You write: "I acknowledge that this kind of thing can feel a little picayune relative to policy disputes that speak more to our core values and our identity as a nation."
Allowing competition, providing a path for individuals (hygienists, in this case) to find a path to financial success, avoiding unnecessary regulation and dismantling regulatory capture wherever it is found are, or should be, part of our core values as a nation.
Occupational restrictions deserve way more criticism than they get, I hope stigma builds up against them like has happened with NIMBYism. The economic cost is bad but there’s also the human cost of people being prevented from fulfilling their potential.
The human cost pisses me off much more than the economic cost. The path to a better and more fulfilling life is being closed off for millions of people through overly restrictive licensing and regulatory structures.
All the new antitrust thinking by Lina Khan, Matt Stoller, et al., is focused on the big tech companies, and seems to be motivated by a general sense of anti-bigness and a little bit of envy at highly profitable businesses. I wish they would focus their intellect on how government protection creates monopoly-like barriers to entry. It would help a lot more people.
I’m always leery of talking about envy, but what’s your specific objection to the anti-bigness?
My personal position is that it’s just generally bad to have businesses that are big enough to compete with the government. Economies of scale are nice, but there’s a point of diminishing returns where we lose our democracy and turn into a corporatocracy.
When being big is achieved because a company provides a superior product or service, I see no issues*. Amazon, to use the example that brought Khan to prominence, is big because they provide something lots of people are willing to pay for. I don't think Amazon is a threat to democracy.
*Anti-competitive behavior should still be investigated and prosecuted where it exists.
But even there, part of how Amazon got big was by using its position as both marketplace and market entrant to rig the game. They’d get pricing information on pacifiers, and then systematically undercut their own sellers until they could corner the market.
What market have they "cornered"? Their share of US retail sales is 10%, and 38% of online sales. I can buy pacifiers (your example) from Target, Walmart, CVS or any number of competing retailers.
Addendum: the example you use would also apply to every store-branded item sold by any retailer, including Walmart, Kroger, Albertson's, Walgreen's or Costco.
Like most human beings with an internet connection and a bank account, I find Amazon has made my life vastly more convenient. And yes, that does indeed imply I remember the era before it. I love Amazon.
But, c'mon, they totally abuse their tradition of dominance on a regular basis.
Capitalism is amoral. Capitalists can't help themselves. Their incentive is to maximize profits and share price, and this dynamic remorselessly leads them to do things that create deadweight losses. No, that doesn't make them evil ( I wrote "amoral" not "immoral"). Yes, that does mean we have to clip the wings of excessively powerful firms from time to time. Apple is next, I hope.
I’m curious what you think about Apple in this context. I’ve sort of convinced that Apple’s huge market share in smartphones is at least part of the reason why Apple iPhones haven’t come down as much in price as say flat screen TVs over the past 20 years. It’s also true that apple’s smart phone has gotten meaningfully better over past 20 years so there is some justification for prices remaining high.
Nonetheless, it seems like Apple’s market share means that while they are not a monopoly, they are close enough to one to have meaningful impact not just on iPhone prices, but squeeze suppliers and meaningfully depress wages.
Sort of a big windup to say I think Robert Bork’s conception of problematic monopoly (which heavily influences how we examine monopolistic practice in this country) is much too narrow and ends up letting too many monopolistic and long term harmful to consumers practices.
Android has a 70% market share of the global smartphone market, and 41% in the US, so I disagree with the premise of the question that Apple has a "huge" market share.
Gut reaction is that the answer lies more in the fact that smartphones have gotten meaningfully better over the past 20 years versus TVs.
Smartphones have gotten more complex and have quite a few core technologies that flagships have to be leading on: CPU/GPUs, cameras, screens, and modems. TVs on the other hand only really push on one technology: screens. They share this technology with a bunch of other products distributing the cost of research and development.
Further, and again this is gut reaction, I think demand for smartphones has been more reliably increasing than TVs. It's fairly normal to buy a new TV every 5 years if you're an enthusiast, maybe, whereas a typical household is probably taking that TV closer to a decade. (Just guessing.) Smartphones seem reliably on that annual cycle for enthusiasts and the 2-3 year cycle for everyone else.
I think Apple should be able to charge software vendors whatever it damn well pleases for access to its retail space (App store). It's very valuable cyber territory. But what it shouldn't be allowed to do is make it so difficult for *customers* to use non Apple retailing for apps. That would be the ideal compromise in my view. Pretty clearly, Apple's rich margins in the app sector are substantially driven by the fact that, if you want to reach customers of iOS apps, you have to go through Cupertino's online space.
Are you not aware of Amazon's anti-competitive-pricing stuff? Basically they tell sellers: You cannot offer a product on marketplace if that product can be found anywhere else at a lower price.
This was key to the creation of the Prime Free Shipping regime, and once people subscribe to Prime, it's easier for Amazon to keep them using Amazon rather than going to more-specialized alternatives for various products. The shipping is getting paid for by way of higher prices. If sellers were free to offer the product elsewhere at a lower price point with shipping broken out into a separate line item, then Amazon would have had a much harder time getting people to subscribe to Prime.
(To be clear I am not _radically_ anti-Amazon, I think some of the criticisms of them go overboard. But I absolutely do think they have engaged in anti-competitive behavior, with price manipulation being the most blatant.)
I agree with this philosophically. However, as a worker in an industry that has seen massive consolidation (which hurts workers (my) bargaining power through reduced employment options), I also see that if you don't do it here, then the competition does it overseas and you get crushed in marketshare. Rock meet hard place..... (semiconductors fwiw)
Someone was talking recently about how monopoly or oligopoly is the incubator of innovation, not competition - think it might have been Ezra Klein using the example of Bell Labs.
They were in a protected moat because AT&T just printed money, so the payoff for their research didn't have to show up next week or next year. Meanwhile the amount they came up with was staggering. Google, Microsoft, Apple and Amazon are in less regulatorily protected but similar situations.
But that's a pretty extreme outlier. AT&T was a utility. How many other utilities ever built a Bell Labs? Vanishingly few. Ameren UE, ComEd, ConEd, PG&E... all of them "print money", but none of them have bothered with anything similar.
Bell Labs seems to me like a peculiar legacy of one inventor, Alexander Graham Bell, a legacy *enabled* by his company "print[ing] money", but not *caused* by it.
I agree that the current crop of tech megalopolies have done *slightly* better -- they're all, along with IBM, deeply involved in the AI race, something we wouldn't have seen previous generations of incumbent tech-firms-cum-industrial-giants-cum-utilities do -- but it doesn't appear to me that any one of them has devised, let alone internalized, the "recipe for success [at innovation]".
Not to mention the fact that there seem to be a lot more examples to the contrary (monopoly stifling innovation) both in the US and abroad. Also: we can't visit the parallel universe where AT&T was broken up decades before. Maybe we'd have seen more innovation than we actually got.
well, I've also heard that innovation described as a product of high tax rates. It was so expensive to get the money out of the corporation that it lowered the threshold for an R&D investment to seem reasonable.
Apologies for not having the footnotes on this one. It was some podcast I think - maybe classic Weeds back in the day?
I am on mobile so apologies if I replied to the wrong comment but I thought you said you didn’t like companies getting big enough to compete with government, when that sounds very good to me.
Also, the “a lot more people” contention suggests that you’re as blind to rural issues as the typical lefty democrat. Just gutting Cargill or Tyson would help a lot more people than scope of practice reforms.
You understate corporate monopoly power’s harms vs those of individual/professional rent-seeking, David M overstates them.
The truth is that we desperately need to go after both sets of problems and there’s no constituency for a grand bargain to do so.
I'm all for enforcing and expanding anti-competitive statutes against Cargill, Tyson (and their competitors, ADM, Pilgrim's Pride, Bunge, Perdue, etc). Just not for "they are big" reasons.
Sure, and I agree that Khan is fucking up by the numbers. But while Stoller whiffs sometimes, he also smacks one out of the park sometimes, as he has done when calling attention to ag. processing collusion, PBM insanity, pharmaceutical supplier contract language, defense contractor consolidation and corruption, or regional hospital system consolidation and private capital investment/debt milking...
His takes on big tech are half-baked at best, but a lot of the rest of what he writes is more on-point.
Why Khan isn't positioning herself on firm ground and daring the Supreme Court's neo-feudalist faction to shoot her down on issues of great importance to rural folks is beyond me. That they *will* is obvious; that it will help Democrats in rural areas and swing states also obvious.
I haven't been able to stomach Stoller's illiteracy with respect to tech, and fear of falling prey to Gell-Mann amnesia has kept me away from everything else he's written. Can you (or anyone else) recommend anything specific where he's been good?
I wonder if your tally of when Stoller "smacks one out of the park" includes this one on realtors, or just those instances where he gores a disfavored ox?
I actually agree with Stoller and Khan regarding the lack of prosecution of anti-competitive actions. I think almost all non-competes should be illegal, for example. But Stoller's exaggerations and tortured rhetoric turns me off.
I’m not aware, one way or the other, of Khan’s work on these fronts but Stoller has gone after the company that monopolizes class rings, along with the company that makes and repairs milkshake machines (true villains, that lot), among many others.
Class rings - something economically unimportant, so it’s easy to ignore, but with sentimental value, so people are willing to pay exorbitantly. That’s insidious.
Respectfully, you’d find a lot more to like about the new antitrust if you’d look closer. The words “licensing” occurs in upwards of 30 issues of Stoller’s substack last year alone; some of these occurrences are about copyright but plenty are about occupational licensing. More broadly I’m often dismayed by the amount of skepticism toward this movement I see from reasonable people who don’t seem to have looked closely. Khan and Kanter are not trivial people. You don’t start to shift 40 years of jurisprudential lockstep on a central part of the political economy just by being really envious of Google.
What's so stupid about the current anti-tech Khan, Stroller, et al. view is what has really destroyed our functioning competitive marketplaces is the massive financial consolidation of nearly every industry over the past 20 years. How many industries can you think of that used to have healthy, fragmented 5-10 player spaces that are now down to 2-3 players? How many industries have gone all the way down to functioning duopolies?
THIS IS LITERALLY THE ENTIRE THESIS OF STOLLER’S BOOK UGH WHAT
…ahem, sorry about that, just continued deep confusion about exactly where a lot of you are getting your impression that the new antitrust movement is largely focused on punishing Big Tech for not being woke enough or something, because it’s sure as hell not in anything any of these people actually write.
Except it's not. The thesis of Matt's book is monopoly power not the downstream effect of consolidation in previously fragmented industries. The end state of consolidation is a duopoly not a monopoly -- which are much trickier because a duopoly can also increase buyer power in zero sum negotiations (e.g., auto dealership consolidation vs. OEMs.).
Or you closed the barn door after the horse was gutted, Netscape and Lotus 1-2-3 lying dead in a ditch. Though Gates claims the anti-trust action took Microsoft’s eye off the ball and allowed Google to establish Android when Microsoft had been all over mobile OS work for years and years. I imagine it also factored in to them keeping Apple alive by porting Office over.
Do people really no longer use Facebook? I personally stopped a few years back, but I was under the impression a lot of people still do. Meta's profits seem healthy of late, no? Is that mostly Instagram (I do use that).
It is still BY FAR the most heavily used social media platform worldwide, with YouTube coming in second. I am fairly aware of this because in my workplace we keep asking if we should expand our social media presence to use other platforms more heavily and/or get rid of Facebook, but then we look at the stats and the number of people with access and FB always crushes the others. Its number of daily active users actually grew in 2023, but it is losing younger people.
There is a difference in HOW people are using it though, with people tending to access FB groups on specific topics more, which is often how we use it at work, and to stay connected with friends and the local community. "Influencers" are leaving it for TikTok and Instagram. It is now considered a more staid platform. If you want to get a lot of followers, FB is not the place to go. If you want to get out information, especially with a low budget and to a targeted geographic area, FB works decently.
From what people in Congress say about it, that's probably generally true. But there's a whole bunch of non-partisan lawyers at the FTC and DOJ who are in it for the love of the game.
I heard somewhere the Carter Admin punctured Xerox’s balloon by making them divest their patents so companies like Canon could compete with them in photocopiers. Interesting decision there.
There should be a bonfire of American privilege, where doctors, lawyers, dentists, car dealers and nimby homeowners all give up their feudal rights for the good of the motherland. It could be an American version of August 4, 1789. The real question is, what will it take to unlock that kind of patriotism?
i don’t think you throw off entrenched interests without upheaval. of course, it would not be worth enduring the wars of the french revolution to reform professional licensure. i’m at a loss for how progress can occur
"it would not be worth enduring the wars of the french revolution to reform professional licensure"
The problem with the French Revolution wasn't the wars. It was the Terror. Reforming professional licensure isn't worth killing a modern-day Lavoisier either.
You should add engineers, architects, and landscape architects. Particularly landscape architects. The idea that a landscape architect does anything that should require their professional license is crazy. Maybe I’m getting out over my skis here and will be hit with “skin cancer” like the Seinfeld episode but if so what is it? What does a landscape architect do that is impactful to the health and safety of the public and therefore needs a professional license? What?
