I have no love for the lobbying efforts of H&R Block et al., but they're not the only problem here. The more social engineering gets layered onto the tax code (some advocated for by this very blog), the harder it is for the IRS to accurately calculate what you owe, and the IRS is not the most nimble IT service in the country.
Indeed. That this is an industry is a real failure. A huge anchor in terms of the opportunity cost stemming from smart people deployed in unnecessary activities and charging hilariously exorbitant fees. But then, tax avoidance is the one biggest way regular folk can do rent seeking...
Turbotax is a lot different then tax lawyers scheming with private bankers. Rich people paying tax professionals to reduce liabilities is inevitable, turbotax is not
For low to middle income wage earners, taxes should absolutely be way simpler than they currently are. But there will still be plenty of jobs in business tax prep, because there is really no good way to make business taxes simple.
I've always wondered if open source tax software could ever take off to be a feasible challenger to killing these middlemen if Congress can't or won't.
I’m more a fan of the “file our taxes on a postcard” plan, or just have everyone use the 1040EZ form. Get rid of deductions and raise the standard deduction. There is no reason we need things to be so complicated. We could lower tax rates substantially by eliminating deductions that only help a small percentage of the population. Get rid of capital gains and tax it all with the same rates, too. Withholdings would be easy to calculate so you wouldn’t have a big bill in April. We could put the accountants and tax lawyers to work doing something productive.
"The origin of American zoning is largely in efforts to uphold racial segregation."
You see this claim a lot in progressive circles and it (a) doesn't really make sense and (b) is wholly unsupported by the linked studies and historiography. The paper linked in this work examines the use of zoning to enforce Racial Segregation in Southern Cities in the early 1900s. The idea that zoning would be used to uphold a de jure system of segregation that already existed is more or less unremarkable, horrific though it may be.
But "the origin of American zoning" is not found at all in the largely rural South. The paper you link to admits this in the second paragraph (!) saying "Benjamin Marsh championed zoning in the early 1900s in an effort to combat urban congestion and thereby improve the quality of working-class neighborhoods." Not only does this progressive, urban origin of zoning happen to be true, it also makes way more sense that an idea that originated in European urban renewal movements would first present itself in large, Northern American cities as opposed to smaller Southern ones.
This claim is akin to the ludicrous 1619 project claim that capitalism was invented in America (wrong) as a way to more efficiently facilitate the trade of enslaved people (also wrong). I don't understand why people feel the need to lie about this stuff, when it seems bad enough to me that the United States spend two centuries using otherwise anodyne or progressive advancements (urban renewal, ledger books) to facilitate the bondage and disenfranchisement of human beings. That is already bad! You don't need to pretend that Central Park is Jim Crow! IMHO it devalues the entire argument to make demonstrably false claims like this.
+1 from an urban planner. It's true that zoning has been *used* to facilitate segregation, but its orgins were related to the problems associated with urban growth and industrialization that you cite. And I superlike (tm) your point about undermining arguments with disingenuous false claims!
That said, I'm broadly sympathetic to the point that emphasizing the racist history of X is not going to be a very convincing argument since it's disconnected from the material consequences for voters you might be trying to persuade.
Well said, Ray. I understand that this was more of a throat-clearing comment by MY, but I think we would all be better off and more able to make real progress if we just dropped this point from the discourse. You will not guilt homeowners into supporting upzoning with the systemic racism argument.
I think it's worth unpacking a few things here. I think overall you're right to note that the origin story of zoning places much too much emphasis on a racist origin story, especially as you note that urban zoning began in Europe and migrated here.
But I think you might be overselling the case a bit too far in the other direction. Zoning became over time a backdoor way of upholding segregation. In some ways I think it might be worth breaking up history of zoning into pre and post WWII phases. But more to the point with modern times, when someone at a local board meeting complains that apartments will bring poverty to the town, it's hard not to see the very obvious racists origins of that claim. I'm aware that people have objections to multifamily projects for all sorts of reasons, including very basic ones as "I don't like how this building looks". But it's also undeniably true that enforcement of single family zoning is at least in part about keeping "those people" out of the neighborhood.
