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One aspect of this issue I haven't seen emphasized enough is that abundance not only makes people better off, it makes them more liberal-minded, tolerant, and generous-- and scarcity does the opposite of all those things. Benjamin Friedman's "The Moral Consequences of Economic Growth" is the key historical text here. Really seems like if you want to create the cultural foundations for people to expand their circles of concern, overcome prejudices, be more open to helping those in need, etc, you should be more focused on creating the abundance that we know is a powerful tool for laying those foundations.

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I often think about Hitler invading Eastern Europe to give German farmers Lebensraum and ensure Germans never went hungry again. Then after the war new agricultural technologies increased crop production to make this a moot point. Abundance could have halted his rise to begin with.

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founding

I had no idea about the US position of physicians per population or the residency scarcity. I've never heard this point brought up in healthcare debates. Or in discussions about fighting healthcare inequity. Thanks for highlighting this.

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It’s med school that is the barrier here not really residency spots. There are residency spots which are highly competitive but they are in fields like dermatology or plastic suregery. It’s actually not that tough to get a spot in internal medicine, family practice or general surgery. In fact, residencies often need to fill their rosters with foreign medical grads (FMGs). A residency program that needs to fill its program with these FMGs is traditionally looked down upon, considered less prestigious 🙄. But there are limited med school spots and that is a real problem. Recognizing this, Kaiser here in the LA area just started its own med school and it’s FREE (!). Also I’m not sure the $$ spent in residency is a big portion of the MC budget. Yes, docs are paid but the wages are not high and it amounts to essentially low-cost labor given the hours. Not complaining- the training is necessary but I’m not sure MYs analysis on this subject is correct.

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Though roughly half of the unmatched US-citizen medical graduates are IMGs, that still raises the question as to why residency programs aren't financially compensated well enough to get them through to the training process. If the process worked well, teaching hospitals would be incentivized not to be choosey, willing to train anyone up to snuff.

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I only knew because there are a lot of doctors on my immigrant side of the family, but yes the residencies are scarce and extremely competitive and pay pretty badly and young doctors are way in the hole for a couple years. I did NOT know this was funded through Medicare and I'm wondering why?

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I'd love to learn more too. But if I had to guess it was likely a very successful lobbying effort by AMA. I think one thing to always consider with a lot of lobbying organizations or trade organizations in general is that their focus is very often slanted towards their older and veteran members. Which is why my hypothesis is that this was successful lobbying by AMA, because it's an org. that will be dominated by veteran doctors. Which means it's organization impulses will be to protect the jobs and livelihood of older doctors which means restricting residency and competition.

I always go back to this, but a lot of policy analysts and political reporters could do well to follow the business of sports. How is this relevant here? In the NFL and NBA rookie salaries are capped at a pretty low number. And for fans this seems great because every fan has the story of the rookie on the team who turns out to suck but was making 5 times as much as a good player. But limiting rookie salaries is really about protecting veterans in a salary cap league. Less money for rookies means more likely a veteran can get a roster spot for a couple million a year.

By the way, this is a big part I think of what's happening with unions. I think most people know that the number of police officers for example who are actually walking off the job is actually quite small despite what breathless TV coverage may tell you. But what's being left out is that these cops are likely veteran cops close to retirement. So not only are the unions protecting their most veteran cops at the expense of younger ones, an important part of context of this story is being left out in that a lot of the cops "taking a stand" are actually going to get close to full pension which means they can afford to leave over vaccine mandates if they want to.

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I would surmise that it's also because residencies are expensive money-losers, even with the low salaries. Medical school is also expensive but at least the students are paying you. Residency is just a continuation of medical training (the "doctors" don't know how to do anything, especially at the beginning, and are walking liabilities) but you're paying them. So it's a strong incentive to socialize the costs by pushing them onto Medicare, and then for Medicare to cut those costs to save money.

The sports analogy would be how it's profitable for the NFL and NBA to be able to rely on the government-funded NCAA for their developmental leagues. Major League Baseball relies far less on the NCAA and its minor league system is kind of a money loser, even with the dirt-poor pay that minor league players get, which is what led MLB to eliminate a lot of its minor league teams last year to the chagrin of a lot of fans.

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Yeah I guess I didn't realize Medicare had broader applications beyond healthcare for seniors. I do agree that the government should be subsidizing residencies, I was just curious about the instrument if that makes sense.

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Biglaw makes big profits off of associates who have three year professional degrees. A first year resident ought to be at least as billable as an RN, and their salaries are similar to RN pay. The private sector could fund this

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RNs generally can't* bill. They are a (very) necessary expense in providing care, but they're not billing providers.

*Exception: In certain low-acuity scenarios with known/established patients (stitch removal, vaccine, blood pressure check, basic wound check/care), typically in a clinic, the encounter can be billed at a low level by an RN.

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Possibly certain parts of resident labor could be profitable such as just working in the wards or working in clinic. My wife even did a "private practice" rotation where they basically pretend to be a Kaiser Permanente doctor for a month, surely Kaiser is making money on this.

That said, residents switch rotations ever 2-4 weeks so they are working in many areas where their work has to be closely supervised, attending physicians in say the NICU have an additional 3 years of training after residency. Also resident salaries cover obviously unprofitable time like research/projects that are not part of the world for new associate lawyers.

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Residents and fellows (Graduate Medical Education, or GME, trainees) cannot bill independently. They almost always need a supervising attending physician to also see the patient and submit a charge. One exception is the "primary care exemption" where in routine outpatient/clinic cases the resident can discuss the patient with an attending who doesn't see the patient but can still bill for the encounter--but this doesn't apply to lots of specialties and certainly nothing in the hospital.

