvious to everyone reading my comment who _didn't_ write a response constructing a series of towering strawmen.

[1] https://freeman.tulane.edu/academics/graduate-programs/doubl...

[2] I'm not a physicist, this is an attempt at a lame joke, don't @ me


"Physicians are just human mechanics" - a disgruntled PhD


Or, as the late-great Christopher Hitchens said - “Picture all experts as if they were mammals.”


> the idea that an entire industry full of people are immune to incentives is an especially pants-on-head stupid model of the world

This is true of nearly every industry, though. Our real estate agent (who was otherwise pretty good) insisted that he was a fiduciary to us and would seek the best financial deal for us, but his advice on our bid was "I don't think that'll be enough to get the job done", and then we were the high bid. I'm a Google engineer, and from my perception, my job is to give people free services that they want, despite HN's perception of my employer. Investors will say that they "get paid for allocating capital and making the economy more efficient", lawyers are here to "help people enforce the rights granted to them by law", salesmen "make people aware of products that they really want to buy anyway", etc.

Of possible interest:

https://slatestarcodex.com/2017/10/02/different-worlds/

People's perceptions really do differ, and people see through their values and emotions. When people hold a self-perception of what they do that is wildly at odds with what you think they do, it's often because folks who actively believe they are doing bad for the world are often so bitter that nobody wants to be around them.


Sorry for the double-reply, but I realize I didn't address the meat of your comment.

> When people hold a self-perception of what they do that is wildly at odds with what you think they do, it's often because folks who actively believe they are doing bad for the world are often so bitter that nobody wants to be around them.

I don't agree with this, at least as applied to my comment. There's a wide, wide gulf of reasonableness between "what I do is unhelpfuly and unworthy" and "everyone in my industry is an omnibenevolent, maximally-selfless angel". I'm quite proud of the work I do without thinking this, and as I mentioned in my previous comment, if my sister had a possibly-irrational but not totally-unreasonable greater pride in her work, I wouldn't blame her at all. But doctors who consider themselves a separate moral species from human beings aren't just egomaniacs, they're _dangerous_ (as I said, my sister luckily grew out of this a little bit).


I think that people vary greatly in terms of their "set point" for how much they believe people in general are benevolent. HN is filled with skeptics and critics; our set point is pretty low. Most of the rest of the world considers that to be an unreasonable downer: if you go into a typical party saying "The AMA is a tax-exempt hedge fund and licensing corporation", best case you'll get smiles and nods and worst case you won't be invited back.

I don't know your sister, and you can judge a lot better than I whether her beliefs in the benevolence of her profession are "reasonable". I'm saying that it's pretty common for people to hold a positive emotional view of their work in particular and the world in general, because, well, positive emotions feel more positive.


> This is true of nearly every industry, though.

Yes, I think this is implied by the portion of my comment that you quoted. The claim that _any_ industry is immune to incentives is what I describe as "pants-on-head stupid".

I've also read every Scott post shortly after its posting for probably the past 8 years, but I appreciate the share!


Ask marginalized people - generally a subset of, but not limited to, people subject to generational poverty, people with prominent genetic ancestry in the Global South, LGBT/queer folk (especially the T), and those with visible, chronic physical (weight, height, mobility, etc.) or mental (developmental disorders, mental illness, etc.) "deviances" - and you'll learn just how effective and esteemed doctors really are. (Of course, people generally don't ask us, so...)

While I imagine that some people have already had a certain particular rage switch thrown in their brain wrt the preceding list, stay with me here. We're not just talking about intersectional pile-ups; go ask your fat friend about his last check-up.


> go ask your fat friend about his last check-up

The doctor probably told him to lose weight. And?


The complaint is usually that doctors are overly reductive towards overweight people, treating their weight as a hard-blocker to listening to any other problems that can potentially be treated (or palliated) in parallel.

I can't speak to its veracity, as I'm not privy to the medical history of anyone I know who's overweight.


Overweight people have more medical problems, and the more overweight you are, the more problems you will have and the more severe they will be (in aggregate, we can find exceptions to every rule).

I've heard this complaint as well but it's usually from people not doing much to lose the weight in the first place. If you've gone from 400 lbs to 300 lbs in 6 months and suddenly you have knee pain you never had before, I think most GPs would take an acute interest in that and not just chalk it up to being 300 lbs. But if you've gone from 250 lbs to 300 lbs and suddenly develop knee pain, you're going to have a hard time convincing anyone that it's not the obvious problem.


Sure, the fact that there's a plausible motivation on the doctor's side is the reason I don't have much of an opinion on the veracity of the claim. That doesn't preclude the possibility a trend exists within the medical system of worse care for the overweight due to treating weight as a hard blocker. I chose my framing of the claim I've heard pretty carefully, and what you're saying only supports it: as being overweight is upstream of so many health problems, it seems entirely plausible that doctors (given that they're human beings) would be prone to falling in the trap of not wanting to think about anything that can be done while the weight problem is still being worked on (or not). Again, this doesn't require assuming that doctors are horrible people; this kind of reductiveness is the way most people respond to everything.