*Also not the point of your post, but in your 1619 project note I'm assuming you're referencing the Matthew Desmond essay? I bring this up because in the intellectual honest criticism of the 1619 project (unfortunately my feeling is most criticisms are intellectually dishonest...mostly along the lines of "how dare you say anything bad about Murica and it's founding. It's UnAmerican", really center around just two essays; Nicole Hannah Jones and Matthew Desmond's essays. Given that NHJ is basically the editor/creator of the project, there is a certain amount of fairness in expanding criticism of her essay as a criticism of the project overall. And I do think Matthew Desmond's essay is kind of garbage for the reasons you noted. But it is striking to me that criticism of the other (numerous) essays is almost non-existent. Like does anyone have any solid critiques of Jamelle Bouie or Kevin Kruse's essays? I'm sure they exist somewhere, but the lack of outrage directed at any of other essays seems really telling to me. Again, I for the most part agree with your comment about 1619 (although I'd quibble with using progressive as I think you're using a very late 19th early 20th century definition of the term that may not apply today), but just thought it worth noting.
I think that the synthesis point for zoning is that it's just like a very powerful and very imprecise tool. Like, as our host likes to point out, what kind of buildings you allow where is a very big deal in both, uh, breadth and depth. That is: land and buildings are expensive, so allowing/forbidding/making changes to what kinds of buildings you can build hits people and businesses very deeply. It's not a minor speedbump that people can just sort of mostly handle and continue on with what they were doing, zoning makes and breaks ideas and projects and businesses and people. But also, it has really wide-ranging consequences, lots of important second-order effects.
And that's a dangerous combination. I think that lots of the people who supported zoning that we now understand limited the opportunities of black people probably did so without a single racist sentiment -- but because the impact of zoning is both so deep and so broad, it was easy to sneak in racially exclusionary zoning even as a second or third order consequence, and even as a second or third order consequence, its impact was deep enough that it was highly meaningful. And regardless of whether you, the hypothetical audiencemember, are personally animated by the racial framing, if it could be used that way, it can also be used to meaningfully impede goals that you do find compelling, or to accelerate projects that you personally find distasteful.
I think Matt Yglesias himself has complained when people claim that the origin of American *policing* is in the American slavery system, noting in his complaint the lack of global context -- other countries have broadly similar police systems and don't have a similar history around slavery.
It looks like he's making the same mistake himself here. (If there is some cross-country analysis that shows a strong link between housing restrictions and a history of segregation, please do correct me!)
There are a lot of things from the first three weeks of the URBS 1001: Introduction to Urban Studies curriculum that have been floating around the broader discourse for the past five or six years that could use a lot of the information from the other four years of the program...
We went over the early zoning cases in 1L Property Law. I remember at one point saying that these laws were designed to keep out poor black people and the professor correcting me with "No! These laws were designed to keep out all poor people, not just black people."
Euclidean zoning was more about anti-density and keeping the sounds and smells of industry (and the riffraff who worked in factories) away from nicer neighborhoods. Racial segregation was absolutely perpetuated by zoning, especially in the post-CRA era, but that was not the original intent.
I’m not a knee-jerk defender of the doctor’s lobby and usually disagree with my specialty organization. But US training really is much better than what exists in many other countries, and also American tourists in many countries are often told to go to “the good hospital” and don’t just visit a random rural hospital when they’re sick.
If we want to intelligently deregulate (which I agree should be a goal), we should follow the example set by other countries like New Zealand, which don’t require a full residency but still require a couple years of supervised practice and a licensing exam before doctors set out on their own. And I totally agree that expanding NP practice is good, although we also have a nursing shortage so we should probably just expand that pipeline in general
>>But US training really is much better than what exists in many other countries<<
Sure, but not *all* countries. Seems nuts to require doctors trained in Canada, UK, France, Israel, etc to do a full residency. Can't the federal government certify the products of certain countries' medical training systems for fast-track status? (I agree with your idea re: the NZ system.)