I assure you, if you didn't require the attending physician to also see the patient, they wouldn't in many cases, and as evan bear said above "they are walking liabilities". Residents are just not ready for prime time in most cases until they are most of the way through.

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why do they need to rotate every 2-4 weeks? shouldn’t they get broad exposure in med school?

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As a hockey fan the salary cap analogy makes sense. As an econ person it also drives me crazy. Hockey players make less than other major sports but in terms of ROI the best player in the league, Connor McDavid, is underpaid by about 8 million dollars relative to how much he's worth to a team. It is very frustrating to think about all the poorly designed and entrenched systems in the world, honestly 😂

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To be fair, an MBBS degree is a six-year bachelor's, which is not as big a difference from a four-year bachelor's and a four-year MD as saying "medicine is a bachelor's" makes it look.

But this would need a complete sea change to how US bachelor's degrees work. In the UK, general ed is a requirement to enter a bachelor's programme, not to graduate from one. Most UK bachelor's degrees are single-subject degrees where you do not take any classes at all outside of that department (remember: you have to pass general ed to get in, which you usually do at the age of 16).

Also, you have to pass the equivalent of AP Chemistry and AP Biology to get into those programmes.

Of major western countries, England expects students to specialise in particular subjects earlier than any other; the US expects students to specialise later than any other country. English graduates will normally have covered more ground in their subject after their three-year degree than US graduates will in their major after their four-year degree - but the English graduate will not have covered any other subject at all since high school, and will have reduced to three or four subjects at the end of the equivalent of tenth grade. Of course English students graduate younger, get a master's younger and get their PhDs younger than Americans - they don't spend nearly as much time studying anything outside of their subject.

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The American system is good for creating a broadly educated elite. However, I don’t think that clinicians really need all the education we require. I graduated in the top 25% of my class at a top ten law school. I learned the practice of law at the Hall County Public Defender’s Office. I wish Georgia let people read for the law. I would be happy to pay a capable young person $18 an hour to learn about the lawyering while working for me.

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Contra my comment about a small trend toward 3 year med school, the other broad trend in medical education is more emphasis on humanities/liberal arts education pre- and in medical school (i.e., more broad education and less science-specialization)....the goal is more compassionate, culturally competent physicians and fewer Dr. science robots.

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anyone who really understands the Georgia Pattern Jury Instructions can pass the bar exam.

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I don't know if it needs a sea change, exactly. A B. Arch. takes 5 years, or you can get a general B.A. and follow it up with an M. Arch. if you want to be an architect. Both paths are considered equivalent (not sure if they are in practice).

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I guess the closest we have is Nurse Practitioners, but even that you’re all-in for 6-8 years post-HS.

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Many Canadian and American medical schools are now launching 3-year programs. (typically initially reserved for top students as they "road-test" them)

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They tend to be compressed programs where you're in school year-round, rather than having summers "off" to work in a research lab or what have you.; e.g. https://cumming.ucalgary.ca/mdprogram/about/our-program/curriculum-structure

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I think it's probably okay.

My suspicion is that the four-year medical program is a long-standing holdover from the era when most medical knowledge was in fact taught during medical school. This was possible because medical knowledge in the 1920s - 70s was a fraction of what it is now. Today, what you need to know to be a practicing physician is almost certainly entirely learned during your residency and fellowship training. Medical school truly is building blocks for that training, but nothing that I do today could I say I actually learned in medical school. All fields have just become too knowledgeable, and too specialized, and it is nearly impossible to teach that in a broad medical school curriculum.

To buttress this, as medical school has remained for years, many residency and fellowship training pathways have lengthened slightly, with some residency programs adding a year, and some specialty fellowship programs doing the same. So you now have both three and four-year emergency medicine agencies, and many one and two, or two and three year fellowship programs in certain fields. Typically the more academic and intensive programs are the longer ones.

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A bachelors is not required fit law school, 90 credit hours are. Chicago Law had a program that took people after three years of college and gave them a BA and JD.

Also, anyone who takes AP classes can graduate in three years. I did and I could have graduated in 2 if I had really wanted

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I graduated from Stanford law School 45 years ago and then spent a career as a deal lawyer on Wall Street. I didn't learn anything at law school that had any practical application to my career, nor did the Bar Exam ask anything relevant. Except for this: how to be a cynic. Before law school, I didn't know it was a thing to ignore the law (like there was a no moral duty to meeting your obligations) if the consequences of ignoring them were better for me (or my client) than following them. How dumb and naive. How we got to Donald Trump, and I've been forever grateful to SLS for opening my eyes 45 years ago.

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You’d need a stricter bar exam to be a filter to avoid incompetent practitioners, and you’d end up with lots of people who fail who have useless but very expensive degrees.

Also, in the UK I believe the market has moved closer to the American model with more people with non-legal undergrad degrees pursuing graduate education in law

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How does making it 3/4 of the way through a generic BA filter for legal competence?

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Or why is both law school and the bar required? Should one or the other be good enough?

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Yeah among lawyers abolishing the bar is really popular (it’s called diploma privilege and exists in WI) but the issue is that there are some really bad law schools

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Had an Iraqi dentist as an Uber driver in Chicago last summer. Not far off the mark here.

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The natural condition of man is poverty. Victorian England was the richest society that had ever existed and yet 80% of Victorian families lived on the equivalent of less than $8,000 a year. The most important fact about modern America is that we can grow 100 bistros of corn and acre and a singe combine operator can harvest 25 acres in a hour. In a long day of work, he can harvest enough calories to feed a small town for a year.

99% of human history has been consumed by the struggle for subsistence. In the last 150 years, growing food has become so easy that producing calories is a trivial problem and we burn corn to power cars. The ease of producing calories means that the remaining nutrition problems really are distributional (getting healthy calories and protein to poor people) but this state of affairs only exists because of miraculous productivity gains.

