Any time a professional class decides that there needs to be an urgent restriction of supply for their skillset, it should be treated with a kind of skepticism touching on scorn.
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.
Well of course they don't call it a protection racket or sandbagging supply when they're pitching it.
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.
Same arguments that any trade guild makes, but most guilds were working- and middle-class affairs. The powers that be only seem to accept these arguments when they're made by the upper-crust of society. Like favours like and all that I suppose.
It’s a mystery indeed. Interestingly Swedish physicians made a very similar mistake in the same time period. The consequences for those who made it was of course very positive.
Every workers union is a labor monopoly designed to transfer money from those outside the union to those in the union. Thats why the laws allowing unions specifically exempt them from antitrust laws.
A union provides a monopoly on labor. This is both the standard economic definition, the legal definition, and the practical definition. Without being a monopoly, the employers could simply hire outside or exclude the union workers. The law, explicitly stating the union is a monopoly, but exempt from antitrust laws, makes the employer accept the monopoly. And, like every monopoly, there are pros and cons. Every workers union tries to gain benefits for its members. Those gains don't happen in a vacuum. Empirically, as you can find on Google Scholar in decades of research literature, those costs fall back on society.
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. You should read up on case law, labor history, and labor economics. It is mystifying how one could think the legal definition of a labor union is a monopoly on labor in the United States. I’m in a union in the U.S. and not all of my colleagues are in it.
Why cite anything to you when you cite nothing? You are absolutely wrong in all of your assertions.
>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.
There are four pigs at the trough of US healthcare. Insurance companies, drug/medical device makers, lawyers, and doctors/AMA.
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.
Regulators are the fifth pig. The amount of resources that flow and careers that exist to make sure all the paperwork involved in this bloated mess is filled out properly probably counts for at least as much as the lawyers.
Hospital administration is increasingly the sixth. For profit hospitals drive up costs even holding everything else constant, and even for-profit management schemas and motives are trickling into nonprofit hospitals and clinics. Mergers are decreasing real choice in many areas as well.
One thing that appears to be unmentioned in this journal article is the explosion of nurse practitioners, physician assistants, and other medical professionals with "different" educational and training standards.
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.
The cost aspect is overblown. NPs and the other alphabet soup of primary care providers charge almost the same as an MD. And the quality of care isn’t the same. You end up getting the general “pop a Tylenol” or “I’ll give you a referral to a specialist” for the money you pay, which either makes the problems worse and/or expensive anyway.
Speaking as an MD, I think a distinction should be drawn between specialist and generalist midlevels. Specialists, and I include midwives here, do an actual residency and are usually excellent on the practical aspects. As a resident I learned a lot of my orthopedics from PA orthos, who were sharp cookies and in their field were highly useful adjuncts to the ortho surgeons for the bread and butter like uncomplicated fractures and surgical assists.
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.
I generally agree. There are some scenarios where NPs or PAs are useful. Some may even be good. My personal experience has found them lacking... multiple times. And the charge has been the same since the practice is the one billing and charges the same whether you see a doctor or other provider.
That has been my experience too. The only time I book appointments with NPs is when I know I need a specialist and want to skip the whole dance of “let’s do some tests and then determine that you need a specialist who will order the same tests”. It’s a cheat code to get better healthcare by working with the system.
That's something interesting I've found over my much time sitting in hospitals. It seems like NPs are just Drs lite edition. But I question if we need all the training we currently have for doctors I remember reading a SSC article about how they don't require undergrad degrees in many countries and their drs. perform at the same levels.
Seems like in the US we just brought in NPs to fill the gaps instead.
Unbelievable that in this country we effectively let the medical union entirely gatekeep the qualifications to practice. It's a legally sanctioned cartel, and should be taken to task on RICO grounds.
Took me three years to get in. Great MCATs (if I do say so myself) but screwed around my freshman year in undergrad and paid dearly for it on my GPA. In the end it was a professor I was doing research work for who knew the dean of admissions at the school that I eventually matriculated at, and put in a good word for me.