Yeah I actually think dumb deregulation would backfire, because inevitably there would be horror stories about a poorly trained immigrant doctor providing bad medical care. And then US medical societies (which I 100% agree are all about rent-seeking) would say “see, all foreign-trained doctors should do residency” and we would be back where we started. I think something like what you are describing would be a better way to sustainably make this work.
They would be if salaries didn't crater. And they would probably continue to practice in large urban areas and continue to leave the rest of the country undersupplied.
Isn't there still a cap on the number of doctors able to train in the US? Really struggle to see how that's justified amid a physician shortage (and heavy restrictions on importing medical professionals).
HHS pays the wages of doctors in training. As far as I know, nothing would stop a private hospital from deciding to fund its own additional residency spots, but hospitals are penny pinchers and don’t do that. So the number of residency slots is determined by the budget Congress will allocate for them.
While most residency spots are government funded (via many routes: CMS/Medicare & Medicaid, VA, HRSA), I have been at 3 institutions that either added residency spots with internal funding, or created entirely new residency programs from internal funding. It is pretty common.
There was a recent big boost to residency funding as well
It's not a "cap" as in a set maximum decided somewhere. It's "the number we have collectively come to" via the independent and often competitive and contradictory decisions of ~200 US medical schools (MD+DO) who graduate new doctors (who really can't do anything) and literally thousands of residency programs of all types (who train doctors to have useful skills).
I agree with the NZ comments from Mark.
Allowing foreign physicians into the US to practice unrestricted if licensed there means one thing from EU countries, and something else entirely from many other places.
There is, because that is centrally set. If we went full unregulated capitalism here, I would argue we should scrap residency and even medical school requirements in general and just let hospitals hire whoever they want and train them the way they want to.
But if we have higher standards for US grads and the more competitive foreign applicants (who will still do a US residency), and lower standards for less competitive foreign doctors from countries with much lower standards for their own residency systems, then you end up with a system where only desperate rural hospitals hire foreign-trained doctors.
This is incorrect. There is no centrally set cap on either physician grads from medical schools (AAMC, LCME), nor one for residencies (ACGME). Each program can adjust size--within existing guidelines and funding sources, which are complex--on their own.
Realistically though, programs generally only increase slots if they get Medicare funding, so we have a defacto shortage. This is exacerbated by the fact specialist residents/fellows are worth more to hospitals than generalists, so if they are going to self fund it's not for the generalists they need.
I'm in the military and have interacted with/have colleagues that interact with the European system. The consensus is that Britain's residencies are as rigorous as the US, but most European residencies don't produce doctors capable of independent practice (in part owing to hour restrictions that reduce training they can get in a set time). My boss said in Italy he'd frequently see docs 10 years out of residency deferring to a super senior doctor on management issues we'd expect a fresh grad to make.
I also was told that care east of Germany (Poland) was severely substandard to the US, even citing OR cleanliness issues.
Data on the US system shows we grade the best for most issues (trauma, heart disease cancer etc.) Controlling for health when you get in trouble. The non US advantage is better population health and management/screening that nips more issues in the bud.
Basically, you need to improve compensation for general practitioners and ramp up their supply. That will reduce the supply of train wreck patients that make our numbers look bad.
I am totally for expanding med schools, residency spots, and importing doctors with appropriate credentials--I appreciate your insights above on European training.
My colleague did months of rotations in Australia and came away horrified at their training for what that's worth....
I am not a member of the AMA, or generally a fan of most specialty society positions on "business and workforce" issues.
I only exist here to correct the misperceptions that there is a set cap of some meaningful sort in the way that people commonly use the term "cap" to mean.