I 100% agree that the goal of political economy should be making housing, education and health care as abundant as food. Let’s license some foreign doctors stat and let Indian radiologists read US scans.

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Yet, weirdly, it seems like an article of faith among both the left and the right that it's all downhill from here, that any facet of the past looks better than the equivalent present (they'll sometimes disagree about just how far back to look), that the best we can do is cushion our society's fall from grace.

Small wonder that "Make America Great Again" resonated on a gut level with some people. Maybe pervasive pessimism is politically stupid?

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Everyone sees their 20s as the prime of their life and ascribes the pessimism of middle/old age to societal decline. Nostalgia breeds pessimism.

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In the last few generations, I think pop media has played a substantial role as well. Why, look at how nice a NYC apartment the Friends friends were able to afford with relatively meh jobs in the 1990s! Yet here in 2021, I pay $3700 to share a windowless garden-level broom closet with seven rats and Harold.

Societal decline!!!

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and my step dad couldn’t support a full on leave it to beaver household on one income, so my mom had to work. oh the rot.

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Yup, though I think you need to segregate the elderly from middle aged. Most happiness studies show middle aged people are at the nadir of popularity. Which makes sense if you think about it.

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Radiology is one of the areas where the battle between what new technology allows and old regulations is most pitched. I've been involved in some efforts in that area, around remote and computer-assisted or AI readings, and while there's a lot of technological advancement still needed, we're already at a point where a large part of the battle is finding a regulatory and reimbursement pathway to do what is technologically possible.

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*bushels of corn

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I mean, I wouldn’t be surprised if we could grow 100 bistros of corn on an acre. French cuisine doesn’t go much for corn or corn products (probably mostly little sprinklings of cornstarch for patisserie and maybe rescuing/experimenting with sauces) so 1 bushel might represent a bistro's annual usage.

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Was just searching to try and find out more about this new unit of measurement. Ty for clarification :)

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I wish progressives were a bit more skeptical of "tax medallion leftism", by putting a bunch of regulation to protect specific existing jobs, rather than thinking bigger picture. You see a fair amount of "people in this occupation deserve a living range, so we need a high barrier to entry."

I'm hoping the tighter labor market helps push back on that temptation.

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A tight labor market won’t put a big dent in rent seeking. The median wage for unskilled work will never be high enough to fund prestige consumption. Thus the need for barriers to entry

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Isn't the whole point of "prestige consumption" is that it is prestigious because its limited. If scarcity is reduced, it becomes less prestigious. We should care less* about what is happening with prestige consumption and more about reducing scarcity for basic needs.

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I'm not optimistic that it would reduce rent-seeking, but I'm hopeful it discourages the movement as a whole from buying into it.

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Warren recently gives me entirely too many "what's important is that we hurt the right people/organizations" vibes. I feel like we dodged a bigly bullet.

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Yeah, she just came out and supported the corrupt, defund, manipulative mayoral candidate for Seattle mayor, Lorena Gonzalez. So pissed. Guess we'll have to persist for real progress without Liz, my former favorite.

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If you want an online-only university one (essentially) already exists: The UK's Open University.

£5000 (about $7000) year in tuition, fully funded solely from tuition alone. Fees are per-class, so you can do it part-time and pay less per year and take more years.

The only in-person classes are residential schools for practical classes - e.g. labs for science students.

Courses are normally marked partly by submitting assignments (like any other class), partly by multiple choice tests taken online, and partly by formal examinations that require you to go to a test centre. Note that there are already test centres all over the world - run by companies like Pearson - that allow a variety of people to take different tests side by side, so this is just another line of business for those centres.

They were originally "distance learning", where you got mailed a packet of information on a weekly basis and mailed back your assignments, but they moved online well over a decade ago.

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There are several others along the same lines: Athabasca in Canada and Western Governors in the US.

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“Saw the movie so let’s talk about the book” is really the essence of slow boring. Love it!

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All about this stuff. To my memory, this was/is pretty standard center-right think tank opinion on many of these topics. We were supposed to be the supply side people at least until Trump.

Universities are tricky. What we have is a signaling problem. Universities are not so much in the business of teaching people, but of certifying quality for employers. As we’ve gone from 10% of the population getting degrees to 50%, there is still a top 10% that top employers want, the rest is just the 13th grade.

Hopefully as universities move away from standardized testing, that a separate market for something like an IQ test can provide a cheaper and more useful alternative. Would save a lot of money if we could just have an SAT score and bypass the need for 4 years of expensive partying.

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>>Would save a lot of money if we could just have an SAT score and bypass the need for 4 years of expensive partying.<<

Unlikely. A university education doesn't signal intelligence only (or likely even "primarily") but also attributes like sociability, perseverance, stability, organizational skills, and so on.

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Yup, also the argument made in "The Case Against Education" by Caplan. But if you think about how high the graduation rate is from top schools, shouldn't one be able to just skip the extra step? Realize it likely won't happen but I just marvel at how much time was wasted in my time spent at "elite" schools.

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Wasted how? Like some bad classes or just how little time was spent in class so it was overall inefficient or was it a wasteful degree vs. career paths?

I'm just thinking about my experience. So I haven't end up using anything I learned in Thermodynamics I or II (e.g., I don't design refrigeration systems) but even still super helpful classes to frame and solve complex problems. I wouldn't classify any of that time as wasted. Seems jaded.

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I think few question the value of technical education and training. It's the other degrees for which their value over on-the-job training, for example, is debatable.

Side note: I would eliminate Thermo for anyone but engineers who really need it. Stat mech is more fundamental and elucidating anyway.