This is where private certification should come into play. Some might pay a premium for a zen-hydrologist-landscape master- but that needn’t be enforced by law. But fraudulent representation of credentials should be something the government has an interest in addressing
For sure, there are professional landscape architect organizations and professional planning organizations and that’s all good. But when a local government requires a landscape architect to sign and seal a landscape plan or even worse submit a certified cost estimate than that’s not worth while. We need to have a core value of protecting health and welfare. But when that is perversely used to create markets to help specific professional groups then that’s bad.
Yes, retaining walls would be a structural engineering function. Geotechnical engineers also provide input to this because soil conditions are an important factor. There are also different kinds of retaining walls. Usually walls under 4-ft or so don’t require a PE. Landscape architects may contribute to aesthetics but that’s not a health and welfare issue.
Wasn’t August 4 an attempt to get ahead of the “great panic” in which peasants had formed themselves into pitchfork brigades determined to end feudalism from the bottom up? In other words, your noble gesture might require a push from below.
History might have unfolded very differently if the harvest of 1788 had been more ample.
But, yes, the fear played into August 4, as did the patriotism inspired by the joining of the three orders in defiance of the King, and the i ability of royalist forces to restrain the Parisian mob.
I mean, liberal democracy is pretty important too, but you’re not wrong.
Moreover, egalitarianism - exemplified by the abolition of the nobility - can be broadly read as a mandate to oppose entrenched forms of economic power such as you describe.
I take great pride in having never had a single cavity and as such I very much enjoy going to the dentist because they tell me I have great teeth and am doing everything right.
I will say that anecdotally flossing makes a huge difference to my apparent gum health, for instance I leave the dentist much less sore than I did before I started flossing regularly. There are other signs too gross to mention in polite company.
I never had a cavity, either, until I moved to Los Angeles. Some of my dentists there used to find a cavity every other visit or so. Since leaving LA I've never had another cavity.
LA is a vain place, and the dentists know it. The movie industry only accepts flawless smiles from actors, and obsession permeates the rest of Angelino society. LA is a place where people go vegan because they're trying to make their skin nicer, not because they care about animals, where they do yoga to get toned physiques rather than for the relaxation and health benefits, and the list goes on. Dentists are in a good position to take advantage of the vanity of Angelinos and the desperation of wannabe actors, so they do so.
In my case, I never had a cavity until moving to LA. My dentist there found some and then I got some fillings and then those fillings had various problems and had to be replaced a few times over the years. I dealt with a very culture shock-y dentist for several years in Texas (Christian radio playing in the background the whole time) until during the pandemic the practice stayed unmasked. I’ve been very worried about my new dentist back in California, especially when the temporary patch on my fillings that needed replacing wore badly in the few weeks I had it. But since the real replacement happened everything has been fine so far.
Floss regularly, floss meaningfully, floss athletically, and above all, never forget who is the boss of you. Me! I am the boss of you! I am the boss of you!...
I knew my current dentist was a good guy and honest dentist when in my first visit he concluded his exam by singing "I can’t make any money off you". Meaning (a) he was willing to admit he was trying to make money but (2) not willing to invent problems to do it (which he totally could have). So far so good—no issues for the last 5 years.
I don't take pride in it, but have never had a cavity and go to the dentist about once a decade, now. Worst my teeth ever feel is always after some "precautionary" work a dentist wants to do.
Dunno. My dad had an impacted wisdom tooth that dentists wouldn't remove because it was right next to a nerve. It would regularly get infected, and it was an all-around pain. I realize that the data about prophylactically removing impacted wisdom teeth is mixed, but at least some impacted wisdom teeth are troublesome.
I didn't have my wisdom teeth out until my late 20s/early 30s, and every single one of them eventually became a major issue before having to be removed. And then it took a few years to deal with the problems they caused in neighboring teeth. Maybe others are luckier, but I'd say if there's any sign they will be trouble, just get them out and be done with it.
As an insurance professional, I simply hate and abhor insurance that only offers small-dollar coverage and doesn't actually mitigate a significant amount of the insured's risk. So I'm glad you highlighted dental insurance for this reason
Lawyers are just as bad, maybe worse. If you ever go to a divorce lawyer for a consultation, you are very likely to be nudged towards divorce. Once you cross this bridge, you’ll be nudged towards detailed discovery to document your spouse’s misdeeds. Then a complex parenting plan that provides fodder for contempt actions.
The lawyers are several orders of magnitude more horrible. They’ve set the goal of turning the United States into Brazil as quickly as possible:
1. Make regulatory compliance impossible, forcing the entire SME sector and wide swathes of the middle and working classes into the gray market.
2. Make the administration of the civil legal code into a luxury only the rich can afford to access despite the specific underpinnings of our court system designed to prevent that very outcome.
3. Completely destroy the criminal justice system and cripple state capacity for law enforcement, ensuring a bifurcated public safety situation for rich and poor.
As in house counsel, what I find it frustrating how the law is generally pretty simple and straight forward but written in an intentionally abstruse manner. Most legal problems could by solved by non lawyers if the law was more plain language than esoterica. I spend lots of time confirming to internal clients that they do in fact understand the contract, even if the sentences themselves are incomprehensible.
If lawyers didn't write like dumbasses we'd have much better access to justice in this country.
Access to small claims/municipal court should be based on fulfilling 2 of 4 criteria:
1. Total claim under $50,000 (not $5-10k as in most jurisdictions today)
2. Plaintiff household income under 1.5X local median (or just set this at $100k for simplicity).
3. Defendant income under local median (or set at $65,000).
4. One of plaintiff or defendant is a corporate person other than a pass-through LLC. (S-corp, registered in multiple states, etc.)
Sure, you can still bring a lawyer, but from experience the judge is going to be much more patient and willing to explain than in any formal courtroom setting.
judges strongly prefer dealing with lawyers. the main benefit of a legal education is learning about relevance. lay people have trouble knowing which facts are dispositive
Haven't tried, but I'm pretty sure ChatGPT is already capable of translating legalese into plain English. No need to spend $750/hour paying a lawyer for it.
Working in law I found it funny that the most universally maligned attorneys - personal injury billboard guys - tend to be some of the only lawyers who at least work on a system where the attorney's financial incentives are aligned with their work. "I will do all the work for free and in exchange I get 40% of the cash we get out of it" incentivizes taking cases with merit, settling when auspicious, avoiding time consuming and costly practices (though, yes, I am aware of the medical lien scams that frequently screw people over) and generally trying to get the best bang for the least work. Whereas hourly lawyers work for a system where it is always in the attorney's best interest to prolong the case and charge the client for everything.
the problem is these incentives encourage attorneys to collude with clients to fabricate or overstate injuries. most pi clients are princesses, and you have to have a great reputation to get the serious injury cases
I remember something about an ethical principle that a lawyer is not supposed to take a case in which they have a financial interest (aside from getting paid for their time), which is what makes the contingent fee system seem sketchy, since their compensation is directly tied to the outcome.
of course PE/M&A lawyers investing in client deals and GCs getting huge stock awards doesn't attract as much criticism as the PI lawyers trying to recover for the little man
Corporate/government lawyers are basically the only people with a cushier gig than environmental and public engagement consultants, and those are the only two groups of people with a cushier gig than transportation design engineering firms.
Corporate lawyers work famously brutal hours and also have nothing to do with the vices of which people here complain. They are basically project managers for deals, they don't really practice law as most people envision it.
I'm confused at what legal and regulatory regime could possibly make M&A lawyers unnecessary. It's just not possible to do a nine-plus-figure deal without a lot of people making the paperwork run right in a lot of different areas.
The structure of criminal defense is interesting. Basically, unless your client is OJ Simpson or Donald Trump, your client gets walloped if you fight too hard. It’s much more efficient than civil law, but it gives prosecutors and judges a great deal of power.
Its really going to mess with law firm economics. The way firms make money is via the mark up on associate and staff work. If it takes fewer associates and staff to produce a legal product, clients will either expect instantaneous service under current staffing or lower prices and fewer staff. I also expect more routine work to be brought in house, leaving firms for bet-the-farm work only.
Law firms have already implemented a lot of labor-saving technology in the past few decades and have only gotten more profitable. Computerization had a cataclysmic effect on legal practice. People and businesses will always be willing to pay hand over fist for expertise and experience handling major events.
A *lot* of bread and butter document management and discovery work that's easy to farm out to junior associates stands to essentially be abolished by AI IMO.
I'm drawing a distinction between bet-the-farm litigation/high stakes dealmaking and the normal bread and butter work that is 95% of law practice for all but a handful of lawyers in any market. Its the flow of routine work that will be at risk from being brought in house. The team at Wachtell that represented Twitter in its merger litigation with Elon Musk will be fine, your average commercial real estate practice group will face tons of pressure. Think about it this way--rather than typing an email to outside counsel, which gets forwarded to an associate/paralegal to do the work, the in house lawyer types the same message into AI legal software, which instantaneously spits out the requested documents. Its really hard to see how the typical law firm model works in that scenario. Its an order of magnitude more productivity enhancing than command-f or copy and paste combined with a document and clause database.
A family law attorney is not a marital counselor. If you’re seeing them then presumably you are divorcing. I actually don’t understand your comment. (Speaking as an attorney but not a family law attorney.) A marital counselor is more like a dentist or dental hygienist. A family law attorney is more like a surgeon.
To complete the analogy, I think DA is saying that these attorneys are like unethical & incompetent chiropractors who knowingly injure patients during "adjustments" in order to keep them as long-term clients.
I don't know enough to say "common", but I'd say "not unheard-of".
To the extent that it's a problem, it's mostly a benign form of malpractice, not malign. As in, they tend to be True Believer types that don't think they're doing any harm, but simply aren't skilled enough/haven't practiced enough/are using riskier techniques in an irresponsible manner. They probably figure that whatever they break, they can fix with the healing power of _woo_.
But most importantly, they don't want to lose face with their clients. So they smile and act like everything's OK and they're in control. And the client ends up staying with them, even if they're actively harming them, and they're effectively leeching off the client.
Breaking my commenting moratorium to say that complaining that when you go to a "divorce lawyer" for a consultation you are "nudged towards divorce" is like complaining that you went to a car dealership and they sold you a car instead of trying to convince you of the benefits of using public transportation. The job of a divorce lawyer is to handle a divorce and related legal proceedings and tell you what you need to do to optimize your position in that process, not counsel you on how to fix your marriage.
Breaking my commenting moratorium to say that it's over tomorrow, although I'm trying to decide whether to penalize myself for making comments during the moratorium by extending it for additional days for each day I made a comment. That would extend it to Saturday.
IME becoming a doctor is so opaque while also requiring a relatively clear commitment to a demanding career path basically right of high school, that the Americans who become doctors are all just the children of doctors.
The thing is, evangelicals are much more likely to get divorced than secular professionals. Because fornication is a sin, they marry younger than secular couples and are unlikely to cohabit before marriage. It’s very hard to pick a good life partner when you are 23 and still very much a work in progress. It’s also harder to stay monogamous when you are in your twenties and your hormones are still raging and you never played the field long enough to get bored.
Cohabiting before marriage is actually correlated to a higher level of divorce overall, I believe. I don’t know about the other stats, though (age and religion).
I always feel like there's selection bias at play that needs to be accounted for. The people who feel that long lasting marriage is an overwhelming good in and of itself seem more likely to prioritize getting married quickly, and staying so.
Oh I am in no way trying to say that not cohabiting is the only path to a happy marriage. My husband and I cohabited for almost 10 years before marriage! It’s just not factually correct to say people who cohabit before marriage have lower divorce rates. Your supposition seems like a perfectly reasonable mechanism for that statistical outcome.
Agreed. My longstanding take is that relationships are a very diverse and complicated thing that each couple has to find for themselves, and broad prescriptions saying what is best are always wrong to make.
Stone has incredibly good points about certain things and is much less insane than some of his peer "Christian pro-natalists," but there are some gaping blind spots in there.
I think research is pretty conclusive that religiosity reduces divorce rates and cohabitation increases them, and that the latter is probably mostly explained by the former.
Can (somewhat) confirm for Mormons, although I’d quibble and change “better at matchmaking” to “overwhelmingly greater social / community support for young married couples.”
I was going to ask about this. Is there any data on the partisan split of dentists? I’d imagine pre-Trump they would be classically Bush republicans but wondering if education polarization has pushed them to be more split these days.
That actually illuminates something for me on education polarization.
To wit, that it's not JUST an educational divide, but an age divide as well. At the risk of triggering certain parties around here, it's a clear-cut example of a small-i intersectional phenomenon - it's a divide that exists along two intersecting axes of identity, education and age.
All that is to say, the Boat Parader Pipeline has most certainly become attenuated for the Millennial dentists, while we should probably expect Boomer and Xer dentists to have broken hard for Trump in recent years.
Ed: Also, the Boat Paraders themselves are probably in part responsible for the polarization. If the senior incumbents in the industry are hogging all the gains, then the younger generations are going to find it harder to break through, and backlash against them. It's classic intra-guild politics.
One of my pickleball friends is a veterinarian, the economics of that sort of business are comparable to dentistry. Having a fancy vet clinic has become so capital intensive that most are owned by venture capitalists. The actual vets are just well paid professionals, they might parade in a 24 foot boat with outboard engines, but their nautical ambitions will always be rather déclassé.
That’s interesting that “dentist” and “dental assistant” and “dental hygienist” are all basically 60-40 for Republicans! Orthodontists are a bit more Republican, and periodontists a bit less.