> it's usually from people not doing much to lose the weight in the first place

This is far too arrogant an assumption for a doctor to be making about a patient. I don't know any overweight people, but I do know people who have had (theoretically solvable) drug problems and other bad health habits, and the blockers to fixing them are not always "just believe in yourself and have some willpower", especially when (even sub-clinical) mental health issues are involved. Hell, I used to smoke way too much weed and not eat particularly well (though never badly enough to get overweight) and it turns out I had an undiagnosed sleep disorder. If smoking weed happened to be associated with a bunch of health problems and I had a doctor who was narrowly focused on it and refused to help me with other incidental issues before I solved it, I'd be pretty upset too.


I think your comment is oversimplifying a little, and I'm generally not a fan of the "woke" take on most things (to the point that I'm glad HN has come around in the last couple of years...), but I admit I'm surprised to see this downvoted so heavily.

It seems trivially true that a relationship in which _techne_ is overesteemed relative to _metis_ is one in which those farther from society's average would suffer more, if only because _techne_ would be less representative of them.


> I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures.

I... what? A DO is a doctor, full stop. Aside from there being different organizations, there is no difference between what an MD can do and a DO. In fact, a DO is trained in OMM while an MD is not. DOs have more training than MDs, not less. A lot (I think most, but I'm not 100% sure) of residency programs are combined and will accept either credentials. Many are still DO-only.

Med schools conferring a DO degree have identical admissions processes to those conferring MDs. It may be unintentional but the wording of the quoted phrase makes it seem like if you can't get into an MD program you will either go "down" and apply to a DO program, or not go into medicine.

> there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers

I'm not defending the ludicrous price of medical school (which is due in large part to the AMA's physician cap that you mentioned), but even mediocre GPs are much more than "professional symptom Googlers."


> it's the health care that's so expensive

Doctors earn well but not particularly different from FAANG-style software salaries.

I don't know how good these numbers are but here's some: https://blog.nomadhealth.com/complete-list-of-average-doctor...

For example emergency medicine doctor is listed at 366K average (~$162/hr). So when I've had to go to the emergency room and end up seeing the doctor for about 20 minutes, that's about $54 worth of doctor-time (as an order-of-magnitude approximation, ignoring fully-loaded employee costs since I don't have that number).

And yet the bill that arrives is on the order of ~$6000. Sure there's also nurse salary to pay for my visit and other legitimate overhead that's part of the actual "care".

So from that bill I got, over $5000 are inefficiencies and non-care-providing rentiers inflating the cost. Nearly all the bill goes to entities other than the actual medical care providers! So no, it's the the actual doctor+nurse salaries that makes the USA health care so exceptionally expensive.


> Doctors earn well but not particularly different from FAANG-style software salaries.

Yes, but ALL doctors earn that much ALL the time, whereas the FAANG salaries you read are the lucky/skilled top 5% of the industry and only during a once-in-a-generation share price boom where stock grants exceed salaries.

And yes, doctor/nurse salaries are a big part of US healthcare excess cost (as is over-prescription, obesity,insurance profits, insurance admin overhead)


No man, this is HN where everyone makes $300k/yr cash comp 6 months out of school. You didn't know?

I think your 5% number is right on point. There are almost 4 million software developers in the US. Company-specific numbers are hard to come by, but estimating, Facebook only has a few thousand developers - Goldman Sachs has approximately 9000 and several sources say FB has "less." Netflix has less than 9,000 employees total and I think it's unlikely a huge percentage of those are developers. Google has less than 30k (and that's assuming 100% of R&D and Ops groups are engineers). Microsoft has about 40k. Even adding a bit to each of these estimates, you're looking at maybe 110,000 developers at FAANG companies themselves. Let's double that to account for other companies (mostly finance) that will pay comparably - it's certainly less. That's about 5.5%.

And you touch on stock price which I think is super important. This isn't cash compensation. It's massive stock grants which are subject to losses. If some black swan event happens and one of the FAANGs goes out of business there are going to be a lot of bankrupt principal and staff engineers. Doctors don't have that problem because their $500k is W2 cash compensation.

The median software engineer salary is somewhere around $100-110k. Half the developers in the US don't even make six figures.


For the emergency room bills most of it is paying for other people who didn't pay. It's kind of socialized medicine.


That would suggest only something on the order of one in every 50 emergency room visits actually pay. I don't have the numbers to confirm or refute that, but that ratio seems highly unlikely.

Or take a general family medicine doctor visit. 242K average salary = ~$116/hr. On a typical appointment I'll see him 15 minutes or $29 of doctor-time. Yet the bill is $450.


It is more a billing negotiation tactic between your health insurance company and the medical facility that you are seeing.