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Just looking at the summary of the book Zack references - it seems like a broad critique of education. There doesn't appear to be a distinction here for tech and non-technical paths.

Also ... how would you determine who would and wouldn't need Thermo? I can't follow. You need to take the actual class to figure out if you need it (e.g., I like this discipline, I'm going to make a career out of it).

https://www.amazon.com/Case-against-Education-System-Waste/dp/0691174652

Despite being immensely popular--and immensely lucrative―education is grossly overrated. In this explosive book, Bryan Caplan argues that the primary function of education is not to enhance students' skill but to certify their intelligence, work ethic, and conformity―in other words, to signal the qualities of a good employee. Learn why students hunt for easy As and casually forget most of what they learn after the final exam, why decades of growing access to education have not resulted in better jobs for the average worker but instead in runaway credential inflation, how employers reward workers for costly schooling they rarely if ever use, and why cutting education spending is the best remedy.

Caplan draws on the latest social science to show how the labor market values grades over knowledge, and why the more education your rivals have, the more you need to impress employers. He explains why graduation is our society's top conformity signal, and why even the most useless degrees can certify employability. He advocates two major policy responses. The first is educational austerity. Government needs to sharply cut education funding to curb this wasteful rat race. The second is more vocational education, because practical skills are more socially valuable than teaching students how to outshine their peers.

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Caplan appears to be less dismissive of STEM education than other subjects, at least based on a couple things I found searching. He only makes one off-handed reference to it here: https://www.theatlantic.com/magazine/archive/2018/01/whats-college-good-for/546590/

"Of course, some college graduates use what they’ve learned and thus hold on to it—engineers and other quantitative types, for example, retain a lot of math."

And in this older post https://www.econlib.org/archives/2012/10/a_bunch_of_argu.html

he is pretty complimentary, saying "STEM majors spend a relatively high fraction of their time acquiring real world skills. Other majors spend a higher fraction simply showing off their intelligence, work ethic, and conformity. Both are privately rewarding, but the former is far more socially rewarding: Useful skills enrich the world, but signaling mostly just enriches the signaler."

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I'm not sure this makes sense to me. I learned more from college than I did in HS. The goal of college isn't to fail students, but to try to educate as many students as possible.

But this rationale shouldn't we skip high school, middle school, and elementary school. Just give kids a test when they turn four and then mark them. We could save a lot of time since the vast majority of people graduate from HS?

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Kind of what Germany does at age 12. Both efficient and inefficient in very different ways.

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I found my undergraduate years (UVa, mid-70s) among the most intellectually stimulating of my life. And fun too! Not sure I want those experiences to disappear. (Be great if we could tamp down tuition inflation, though.)

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In lieu of (or more likely in addition to) IQ tests, I’d like to see expanded testing that goes much broader than life cognitive horsepower. A few years ago, when pondering a career change, I took a battery of tests from a company called Johnson O’Connor, which was set up by GE in the thirties to help them do a better job of hiring.

https://www.jocrf.org/

They test everything from traditional SAT-like abilities to memory to spatial intelligence to pitch recognition to fine motor control. They even test grip strength. I wish I’d taken these tests when I was 18 instead of in my forties.

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When I was in high school (mid 90's) local businesses and the military offered us tests like these to line us up with jobs when we graduated. For example, I took one that sorted us into call center or fruit-packer depending on how you scored on social/linguistic versus fine/gross motor coordination. So some of us would work in the call center taking orders for fruit baskets while the others fulfilled those orders in the warehouse. I have horrible eyesight and am not very athletic, so Air Force and Marines weren't so interested in me, but Navy really wanted me to serve on a nuclear submarine. I was inundated calls and letters from Navy and Army throughout my senior year.

Do high schools still do this? Or is this a rural thing?

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Great question. I don’t know the answer to that. The testing I did was over the course of two days and required a lot of one on one with the test proctor. He would do things like time me with a stopwatch on certain tasks. It was fairly resource intensive.

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The fruit-picking / call center test was like that; i.e., one-on-one with someone from the company doing mini interviews and timing us while we put wooden blocks into slots in a box.

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I grew up in a rural area and this was very much a thing in high school. Basically everyone took the ASVAB because it excused you from a day of regular classes.

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Matt, you should check out what Georgia Tech is doing with their online masters programs. There are actually several of these, very highly rated/ranked, while allowing something like 10x more graduates compared to the on-campus program. They’re not the only one, but they’re pioneering here.

Also I just wanted to say I could not agree more with this post, the energy one, and the new center party one. So when are you going to put these things together into the new center party platform, and how can we make it happen? :)

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Yes, also Ball State University. I think the people on this list are not very represent in their higher ed understanding... very loaded toward "prestige college" alumni. I would look at the work being done in community colleges, but also state schools that serve more non-traditional students.

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founding

I don’t think he’s proposing the Center Party Platform. I think he’s proposing the Democratic Party Platform that you can run on after you let the Center Party go their own way.

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Seconded. Tech schools seem to "get" to some degree while the liberal arts schools are busy rearranging endowed deck chairs.

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Georgia Tech is a very good brand.

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IIRC their job offer rates are high. Like 97% high.

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To be fair ... they were and so discounted appropriately. I think what's different here is the GT program is an actual reputable program.

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I *think* in the end, there is no way to distinguish between the online and on-campus versions of the degree. That says a lot that GT was willing to put their program's reputation on the line, rather than just create a lesser version of it and let others judge for themselves.

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Matt do a deep dive on the new billionaires tax. Why not just do a far more aggressive estate tax? Seems to have far fewer implementation/court issues

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founding

The people who desire to take money from the billionaires don't want to wait until they die. They want to hurt them now.