I feel that. As someone who’s going back to med school well out of undergrad, I have no doubt that even with good MCAT scores, I’m still going to need to be lucky to find the right med school who will appreciate my atypical profile. I feel like I’m competing with teenage prodigies for coveted spots.
That's exactly whom you're competing with. The MCAT got me interviews in which the first question was, "what's up with your GPA?" Invariably I'd end up on the waiting list. This was in the late 1990s.
Is that a joke? If it is I don't get it. If it isn't I don't understand what the relevance is, since Ted Bundy was never to my knowledge in medical school.
This failure is 100% on the government. Regulators should expect the guild to act in their own interests.
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).
The failure is on the people who don't harass their politicians and make noise when the politicians cave to the guilds' lobby.
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.
Manufacturers don't rely on the government to train engineers.
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.
No, but we're discussing the governement failure - current tense. I was merely pointing out that government funding of residence slots should be considered the primary failure, not regulation.
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.
That's basically correct to a first approximation. Osteopathic schools do have some additional training in spinal manipulation as the article says but the curricula are now substantially identical otherwise and in the vast majority of states both have the same scope of practice. Relatively few DOs do spinal work anymore (none of the ones I know do, in fact), and even those that still offer it limit it to pain syndromes; compare with quack chiropracty. Some of us were MDs and some were DOs in residency and we were instructed and treated identically by our attendings.
We should import massive numbers of doctors from overseas with a streamlined short-term training program to get them up to speed with how things are done in the US. If existing graduates get mad about the recent surge of workers in their field pulling wages down, some student loan forgiveness can be done for recent graduates most affected and most indebted.
The UK has tried that with mixed results. Doctors who have trouble understanding their patients, sometimes falsified credentials bought from corrupt administration at home country universities, etc.
maybe so. 30 years ago I don't think Northeastern would have been considered elite tier. But based on its current acceptance rates, it's getting pretty close.
Did I miss it or did this article not talk about the real issue - residency funding.
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.
For any interested, here[1] is the late Milton Friedman's take on how we might protect against quacks, frauds, and snake-oil salesmen posing as doctors if government didn't step in to limit the supply of medical doctors in the name of quality control.
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:
I think the problem is not that they didn't recognize this fact, but that they intentionally ignored it in order to maintain an artificial scarcity of physicians, thereby ensuring higher wages.
That there are thousands of graduated doctors that can't get residencies because they went to school in the Caribbean, needs to be resolved. Get them in residencies and we will be on an accelerated resolution path.
We already do this sort of thing via Medicare. It's simply underfunded. It seems it would be more effective to expanded and properly manage the existing tax than start a new one. In theory, this would scale well based on population.
How would it reduce staffing shortages? Hospitals wouldn't care if they pass it on to patients. It would be cheaper to continue to understaff since they'd pay the tax either way.
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.
This is how every guild in history has operated. Every profession when it controls the supply of its own members seeks to limit it. The AMA can only furnish the weakest of excuses for this practice. They say it has to do with federal funding for residency programs. But there's no reason for residency programs to need federal funding at all. They generate more value for hospitals than they cost to run.
This is a case where the act itself is evidence of the intent.
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
It's an hypothesis that's worth exploring because of the apparent effect you point out, which is I think is fact. Based on this discussion, I suspect nobody here knows any evidence.
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.)
Why doctors would be displeased? They could offload some ungodly load to their peers, while enjoying less desperate patients. BTW patients significantly outnumber doctors, and they would probably be pleased, no?
Interesting that while US population increased over the last century, at least the percentage of agricultural workers actually sharply decreased.
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.
A more efficient plow can increase agricultural yields and a machine that can automatically core apples will remove the need for people to core the apples -- is there an equivalent for medical diagnostics?
Better tests and more access to diagnostic tools helps medical productivity to some degree, although unnecessary testing pushes the other way. And sometimes better diagnostics leads to more interventions which may mean more labor (and sometimes better outcomes too)
When it works, imaging (x-ray, CT, MRI, etc.) is ridiculously effective.
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.
> "In retrospect, we should have recognized that as the US population increases the number of US medical graduates should increase" is an all-timer.
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.