Yeah, I would have expected the assistants and hygienist (who make less money than dentist) to be less Republican.
I should say that I wouldn't take that dataset as gospel. I think it's generally useful, but there might not be enough data to have good statistics on certain specialties. (How many periodontists are there? Probably less than orthodontists.)
Floss regularly, floss meaningfully, floss athletically, and above all, never forget who is the boss of you. Me! I am the boss of you! I am the boss of you!...
You need to expand the homeowner class well beyond CA. Also, re parking, should read “I can’t park my vehicle right outside the door of my destination indefinitely without paying, and I shouldn’t have to encounter losers who walk or bike during my journey”
Basically any alumni community that slaps each other’s backs while bragging about their IRAs (they pronounce it “Ira”) over their “alma mater’s” football game...
... all while wearing a nylon v-neck pullover jacket in their school colors.
Good stuff, as usual. Minor point: MOST Cochrane reviews (not just of dentistry) conclude that insufficient evidence is available to reach a clear conclusion.
Was going to say, they're famous for "quality of evidence is low..." I'm not sure how much dental research goes on compared to other medical specialties but I'd assume it's tough for them to hit the Cochrane bar.
You're missing the point. The right takeaway from looking at the evidence in many cases and concluding the "quality of evidence is low" is that the quality of evidence is often low! And it's even worse for dentistry than medicine!
I haven’t looked into Cochrane, but often the “evidence-based medicine” movement has a lot of problematic takes where they pretend low quality evidence doesn’t exist, rather than trying to aggregate it in ways that let you draw some tentative conclusions. This was one of the big problems with masks - there was a lot of low quality evidence and no high quality evidence, so they pretended there was no evidence.
I think this often describes a situation in which low-quality evidence, the likes of which Cochrane denigrates, is competing with one's own empirical observations. (Which are, of course plagued by many kinds of bias, but are immune from others.) But that's almost always implicit, so it seems like they're saying there's "no evidence".
Cochrane reviews are wonderfully in-depth and get reexamined from time to time. It's not like they're a red vs. green light guideline. Almost everything in Medicine is tagged "proceed with caution" instead of "proceed with confidence" or "do not proceed" so the Cochrane analysis still gives us some direction through the gray area.
Also, my dentist growing up was coincidentally an Air Force dentist in the '80s. Wonder if any of his records made it into the study you cited!
Also do optometrists next. Why do I need a new prescription (< 1 year) to get glasses! I know if I can see or not! It's to force me back every year that's what. Even worse for my fellow folx experiencing nearsightedness who need contacts!
And do car dealers! And hair dressers! DEATH TO RENT SEEKING!
Optometrists vs. opthalmologists have a similar scope of care battle as dentistry though optometrists have achieved more independence than hygienists. But, yes, there is definitely rent-seeking going on with optometrists because, like dentistry, the routine care doesn't pay the bills. It is a valuable service but does open the door to the moneymakers: procedures and product. The feds forced optometrists to provide glasses prescriptions and, later, contact lens prescriptions because the rent-seeking was so obvious.
During the pandemic, a police officer smashed my glasses (long story), and when I tried to get them replaced Kaiser told me 1) my prescription was 28 months old, so they couldn’t refill it; 2) they couldn’t provide my prescription to me so I could get glasses elsewhere; 3) “no one else” would take an outdated prescription; 4) because of the pandemic they weren’t doing appointments to renew prescriptions, so I was SOL.
I ended up punching random numbers into Zenni based on a very old RX and suffering chronic headaches for three weeks before LensCrafters had an opening.
Especially since there are plenty of rich counties where your glasses or contact lens prescription doesn’t expire after 2 years, so it’s not as if our rules are a safety issue.
Do you, though? For a few years until I got my first glasses, I just thought all the whiteboard text looked faint because the markers were running out of ink. Gradual shifts in one's eyesight seem like they could be easy to miss in general.
Why is insurance so bad with glasses? If you want coated and compressed lenses, that will be $300 on top of what your insurance pays us. But you can buy this stuff from China for $50, shipped. What exactly is your margin here?
There are some interesting deep dives into how tons of glasses and sunglasses brands are owned by Luxottica, who keeps their margins very high and competition fairly low. Not sure how much of the articles were hype, but it does kind of feel like a racket. Tons of little startups have come around to undercut them (Warby Parker, etc).
I don't think I get it. We get insurance to protect us from unexpected exorbitant expenses. Dialysis is a major expense. What difference does it make that the expense is spread out over a long period of time? After all, disability insurance is a thing. If I know that there's a chance that I'll get stuck in a condition where I need to spend >$50,000 a year or I'll die, wouldn't I want to be insured against that?
As for glasses, what I have is not insurance, but a "vision plan." Is that fine because it's not called insurance?
Not disagreeing with you about what optometrists will do, but I want to point out that I can go on eyebuydirect.com (and others) and buy glasses with any prescription I want of any age I want.
What's really bonkers is how many non-optometrists will defend the new prescription thing. E.g. it may have a second-order effect that drivers are more likely to have up-to-date prescriptions, and that's clearly the best way to achieve that aim.
Fun fact: in the bike industry, the term for someone who walks into a bike shop and buys an expensive ($5k+) bike is a “dentist” --- not a lawyer, programmer, or doctor.
I dunno. I recently had some work done. (Teeth, that is). There was plenty of info on the web. I'd say it's a wash. And the the auto repair industry if anything is probably a stronger rent-seeker in terms of stifling competition.
Someone needs to figure out how to separate the business of inspection/diagnosis from repair.
Someone start a startup that does inspection/diagnosis and get quotes for you - they could probably charge a yearly subscription. Anything as long as they don't have a financial stake in the cost of repair. Then, they get quotes from mechanics and repair shops.
>Someone needs to figure out how to separate the business of inspection/diagnosis from repair.<
Agreed. In the real world, though, I think that's called "being lucky enough to personally knows a highly knowledgeable person they genuinely can trust."
I love this. Except if you show one case to three dentists and you'll get three different diagnoses and 10 different treatment plans. This is a bug but also a feature. I don't know how you get around the problem of differential experience/personal skill sets of individual dentists. Standardization in what is essentially a cottage industry is a really difficult problem.
I was thinking of typing this identical post...there needs to be a Jiffy Lube for oral care, where they do teeth cleaning and other simple services, but refer you to a dentist when they spot trouble. This has happened to a small degree with basic medical care given the growth of ZoomCare and other chains where a PA can examine you and order basic tests and prescribe limited meds....
But of course there aren’t state regulations on automechanics limiting what you can do in your own driveway, or what you can pay to do at a Jiffy Lube versus a dealership versus a full service garage. Mechanics simply take advantage of information asymmetry and do relentless upselling just like every other service provider in the world: plumbers, furnace repairmen, roofers, foundation repair, etc.
The best advice I ever got...have one person in your life at all times who changes his or her own oil. Gives you someone to call when your car shows a certain symptom, or dealership tells you your fetzer valves need replacement.
Oh - and make sure you always make friends with someone who owns a pickup truck too...
I hate to say it, but this article may be making a case for insurance company reviews of the appropriateness of care provided. I'm sure doctors want to provide care appropriately, but knowing that a 3rd party payor is looking over their shoulder, or an HMO organization is doing an analysis probably keeps people on straighter and narrower paths than they might actually cleave to naturally. Of course other countries' health systems have much different mechanisms of review, but they certainly proscribe the kinds of care that are appropriate, moreso than in the US.
The only way to anything close to that kind of third party review with dentistry in the state it is in, is to never allow the first dentist you go to to do any kind of questionable procedure on you without having gotten at least a second opinion.
The thing is, when the insurance company does their review of the appropriateness of the care provided, what happens is that the care was already done weeks ago and it's just a matter of if the patient or the insurance company has to pay the bill. It's not going to stop the procedure from happening; it's far too late for that.
They have prior authorizations. Also being an in network provider and doing medically unnecessary procedures will not be good for your future relationship to that insurance company, I’d wager.
EDIT: Also it really won’t be good if the doctor works for the organization - like Kaiser or another managed care setup which are getting more common all the time.
I'm not a fan of the prior authorizations, because in practice the insurance company is basically just a distant bureaucrat who isn't on the ground evaluating every case -- which would be prohibitively expensive.
I lost a comment draft, but I like the idea of having a process where post-hoc review feeds into approved standards of care. Which is essentially what we already have, albeit with tons of intervening distortions. Seems to me like a competent application of Slow Boring Process would be to simply bore away at eliminating those distortions, not trying to invent and perfect entirely new mechanisms.
Insurance denies expensive stuff, not things that are inappropriate. As a physician, the only results of insurance denials I've ever experienced are 1) doing an hour of paperwork and ultimately being allowed to do what I wanted, or 2) being denied a newer medication or a dose that is less commonly manufactured and having to put my patient on something with more side effects or risks because I can't get the best care approved. Often the patient can then get the original med I wanted after the insurance approved one doesn't work or causes the side effect we were trying to avoid.
Dentists who drill patients' teeth without medical justification are committing criminal battery. The injuries they inflict, purely for financial gain, lead to a lifetime of physical impairment, pain, and the need for further medical intervention
"Drill 'em fill 'em bill 'em", when not medically necessary, is not a joke. It's a crime.
I'm not as up on the details as some who were discussing it in detail (and posting links and everything) on this stack, but apparently a (banned?) subscriber was using your handle to troll? Or something? Anyway, don't mean to alarm you...just thought I'd pass it along.
Yeah, puni's can do some of what criminal charges can do for deterrence, and with less hassle (don't have to persuade a prosecutor to bring charges, e.g.).
People are bad at evaluating when dentists are being shysters as opposed to giving reasonable medical advice, because they both have similar external presentations, viz. "this is a problem, you should fix it," and patients don't know enough to consistently evaluate that claim correctly.
Or overtreating. There are a lot of "you'll need to deal with that down the road" things in any medical specialty that create a gray zone. And a lot of things will have a small positive marginal value if cost isn't a consideration. A doc/dentist being risk-averse can look similar to being financially-motivated.
One of the problems is standardization. If you show one set of x-rays to multiple dentist you'll have multiple judgements based on education, clinical experience and personal experiences of the dentists. I don't love that this is the case, but it is.
Some dentists will treat a cavity when it's a tiny speck on the x-ray. Some wait until it's broken into the dentin on the x-ray. Who is right?
This is not some kind of unknowable mystery of the universe. Juries in med mal trials determine these things all the time, with the assistance of expert witnesses on both sides.
If someone hacked off your leg claiming that you had cancer, and it turned out they were lying, they would face at the least a civil tort for malpractice. If they did it knowingly for gain they could face criminal liability as well. We should not think of teeth differently. Intentional mutilation of someone's mouth for gain is a vicious assault on their bodily integrity.
"if you don't trust your dentist's judgement, then why go to that dentist?"
I get it, but asymmetrical information is a problem that plagues all medical fields. There comes a time where you have to trust your practitioner.
I suspect that "intentional mutilation" happens in dentistry rarely. I think poorly thought out treatment plans that are executed poorly is much more common. The idea that a dentist walks in the room, tells you what you need and you accept without any discussion goes against reality, IMO. In my experience proper informed consent happens in dentistry much more often than medicine. If you don't trust your dentist and their team and they won't answer questions to your satisfaction, you should walk.
I am a physician and it astonishes me how often there are no high quality trials to describe what is best in dental care, particularly compared with medical care.
And then Matt goes on to quote some study that is the exact sort of low quality evidence that the Cochrane folks are talking about. So Air Force recruits from Mississippi have worse teeth than those from Oregon? And he concludes it must be the lack of restrictions on dental hygienists in Oregon. It doesn't take a serious medical researcher to wonder if it might be one of 14 million other potential explanations.
It never ceases to amaze me that some people push for healthcare providers with a fraction of the training to be allowed to do more and more things that they are simply not trained to do. Are we sure there isn't a dental hygienist in the family?
i think the point in this case is that the hygienists basically do all of this stuff anyway and if they were allowed to do it as an independent operator instead of as some guy's employee it would be better. 'how to run an enterprise' is not, in fact, privileged information
of course, as a physician, one wonders if you might have an axiomatic opposition to this notion of independent operators who did not shell out for incredibly expensive and mostly-unnecessary training that is not the global standard because your own profession is full of rent-seeking, regulatory barriers, and lots and lots of overworked and underpaid NPs who can do most PCP work themselves
Same: I always instead just use the British version of general practitioner to avoid this confusion. That and the word queue are my two favorite British English differences.
I am too lazy to go back and read it again, but I don't think Matt was proposing only that hygienists open their own teeth cleaning shops. He was advocating for them to start filling your cavities too. If all they wanted to do was open more places to clean teeth with no supervision, that might be viable and within the level of their training. Are they trained to read Xrays and diagnose tooth problems?
Evidence is increasingly showing that lesser trained primary care providers (NP's and PA's) make for more expensive care, particularly as primary care providers.
Some of my medical training was more valuable than other parts, but calling it 'mostly-unnecessary' is ridiculous. I would think 'mostly' means more than 50%, and I am just going to assume you googled this.
I'm also a physician and understand that scope of practice for mid-levels is tough, especially since the slippery slope arguments aren't fallacious. The equilibrium "hygienist cleans but dentist diagnoses and does procedures" is similar to where most medical fields are right now. But high access to medical care (and technological advancement) has really increased demand in a way that stresses that equilibrium without a way to generate more doctors/dentists to meet it.