The "every billionaire is a policy failure" thinking is corrosive and an outgrowth of the scarcity mindset. Those folks think the size of the pie is fixed, so they focus on the distribution of the pieces. The goal is to grow the pie, even if that means Elon Musk is a hell of a lot richer than you and me.

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If Elon Musk having >$200B is what it takes to get us to Mars, then I say let him get to $500B and see if we can colonize the moons of Jupiter next.

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I'd like to see a billionaire establish a regular private research university and put it in a city that could really benefit from having one, like Detroit. We haven't seen that happen since, what, Carnegie Mellon? Not counting oddball schools like Ave Maria or Olin College.

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Why doesn’t that ever happen?

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It seems like there are two kinds of abundance: that from technological change and productivity improvements, and that from overruling rentier groups and transferring benefits to a larger population. In the first, we get smartphones, cheap solar energy, and falling costs of cars; in the latter, we get more housing, more doctors, and a bigger Harvard class size.

Benefiting from the first one is great, but is largely out of our control. Getting the second one benefits the many over the few, but is hard because of the entrenched interests that grow in a successful society, as Mancur Olson brilliantly laid out in "The Rise and Decline of Nations." And while I think we all decry their narrow, parochial interests, in truth it's a lot easier to do when we're the ones who stand to benefit and not the ones who are targeted for losing some of what we have. I think it would behoove all of us to think in what ways we ourselves are rentiers as well, and how we would react if it's our turn in the barrel.

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founding

I would suggest that the benefits of your first type, while unpredictable, are _more_ under our control than you're suggesting. Government willingness to invest in blue-sky research has been going down over time. Both the real value of investment dollars has been pinched, and the constraints on what research can get funded has been narrowed, because of a successful campaign of lampooning things that sound weird to a layman. I'm sure you can list off plenty of examples of industries that exist thanks to government research. And it's much harder for the private sector to invest in the kind of basic, exploratory work that produces these big long-run benefits, because it's so hard to predict the timeline on which it will produce any return.

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I think we've gotten immensely great things from government research --and not just Tang and Teflon! But it's not under our "control" unless one thinks mechanically that X dollars of basic R&D will produce Y value to society in the long run, though we have no idea which 1% of those X dollars will be the winners.

The place where I spent my career did much of the early intellectual work underlying the Internet (packet switching, going digital vice analogue and all that), purely for defense purposes (how to communicate during a nuclear war). Trust me, no one doing that work back in the 60s had any idea that this work would contribute to the global transformation we witnessed as a result of that incredibly tiny expenditure of R&D funds.

And then, on the other hand, we have the billions and billions of federal dollars spent on fusion research. Could be a big deal in the 22nd century I guess. Maybe the 23rd . . .

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founding

That's just my point though -- of course you can't mechanically predict that $X of additional research funding will translate into Y% improvement in future growth.

But we definitely know that past research paid off in HUGE ways, and we are a rich enough society that it seems ludicrous to suppose that the social payoff to handing another $1B in reduced taxes to people who already have billions and are having trouble coming up with investments that they consider to have safe enough returns will be better than keeping that $1B and funneling it into long-shot research. (And this leaves aside the argument that very high taxes on corporate and individual income actually incentivized private corporations to instead funnel their money into long-shot research, both for the glory of it, and because actually growing their industry would make everyone involved richer than paying out the cash. See: https://slate.com/business/2012/07/xerox-parc-and-bell-labs-brought-to-you-by-high-taxes.html )

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I agree that we should be spending a lot more public money on R&D. Also a lot more money on clinical trials. For example, testing generic drugs like metformin that quite probably will be the first approved life extension drug (people with diabetes on metformin have been shown to outlive people without diabetes that aren't taking the drug).

But higher taxes spurring companies to do more R&D? nope, not even close. higher taxes spur companies to spend more money to figure out how to get out of paying taxes.

Not to mention in the past the government hasn't exactly been good stewards of money...

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The State Bar of Georgia is a fine guild. That being said, I would be happy to let paralegals do simple divorces if I had guaranteed health care

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Agree with most of this, but there are a couple of things missing:

- Congress failing to increase the number of residencies has nothing to do with not wanting to spend more money, it's due to the lobbying power of existing doctors. It was that same lobbying power that compelled Congress to spend more money by doing "doc fix" legislation for a decade before repealing the Medicare growth caps completely. The difficulty in modernizing medicine away from artisanal practices is also due to these entrenched interests.

- Expanding higher education is unlikely to bring the price down - there is plenty of room at low-tier schools and community colleges. Anyone who wants to go to college can. The problem is that college acts very much like a luxury good where status is a very important factor.

- And the regulatory and lobbying capture is just as present in higher education. I agree that we shouldn't be subsidizing schools that don't expand, or are wealthy enough to stand on their own. But the government isn't run by philosopher-kings, it's run by bureaucrats and politicians who listen to influential and organized "stakeholders" more than anything else.

"On higher education, we’re stuck between the left saying “spend more” and the right saying “spend less” with very little interest in trying to do something different."

This I agree with completely and it's been the main reason why I don't identify with or support either party. It's not limited to higher education - partisans on either side are simply not interested in effective governance.

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It seems like you’re 180 degrees wrong about residency slots.

“ According to the Association of American Medical Colleges—the country’s leading advocates for lifting the residency cap….”

“ The AMA has been a long-time advocate for modernizing GME [Graduate Medical Education]. This includes increasing funding for medical residency slots, developing innovative practice models, and creating residency positions that reflect patient and societal needs. Most recently, the AMA urged support for two federal bills. These include the Resident Physician Shortage Reduction Act of 2017, which would expand Medicare funding for 15,000 additional residency positions, and the Advancing Medical Resident Training in Community Hospitals Act of 2017, which would close a loophole in GME cap-setting criteria affecting hospitals who host small numbers of residents for temporary training assignments, also known as “resident rotators.”