The insurance company negotiates the bill to a rate of $x for in network $y for out of network. So no they are not expecting you to pay that $6000.

I got a bill from my therapist for $430 for a 30min appointment, insurance paid $186 with zero copay, it just had to go through the magical cost-reducing power of an insurance company.

This system is wierd.


According to the AAMC, it seems like residency slots have also been an issue: https://www.aamc.org/news-insights/medical-school-enrollment...


Do all doctors need residency or is it another barrier to having enough cheap doctors?


Medical license rules differ by state, but doctors need at least 1 year of postgraduate training to apply for a license (though without completing a residency, which is 3 years at a minimum, career options are severely limited).


I’m not sure most people would be comfortable with doctors that have zero on-the-job training. There are some places that don’t require it or only require it for a short period but I think most people are in the camp that residency programs are a good thing and not an artificial barrier.


There's a joke in the NHS that when the new batch of doctors join in September - the risk on mistakes increases.

I had a major operation just before 2017's intake it was interesting having a new doctor trying to cannulate me - I suspect the nurses where round the corner trying do to laugh.


It's a way of forcing ungraduated docs to pay to work. No joke - you have to pay to attend residency and work. And this isn't covered by student debt/government assistance programs.

I know of several doctors who are in _significant_ debt despite working for the public sector for years. Their loans are forgiven, but the residency sits and accumulates interest that they can't quickly pay off because that same public sector work doesn't pay as well.

It's not-quite slave labour.


What are you talking about? Residents earn a salary (just google "XYZ university resident salary" to find it...). Medical school (which is prior to residency) is where the debt gets heaped on.


I suppose it depends on where you study. If you're at a school (a school based hospital), you pay to go. You might get a stipend, but I know people from NYU who have had to pay to attend residency.

I don't know the most about this field and you're right, a bunch of hospitals do pay. That's cool.


The biggest issue isn't domestic medical school slots, it's a lack of residency training slots (for which federal funding was capped in 1996). If more residency slots were available with adequate funding, these positions could easily be filled with foreign medical graduates that have passed the US's medical boards (USMLE steps 1 & 2, with 3 taken during or after intern year).


There were more US residency spots (23,339) than US allopathic medical school graduates (17,789) in 2016. https://pubmed.ncbi.nlm.nih.gov/28919221/


Don’t neglect osteopathic graduates as well (though I’d imagine that is only several thousand more)


This reminds me of a debate I had in high school, where the topic was (and I quote verbatim) "A country that does not provide universal healthcare to its residents is evil".

I was assigned the side that argued that it's not evil. The problem our opponents had was that they could not could not argue for a definition of evil that was strict enough to capture universal healthcare but not so strict that a doctor who makes a mistake and kills someone is also evil.


Is it the AMA that puts that cap on? I was always under the impression that was really a consequence of the 1997 Balanced Budget Act (?).



Well said. If anyone would care to read further on the history from a similar point of view:

https://mises.org/library/100-years-medical-robbery


The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine, has extremely strong pricing power over the entire healthcare system via the RUC (https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...), advocates on behalf of doctors whether or not you agree, and much more, all under a guise of "non-profit advocacy for public health." They are a racket -- we would do well to have a rogue upstart competing licensing body.


Most of what is stated is simply not true. I am a physician, not a member of the AMA. They have absolutely no role in the selection of medical students, training of physicians, or their licensing. I have no particular love for the AMA. But lets keep the criticisms accurate.


The AMA lobbied in the 90s to limit federally funded residency slots. This served to restrict supply of doctors because medical schools base acceptance on available residency slots. The AMA has pushed for more funding of residency slots in more recent times, but their lobbying behavior in the 90s clearly shows they have an interest in controlling the supply of doctors.


The AMA was founded to get control of the "snake oil salesman" problem in the 1800s, and their stated method was lobbying to get licensing laws passed in every state. Controlling who gets to be a doctor was unambiguously the central function of the organization. Along the way, they were no doubt approached with a lot of other suggestions about how they could help and once they outlived their original purpose, have carried on as a zombie improving their ability to profit from all the little suggestions they got along the way.


To (mis-)quote Eric Hoffer, “Every great cause starts off as a movement, turns into a business, and ends up as a racket.”


Is that misquoting? I think that's almost verbatim the quote.


I believe the AMA is responsible for accreditation of medical schools. Without accreditation, they can't make doctors, thus the AMA controls the supply of doctors.


^ Yeah that's directionally accurate. The AMA is one of the two funders of LCME, the accrediting agency of medical schools for MDs (outside of the med school trade association itself). While they do not run medical schools, they have enormous power over training standards, who should be a physician, how medicine should be practiced, and who shouldn't practice. As an example, they lobby pretty regularly against the expansion of the role of RNs/NPs (https://www.ama-assn.org/press-center/ama-statements/ama-sta...). Much of this derives originally from the Flexner Report which created the current system of US medical education, which is still based on old sensibilities that physicians should be professional gentlemen and "proper" (and perhaps fueled by cocaine -- no seriously, google "halstead cocaine").