I do think dentistry is pretty similar to Medicine in the '80s and there's a reason things changed. Too many people get zero dental care and others get too much elective care. While dentistry has sidestepped the expansion of access Medicine has, governments REALLY don't like a labor shortage so will often step in (though they don't tend to act just for cost savings).
I'm not specifically advocating that loosening scope of practice is good or bad. It just has trade-offs and governments will eventually step in once the public gets mad enough.
Low quality evidence is better than no evidence, as long as you recognize that it is low quality.
If all you had was a comparison of Mississippi and Oregon, obviously there would be lots of confounds, but unless there is a systematic correlation between (say) rural poverty and regulations on what dental hygienists can do, you can mitigate this by looking at 50 states rather than just 2.
Ignoring low quality evidence is how we got the idea in the early pandemic that there’s no reason for anyone to wear a mask, because we don’t have any randomized controlled trials of the effectiveness of non-medical-professionals wearing masks.
Matt has gone after doctors in previous posts as well. I love his stuff generally but for some reason he has a huge issue with the salaries of educated professionals specifically. As a physician, I can only conclude that I shouldn't have spent 10 years in training after college and should have spent my time on something people value like PE or writing code for a dating app.
If the reason you became a doctor was to take advantage of industry organizations that lobby state governments to over-regulate your work, shifting a utility surplus from average Americans to your community of high-income earning professionals ... than yeah, maybe you should have gone into PE or coding.
I became a doctor to help patients. The amount of training, time, and tuition put into being able to do so needs to be adequately compensated just like for any other job. Otherwise talent will go elsewhere.
Sure but if there wasn't a hard cap on new doctors per year, costs would come down. Right now, a lot of the talent can't enter the profession in the first place.
Physician salaries are 7% of total healthcare costs. You could cut them in half and not much would change. I agree we need more residency spots to increase access to care, and I could take a pay cut in pursuit of that goal, but no you are not going to address healthcare costs that way.
It's the scarcity of access through the gatekeepers that has a lot of secondary costs to my mind, not just salary. Any fixed cost that can be split between more physicians can be reduced, (like expensive specialty equipment) for instance. More practices means competition to keep costs down across the board.
Is there a reason why traditional market forces won't work if scarcity of physicians is eliminated?
This is timely for me. I’ve been going to the same dentist for several years, who I like. When I saw him this summer, he recommended no new treatments. This fall, he hired a new dentist to work under him, and I saw her this time. She recommended treatments for EIGHT teeth and a nighttime mouth guard, despite no issues on my end. I decided it’s time for a new practice. Ironically, if she had recommended treatment on one or two teeth, I definitely would have said “oh, sure, let’s do it.”
I can't tell you how many patients my Wife has converted just because she does the opposite of sell them on unnecessary treatments and procedures. She gains their trust precisely because she will never oversell them.
It's the opposite for me: when I came back from college and started going to the dentist the rest of my family goes to, the old dentist pushed hard on procedures that seemed overkill. The worst was recommending jaw surgery to correct my childhood dentist overcorrecting my bite, which I pushed back on immediately. Then that guy retired, and was replaced with a friend I knew beforehand, and he never tries to pull any funny stuff on me. Glad he's my dentist.
I had a dentist note a few issues with fillings and minor cavities. They gave me a prescription tooth paste, but 9 months later they had to do 4 fillings. A big problem was seltzer and grinding (which runs in my family).
I am skeptical that carbonated water is hard on your teeth. There are studies going both ways. Additionally, you breathe out carbon dioxide continuously, so your saliva contains carbonic acid 24/7. If a few seconds to swallow some bubbly water is bad, one would think we would have lost all our teeth to breathing before adulthood.
The issue is it acidic and if you don't eat while drinking it, then you saliva won't wash the acid away. It is also substantially more acidic than saliva, which tends to be neutral.
"In a study using teeth that were removed as a part of treatment and donated for research, researchers tested to see whether sparkling water would attack tooth enamel more aggressively than regular lab water. The result? The two forms of water were about the same in their effects on tooth enamel. This finding suggests that, even though sparkling water is slightly more acidic than ordinary water, it's all just water to your teeth."
I'm a dentist and I think some of the concerns addressed here are legitimate. Specifically the problem with good science in dentistry. Experimental design is hard and everyone is affected by incentives, even dental researchers.
I'm on the inside with dentistry and see a bunch of statements that anyone in the industry would see as misguided or even outright incorrect. There are some TERRIBLE things about dentistry (private equity, anyone?) but much of what Matt talks about misses the terrible stuff. The article has given me a case of Gell-Man Amnesia. I honestly worry about the things Matt gets wrong in other reporting simply because I don't know a lot about it. It makes me worry about journalism in general that someone I generally think of as a quality journalist would publish in this way.
For instance, if allowing hygienists independent practice would make dental outcomes better and dental care cheaper, I say bring it on. But practice overhead, staffing and dental benefit coverage are problems that independent hygiene will face just like dental offices. No hygienist is going to go into independent practice simply to help people more effectively. They would do it to run their own business and to make a profit. And they would face the exact same problems that dental offices face. Again...there is a lot about dentistry that's messed up, but much of what Matt talked about isn't it, IMO.
Also, if you ever see a negative article posted about dentistry the comments almost always devolve into "my dentist was a hack and a crook" stories. Which are undoubtedly true, but all of them are anecdotal and cannot be extrapolated onto the profession. Dentists are one of the least sympathetic characters in day to day life. Trust me, I get it. The number of times I hear, "no offense, but I hate dentists" in a day is shocking.
I host the "Very Dental Podcast Network" and have for the last 10 years. I would LOVE to have Matt on to talk about some of this. :-)
> For instance, if allowing hygienists independent practice would make dental outcomes better and dental care cheaper, I say bring it on. But practice overhead, staffing and dental benefit coverage are problems that independent hygiene will face just like dental offices.
I think that the intuition is that if the supply of basic dental services increases, prices will go down. They certainly have room to go down, given the extremely high incomes of dentists relative to the population. Recall this passage from Matt's post:
> And dentists make a lot of money. As Jonathan Rothwell points out, “there are five times as many top 1 percent workers in dental services as in software services.” About fifteen percent of dentists earn enough to qualify for that lofty status. The median hourly wage in the United States is $22.26 versus $74.54 for dentists.
I wonder how the payout works for DSOs with venture capital backing. I would imagine it's a phased payout with targets so the owner or partners have an incentive to maintain revenue and margins as they ease into retirement. (But maybe it's a one-and-done. I have no idea.) Also, rolling up practices with venture capital is a fairly new game, so anyone looking at recent data will see recent trends.
Perhaps it's more informative to look at the Bureau of Labor Statistics' page on dentists' pay: https://www.bls.gov/ooh/healthcare/dentists.htm#tab-5. It indicates that, as of May 2022, their average wage was $155,040. This figure excludes the incomes of orthodontists and other specialists.
Medicine went through the same thing. People thought they could get the same quality care for less by going to an NP instead of a "greedy doctor". Turns out nurses are also humans capable of greed and less education doesn't lead to better outcomes. I think people just don't like being in a situation where they feel out of control and have to pay to fix something. Everyone at any business is trying to sell you someone but only lawyers, doctors, dentists, and auto mechanics regularly get accused of being crooks. It's the information asymmetry and circumstances of your arrival.
It's also easy and not time-consuming to price compare between Target and Wal-mart. It is not easy and is quite time consuming to price compare different dentists.
"Everyone at any business is trying to sell you someone but only lawyers, doctors, dentists, and auto mechanics regularly get accused of being crooks. It's the information asymmetry and circumstances of your arrival."
Information asymmetry is the problem and the solution is a really difficult problem.
You write: "I acknowledge that this kind of thing can feel a little picayune relative to policy disputes that speak more to our core values and our identity as a nation."
Allowing competition, providing a path for individuals (hygienists, in this case) to find a path to financial success, avoiding unnecessary regulation and dismantling regulatory capture wherever it is found are, or should be, part of our core values as a nation.
Thank you for highlighting this example.
Occupational restrictions deserve way more criticism than they get, I hope stigma builds up against them like has happened with NIMBYism. The economic cost is bad but there’s also the human cost of people being prevented from fulfilling their potential.
The human cost pisses me off much more than the economic cost. The path to a better and more fulfilling life is being closed off for millions of people through overly restrictive licensing and regulatory structures.
All the new antitrust thinking by Lina Khan, Matt Stoller, et al., is focused on the big tech companies, and seems to be motivated by a general sense of anti-bigness and a little bit of envy at highly profitable businesses. I wish they would focus their intellect on how government protection creates monopoly-like barriers to entry. It would help a lot more people.
I’m always leery of talking about envy, but what’s your specific objection to the anti-bigness?
My personal position is that it’s just generally bad to have businesses that are big enough to compete with the government. Economies of scale are nice, but there’s a point of diminishing returns where we lose our democracy and turn into a corporatocracy.
When being big is achieved because a company provides a superior product or service, I see no issues*. Amazon, to use the example that brought Khan to prominence, is big because they provide something lots of people are willing to pay for. I don't think Amazon is a threat to democracy.
*Anti-competitive behavior should still be investigated and prosecuted where it exists.
But even there, part of how Amazon got big was by using its position as both marketplace and market entrant to rig the game. They’d get pricing information on pacifiers, and then systematically undercut their own sellers until they could corner the market.
What market have they "cornered"? Their share of US retail sales is 10%, and 38% of online sales. I can buy pacifiers (your example) from Target, Walmart, CVS or any number of competing retailers.
Addendum: the example you use would also apply to every store-branded item sold by any retailer, including Walmart, Kroger, Albertson's, Walgreen's or Costco.
I find this a little maddening! What consumer is worse off because Amazon exists! They clearly provide enormous value to consumers!
Like most human beings with an internet connection and a bank account, I find Amazon has made my life vastly more convenient. And yes, that does indeed imply I remember the era before it. I love Amazon.
But, c'mon, they totally abuse their tradition of dominance on a regular basis.
https://www.ftc.gov/news-events/news/press-releases/2023/09/ftc-sues-amazon-illegally-maintaining-monopoly-power
Capitalism is amoral. Capitalists can't help themselves. Their incentive is to maximize profits and share price, and this dynamic remorselessly leads them to do things that create deadweight losses. No, that doesn't make them evil ( I wrote "amoral" not "immoral"). Yes, that does mean we have to clip the wings of excessively powerful firms from time to time. Apple is next, I hope.
I’m curious what you think about Apple in this context. I’ve sort of convinced that Apple’s huge market share in smartphones is at least part of the reason why Apple iPhones haven’t come down as much in price as say flat screen TVs over the past 20 years. It’s also true that apple’s smart phone has gotten meaningfully better over past 20 years so there is some justification for prices remaining high.
Nonetheless, it seems like Apple’s market share means that while they are not a monopoly, they are close enough to one to have meaningful impact not just on iPhone prices, but squeeze suppliers and meaningfully depress wages.
Sort of a big windup to say I think Robert Bork’s conception of problematic monopoly (which heavily influences how we examine monopolistic practice in this country) is much too narrow and ends up letting too many monopolistic and long term harmful to consumers practices.
Android has a 70% market share of the global smartphone market, and 41% in the US, so I disagree with the premise of the question that Apple has a "huge" market share.
https://explodingtopics.com/blog/iphone-android-users
Gut reaction is that the answer lies more in the fact that smartphones have gotten meaningfully better over the past 20 years versus TVs.
Smartphones have gotten more complex and have quite a few core technologies that flagships have to be leading on: CPU/GPUs, cameras, screens, and modems. TVs on the other hand only really push on one technology: screens. They share this technology with a bunch of other products distributing the cost of research and development.
Further, and again this is gut reaction, I think demand for smartphones has been more reliably increasing than TVs. It's fairly normal to buy a new TV every 5 years if you're an enthusiast, maybe, whereas a typical household is probably taking that TV closer to a decade. (Just guessing.) Smartphones seem reliably on that annual cycle for enthusiasts and the 2-3 year cycle for everyone else.
I think Apple should be able to charge software vendors whatever it damn well pleases for access to its retail space (App store). It's very valuable cyber territory. But what it shouldn't be allowed to do is make it so difficult for *customers* to use non Apple retailing for apps. That would be the ideal compromise in my view. Pretty clearly, Apple's rich margins in the app sector are substantially driven by the fact that, if you want to reach customers of iOS apps, you have to go through Cupertino's online space.
Are you not aware of Amazon's anti-competitive-pricing stuff? Basically they tell sellers: You cannot offer a product on marketplace if that product can be found anywhere else at a lower price.
This was key to the creation of the Prime Free Shipping regime, and once people subscribe to Prime, it's easier for Amazon to keep them using Amazon rather than going to more-specialized alternatives for various products. The shipping is getting paid for by way of higher prices. If sellers were free to offer the product elsewhere at a lower price point with shipping broken out into a separate line item, then Amazon would have had a much harder time getting people to subscribe to Prime.
(To be clear I am not _radically_ anti-Amazon, I think some of the criticisms of them go overboard. But I absolutely do think they have engaged in anti-competitive behavior, with price manipulation being the most blatant.)
>big enough to compete with the government
I mean what business has $4T/year in revenue?