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Thanks for that - it seems that things have changed since I last seriously looked at this.

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I am curious about scarcity and how it relates to quality, and how do you balance abundance with costs and profit.

One of the advantages of capitalism is the intrisic motivation to provide services is motivated by profits.

For instance, becoming a Doctor is a long, arduous and demanding road, but at the end of it, most Doctors are compensated pretty well. They are compensated well because the demand for them outweighs the supply. Now it occurs to me that medical school is artificially limited and there are probably plenty of excellent potential Doctors out there who don't go to medical school because of the cost, or just no openings. But at some point, is there a point of diminishing returns. As you get more Doctors, does their compensation go down? Do we end up with the scenario where the top candidates decide to go into molecular biology to make more money? Do we start graduating Doctors with less skills? What is the balance. Obviously, Europe has managed to find the right balance, but there are other countries in the world where a Medical Degree might not have the same amount of requirements as we expect our Doctors to have?

The same thought go to higher education. Colleges and Universities are such a complicated situation. Because I work for a German company, and used to live there, I will use them as an example.

Germany has a lot less 4-year and 2-year college graduates that the United States does, but overall their expertise and competence at any given occupation exceeds our average, at least from what I experience.

The price of University and College in the United States is a problem, but I think our whole system is a problem. State and regional colleges in the US appear to attempt to mirror the same sort of curriculum, majors and experience that we see at our elite schools.

You go to Harvard to get a degree in History, but you can also get one at Boise State. However the demand for History majors is such that the a Harvard History major is going to have a lot more options than one from BSU. (I actually know nothing about the quality of BSU's history program. I am sure it is excellent in its own right).

If anything, I think one of the problems with our higher education system is an overabundance. I wont find the link, but I have read several studies/articles that talk about how a signficant number of college graduates go into jobs where a degree is not absoluely required.

Meanwhile, we have a shortage of certain specialities that require some technical education, but are unable to meet all the demand. For instance, my daughter is completing a Mechatronics program at the College of Western Idaho (community college), and the program can't pump out graduates fast enough.

I am strongly on the side of College is nothing but a signaling mechanism for most jobs, though Noah Smith recently posted about a study that shows this might not be absolutely true.

Let's just say we magically come up with enough money to put everyone through college for free. If nothing else changes, I really don't see how we come out any better. If anything, we might come out worse as people take longer in life to sort themselves out into the most efficient use of their labor and skills.

I actually have a Bachelors Degree of Science from Southwestern Collge in Kansas that I completed mostly online while I was in the Military. I thoughougly enjoyed it, and I learned a lot, but I am not naive enough that it prepared me to compete with a Computer Science major from the University of Idaho in the job market. I chose it because the program was realatively easy to complete while in the Miiltary, and because I though having a Bachelor of Science in Computer Programming would sound impressive to employers from a wide range of companies, even when it wasn't required.

Truthfully, my degree does me no good at all. I work with people who are as equally qualified as I am that only had on the job training and certification. I am the go to guy for computers and software, but that is more out of natural talent than anything I learned from my degree.

I just don't think online education can offer the same quality of instruction to anyone but the most motivated of self-learners.

The idea of free public Universities is a good one, but they would only be as good as their selection rate. Though they aren't free, the Maritime Universities offer a good equivalent. The graduates of the Maritime Universities have excellent job prospects, but they are selective in who they take in.

And always, since selectivity is a prequisite, there is inevitable issues with equality and diversity, given the unequal outcome of our K-12 public schools.

Housing though is probably the one thing that a simple losening of regulations would fix. Even if the costs were reduced, as long as the administrative burdon was reduces, companies would still make enough profits to put up more housing. The housing issue needs to be solved at the local level, zoning must come first.

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Europe also does medical school as a single 6-year degree, rather than 4-year undergrad + 4-year graduate. A lot cheaper and gets people into practice sooner.

https://www.niskanencenter.org/the-case-for-shortening-medical-education/

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I was vaguely aware of this. I assume they cut out a lot of the bullshit extra curriculas that American students have to take. They can't really remove any of the medical requirements I assume, so its a matter of removing the general education requirements. Which in some ways will make medicine more of a technical degree.

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Yeah, European medical education not only cut out all the general education stuff but the students actually get more hands-on clinical experience than US doctors as well. Illustrating how superfluous much of the undergrad content actually is, a surprising number of aspiring US doctors major in something totally unrelated to medicine in undergrad prior to attending medical school.

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General education requirements are the albatross around a large number of majors.

We have internalized the image of the well rounded Ivy League graduate as the model for achievement.

We mistake their comprehensive education as the secret to their success, as opposed to the neopotism and social connections which actually drive it.

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Since undergraduate education is probably the last opportunity for Americans to be exposed to larger concepts and ideas about the world, I'm not sure it's such a good idea to throw it in the trash can.

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In theory sure, but general education classes are almost exclusively busywork, making this a dubious proposition in practice.

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"Since undergraduate education is probably the last opportunity for Americans to be exposed to larger concepts and ideas about the world"

You saying the posts and commentary here at Slow Boring don't measure up...

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Yes: ideas and concepts, and writing.

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Yes. There is a trade off. I just wonder how effective our general Ed really is. And only a minority actually attend college.

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This!!! The general education classes are exclusively busywork for the most part.

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Good points, but who says doctors "need" to make a lot of money anyways? My understanding is that European doctors do in fact make less than American ones, and I think that's a good trade in exchange for lower prices (note that this issue doesn't really affect my pocketbook and I'd probably think differently if it did).