I am not a physician, but I have been in the guts of healthcare for quite a while, and the AMA continues to pop up as the man behind the curtain surprisingly often.


They're all connected in some capacity, but AMA does not accredit medical schools.

* LCME accredits M.D. Schools

* D.O. Schools have their own accreditation (not sure what it is)

* AAMC runs the racket of "MATCH" to appoint graduating medical students to programs (and strip most of their rights as employees).

* ACGME accredits Residency Programs.


The ABA pretty much does the same for their profession and I would not double many of such organizations is the same. Why dock just one, we need to get them all.


The ABA does not do anywhere near as good a job of protecting their market. There are far more law school slots each year, and that's reflected in salaries for lawyers, a huge portion of which are well under $100k/year.


> The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine

The majority of doctors are not AMA members. The oft-cited claim that they choose who can be a doctor or how many people get to be doctors is also a myth.

There are a lot of criticisms of the AMA, but these two are not really factual in basis.


You're correct that they do not choose who can be a doctor.

You're incorrect in that they are the primary force and loudest voice restricting the number of residency slots in the US. You cannot practice medicine without matching into a residency program, whether you have an MD/DO or not.


> You're incorrect in that they are the primary force and loudest voice restricting the number of residency slots in the US.

They are not, and haven't been for at least something like 20 years, which is when they publicly came out in favor of increasing the number of residency slots.


They are a racket -- we would do well to have a rogue upstart competing licensing body.

And programmers think that they are too intelligent and have too much variation in productivity to form any sort of professional organisation, or “union”, you could call it.

Doctors don’t worry about ageism or offshoring or being stabbed in the back by their peers or managers.


Unions work, there's no question in my mind about that. Just look at macroeconomic stats from the 40s to 70s. All that inflation took pretty much all the wealth from capital owners and handed it over to workers.

However, most software people are clearly in the capital owners category (despite still having salaries), so maybe it is justified to keep the status quo.


You can be both a wage earner and a capital owner. 401K or just a standard discount brokerage account are easy paths to that. I don't know why this is always presented as two sides with no overlap.


The point is you can say goodbye to the S&P500 performance if unions become as popular as in the post-FDR era. You'll experience low to negative real performance for decades.

Find old Warren Buffett shareholder letters or opinion pieces from those times if you want a capitalist's point of view, the guy has been around forever and has seen this particular story play out. Also, he's still for greater wealth redistribution, but that's just his personal political opinion.


A developer union/guild system probably would build off of professional engineer certifications which exist for other fields of engineering (predominantly civil because of interactions with regulators). So if you don't have a 4-year degree from an appropriate institution and mentorship (or don't pass the appropriate exams), you're going to have some lower-status tech status. But, yes, would absolutely check the boxes for someone like myself--who admittedly isn't in a position to care any longer.


I’d actually argue that they don’t work, and that comes from someone who is pro-labor but has worked in union shops. Unions are intended to give a voice to the voiceless but in my experience they end up promoting a toxic culture that is counterproductive to everything. Management is unhappy not because of wages but because production drops and every incentive is now to do the bare minimum. Employees are unhappy because they’re not rewarded for hard work and instead rewarded for tenure. I’ve seen so many shit employees fired for blatantly disregarding safety practices but were then brought back by the union with back pay. Support staff is unhappy because they are caught in the middle of a culture war when all they want to do is be productive. And the culture goes to shit because both sides are constantly at war with each other. The only people “happy” with the union were the old timers at the top and they hated the company and hated working there but they were trapped there because no other job will have the same perks. I worked closely with the people on the shop floor and they hated both sides, and one stands out in my mind because he preferred the underpaid and overworked Foxconn factory to his current gig in the unionized factory.

If you want to argue about economic trends from the 40s to 70s I can go down that road too. Those unions aren’t around because they clearly weren’t competitive. A great example is the truckers unions that controlled pricing thanks to heavy lobbying and regulation. Those truckers were very well paid and made a very comfortable living but the high costs meant transportation of goods was incredibly expensive. Deregulation in the 70s opened that industry to competition, rates plummeted and now truck driving is more competitive than ever which has enabled other businesses that depend on transportation to be more productive than ever.


Oh, I didn't mean to imply they work in the sense that they result in better allocation of resources. That I do not know. It's probably a balance problem, for example modern Germany has strong unions and does not experience much shit show because of that. I just meant they're effective at redirecting the capital from capital owners to workers.

Also, yes, the 70s took it over the edge and then we've had 80s, 90s, 00s, 10s all very capital friendly. What will the 20s show? Again, no idea.

This is important to remember when "planning your stock market returns" - do include the 40s-70s period in your analysis! Things are sometimes very very different.