Apple's peak sales was something like $383B in 2023 per Bing. That's almost 10% of the way there.
Think how much revenue Apple could produce if they had an IRS.
Private firms cannot compete with government, The very idea is absurd.
At its height the Dutch East India Company was worth about ~$8 trillion in today's dollars.
It's mergers/acquisitions that seem worth of super attention.
The US Steel story is a useful cautionary tale about allowing growth by mergers.
I agree with this philosophically. However, as a worker in an industry that has seen massive consolidation (which hurts workers (my) bargaining power through reduced employment options), I also see that if you don't do it here, then the competition does it overseas and you get crushed in marketshare. Rock meet hard place..... (semiconductors fwiw)
Oddly I recall writing an undergraduate paper (~ '1959) about the US steel industry and reading about the US not being first with the BOF.
Not if you have a government that recognizes the strategic need to have a local semiconductor industry…
Someone was talking recently about how monopoly or oligopoly is the incubator of innovation, not competition - think it might have been Ezra Klein using the example of Bell Labs.
They were in a protected moat because AT&T just printed money, so the payoff for their research didn't have to show up next week or next year. Meanwhile the amount they came up with was staggering. Google, Microsoft, Apple and Amazon are in less regulatorily protected but similar situations.
But that's a pretty extreme outlier. AT&T was a utility. How many other utilities ever built a Bell Labs? Vanishingly few. Ameren UE, ComEd, ConEd, PG&E... all of them "print money", but none of them have bothered with anything similar.
Bell Labs seems to me like a peculiar legacy of one inventor, Alexander Graham Bell, a legacy *enabled* by his company "print[ing] money", but not *caused* by it.
I agree that the current crop of tech megalopolies have done *slightly* better -- they're all, along with IBM, deeply involved in the AI race, something we wouldn't have seen previous generations of incumbent tech-firms-cum-industrial-giants-cum-utilities do -- but it doesn't appear to me that any one of them has devised, let alone internalized, the "recipe for success [at innovation]".
Not to mention the fact that there seem to be a lot more examples to the contrary (monopoly stifling innovation) both in the US and abroad. Also: we can't visit the parallel universe where AT&T was broken up decades before. Maybe we'd have seen more innovation than we actually got.
well, I've also heard that innovation described as a product of high tax rates. It was so expensive to get the money out of the corporation that it lowered the threshold for an R&D investment to seem reasonable.
Apologies for not having the footnotes on this one. It was some podcast I think - maybe classic Weeds back in the day?
Similar situations, except for, er, the part where they come up with staggering amounts of innovation, I guess…
Why? Competition is generally very good.
Not sure how you think "bigness" serves competition. I didn't even bring up competition.
I am on mobile so apologies if I replied to the wrong comment but I thought you said you didn’t like companies getting big enough to compete with government, when that sounds very good to me.
Porque no los dos?
Also, the “a lot more people” contention suggests that you’re as blind to rural issues as the typical lefty democrat. Just gutting Cargill or Tyson would help a lot more people than scope of practice reforms.
You understate corporate monopoly power’s harms vs those of individual/professional rent-seeking, David M overstates them.
The truth is that we desperately need to go after both sets of problems and there’s no constituency for a grand bargain to do so.
I'm all for enforcing and expanding anti-competitive statutes against Cargill, Tyson (and their competitors, ADM, Pilgrim's Pride, Bunge, Perdue, etc). Just not for "they are big" reasons.
Sure, and I agree that Khan is fucking up by the numbers. But while Stoller whiffs sometimes, he also smacks one out of the park sometimes, as he has done when calling attention to ag. processing collusion, PBM insanity, pharmaceutical supplier contract language, defense contractor consolidation and corruption, or regional hospital system consolidation and private capital investment/debt milking...
His takes on big tech are half-baked at best, but a lot of the rest of what he writes is more on-point.
Why Khan isn't positioning herself on firm ground and daring the Supreme Court's neo-feudalist faction to shoot her down on issues of great importance to rural folks is beyond me. That they *will* is obvious; that it will help Democrats in rural areas and swing states also obvious.
“ His takes on big tech are half-baked at best, but a lot of the rest of what he writes is more on-point.”
Or is this just Crichton’s Gell-Man amnesia?
I haven't been able to stomach Stoller's illiteracy with respect to tech, and fear of falling prey to Gell-Mann amnesia has kept me away from everything else he's written. Can you (or anyone else) recommend anything specific where he's been good?
(Er, never mind, I kept reading down thread)
I wonder if your tally of when Stoller "smacks one out of the park" includes this one on realtors, or just those instances where he gores a disfavored ox?
I actually agree with Stoller and Khan regarding the lack of prosecution of anti-competitive actions. I think almost all non-competes should be illegal, for example. But Stoller's exaggerations and tortured rhetoric turns me off.
https://www.thebignewsletter.com/p/the-middleman-economy-why-realtors
I’m not aware, one way or the other, of Khan’s work on these fronts but Stoller has gone after the company that monopolizes class rings, along with the company that makes and repairs milkshake machines (true villains, that lot), among many others.
Class rings - something economically unimportant, so it’s easy to ignore, but with sentimental value, so people are willing to pay exorbitantly. That’s insidious.
“…the company that makes and repairs milkshake machines…”
There are dozens, scores of such companies. Which one is a monopoly?
Had been a long time since I read about it, first thing that came up in my search (warning: profanity aplenty):
https://gizmodo.com/the-feds-want-to-know-what-the-mcfuck-is-going-on-with-1847601805
More of a right to repair issue with McDonald’s supplier, a company called Taylor.
Yeah, I'm aware of that. There used to be a website that tracked the broken machines through crowdsourcing.
Respectfully, you’d find a lot more to like about the new antitrust if you’d look closer. The words “licensing” occurs in upwards of 30 issues of Stoller’s substack last year alone; some of these occurrences are about copyright but plenty are about occupational licensing. More broadly I’m often dismayed by the amount of skepticism toward this movement I see from reasonable people who don’t seem to have looked closely. Khan and Kanter are not trivial people. You don’t start to shift 40 years of jurisprudential lockstep on a central part of the political economy just by being really envious of Google.
What's so stupid about the current anti-tech Khan, Stroller, et al. view is what has really destroyed our functioning competitive marketplaces is the massive financial consolidation of nearly every industry over the past 20 years. How many industries can you think of that used to have healthy, fragmented 5-10 player spaces that are now down to 2-3 players? How many industries have gone all the way down to functioning duopolies?
THIS IS LITERALLY THE ENTIRE THESIS OF STOLLER’S BOOK UGH WHAT
…ahem, sorry about that, just continued deep confusion about exactly where a lot of you are getting your impression that the new antitrust movement is largely focused on punishing Big Tech for not being woke enough or something, because it’s sure as hell not in anything any of these people actually write.
Except it's not. The thesis of Matt's book is monopoly power not the downstream effect of consolidation in previously fragmented industries. The end state of consolidation is a duopoly not a monopoly -- which are much trickier because a duopoly can also increase buyer power in zero sum negotiations (e.g., auto dealership consolidation vs. OEMs.).
Or you closed the barn door after the horse was gutted, Netscape and Lotus 1-2-3 lying dead in a ditch. Though Gates claims the anti-trust action took Microsoft’s eye off the ball and allowed Google to establish Android when Microsoft had been all over mobile OS work for years and years. I imagine it also factored in to them keeping Apple alive by porting Office over.
It's not Microsoft's fault that Netscape collapsed; see https://www.joelonsoftware.com/2000/11/20/netscape-goes-bonkers/ and the linked post https://www.joelonsoftware.com/2000/04/06/things-you-should-never-do-part-i/.
(I can't speak to Lotus 1-2-3.)
Do people really no longer use Facebook? I personally stopped a few years back, but I was under the impression a lot of people still do. Meta's profits seem healthy of late, no? Is that mostly Instagram (I do use that).
It is still BY FAR the most heavily used social media platform worldwide, with YouTube coming in second. I am fairly aware of this because in my workplace we keep asking if we should expand our social media presence to use other platforms more heavily and/or get rid of Facebook, but then we look at the stats and the number of people with access and FB always crushes the others. Its number of daily active users actually grew in 2023, but it is losing younger people.
There is a difference in HOW people are using it though, with people tending to access FB groups on specific topics more, which is often how we use it at work, and to stay connected with friends and the local community. "Influencers" are leaving it for TikTok and Instagram. It is now considered a more staid platform. If you want to get a lot of followers, FB is not the place to go. If you want to get out information, especially with a low budget and to a targeted geographic area, FB works decently.
From what people in Congress say about it, that's probably generally true. But there's a whole bunch of non-partisan lawyers at the FTC and DOJ who are in it for the love of the game.
>non-partisan lawyers
They're political appointees!
I heard somewhere the Carter Admin punctured Xerox’s balloon by making them divest their patents so companies like Canon could compete with them in photocopiers. Interesting decision there.
There should be a bonfire of American privilege, where doctors, lawyers, dentists, car dealers and nimby homeowners all give up their feudal rights for the good of the motherland. It could be an American version of August 4, 1789. The real question is, what will it take to unlock that kind of patriotism?
Bane.
Framing things as a recreation of the French Revolution seems...ill-advised.
i don’t think you throw off entrenched interests without upheaval. of course, it would not be worth enduring the wars of the french revolution to reform professional licensure. i’m at a loss for how progress can occur
"it would not be worth enduring the wars of the french revolution to reform professional licensure"
The problem with the French Revolution wasn't the wars. It was the Terror. Reforming professional licensure isn't worth killing a modern-day Lavoisier either.
the terror killed 19,000 people. the wars killed far more. if you include the napoleonic wars, we’ll over a million
The beauty of it is that if you can get a few people paying attention, the dentists don’t actually get any extra votes on their own regulatory regime.
we should imprison them in the tuileries first. but if they make for varennes or collude with emigres, the cold handshake awaits!
You should add engineers, architects, and landscape architects. Particularly landscape architects. The idea that a landscape architect does anything that should require their professional license is crazy. Maybe I’m getting out over my skis here and will be hit with “skin cancer” like the Seinfeld episode but if so what is it? What does a landscape architect do that is impactful to the health and safety of the public and therefore needs a professional license? What?
This is where private certification should come into play. Some might pay a premium for a zen-hydrologist-landscape master- but that needn’t be enforced by law. But fraudulent representation of credentials should be something the government has an interest in addressing
For sure, there are professional landscape architect organizations and professional planning organizations and that’s all good. But when a local government requires a landscape architect to sign and seal a landscape plan or even worse submit a certified cost estimate than that’s not worth while. We need to have a core value of protecting health and welfare. But when that is perversely used to create markets to help specific professional groups then that’s bad.
Yes, retaining walls would be a structural engineering function. Geotechnical engineers also provide input to this because soil conditions are an important factor. There are also different kinds of retaining walls. Usually walls under 4-ft or so don’t require a PE. Landscape architects may contribute to aesthetics but that’s not a health and welfare issue.
Wasn’t August 4 an attempt to get ahead of the “great panic” in which peasants had formed themselves into pitchfork brigades determined to end feudalism from the bottom up? In other words, your noble gesture might require a push from below.
History might have unfolded very differently if the harvest of 1788 had been more ample.
But, yes, the fear played into August 4, as did the patriotism inspired by the joining of the three orders in defiance of the King, and the i ability of royalist forces to restrain the Parisian mob.
Are you including yourself in this American Bastille Day?
yes!
I mean, liberal democracy is pretty important too, but you’re not wrong.
Moreover, egalitarianism - exemplified by the abolition of the nobility - can be broadly read as a mandate to oppose entrenched forms of economic power such as you describe.
I take great pride in having never had a single cavity and as such I very much enjoy going to the dentist because they tell me I have great teeth and am doing everything right.
Oh look at this flosser over here...
"People who smoke cigarettes say man you don't know how hard it is to quick smoking. Yes I do. Its as hard as it is to start flossing." -Mitch Hedberg
Another dental practice lacking in evidence for benefit
I will say that anecdotally flossing makes a huge difference to my apparent gum health, for instance I leave the dentist much less sore than I did before I started flossing regularly. There are other signs too gross to mention in polite company.
You mean your dentist never found a cavity.
I never had a cavity, either, until I moved to Los Angeles. Some of my dentists there used to find a cavity every other visit or so. Since leaving LA I've never had another cavity.
What is it about LA? My friend moved there and was told he needed a full set of veneers. He got them and he looked creepy!
Hi Ben! Apologies for spamming you (and I'm sure that others have reached out by now), but just in case: https://www.slowboring.com/p/monday-mailbag-7a6/comment/46908559
(If Substack allows, delete my post, as well. I don't want to take up space here with moderating requests. Thank you!)
I was going to do the same, thanks for getting to it before I could due to other tasks I had to catch up on.
Yeah, a version of this happened to me too. Really underscores how arbitrary a lot of dental treatment is.
LA is a vain place, and the dentists know it. The movie industry only accepts flawless smiles from actors, and obsession permeates the rest of Angelino society. LA is a place where people go vegan because they're trying to make their skin nicer, not because they care about animals, where they do yoga to get toned physiques rather than for the relaxation and health benefits, and the list goes on. Dentists are in a good position to take advantage of the vanity of Angelinos and the desperation of wannabe actors, so they do so.