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Sure, they don't "need" to but any government attempt to reduce that amount will run into the obstacle that doctors are very well-organized and are highly respected in society, so they can lobby hard (and successfully) against any such attempt.

I found it striking but not surprising that when progressive leaders (Bernie, Warren etc) pushed for reduced healthcare costs, they always targeted hospital administrators, drug companies and the like. The word "doctor" never passes their lips.

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Vertical integration of the healthcare delivery system will accomplish this through market forces without the government needing to get its hands dirty. But sure enough, the Bernie's of the world oppose that, too.

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Oh yeah, the logistics of actually doing this and reducing doctor salaries (or freezing them or whatever) would be politically impossible. Such is life

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They also tend to have less debt in European counties. It is not at all unusual for an MD to graduate with 250k in student loans. There are programs through the military or Public Health Service that reduce or eliminate costs for tuition etc. and of course, many medical students come from very affluent families that can afford to pay tuition outright.

We have a lot of specialists relative to PCPs here in the US and part of that is that primary care doesn’t pay as well. If you have six figures in loans, then primary care becomes less appealing. Especially since primary care doctors do a lot of tedious administrative tasks as well

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I would imagine they don’t need to make as much as they do. But certainly compensation should reflect their effort and talent.

Plus any reform needs to take into account current Doctors. Hard to advocate for anything that will reduce one’s own pay.

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"The idea of free public Universities is a good one, but they would only be as good as their selection rate"

I don't think they should have a selection rate. If you want to go, go. Sure some would not complete, but many would

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As regards doctors - it would be doctors who decide what they make. Wages will move based on people assessing what wages are now and choosing to train or not train for the job, and things’ll go into equilibrium.

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"And while the government can’t force the rich private institutions that sit atop the higher ed hierarchy pyramid..." This is mostly not true. The federal government spends a lot of money on private universities (through federally sponsored research), so it has considerable leverage over them. Private institutions will almost certainly obey a law that says "If you want federal research dollars, you have to do this.", unless it is a really really weird law. They can pay less than six figures the Associate Dean of Literally Doing Nothing to compensate.

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I could see President J. D. Vance and a Trumpy Republican Congress getting such legislation done. Otherwise -- nope.

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When my kids were undergrads I remember asking for a chart that explained “where the money goes.” I never got one and they eventually graduated.

Does anyone know where to find such a chart?

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I'm pretty sure every university will publish this somewhere. Here it is for Harvard, for example: https://finance.harvard.edu/financial-overview

One of the interesting things I've learned from looking at these for R1 (high research activity) universities is that research dollars are a bigger source of income than tuition (sometimes *much* bigger).

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Fall and spring are when all of the damn undergrads are running around, getting in the way of our real mission.

So went the joke, but every good joke has at least a glimmer of truth to it.

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More than a glimmer! I was extremely productive last year. Even though we offered a residential experience, only a fraction of students came, and even then they were mostly confined to their dorms. I was shocked at how packed the campus suddenly became in August.

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This is useless information until Harvard breaks out its operating expenses for salaries, wages and benefits into categories of those making a difference by teaching and research and those in the Deans of No Value office. My sense, as a child of a Cornell professor decades ago, with no first-hand knowledge since, is there's been a showering of money on Deans of no Value (plus climbing walls and cushy dorms) and throwing more money without strings attached to teaching and research is not the way we should be going. There's a tendency among Democrats to think any problem can be solved with more money, without being thoughtful how it's going to end up being spent and what it does to costs at the consumer end and the relative power of different sectors of the economy.

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/stares thoughtfully at the fairly crappy coronavirus response of the CDC

That recurring budget needs some very thoughtful justification, Atlanta. 'Cause I'm not sure we've received appropriate value out of the money you already get.

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Actually, all nonprofit entities, including colleges, have to make a public accounting of their finances. You can find them easily online.

Harvard: https://finance.harvard.edu/annual-report

Princeton: https://finance.princeton.edu/report-treasurer

U Michigan: https://finance.umich.edu/finops/reporting/annualreports

Georgia Tech: https://president.gatech.edu/publications-presentations/publications/annual-reports

You have to rely that the numbers are honest and not obfuscated, but that goes for all such entities, including literally all publicly traded companies. And colleges do go through financial audits, separate from educational accreditation.

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Thanks to all for the insights here. I’ve been especially curious about the costs of maintaining extensive grounds in a city where it’s in short supply like DC or the costs of paying for extensive support services in places like DC or Amherst where there are many potential student customers.

Why does each college have its own dining & mental health system?

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That is completely true and is the cornerstone of administrative tribble problem.

And yet, 20-ish years ago when Congress made a big stink about stem cell research, labs had to show that they weren't even using federal grant money to pay for electricity for lights that might illuminate a bench on which stem cell research was conducted. It was amazing (in a bad way) to watch the university scramble to renovate labs and rejigger employment contracts to quarantine stem cell research.

When Congress wants to push universities around, they can easily grab the R1's by the short hairs—it's just that they'll only do it when they see direct political benefit.

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Very true and the same is true for medical doctors. Contra Matt, this is the reason Congress hasn’t increased the number of residencies in decades. and there is also the “doc fix” which was another successful medical lobby effort.

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I agree with you unfortunately. I just wanted to point out that the power is there for the feds to use (and I think they did use it to desegregate higher ed back in the day, but I may be wrong on this, or what I've read might be inaccurate).

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What is power? Ha

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I mean, the executive branch just issued an executive order to force all companies that have or compete for government contracts to mandate vaccines for their employees. Stroke of a pen and everyone jumped. It can be done (though it pisses people off.)