That might be true in the FAANG/bay area world, but there was a time when nearly all of my social circle was "software people" and none of them were in any way in the capital owners category.


Offshoring maybe, but I think pretty much anyone in a corporatized career worries about those others. I know for certain that doctors have no shortage of office politics.


I know for certain that doctors have no shortage of office politics.

No 40- or 50-something doctor worries he or she is going to be sidelined by a 20-something with a cool new style of surgery that’s getting loads of retweets and stars on Medhub. He or she is senior and respected because experience is valued. A lot of people are going to feel the cold wind of ageism and wish they hadn’t been so eager to stab their older coworkers in the back for the sake of which JavaScript framework was hot this week.


> He or she is senior and respected because experience is valued.

Medicine is not the field we should be modeling our value of experience on. If you've been there 1 year longer, your opinion is more valued. Not because you're more knowledgeable, but because you happened to have graduated residency one year sooner. Medicine is about as far away from meritocracy as you can get while still somewhat feigning support for it.

Should we be trusting the experienced folks that say mainframes are fine and editing the DOM directly with jQuery is good enough? I mean zipping up binaries and dropping them on a share is just as good as GitHub, right?

Ageism is an excuse for being uncompromising and unwilling to accept that someone younger than you might have a good idea or know something you don't.


Should we be trusting the experienced folks that say mainframes are fine and editing the DOM directly with jQuery is good enough? I mean zipping up binaries and dropping them on a share is just as good as GitHub, right?

Do you think that older doctors insist on using obsolete surgical techniques or less effective medications? Or older lawyers reference laws that have already been repealed?

Ageism is an excuse for being uncompromising and unwilling to accept that someone younger than you might have a good idea or know something you don't.

They might do, sure. But you’ll hit ageism eventually and see younger people reinventing a wheel that you too reinvented.


Obsolete? Probably not. Indicated in outdated literature but contraindicated in current literature? Absolutely. I am old enough to have experienced it, and haven't. I'm also not against doing things differently than I did in the past. I've worked with 30 year olds who were completely unwilling to compromise, and folks in their 60s who were. I don't know anyone who would rather work with the former over the later because of age.


If you are an Illinois-based AMA member, consider calling your Attorney General’s Charitable Trust Bureau to make a complaint citing this article [1].

AMA is registered in Illinois; your voice will be louder. As a paying member, you have standing to show harm.

[1] https://ag.state.il.us/charities/rules_statutes.html


Author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA, rather than the supposed members of the organization. It seems to have strong political opinions that arise out of ether.


> author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA

That would make the post look like infighting.

By focussing on dereliction of fiduciary duty, possibly to an unlawful extent, the argument is rendered sharper.


YES


Don't forget that CPT is also a massive money maker and completely proprietary. Want to do open research to improve patient care and health and use CPT codes? Probably not going to happen [1].

1. https://www.ama-assn.org/practice-management/cpt/ama-cpt-lic...


Yeah, this was a big stumbling block for a project we wanted to work on. So completely bizarre that you essentially need to pay a toll to them to do public projects with medical billing data that uses standard codes. One of the more egregious examples of rent seeking I’ve seen recently.


Another one is cusips in a similar fashion. Cusips are unique identifiers that identify a security. They are also proprietary with fairly expensive pricing for startups.


... I wrote Hacking Healthcare, created ClearHealth & HealthCloud, many other credentials...

I have negotiated with the AMA in several arenas. If they had anymore lawyers in a single place it would create a black hole.

Everything in healthcare anything (procedure, test, sponge, scalpel, etc) that gets billed or reported to the federal government, that is roughly ~2.7 Trillion worth of transactions a year, roughly 160 billion line items, requires a CPT code (current procedure terminology). The federal government legally requires this. CPT is owned and licensed by the AMA, they spend incredible lobbying dollars to maintain that the CPT codes are used and required by the federal government. It is legally impossible to create an alternative. It is complete regulatory capture. That CPT revenue was 160 million a year as of 2018. A pure tax on healthcare, sadly one among many. Also a reason truly fully open source systems are impossible in healthcare.


You need to pay somebody to use a lookup table? I just realized I forgot to pay my language license to Webster’s. If they haven’t licensed the human anatomical nomenclature and all known DNA sequences yet, they are missing out.


Similarly the American Heart Association is a licensing and fundraising organization which rakes in around $750 million in revenues and gave out $150 in grants. The rest of the program spend of $595 million which was $445 million (!!) goes on salaries and fund raising. The AHA has around 4,000 employees. They have an endowment of $1.2B. [1]

Amongst the most dubious of AHA recommendations are dietary sodium around 1.5-2.5g/day [2] which flouts established research which shows all-cause mortality doubling from 4-6 g/day to 1.5-2.5g/day to those who do not have salt specific hypertension. But they dgaf as their primary focus is not the heart and cardiovascular health of Americans but licensing the "Good Heart" license to cereal companies so they can use it to sell more obesity causing products like Honey Nut Cheerios.