In my case, I never had a cavity until moving to LA. My dentist there found some and then I got some fillings and then those fillings had various problems and had to be replaced a few times over the years. I dealt with a very culture shock-y dentist for several years in Texas (Christian radio playing in the background the whole time) until during the pandemic the practice stayed unmasked. I’ve been very worried about my new dentist back in California, especially when the temporary patch on my fillings that needed replacing wore badly in the few weeks I had it. But since the real replacement happened everything has been fine so far.
I was like you until I was in my 30s. Still not sure if my first filling was even needed, think I got taken for a ride.
Floss regularly, floss meaningfully, floss athletically, and above all, never forget who is the boss of you. Me! I am the boss of you! I am the boss of you!...
https://youtu.be/kr1QbNBxj8Q?si=88CLCVKQz1l1n7nI&t=587
I also never had a cavity into my late 30s and I never flossed. Genetics matter way more than anything else.
Apparently it isn’t so much your human genetics as much as the lineage of your mouth flora.
Partly genetics, but also consistent fluoride treatments in your youth and a teeth-friendly diet help a lot.
I was like you...then I got a single random cavity when I was 30, and my world crumbled.
I knew my current dentist was a good guy and honest dentist when in my first visit he concluded his exam by singing "I can’t make any money off you". Meaning (a) he was willing to admit he was trying to make money but (2) not willing to invent problems to do it (which he totally could have). So far so good—no issues for the last 5 years.
My kids are pretty much the same. They grew up with fluoridated water, and got fluoride treatments on their teeth.
I on the other hand, didn't, and my teeth are terrible.
This is the problem with the meritocracy in a nutshell.
I don't take pride in it, but have never had a cavity and go to the dentist about once a decade, now. Worst my teeth ever feel is always after some "precautionary" work a dentist wants to do.
Yep I get an absurd amount of pleasure from getting "A+" report cards from the dentist, especially on my flossing work :D
same, and I’m nearing forty. I don’t eat candy, ice cream, cookies, etc, not out of discipline just taste. Not one issue at the dentist.
you don't like the taste of ice cream or cookies?
Call NASA. We have discovered an alien life form on Substack.
I wish I had this affliction.
cant stand them
I let them take mine, and since then the penalty to my skill checks and saving throws has been brutal.
Dunno. My dad had an impacted wisdom tooth that dentists wouldn't remove because it was right next to a nerve. It would regularly get infected, and it was an all-around pain. I realize that the data about prophylactically removing impacted wisdom teeth is mixed, but at least some impacted wisdom teeth are troublesome.
I didn't have my wisdom teeth out until my late 20s/early 30s, and every single one of them eventually became a major issue before having to be removed. And then it took a few years to deal with the problems they caused in neighboring teeth. Maybe others are luckier, but I'd say if there's any sign they will be trouble, just get them out and be done with it.
*steeples hands* Yes. This is the kind of inflammatory but not obviously political take I like to see in my inbox when I wake up.
I nearly did a spit take when I saw this title in my inbox...just classic Yglesias. Couldn't be happier to support this stack :D
As an insurance professional, I simply hate and abhor insurance that only offers small-dollar coverage and doesn't actually mitigate a significant amount of the insured's risk. So I'm glad you highlighted dental insurance for this reason
Lawyers are just as bad, maybe worse. If you ever go to a divorce lawyer for a consultation, you are very likely to be nudged towards divorce. Once you cross this bridge, you’ll be nudged towards detailed discovery to document your spouse’s misdeeds. Then a complex parenting plan that provides fodder for contempt actions.
The lawyers are several orders of magnitude more horrible. They’ve set the goal of turning the United States into Brazil as quickly as possible:
1. Make regulatory compliance impossible, forcing the entire SME sector and wide swathes of the middle and working classes into the gray market.
2. Make the administration of the civil legal code into a luxury only the rich can afford to access despite the specific underpinnings of our court system designed to prevent that very outcome.
3. Completely destroy the criminal justice system and cripple state capacity for law enforcement, ensuring a bifurcated public safety situation for rich and poor.
All in support of rent-seeking.
As in house counsel, what I find it frustrating how the law is generally pretty simple and straight forward but written in an intentionally abstruse manner. Most legal problems could by solved by non lawyers if the law was more plain language than esoterica. I spend lots of time confirming to internal clients that they do in fact understand the contract, even if the sentences themselves are incomprehensible.
If lawyers didn't write like dumbasses we'd have much better access to justice in this country.
They write like academics, that is, in a manner which makes things inaccessible to ordinary people.
I mean you can't charge $750 an hour to interpret something people understand! Think of all the unsold BMW X5s that would result. Utter horror.
Hot take...
Access to small claims/municipal court should be based on fulfilling 2 of 4 criteria:
1. Total claim under $50,000 (not $5-10k as in most jurisdictions today)
2. Plaintiff household income under 1.5X local median (or just set this at $100k for simplicity).
3. Defendant income under local median (or set at $65,000).
4. One of plaintiff or defendant is a corporate person other than a pass-through LLC. (S-corp, registered in multiple states, etc.)
Sure, you can still bring a lawyer, but from experience the judge is going to be much more patient and willing to explain than in any formal courtroom setting.
judges strongly prefer dealing with lawyers. the main benefit of a legal education is learning about relevance. lay people have trouble knowing which facts are dispositive
Haven't tried, but I'm pretty sure ChatGPT is already capable of translating legalese into plain English. No need to spend $750/hour paying a lawyer for it.
Working in law I found it funny that the most universally maligned attorneys - personal injury billboard guys - tend to be some of the only lawyers who at least work on a system where the attorney's financial incentives are aligned with their work. "I will do all the work for free and in exchange I get 40% of the cash we get out of it" incentivizes taking cases with merit, settling when auspicious, avoiding time consuming and costly practices (though, yes, I am aware of the medical lien scams that frequently screw people over) and generally trying to get the best bang for the least work. Whereas hourly lawyers work for a system where it is always in the attorney's best interest to prolong the case and charge the client for everything.
the problem is these incentives encourage attorneys to collude with clients to fabricate or overstate injuries. most pi clients are princesses, and you have to have a great reputation to get the serious injury cases
I remember something about an ethical principle that a lawyer is not supposed to take a case in which they have a financial interest (aside from getting paid for their time), which is what makes the contingent fee system seem sketchy, since their compensation is directly tied to the outcome.
of course PE/M&A lawyers investing in client deals and GCs getting huge stock awards doesn't attract as much criticism as the PI lawyers trying to recover for the little man
Corporate/government lawyers are basically the only people with a cushier gig than environmental and public engagement consultants, and those are the only two groups of people with a cushier gig than transportation design engineering firms.
Corporate lawyers work famously brutal hours and also have nothing to do with the vices of which people here complain. They are basically project managers for deals, they don't really practice law as most people envision it.
Not in-house counsel, rather BigLaw.
They're very, very good at lobbying for the legal and regulatory regime that justifies their existence.
I'm confused at what legal and regulatory regime could possibly make M&A lawyers unnecessary. It's just not possible to do a nine-plus-figure deal without a lot of people making the paperwork run right in a lot of different areas.
The structure of criminal defense is interesting. Basically, unless your client is OJ Simpson or Donald Trump, your client gets walloped if you fight too hard. It’s much more efficient than civil law, but it gives prosecutors and judges a great deal of power.
I wonder how AI will change this, since people will have access to extremely cheap second opinions.
Its really going to mess with law firm economics. The way firms make money is via the mark up on associate and staff work. If it takes fewer associates and staff to produce a legal product, clients will either expect instantaneous service under current staffing or lower prices and fewer staff. I also expect more routine work to be brought in house, leaving firms for bet-the-farm work only.
Law firms have already implemented a lot of labor-saving technology in the past few decades and have only gotten more profitable. Computerization had a cataclysmic effect on legal practice. People and businesses will always be willing to pay hand over fist for expertise and experience handling major events.
A *lot* of bread and butter document management and discovery work that's easy to farm out to junior associates stands to essentially be abolished by AI IMO.
I'm drawing a distinction between bet-the-farm litigation/high stakes dealmaking and the normal bread and butter work that is 95% of law practice for all but a handful of lawyers in any market. Its the flow of routine work that will be at risk from being brought in house. The team at Wachtell that represented Twitter in its merger litigation with Elon Musk will be fine, your average commercial real estate practice group will face tons of pressure. Think about it this way--rather than typing an email to outside counsel, which gets forwarded to an associate/paralegal to do the work, the in house lawyer types the same message into AI legal software, which instantaneously spits out the requested documents. Its really hard to see how the typical law firm model works in that scenario. Its an order of magnitude more productivity enhancing than command-f or copy and paste combined with a document and clause database.
If AI actually kills (replaces) all the lawyers, I'll stop bitching about it's unlikelihood, lol.
https://www.youtube.com/watch?v=uG3uea-Hvy4
A family law attorney is not a marital counselor. If you’re seeing them then presumably you are divorcing. I actually don’t understand your comment. (Speaking as an attorney but not a family law attorney.) A marital counselor is more like a dentist or dental hygienist. A family law attorney is more like a surgeon.
I think he's saying they nudge you in the direction of higher-priced fees and services, like the unethical dentists MY is writing about.
To complete the analogy, I think DA is saying that these attorneys are like unethical & incompetent chiropractors who knowingly injure patients during "adjustments" in order to keep them as long-term clients.
I don't know enough to say "common", but I'd say "not unheard-of".
To the extent that it's a problem, it's mostly a benign form of malpractice, not malign. As in, they tend to be True Believer types that don't think they're doing any harm, but simply aren't skilled enough/haven't practiced enough/are using riskier techniques in an irresponsible manner. They probably figure that whatever they break, they can fix with the healing power of _woo_.
But most importantly, they don't want to lose face with their clients. So they smile and act like everything's OK and they're in control. And the client ends up staying with them, even if they're actively harming them, and they're effectively leeching off the client.
An attorney friend of mine describes family law as much more like counseling than it is like law, honestly, especially when children are involved.
Breaking my commenting moratorium to say that complaining that when you go to a "divorce lawyer" for a consultation you are "nudged towards divorce" is like complaining that you went to a car dealership and they sold you a car instead of trying to convince you of the benefits of using public transportation. The job of a divorce lawyer is to handle a divorce and related legal proceedings and tell you what you need to do to optimize your position in that process, not counsel you on how to fix your marriage.
When is your moratorium over, again?
Breaking my commenting moratorium to say that it's over tomorrow, although I'm trying to decide whether to penalize myself for making comments during the moratorium by extending it for additional days for each day I made a comment. That would extend it to Saturday.
When you come back remind us why the moratorium happened in the first place.
I said that Claudine Gay would still be President of Harvard as of December 31, 2024 and that I wouldn't post for a week if I was wrong.
Nah, don't punish yourself more, we miss you.
becoming a doctor is so demanding it attracts immigrant strivers more than smart frat boys.
IME becoming a doctor is so opaque while also requiring a relatively clear commitment to a demanding career path basically right of high school, that the Americans who become doctors are all just the children of doctors.
Noted. 1st generation doctors should be held on a higher pedestal. That's some impressive ceiling breaking.
Same goes for tenured professors.
Aren't the number of US MDs limited by the [I'm not sure who exactly]?
Point being that the limitation isn't the number of US citizens who could and would become doctors if there were more slots open
The thing is, evangelicals are much more likely to get divorced than secular professionals. Because fornication is a sin, they marry younger than secular couples and are unlikely to cohabit before marriage. It’s very hard to pick a good life partner when you are 23 and still very much a work in progress. It’s also harder to stay monogamous when you are in your twenties and your hormones are still raging and you never played the field long enough to get bored.
Cohabiting before marriage is actually correlated to a higher level of divorce overall, I believe. I don’t know about the other stats, though (age and religion).
I always feel like there's selection bias at play that needs to be accounted for. The people who feel that long lasting marriage is an overwhelming good in and of itself seem more likely to prioritize getting married quickly, and staying so.
Oh I am in no way trying to say that not cohabiting is the only path to a happy marriage. My husband and I cohabited for almost 10 years before marriage! It’s just not factually correct to say people who cohabit before marriage have lower divorce rates. Your supposition seems like a perfectly reasonable mechanism for that statistical outcome.
Agreed. My longstanding take is that relationships are a very diverse and complicated thing that each couple has to find for themselves, and broad prescriptions saying what is best are always wrong to make.
This always makes good sense to me, and it's always puzzling to see people like Lyman Stone try to look at data to argue otherwise.
Stone has incredibly good points about certain things and is much less insane than some of his peer "Christian pro-natalists," but there are some gaping blind spots in there.
I think research is pretty conclusive that religiosity reduces divorce rates and cohabitation increases them, and that the latter is probably mostly explained by the former.
I imagine tight knit communities like Mormons and Orthodox Jews are better at matchmaking and have higher stigma against divorce
Can (somewhat) confirm for Mormons, although I’d quibble and change “better at matchmaking” to “overwhelmingly greater social / community support for young married couples.”
correct, but the christian penumbra is much bigger than the core.
Matt expects us to be ready to read at 6 AM at the *latest*.
I dunno about orthogonality to culture wars; dentists seem pretty entrenched in the Boat Parader class.
I was going to ask about this. Is there any data on the partisan split of dentists? I’d imagine pre-Trump they would be classically Bush republicans but wondering if education polarization has pushed them to be more split these days.
That actually illuminates something for me on education polarization.