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founding

I’ve heard from people at some universities that their institutions interpret their federal grants as meaning they are contractors. I haven’t heard anything about this internally at Texas A&M. Is there about to be a collision here?

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Title IX places requirements on any educational institution receiving federal assistance. The university could pull out of all federal assistance, but none do - and Title IX compliance is a real regulatory burden. I think it's a worthwhile one, but that doesn't mean it doesn't have real impacts on the institutions.

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That's how the federal regulatory system works at multiple levels. Most of the federal government's regulatory power comes from conditions attached to federal dollars and little else.

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Matt, this question seemed obvious to me but maybe because I consume a ton of healthcare (bipolar disorder) and have a lot of friends and family in the sector- do you have any thoughts on the increased ability of physicians assistants and nurse practitioners to perform a lot of the functions of doctors, including prescribing medication? Could that be a lever for increasing the supply of health care as well? (Especially since medical school spots are also very limited, with a lot of people moving to the Caribbean to do it for that reason)

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The issue you get is PA's/NP's get a lot less training. In a specialty clinic with good oversight they generally help increase physician productivity. However in primary care/unsupervised practices you see over ordering tests and ordering consults a good PCP could handle in house. So overall Healthcare costs go up but "provider" costs go down.

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Yeah I would expect there would be variances in efficiency depending on the type of medicine and other factors. In general I don't know what kind of policy would reduce unnecessary tests- maybe something to do with billing or something from the malpractice side- but that to me is its own issue across GPs nurse practitioners and hospital systems. What I've found is that for my two major healthcare needs, basic periodic gyno exam and med checks periodically to make sure my depression etc. are under control, me having a good amount of knowledge of my medical history and a nurse practitioner is more than sufficient. I guess I would compare it to paying a professor with a PhD in mathematics to go to a daycare and teach kids how to count. The tricky part, obviously, will be figuring out where those lines are and probably firming up the standards required to get "lesser" credentials. NPs specifically I know have done full training as RNs and usually some work experience as well. Then again, I think it was another thread where someone pointed out residents don't know anything to start, so an RN or an NP may be more valuable in specific situations.

Not having a character limit is dangerous, I feel like I'm rambling, but I will say I have 4 aunts and uncles who are MDs and my current psychiatrist is as well. And if I got really sick, like cancer or something requiring surgery or even just hard to diagnose, I would see a specialist with an MD. My bias for NPs is partly that they tend to be close to my age (28) and more personable and patient, so for routine care that works for me. (Caveat all of this I have always had good healthcare which is another huge factor)

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“…including prescribing medication?”

You’re thinking too small: Why not eliminate the entire prescription drug regulatory scheme?

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Prescription drugs are drugs that, by definition, sometimes cause harmful side effects but are used anyway because for some patients the benefit is worth the risk.

If you're a drug manufacturer, as between the FDA and random jurors that can't understand the science but sure do pay attention to which side's paid expert witness is better looking and has a more confident speaking style, who would you rather have evaluating the safety of your product? FDA approval doesn't directly bar a lot of suits but it definitely makes them harder to bring.

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Your definition of prescription drugs fits OTC drugs too.

I agree that there is serious need for tort reform.

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True, the difference in risk between prescription and OTC drugs is one of degree not kind. Some drugs - Claritin, for example - have started as prescription-only, and then FDA allowed them to be sold OTC after widespread use convinced FDA they were very low risk.

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"...after widespread use convinced FDA they were very low risk."

Gave 'em ass-cover, you mean.

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I agree with below that prescription medications need to be safe- not only that, with mental health conditions you need a significant amount of subject matter knowledge about the various options for different types of drugs and how to combine them safely and effectively. I'm fine with paying a premium for someone to specialize and be trained in that stuff. I don't think prescribing is even the most important function of a doctor but I think it's regulated reasonably now (besides marijuana and some other specific cases.) Also, I was thinking in terms of policies it would be possible to implement in the short or medium term, in the United States, in this version of reality lol.

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“I'm fine with paying a premium for someone to specialize and be trained in that stuff.”

So am I, but I don’t have a problem with someone else making a different choice.

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I don’t see how you could possibly eliminate it without serious downstream consequences. We already have tons of quack cures and “supplements” that fly under the radar. What happens when a company introduces crystal meth for ADHD?

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Is meth a prescription drug?

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Yes. It’s called desoxyn. It’s for ADHD.

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To clarify, there are lots of different kinds of meth. The kind that’s been ravaging/creating homeless people is a newer type that emerged in the last 10-15 years. The most recent Atlantic has an article about it: https://www.theatlantic.com/magazine/archive/2021/11/the-new-meth/620174/

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“The kind that’s been ravaging/creating homeless people is a newer type that emerged…”

A newer variant molecule that learned to replicate itself.

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Is it a quack cure?

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No it’s an effective treatment for ADHD, like the other amphetamines.

Cocaine is also available by prescription but I think it’s usually used topically.

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If you “eliminate the entire prescription drug regulatory scheme” for that won’t matter. Am I misunderstanding what you mean by that? If so then I’d like to know what the alternative is.

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The alternative is somewhere between where we are today and entirely eliminating prescription requirements.

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This is a complicated issue. I'm not for going back to the days pre-FDA, when any huckster could peddle any patent medicine. On the other hand, I know when I'm being stiffed by my doctor to get a prescription renewed so he can get a payment from my insurance company which ultimately gets passed on to me. Don't know the solution, but getting your blood pressure meds shouldn't require a useless and tedious trip to the doctor every 6 months.

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I've asked someone at AEI (American Enterprise Institute) if they ever considered founding AEU, since they sort of have the faculty part built up. He said yes, but that it was just too heavy a lift. Presumably, if they had a benefactor sufficiently committed to the project, it would be a lighter lift.

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