[1] https://paddockpost.com/2016/02/09/where-does-1-to-the-ameri...

[2] https://www.heart.org/en/health-topics/high-blood-pressure/c...

[3] https://www.nejm.org/doi/full/10.1056/nejmoa1311889


    "The American Medical Association is perhaps the strongest trade union in the United States."

        --- Milton Friedman
From https://www.fff.org/explore-freedom/article/freedom-daily-cl...


> The AMA has a Chief Strategy Officer who was paid $1,130,000 in 2018.

> The AMA has a Chief Operating Officer who was paid $1,350,000 in 2018.

> The AMA has a Chief Financial Officer who was paid … huh? … only $730,000 in 2018. Wow, that’s weird. I mean, she’s the only woman in the C-suite, but I’m sure that has nothing to do with it. I think we all know that being a CFO is nowhere near as rigorous or demanding a job as being a ((checks notes)) Chief Strategy Officer...

> That’s Jim Madara... telling us that the core challenge for the medical profession in general and the AMA in particular will be finding ways to address health inequity – the disparate healthcare outcomes for Americans stemming from food and housing insecurity, limited access to transportation, and above all, income inequality.

A great demonstration of what "diversity," "the triple bottom line," "social responsibility" and "addressing income inequality" really looks like at the corporate level.


The doctor-centric medical system is rapidly becoming technologically obsolete. It’s now cheaper to get an MRI with radiology report than a primary care office visit. Lab tests for most common ailments are less than gas to get to the hospital (GSA schedule pricing). Doctors don’t have any more information than the diagnostics tell them. Office visits are a functionally useless exercise. Innovations in private elective procedures have dramatically reduced costs and increased safety compared to procedures controlled by hospitals and paid by insurance. The government pays for drug development and then the FDA grants monopolies charging several orders of magnitude markups and giving kickbacks for prescriptions. Although there is little technological need for most doctors, the administrative demand is greater than any other industry, but don’t expect many H1Bs granted for physicians. Limiting access to the profession through high standards is actually great for innovation, if innovation is allowed, but protecting obsolete functions is probably bad for everybody.

I’d like to do some angel funding of new concepts in private consumer healthcare that go around the system. Medical hacker stuff. For instance, you can buy an imaging ultrasound system from China for roughly the cost of a single ultrasound appointment. I think micro-MRI is achievable under $10k, mostly a problem of data analysis. X-rays of course could be very cheap if people could be trusted not to abuse them. DIY blood and urine testing could be nearly free. I don’t want to sound like Elizabeth Holmes here; I’m mostly talking about known existing simple procedures with huge unnecessary overheads, replaced by DIY, community, or AI business models that are aligned with users.


> I’d like to do some angel funding of new concepts in private consumer healthcare that go around the system. Medical hacker stuff. For instance, you can buy an imaging ultrasound system from China for roughly the cost of a single ultrasound appointment. I think micro-MRI is achievable under $10k, mostly a problem of data analysis. X-rays of course could be very cheap if people could be trusted not to abuse them. DIY blood and urine testing could be nearly free.

The challenge here isn't technological. As you point out, there are a lot of things you could do, but I'm not confident that the relevant lobbying groups won't just pay off the government to ban whatever it is you want to do.

Corruption is more or less open the minute it gets too complex for the average person to understand, and healthcare regulation falls squarely into this bucket. Name some protectionist, anti-patient, cost-increasing move the "Patient Protection Act" and half the idiot voters out there will support it. Specifically, the half of the country reflexively inclined to support any positive-sounding regulation instead of those reflexively inclined to oppose it (most voters' brains consist almost entirely of these "reflexes")


The worst problem with the AMA is that it's worked to completely distort our expectations about what is possible in a healthcare system. A lot of the comments here are focused on artificial restrictions in supply of physicians and so forth, which are important issues, but the more insidious problem is the way in which licensing and practice laws distort alternative structurings of healthcare delivery.

As you point out, healthcare should be more consumer-driven, with providers acting more as consultants, akin to how tax accountants and lawyers work. The problem isn't necessarily that we need more physicians, it's that we need consumers to get more of their healthcare directly, and/or through alternate providers like pharmacists, psychologists, dentists, optometrists, or some other classes of providers we haven't even dreamed up yet because the healthcare system is so centralized and rigid.

The discussion of healthcare in the US has focused so much on who pays, with such little attention to how the care is structured, when it seems to me that's a much bigger problem. To me the payment issue is almost an entirely different issue.

I have lots of family in healthcare, including physicians in administration, and they're terrified of single-payer not because they don't want universal care, but because they already see the healthcare system overburdened by regulation and red tape, and don't really see how having single payer (as opposed to something like the ACA) will really help a lot. In their minds the only thing worse than what existed 10 years ago, is what existed 10 years ago plus a monolithic government agency controlling payment as well.