To wit, that it's not JUST an educational divide, but an age divide as well. At the risk of triggering certain parties around here, it's a clear-cut example of a small-i intersectional phenomenon - it's a divide that exists along two intersecting axes of identity, education and age.
All that is to say, the Boat Parader Pipeline has most certainly become attenuated for the Millennial dentists, while we should probably expect Boomer and Xer dentists to have broken hard for Trump in recent years.
Ed: Also, the Boat Paraders themselves are probably in part responsible for the polarization. If the senior incumbents in the industry are hogging all the gains, then the younger generations are going to find it harder to break through, and backlash against them. It's classic intra-guild politics.
One of my pickleball friends is a veterinarian, the economics of that sort of business are comparable to dentistry. Having a fancy vet clinic has become so capital intensive that most are owned by venture capitalists. The actual vets are just well paid professionals, they might parade in a 24 foot boat with outboard engines, but their nautical ambitions will always be rather déclassé.
https://verdantlabs.com/politics_of_professions/
From campaign donation data. (2016 and onwards, I think.) They definitely lean republican, although there is some variation by specialty.
That’s interesting that “dentist” and “dental assistant” and “dental hygienist” are all basically 60-40 for Republicans! Orthodontists are a bit more Republican, and periodontists a bit less.
Yeah, I would have expected the assistants and hygienist (who make less money than dentist) to be less Republican.
I should say that I wouldn't take that dataset as gospel. I think it's generally useful, but there might not be enough data to have good statistics on certain specialties. (How many periodontists are there? Probably less than orthodontists.)
Income level and education level often pull in opposite directions - interesting that they seem so balanced here.
Floss regularly, floss meaningfully, floss athletically, and above all, never forget who is the boss of you. Me! I am the boss of you! I am the boss of you!...
https://youtu.be/kr1QbNBxj8Q?si=88CLCVKQz1l1n7nI&t=587
It's a bit prophetic, no? (Actually no.)
I hesitate to ask, but am I on that list?
You need to expand the homeowner class well beyond CA. Also, re parking, should read “I can’t park my vehicle right outside the door of my destination indefinitely without paying, and I shouldn’t have to encounter losers who walk or bike during my journey”
So... most of the SB readership?
I'd also add Notre Dame football to this list.
Basically any alumni community that slaps each other’s backs while bragging about their IRAs (they pronounce it “Ira”) over their “alma mater’s” football game...
... all while wearing a nylon v-neck pullover jacket in their school colors.
Good stuff, as usual. Minor point: MOST Cochrane reviews (not just of dentistry) conclude that insufficient evidence is available to reach a clear conclusion.
Was going to say, they're famous for "quality of evidence is low..." I'm not sure how much dental research goes on compared to other medical specialties but I'd assume it's tough for them to hit the Cochrane bar.
You're missing the point. The right takeaway from looking at the evidence in many cases and concluding the "quality of evidence is low" is that the quality of evidence is often low! And it's even worse for dentistry than medicine!
I haven’t looked into Cochrane, but often the “evidence-based medicine” movement has a lot of problematic takes where they pretend low quality evidence doesn’t exist, rather than trying to aggregate it in ways that let you draw some tentative conclusions. This was one of the big problems with masks - there was a lot of low quality evidence and no high quality evidence, so they pretended there was no evidence.
I think this often describes a situation in which low-quality evidence, the likes of which Cochrane denigrates, is competing with one's own empirical observations. (Which are, of course plagued by many kinds of bias, but are immune from others.) But that's almost always implicit, so it seems like they're saying there's "no evidence".
Cochrane reviews are wonderfully in-depth and get reexamined from time to time. It's not like they're a red vs. green light guideline. Almost everything in Medicine is tagged "proceed with caution" instead of "proceed with confidence" or "do not proceed" so the Cochrane analysis still gives us some direction through the gray area.
That's exactly my takeaway.
More of this, right into my veins
Also, my dentist growing up was coincidentally an Air Force dentist in the '80s. Wonder if any of his records made it into the study you cited!
Also do optometrists next. Why do I need a new prescription (< 1 year) to get glasses! I know if I can see or not! It's to force me back every year that's what. Even worse for my fellow folx experiencing nearsightedness who need contacts!
And do car dealers! And hair dressers! DEATH TO RENT SEEKING!
Optometrists vs. opthalmologists have a similar scope of care battle as dentistry though optometrists have achieved more independence than hygienists. But, yes, there is definitely rent-seeking going on with optometrists because, like dentistry, the routine care doesn't pay the bills. It is a valuable service but does open the door to the moneymakers: procedures and product. The feds forced optometrists to provide glasses prescriptions and, later, contact lens prescriptions because the rent-seeking was so obvious.
During the pandemic, a police officer smashed my glasses (long story), and when I tried to get them replaced Kaiser told me 1) my prescription was 28 months old, so they couldn’t refill it; 2) they couldn’t provide my prescription to me so I could get glasses elsewhere; 3) “no one else” would take an outdated prescription; 4) because of the pandemic they weren’t doing appointments to renew prescriptions, so I was SOL.
I ended up punching random numbers into Zenni based on a very old RX and suffering chronic headaches for three weeks before LensCrafters had an opening.
This was awful bureaucracy bingo
Especially since there are plenty of rich counties where your glasses or contact lens prescription doesn’t expire after 2 years, so it’s not as if our rules are a safety issue.
https://www.theatlantic.com/ideas/archive/2019/11/great-american-eye-exam-scam/602482/
"I know if I can see or not!"
Do you, though? For a few years until I got my first glasses, I just thought all the whiteboard text looked faint because the markers were running out of ink. Gradual shifts in one's eyesight seem like they could be easy to miss in general.
Check out the big Opto shill over here
Why is insurance so bad with glasses? If you want coated and compressed lenses, that will be $300 on top of what your insurance pays us. But you can buy this stuff from China for $50, shipped. What exactly is your margin here?
There are some interesting deep dives into how tons of glasses and sunglasses brands are owned by Luxottica, who keeps their margins very high and competition fairly low. Not sure how much of the articles were hype, but it does kind of feel like a racket. Tons of little startups have come around to undercut them (Warby Parker, etc).
I mean dialysis is also covered by insurance.
I don't think I get it. We get insurance to protect us from unexpected exorbitant expenses. Dialysis is a major expense. What difference does it make that the expense is spread out over a long period of time? After all, disability insurance is a thing. If I know that there's a chance that I'll get stuck in a condition where I need to spend >$50,000 a year or I'll die, wouldn't I want to be insured against that?
As for glasses, what I have is not insurance, but a "vision plan." Is that fine because it's not called insurance?
Not disagreeing with you about what optometrists will do, but I want to point out that I can go on eyebuydirect.com (and others) and buy glasses with any prescription I want of any age I want.
I think glasses are easier to get than contact lenses with an old prescription, but I'm not actually sure!
What's really bonkers is how many non-optometrists will defend the new prescription thing. E.g. it may have a second-order effect that drivers are more likely to have up-to-date prescriptions, and that's clearly the best way to achieve that aim.
Fun fact: in the bike industry, the term for someone who walks into a bike shop and buys an expensive ($5k+) bike is a “dentist” --- not a lawyer, programmer, or doctor.
I think I've also heard it applied to photography hobbyists who buy 10 grand of gear on their third day shooting.
Haven't read the article yet, but love that you actually went with "Dentists are bad" as the headline
It's because they are!
I appreciate the editorial honesty
Now do auto mechanics.
Less information asymmetry, I'd say. Much easier to tell you're getting codswalloped with a modicum of mechanical understanding than dentistry.
Yeah, well, first you need that modicum.
fewer barriers to entry
And it's easier to find and understand information online for cars than teeth.
I dunno. I recently had some work done. (Teeth, that is). There was plenty of info on the web. I'd say it's a wash. And the the auto repair industry if anything is probably a stronger rent-seeker in terms of stifling competition.
Someone needs to figure out how to separate the business of inspection/diagnosis from repair.
Someone start a startup that does inspection/diagnosis and get quotes for you - they could probably charge a yearly subscription. Anything as long as they don't have a financial stake in the cost of repair. Then, they get quotes from mechanics and repair shops.
>Someone needs to figure out how to separate the business of inspection/diagnosis from repair.<
Agreed. In the real world, though, I think that's called "being lucky enough to personally knows a highly knowledgeable person they genuinely can trust."
I’ve always wanted an HMO plan for my car. Give me a predictable annual fee, make sure my car stays in good shape, and be done with it.
Isn't this what an "extended warranty" is?
Yeah, I want that except without the scam calls and with a company I can trust
I love this. Except if you show one case to three dentists and you'll get three different diagnoses and 10 different treatment plans. This is a bug but also a feature. I don't know how you get around the problem of differential experience/personal skill sets of individual dentists. Standardization in what is essentially a cottage industry is a really difficult problem.
I was thinking of typing this identical post...there needs to be a Jiffy Lube for oral care, where they do teeth cleaning and other simple services, but refer you to a dentist when they spot trouble. This has happened to a small degree with basic medical care given the growth of ZoomCare and other chains where a PA can examine you and order basic tests and prescribe limited meds....
But of course there aren’t state regulations on automechanics limiting what you can do in your own driveway, or what you can pay to do at a Jiffy Lube versus a dealership versus a full service garage. Mechanics simply take advantage of information asymmetry and do relentless upselling just like every other service provider in the world: plumbers, furnace repairmen, roofers, foundation repair, etc.
The best advice I ever got...have one person in your life at all times who changes his or her own oil. Gives you someone to call when your car shows a certain symptom, or dealership tells you your fetzer valves need replacement.
Oh - and make sure you always make friends with someone who owns a pickup truck too...
I love the Jiffy Lube concept for dentistry. It would be great for people who have minimal dental disease or needs.
How does one know if they have minimal dental disease or needs?
If you’re not having problems (pain, bleeding, etc.) that’s probably a good sign.
Would have the benefit of also opening the door to Seinfeld references.
I hate to say it, but this article may be making a case for insurance company reviews of the appropriateness of care provided. I'm sure doctors want to provide care appropriately, but knowing that a 3rd party payor is looking over their shoulder, or an HMO organization is doing an analysis probably keeps people on straighter and narrower paths than they might actually cleave to naturally. Of course other countries' health systems have much different mechanisms of review, but they certainly proscribe the kinds of care that are appropriate, moreso than in the US.
The only way to anything close to that kind of third party review with dentistry in the state it is in, is to never allow the first dentist you go to to do any kind of questionable procedure on you without having gotten at least a second opinion.
The thing is, when the insurance company does their review of the appropriateness of the care provided, what happens is that the care was already done weeks ago and it's just a matter of if the patient or the insurance company has to pay the bill. It's not going to stop the procedure from happening; it's far too late for that.
They have prior authorizations. Also being an in network provider and doing medically unnecessary procedures will not be good for your future relationship to that insurance company, I’d wager.
EDIT: Also it really won’t be good if the doctor works for the organization - like Kaiser or another managed care setup which are getting more common all the time.
I'm not a fan of the prior authorizations, because in practice the insurance company is basically just a distant bureaucrat who isn't on the ground evaluating every case -- which would be prohibitively expensive.
I lost a comment draft, but I like the idea of having a process where post-hoc review feeds into approved standards of care. Which is essentially what we already have, albeit with tons of intervening distortions. Seems to me like a competent application of Slow Boring Process would be to simply bore away at eliminating those distortions, not trying to invent and perfect entirely new mechanisms.
Insurance denies expensive stuff, not things that are inappropriate. As a physician, the only results of insurance denials I've ever experienced are 1) doing an hour of paperwork and ultimately being allowed to do what I wanted, or 2) being denied a newer medication or a dose that is less commonly manufactured and having to put my patient on something with more side effects or risks because I can't get the best care approved. Often the patient can then get the original med I wanted after the insurance approved one doesn't work or causes the side effect we were trying to avoid.
Dentists who drill patients' teeth without medical justification are committing criminal battery. The injuries they inflict, purely for financial gain, lead to a lifetime of physical impairment, pain, and the need for further medical intervention
"Drill 'em fill 'em bill 'em", when not medically necessary, is not a joke. It's a crime.
Did you know you had an impersonator?
"Did you know you had an impersonator."
I'm not sure what you mean?
This happened in yesterday's mailbox, this is just one of several subthreads:
https://www.slowboring.com/p/monday-mailbag-7a6/comment/46902324
Oh, that's weird.
Ben Krauss, can you do something to prevent trolls from abusing my nym?
Good to know. Wouldn't want to take any of spiky's bait.
This troll wants to make the troll activity very evident, otherwise the covert move would be to just use the username David, and run under the radar.
I'm not as up on the details as some who were discussing it in detail (and posting links and everything) on this stack, but apparently a (banned?) subscriber was using your handle to troll? Or something? Anyway, don't mean to alarm you...just thought I'd pass it along.
How do we know that’s the real one? Maybe that’s really Earth - 617 Dysphemistic Treadmill? Crisis on Infinite Slow Borings.
Fantastic case law in Australia on this where dentists have been hit with punitive damages in negligence cases for shit like this.
Yeah, puni's can do some of what criminal charges can do for deterrence, and with less hassle (don't have to persuade a prosecutor to bring charges, e.g.).
Who determines when intervention is required? I mean, if you don't trust your dentist's judgement, then why go to that dentist?