I always wondered: ok, the US medical system is atrociously expensive and inaccessible, but where does all that money go? Surely a surgery cannot really cost half a million dollars, can it?
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 doctors aren't getting "absurdly rich" in medicine, at least not anymore, and certainly not by tech industry standards. (Source: I am a medspouse who works in tech outside of SV.)
Most of the money is going to private insurance companies and their non-med staff, as well as hospital administrators.
> Most doctors aren't getting "absurdly rich" in medicine, at least not anymore, and certainly not by tech industry standards. (Source: I am a medspouse.)
"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.
You can’t overlook the fact that doctors also work about 1.5–2x standard work hours. About 60 hrs/week is on par for most doctors. Many surgeons will be putting in 80 hrs/week or else take a pay cut. Adjusting for that in addition to cost of medical school and time spent in school and residency (7–11 years after college), I don’t think the salary is really that substantially different.
These numbers are arguably biased high from a median point of view for comparison with tech salaries due to the long training required before anyone can start making money as a doctor. Especially for the high end ones that require fellowships.
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.
You are not considering the cost of graduate school and the opportunity cost of medical school + residency + fellowship (7-12 years), as well as malpractice insurance costs, long working hours, and on-call burden.
The majority of people in Tech are making under 100k and most cap out under 150k.
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 by-and-large isn't going to the surgeon; it's going to the insurance company's layers of bureaucracy, and to the hospitals' fattened administrative staffs.
When the price of an end product (in this case medical care) goes up, all of the suppliers prices go up as well. When you charge a lot for something you tend to justify it by expanding your headcount, and to give them something to do you make things more complicated.
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.
> 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.
no quibble with the theme of your post overall, but to clarify: US physician wages have been decreasing in real terms since the 1980s.
Everybody accuses somebody else of gouging us. That's a sure sign that they're all gouging us. I wonder if benefit of a government system is just that it's possible to figure out where the money is going.
In the US it's more or less normal for Osteopaths to be general doctors yes. The modern degree for an Osteopath in the US, DO, would cover roughly the same ground as MD (a conventional doctor) except from a different angle.
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.
In France, Osteopathy is entirely different from conventional medicine and isn't taught in medical schools as it is considered to be unscientific. Also, osteopaths can't prescribe drugs. That being said, it's extremely popular among people who don't trust conventional doctors, or suffer from troubles that conventional medicine is unable to solve.
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.
> 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.
Yeah DOs in the US are quite similar to an MD, and MDs aren’t ashamed to call them colleagues. However, I know from experience in France that I wouldn’t expect the same care or treatment as a DO in the US. A chiropractor here might be more of an apt comparison to osteopaths in France, though it’s bound to fail in some places.
The training, and resulting skills and privileges are nearly identical between DOs and MDs. I don’t know about interchangeable - every DO and MD I know would be offended if you put the wrong two letters after their name, but DO and MD schools are not significantly different paths to producing physicians.
I keep hearing this claimed, but I have never met a physician in my life who would honestly say that, given acceptance to both an MD and DO program, he would pick the DO. It is widely viewed as an alternative path to becoming a physician if you cannot get accepted by an MD program and do not want to go overseas.
I know a DO, and she was indeed not accepted by an MD program. But the end result is equivalent; doctors from her school are DOs, not MDs, but residency is the same, and you've got to have the same base of skills and knowledge to get into and through a residency, so there you go.
The important skills and knowledged are learned during the MD or DO program, not as much before. The DO programs are essentially lower prestige MD programs with a different name.
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.
That was my first go to, followed by a search for evidence it ever works. The TLDR was that it’s showing promise that it might work for musculoskeletal pain.
Right, but what most DOs actually do is just practice regular medicine, not osteopathy. (At least, the ones I interact with at major medical centers.) Like, unless you looked at the degree, you wouldn't notice.
Well, if you read the article, osteopathic schools did not participate in the moratorium. SO, it seems like a pretty crucial distinction in the context of this article.
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.
I see, interesting. In the US, osteopath medical schools are pretty nearly similar allopathic in terms of base curriculum; and ultimately the residency training (where one obtains their specialty) is the same.
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.