I see an important role for physicians, but there needs to be a lot more flexibility and deregulation in healthcare. There's so much that could be written about this it's absurd.


Russ Roberts did a good interview on EconTalk with Christy Ford Chapin, who wrote a book about the history of health insurance in the US and pointed several fingers at the AMA for preventing any progress or innovation in the healthcare industry.

https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...


Note original title “AMA? BITFD!” is vague so chose another line from the article that better describes it.


Thank you!


The AMA was the first group to lobby against publicly-funded healthcare (1930s-40s).

See here [1] for some examples of cartoons they commissioned, playing to base emotions to sink the healthcare components of Truman's Fair Deal.

There's not a lot of content on wikipedia about the details of the opposition, but here's the summary of the context of the pre-WWII years [2].

Then after WWII, Truman proposed revisiting this problem. There's a really good account of what followed here [3].

Essentially, the AMA engaged in a mass-marketing scheme to paint universal healthcare as part of a communist agenda and therefore un-American.

This advertising, coupled with the ironically-government-induced rise of employer-subsidized insurance, decimated what had been broad public support for universal healthcare.

So, yeah. There's a pretty proximate alternate history where we've had universal healthcare since 1947. It'd be interesting to see what that world looks like today.

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935669/

[2]: https://en.wikipedia.org/wiki/History_of_health_care_reform_...

[3]: https://www.pbs.org/newshour/health/november-19-1945-harry-t...


One thing they could fund with all that money is an independent, regularly televised frank discussion between patients, doctors, and administrators about their issues with the healthcare system, and each other, from a moral and ethical perspective. It seems to me that if you want to represent some sort of "halo of authority" then you better earn it by hosting some frank and real dialectic!


You'd think Hospitals would want to strip the AMA of its power in order to lower worker wages. Health care wages are unusually high in America, though that's true of other fields as well. Compared to technology, however, the regulatory environment is mostly the same: yet SWE's in America are paid a premium (even without a group formalizing 'who' can be a SWE).


Industry-wide unions like the AMA, UAW, and Longshoremen help to maintain a tacit price-fixing (as everyone is subject to the same price floor on their major expense), which can be very convenient for large, established players.


As someone forming a private foundation, this is very inspirational, thank you!

Albeit under 501(c)3 and not 501(c)6 like this organization.


The two categories are pretty different. A 501(c)6 exists for the benefit of its members. That doesn't mean it's bad or can't have a positive mission but it's a trade association at the end of the day. A 501(c)3, as you know, at least ostensibly has some sort of charitable/educational/etc. mission.


I'm aware, and I take issue with the "this is bad because I have an uncomfortable relationship with money" approach that the article took.

The point of the author's digital sleuthing was not for inspiration, it was to find fault to reinforce a conclusion they had already made. I doubt there was any transparent and accurate reporting that would have satisfied their idea of acceptable.

The primary difference with the 501(c)3 is that 5% of the assets has to be granted per year. It would for the most part have the exact same flexibility as this organization.


The AMA killed the single payer option in the ACA under Obama, and they'll do their damndest to keep it dead under Biden:

https://www.nytimes.com/2009/06/11/us/politics/11health.html

https://www.modernhealthcare.com/physicians/ama-maintains-it...


Single payer makes US healthcare a monopsony, a market with only one buyer. All sellers/providers inherently hate that as the single buyer can check each companies margin, and dictate a lower price in the future.


The problem with monopsony in theory is that it reduces the actual wage below the market-clearing wage, which results in a lower quantity of labor supplied. A better arrangement in such cases is usually a bilateral monopoly (think of how sports leagues negotiate with players' unions), which results in wages and labor supplied much closer to market clearing amounts (again, in theory).

In many ways, the US already has a soft form of monopsony, given the total dominance of CMMS in determining everything from reimbursements to billing codes to proper medical procedures. We shouldn't be surprised by the already significant shortages within US medical professions given this situation. CMMS regulation has also resulted in large hospital groups absorbing private practices such that most physicians now work for some large hospital group, and most of the rest work for larger companies focused on one or a few specialities.


Access, not quality, is the principle determinant of health outcomes.

Since 1960, life expectancy advances have been greatest among minority, poor, and under-served populations. Not wealthy whites.


Assuming that this extremely simplified model ("access is all you need!"), how can you improve access if there are fewer doctors? I didn't say much about quality, but quantity. Hence, access.

Access to professional medical care is a minor factor anyway. Increases in life expectancy are not not primarily due to medical care, but to other improvements like better nutrition, better drinking water, better sleep, safer neighborhoods, even things like better financial security. And as it turns out, the effect of access to health care on life expectancy or better health outcomes for the poor is much weaker for the groups you mentioned. In a real sense, access to care itself matters mostly to the middle & wealthy classes (of whatever "race"). Also, I'd quibble that wealthy whites aren't also improving. Poor whites seem to be suffering, but by all indications, wealthy whites are also doing well.