People are bad at evaluating when dentists are being shysters as opposed to giving reasonable medical advice, because they both have similar external presentations, viz. "this is a problem, you should fix it," and patients don't know enough to consistently evaluate that claim correctly.
Dentists are also bad at evaluating when they are being shysters.
For the record, I am a dentist.
“For the record, I am a dentist”
Are you a shyster dentist?
I'd like to think not.
All shysters like to think that.
what does this mean? It's hard to actually tell if you're over diagnosing?
Or overtreating. There are a lot of "you'll need to deal with that down the road" things in any medical specialty that create a gray zone. And a lot of things will have a small positive marginal value if cost isn't a consideration. A doc/dentist being risk-averse can look similar to being financially-motivated.
Yes, there will be some hard cases.
But there will also be some easy cases. And those should be punished severely.
One of the problems is standardization. If you show one set of x-rays to multiple dentist you'll have multiple judgements based on education, clinical experience and personal experiences of the dentists. I don't love that this is the case, but it is.
Some dentists will treat a cavity when it's a tiny speck on the x-ray. Some wait until it's broken into the dentin on the x-ray. Who is right?
There’s seriously no industry-standard answer to that?
"Who determines when intervention is required?"
This is not some kind of unknowable mystery of the universe. Juries in med mal trials determine these things all the time, with the assistance of expert witnesses on both sides.
If someone hacked off your leg claiming that you had cancer, and it turned out they were lying, they would face at the least a civil tort for malpractice. If they did it knowingly for gain they could face criminal liability as well. We should not think of teeth differently. Intentional mutilation of someone's mouth for gain is a vicious assault on their bodily integrity.
"if you don't trust your dentist's judgement, then why go to that dentist?"
Reread the part about Ken Arrow's paper.
I get it, but asymmetrical information is a problem that plagues all medical fields. There comes a time where you have to trust your practitioner.
I suspect that "intentional mutilation" happens in dentistry rarely. I think poorly thought out treatment plans that are executed poorly is much more common. The idea that a dentist walks in the room, tells you what you need and you accept without any discussion goes against reality, IMO. In my experience proper informed consent happens in dentistry much more often than medicine. If you don't trust your dentist and their team and they won't answer questions to your satisfaction, you should walk.
Big difference
I am a physician and it astonishes me how often there are no high quality trials to describe what is best in dental care, particularly compared with medical care.
And then Matt goes on to quote some study that is the exact sort of low quality evidence that the Cochrane folks are talking about. So Air Force recruits from Mississippi have worse teeth than those from Oregon? And he concludes it must be the lack of restrictions on dental hygienists in Oregon. It doesn't take a serious medical researcher to wonder if it might be one of 14 million other potential explanations.
It never ceases to amaze me that some people push for healthcare providers with a fraction of the training to be allowed to do more and more things that they are simply not trained to do. Are we sure there isn't a dental hygienist in the family?
i think the point in this case is that the hygienists basically do all of this stuff anyway and if they were allowed to do it as an independent operator instead of as some guy's employee it would be better. 'how to run an enterprise' is not, in fact, privileged information
of course, as a physician, one wonders if you might have an axiomatic opposition to this notion of independent operators who did not shell out for incredibly expensive and mostly-unnecessary training that is not the global standard because your own profession is full of rent-seeking, regulatory barriers, and lots and lots of overworked and underpaid NPs who can do most PCP work themselves
I cannot read PCP as “primary care provider/physician”.
Try again when your animal tranquilizer high wears off
Same: I always instead just use the British version of general practitioner to avoid this confusion. That and the word queue are my two favorite British English differences.
It would be a lot less distracting if they didn't also put "NP" only a few words before it....
I am too lazy to go back and read it again, but I don't think Matt was proposing only that hygienists open their own teeth cleaning shops. He was advocating for them to start filling your cavities too. If all they wanted to do was open more places to clean teeth with no supervision, that might be viable and within the level of their training. Are they trained to read Xrays and diagnose tooth problems?
Evidence is increasingly showing that lesser trained primary care providers (NP's and PA's) make for more expensive care, particularly as primary care providers.
Some of my medical training was more valuable than other parts, but calling it 'mostly-unnecessary' is ridiculous. I would think 'mostly' means more than 50%, and I am just going to assume you googled this.
I'm also a physician and understand that scope of practice for mid-levels is tough, especially since the slippery slope arguments aren't fallacious. The equilibrium "hygienist cleans but dentist diagnoses and does procedures" is similar to where most medical fields are right now. But high access to medical care (and technological advancement) has really increased demand in a way that stresses that equilibrium without a way to generate more doctors/dentists to meet it.
I do think dentistry is pretty similar to Medicine in the '80s and there's a reason things changed. Too many people get zero dental care and others get too much elective care. While dentistry has sidestepped the expansion of access Medicine has, governments REALLY don't like a labor shortage so will often step in (though they don't tend to act just for cost savings).
I'm not specifically advocating that loosening scope of practice is good or bad. It just has trade-offs and governments will eventually step in once the public gets mad enough.
Low quality evidence is better than no evidence, as long as you recognize that it is low quality.
If all you had was a comparison of Mississippi and Oregon, obviously there would be lots of confounds, but unless there is a systematic correlation between (say) rural poverty and regulations on what dental hygienists can do, you can mitigate this by looking at 50 states rather than just 2.
Ignoring low quality evidence is how we got the idea in the early pandemic that there’s no reason for anyone to wear a mask, because we don’t have any randomized controlled trials of the effectiveness of non-medical-professionals wearing masks.
Matt has gone after doctors in previous posts as well. I love his stuff generally but for some reason he has a huge issue with the salaries of educated professionals specifically. As a physician, I can only conclude that I shouldn't have spent 10 years in training after college and should have spent my time on something people value like PE or writing code for a dating app.
If the reason you became a doctor was to take advantage of industry organizations that lobby state governments to over-regulate your work, shifting a utility surplus from average Americans to your community of high-income earning professionals ... than yeah, maybe you should have gone into PE or coding.
I became a doctor to help patients. The amount of training, time, and tuition put into being able to do so needs to be adequately compensated just like for any other job. Otherwise talent will go elsewhere.
Sure but if there wasn't a hard cap on new doctors per year, costs would come down. Right now, a lot of the talent can't enter the profession in the first place.
Physician salaries are 7% of total healthcare costs. You could cut them in half and not much would change. I agree we need more residency spots to increase access to care, and I could take a pay cut in pursuit of that goal, but no you are not going to address healthcare costs that way.
It's the scarcity of access through the gatekeepers that has a lot of secondary costs to my mind, not just salary. Any fixed cost that can be split between more physicians can be reduced, (like expensive specialty equipment) for instance. More practices means competition to keep costs down across the board.
Is there a reason why traditional market forces won't work if scarcity of physicians is eliminated?
This is timely for me. I’ve been going to the same dentist for several years, who I like. When I saw him this summer, he recommended no new treatments. This fall, he hired a new dentist to work under him, and I saw her this time. She recommended treatments for EIGHT teeth and a nighttime mouth guard, despite no issues on my end. I decided it’s time for a new practice. Ironically, if she had recommended treatment on one or two teeth, I definitely would have said “oh, sure, let’s do it.”
I can't tell you how many patients my Wife has converted just because she does the opposite of sell them on unnecessary treatments and procedures. She gains their trust precisely because she will never oversell them.
It's the opposite for me: when I came back from college and started going to the dentist the rest of my family goes to, the old dentist pushed hard on procedures that seemed overkill. The worst was recommending jaw surgery to correct my childhood dentist overcorrecting my bite, which I pushed back on immediately. Then that guy retired, and was replaced with a friend I knew beforehand, and he never tries to pull any funny stuff on me. Glad he's my dentist.
I had a dentist note a few issues with fillings and minor cavities. They gave me a prescription tooth paste, but 9 months later they had to do 4 fillings. A big problem was seltzer and grinding (which runs in my family).
I am skeptical that carbonated water is hard on your teeth. There are studies going both ways. Additionally, you breathe out carbon dioxide continuously, so your saliva contains carbonic acid 24/7. If a few seconds to swallow some bubbly water is bad, one would think we would have lost all our teeth to breathing before adulthood.
The issue is it acidic and if you don't eat while drinking it, then you saliva won't wash the acid away. It is also substantially more acidic than saliva, which tends to be neutral.
https://www.bannerhealth.com/healthcareblog/teach-me/are-sparkling-waters-bad-for-you#:~:text=%E2%80%9CSparkling%20water%20has%20a%20pH,carbonic%20acid%2C%20a%20weak%20acid.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3800408/#:~:text=Saliva%20has%20a%20pH%20normal,does%20not%20fall%20below%206.3.
I get that carbon dioxide dissolves in water creating an equilibrium solution of carbonic acid. As I said though, there is conflicting advice:
https://www.mouthhealthy.org/nutrition/the-truth-about-sparkling-water-and-your-teeth
"In a study using teeth that were removed as a part of treatment and donated for research, researchers tested to see whether sparkling water would attack tooth enamel more aggressively than regular lab water. The result? The two forms of water were about the same in their effects on tooth enamel. This finding suggests that, even though sparkling water is slightly more acidic than ordinary water, it's all just water to your teeth."
I don’t think you’re going to be able to convince him: seltzer & grinding runs in his family. So probably genetic.
I love Matt and I liked this article.
I'm a dentist and I think some of the concerns addressed here are legitimate. Specifically the problem with good science in dentistry. Experimental design is hard and everyone is affected by incentives, even dental researchers.
I'm on the inside with dentistry and see a bunch of statements that anyone in the industry would see as misguided or even outright incorrect. There are some TERRIBLE things about dentistry (private equity, anyone?) but much of what Matt talks about misses the terrible stuff. The article has given me a case of Gell-Man Amnesia. I honestly worry about the things Matt gets wrong in other reporting simply because I don't know a lot about it. It makes me worry about journalism in general that someone I generally think of as a quality journalist would publish in this way.
For instance, if allowing hygienists independent practice would make dental outcomes better and dental care cheaper, I say bring it on. But practice overhead, staffing and dental benefit coverage are problems that independent hygiene will face just like dental offices. No hygienist is going to go into independent practice simply to help people more effectively. They would do it to run their own business and to make a profit. And they would face the exact same problems that dental offices face. Again...there is a lot about dentistry that's messed up, but much of what Matt talked about isn't it, IMO.
Also, if you ever see a negative article posted about dentistry the comments almost always devolve into "my dentist was a hack and a crook" stories. Which are undoubtedly true, but all of them are anecdotal and cannot be extrapolated onto the profession. Dentists are one of the least sympathetic characters in day to day life. Trust me, I get it. The number of times I hear, "no offense, but I hate dentists" in a day is shocking.
I host the "Very Dental Podcast Network" and have for the last 10 years. I would LOVE to have Matt on to talk about some of this. :-)
> For instance, if allowing hygienists independent practice would make dental outcomes better and dental care cheaper, I say bring it on. But practice overhead, staffing and dental benefit coverage are problems that independent hygiene will face just like dental offices.
I think that the intuition is that if the supply of basic dental services increases, prices will go down. They certainly have room to go down, given the extremely high incomes of dentists relative to the population. Recall this passage from Matt's post:
> And dentists make a lot of money. As Jonathan Rothwell points out, “there are five times as many top 1 percent workers in dental services as in software services.” About fifteen percent of dentists earn enough to qualify for that lofty status. The median hourly wage in the United States is $22.26 versus $74.54 for dentists.
“there are five times as many top 1 percent workers in dental services as in software services”
Dumbest part of the essay. 1%-er dentists are probably almost all successful small business owners, not wage slaves.
This is exactly correct. I expect most of the highest income dentists are practice owners. Likely MULTIPLE practice owners.
I wonder how the payout works for DSOs with venture capital backing. I would imagine it's a phased payout with targets so the owner or partners have an incentive to maintain revenue and margins as they ease into retirement. (But maybe it's a one-and-done. I have no idea.) Also, rolling up practices with venture capital is a fairly new game, so anyone looking at recent data will see recent trends.
Perhaps it's more informative to look at the Bureau of Labor Statistics' page on dentists' pay: https://www.bls.gov/ooh/healthcare/dentists.htm#tab-5. It indicates that, as of May 2022, their average wage was $155,040. This figure excludes the incomes of orthodontists and other specialists.
That was in the essay: $74.54 is $155K.
Medicine went through the same thing. People thought they could get the same quality care for less by going to an NP instead of a "greedy doctor". Turns out nurses are also humans capable of greed and less education doesn't lead to better outcomes. I think people just don't like being in a situation where they feel out of control and have to pay to fix something. Everyone at any business is trying to sell you someone but only lawyers, doctors, dentists, and auto mechanics regularly get accused of being crooks. It's the information asymmetry and circumstances of your arrival.
It's also easy and not time-consuming to price compare between Target and Wal-mart. It is not easy and is quite time consuming to price compare different dentists.
"Everyone at any business is trying to sell you someone but only lawyers, doctors, dentists, and auto mechanics regularly get accused of being crooks. It's the information asymmetry and circumstances of your arrival."
Information asymmetry is the problem and the solution is a really difficult problem.
It occurs to me that it's not simply asymmetry, but that dentist 1 and dentist 2 may disagree, and that causes distrust. "Shouldn't experts agree?"
You would think. But...nope.