Anecdotally my ophthalmologist has told me that they would actually prefer single payer, as it would make their finances more predictable for investing in new equipment. My personal bias is wanting to fix healthcare by fixing its price signals, so this surprised me.


> My personal bias is wanting to fix healthcare by fixing its price signals, so this surprised me.

The problem is that we're very far from market signals, and "quality of the healthcare system" is not a monotonic function of market-orientation. If we were to go all the way to a fully market-oriented system, a lot of the obscene inefficiencies and horrors of the healthcare system would be addressed. There may even be people by whose chosen measure, our healthcare system functions better than it does today. But we'd have new horrors around access that we as a society have chosen not to accept, which means we're in this grotesque inefficient middle-ground where we have neither the advantages of a centralized system nor the advantages of a system where market signals aren't choked off at every turn. It's completely plausible that we're at the part of the curve where more centralization moves us up the U-shaped curve instead of down


I tried to word that as nonargumentatively as I could, as single payer does seem like the best concrete plan for moving forward despite it not being my preferred style.

I just think there's a lot of low hanging fruit that would reform the system bottom up, such as stopping providers from making up fictitious bills and prosecuting the ones that attempt to defraud customers with them.

Requiring providers to set uniform prices across all payers and publish their price list would go a long way. And even moving towards a "single payer" system, this dynamic is still going to exist for many kinds of care.

If by "new horrors around access" you just mean the poor not being able to pay for care, I see that as orthogonal and have no problem with subsidies. Of course I acknowledge the realpolitik would be different.


I think you might be misreading my comment as advocacy of one solution vs another; it absolutely wasn't, and in fact my views are roughly the same as yours (I think that a more market-oriented system would cause far less suffering than the current system, but that single-payer is a lot more feasible and that either solution would be preferable to the grotesque status quo).

Where we disagree is that I don't think minor market-friendly improvements to the system would get us, given the mountain of regulation and other govt involvement that already exists.

My thesis is basically: I'd prefer a more fully market-oriented solution, with the access problem explicitly handled through subsidies et al. But if we're going to have a healthcare economy that's planned in much more detail, let's actually plan it instead of the current nightmarish hodgepodge of inconsistent and mutually counter-productive one-off gov't interventions.



There are four pigs at the trough of US healthcare:

1) drug/device companies 2) insurance companies 3) trial lawyers 4) doctors

When asked what's wrong, they point at one of the other three.

The AMA is guild that makes sure doctors stay rich, valued, and semi-scarce.


What about for profit hospitals?

It’s the marketization of health care that incentivizes suffering and death, not any particular group.


For-profit hospitals are not that important (~20% of the hospital system). Edit: But if lawyers can make it to that list hospitals can as well (including not-for-profit hospitals paying huge salaries, just because they are not “for profit” it doesn’t mean they are not profit-driven).


Non-profit hospitals are responsible for the bulk of health care costs, they just extract the profits in salaries.


Calling salaries extraction of profits is a weird way of spinning people being paid for their work. Even the most egregious executive and administrator salaries are small potatoes on a hospital’s balance sheet.


Ok so 5 pigs at the trough.


To me this seems to highlight the worry about "fake news" and "credible sources". To me it seems less like the quality of journalism and reporting has gone down hill and more like because we have so many new independent sources of news and information we are starting to realize that the originally "trusted" organizations were not as objective and honest as we originally thought.

Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information.


> Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information.

Why not both...?

> isn't that we have illegitimate news flooding the market of information

This is absolutely a problem. Old media seems to be pretty content with narrative framing for the most part, this new brand of illegitimate media just makes shit up. They have no intent to engage in the public discourse, their only purpose is to reinforce alternate realities and to shift the Overton window.


Old media also sometimes just makes things up, but usually they uncritically pass on things that anonymous administration officials and intelligence agencies just make up. The real way to distinguish mainstream news outlets from less mainstream news outlets is that mainstream outlets have cultivated relationships with administration and intelligence officials, relationships that are maintained by those outlets' willingness to publish whatever those officials want to publicize.

It's almost the only criterion. "Mainstream" outlets will have a lot of inside information that will later turn out to be true, but will also constantly publish completely false stories on the behalf of government officials "leaking" as part of their jobs, and conceal their origin.


> the originally "trusted" organizations were not as objective and honest as we originally thought

Has AMA been plumped up by mainstream journalists? I can’t recall them being quoted as an authority.


Conveniently ignoring -- for decades -- major questions about national healthcare (e.g., who creates the artificial scarcity in medical specialists) is essentially fostering the status quo.

I'm happy with the AMA being the authority on medical news, but that does not mean their business practices should be beyond scrutiny.


The AMA decides who gets to call themselves a doctor. Can’t imagine a more pivotal arbiter of trust.


AFAIK, it's technically state licensing boards. Of course, licensing, the AMA, and other medical organizations are pretty intertwined in various ways.




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