I agree, there isn't a cap, the same way there isn't a cap on housing. However the way the system is set up you generate a shortage and residency is where the shortage manifests. The easiest way to fix that is probably some increased Medicare funding for primary care residencies in undeserved areas.
I'd also say a lot of mid-level proliferation is a work around on this. Whatever you think of foreign trained docs, they're better than an online NP grad heading straight into independent practice.
They are good for some things like fishing-related or farming-related injuries, but I would definitely get my cancer care (or more specialized care in general) elsewhere. Primary care is probably more or less equivalent, there are a lot of good rural family doctors
I don't know. Obviously there is selection bias skewing this but the amount of "oh my god, this medicine hasn't been the standard of care for this problem since the 90s" or "how could they have never considered to run this test or treatment when the chart indicates that the patient has been complaining of this problem for years?" I hear from my wife about patients ending up in the urban hospital she works at after having their care mismanaged doesn't make me feel great about the quality of care in a lot of rural settings.
I accept many patients transferred to the big fancy university hospital from small rural critical-access hospitals. Some for clear good reasons (complexity) some because the small hospital is just failing to do what they clearly need to do. Yes, there is often a knowledge deficit in the small places--I don't think they see enough, do enough to keep up their knowledge and practice with anything but the most very common things they care for.
For me though, my hesitation is more based on the limited resources in case of something going wrong, something new and bad found, or just general lack of 24/7 coverage for important things (it's often ~12/5).
Agreed. At the same time, NPs who aren’t doctors at all are increasingly replacing doctors. And the trend continues. Now you have nurse anesthesiologists etc. You’re telling me that an EU trained doctor would on average give you less qualified treatment than an American np? As others commented, o think a rigorous regulation that very much cuts hurdles for doctors trained in. *specific countries* only would be a good thing. Not goin as far as MY but not accepting the untenable status quo either.
US training is indeed better than what exists in many other countries, but is it better than the EU, for example? I’m very skeptical having lived both in the EU and the US. I would only go to an American doctor for an emergency, and I always wait to go back home on vacation for doctor visits I can schedule.
"I would only go to an American doctor for an emergency"
Because of the quality of the doctor or the quality of the health care system? I feel like the latter is 90% of what's important or more but doctor training only impacts that other 10% that is doctor quality.
Good question. I only have anecdotal evidence to offer. My American experience says that doctors will spend as little time with you as possible and try to do as many tests as possible so that they can charge you. I view them more as salesmen than doctors to be honest. I’m used to the doctor taking her time to listen to you before anything, and then also taking the time to explain to you in detail what’s going on, and I haven’t seen that in the US at the times I needed to go to a doctor. I also know that American residencies tend to be more brutal than the ones back home, and you end up with doctors that are more sleep deprived than normal. I don’t want a sleep deprived doctor!
However, nothing here is data. The only data I’m aware of say that the US has unusually short life expectancies for the wealth it exists here. But that could point to problems at many areas of healthcare other than doctor training.
My anecdotal experience with GPs has been really good - they've always taken a lot of time to listen and answer questions - but maybe I've just gotten lucky.
With other care I find that I have to wait a long time and barely see the doctor. It just seems like there's staffing shortages across the board, at least that's my explanation but I don't really know or have a point of comparison.
"unusually short life expectancies for the wealth" - I'm skeptical of healthcare explanations for that gap. Or at least I'm skeptical healthcare is the majority of the explanation. There's too much geographic and demographic variation in LE between counties, states and demographics within the US for healthcare to be the main driver. It could be one driver, but other cultural or lifestyle factors most be at work, too.
Why so skeptical? US stands out in western world for low and decreasing life expectancy. It also is *unique* in the terrible healthcare system and lack of any kind of universal coverage. I see no other potentially relevant factor in which the US stands out so clearly from peer countries. Why wouldn't you think this is extremely plausible a priori as at least one significant factor explaining the phenomenon?
“Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer’s disease) account for 86% and 67% of American men’s and women’s life expectancy shortfall, respectively.”
As a relevant factor, I'm not quite so skeptical as I must have sounded. But I'm very skeptical that it's the major or only factor.
One part I didn't mention is that I'm just somewhat skeptical of our healthcare systems ability to treat non-acute issues. If I have an appendicitis or a heart attack, I'll be glad I live near an ER. But if I needed a plan to lose weight or eat healthy I'm not expecting a doctor to prescribe that for me. And in between the acute stuff and the lifestyle stuff there's a huge volume of elective procedures and diagnostics that I have a very skeptical view of. I just don't think they move the needle much and can do as much harm as good.
I don't have great evidence for this latter POV other than "lived experience". And I may be entirely ignorant of how much better Western Europe is on one of those 3 areas of healthcare: lifestyle, acute, elective/diagnostic. A good source of evidence that I may dig through at some point is mortality data during covid when hospitals stopped doing elective and diagnostic work: many editorials predicted people would die of cancers, etc.. due to lack of screening but as far as I can see that never happened.
The part I did state above, though, is there's so much non-healthcare variation in American Health. Non-college degreed people live many years fewer than the degreed, but in general we all go to the same hospitals for acute stuff and are left to our own devices wrt to lifestyle (and as I said I don't think the elective stuff does much anyway) so lifestyle is probably what explains the gap.
I'm glad about your GP experiences! I mostly have that type of visits when I go home on vacation, so I really only use the medical system here for relatively urgent staff. For the lifestyle conversation, check my answer to Mark below.
The time limits are set by insurance companies and the government, and probably influenced by low supply of doctors (it’s still hard to get an appointment). The excessive testing is dumb but a separate issue - lots of medical training here is based on highly conscientious people who think you need to test for every rare disease under the sun. And insurance companies/Medicare will always reimburse, so it’s never challenged.
If this was driven by doctor greed, then academic hospitals that pay on salary would have lower costs of care than community hospitals that pay more based on incentives, but we don’t see that pattern. It still leads to excessive costs either way, but assuming all doctors are bad people isn’t any more useful than saying that all academics are bad people because tuition at US universities is too high
And I think a lot of people *want* a bunch of tests/meds, so for doctors that can be the path of least resistance. I know a lot of people in my middle-aged cohort and older who are convinced that they're sick a lot of the time...
Academic hospital cost >> community hospital cost.
Academic hospital care ?? community hospital care...depends on the issue for; for some complex stuff there just isn't much comparison (since it doesn't happen at community hospitals, but for other things (particularly routine things) a great community hospital could be far better.
I'm at a big academic place and my income changes based on the number of patients I see is <10-15%, and it is not affected whatsoever based on tests, consults, whatever that I actually order/do (I am not a proceduralist).
First, I'm not saying that all American doctors are bad people! I'm saying that from my anecdotal evidence (and not data) I would describe my interactions with doctors here as mediocre at best. I said that I'm not sure that points to training issues even. The only direct knowledge of a problem with doctor training I have from the US is that the residents I know here are far more overworked than the ones back home, and I don't want a tired doctor.
However, I find it rather implausible that American doctors are such an outlier in conscientiousness. If insurers paid providers (hospitals, clinics, etc) a fixed amount of money every month regardless of the number of tests they did, I suspect that American conscientiousness would go to European levels.
Didn’t mean to imply that, but the relationship between money and healthcare implied by the salesman model is wrong. The difference between US and Euro doctors isn’t that we’re paid more for doing tests, otherwise you would see that relationship based on practice setting, and academic doctors would spend less since we are on salary. It’s that nobody tells us “no”, so we assume/feel that all tests are justified (as opposed to Europe where cost control exists). We also have a very human bias that the work we do is useful - not always true! And external cost control can fix that.
The better analogy is an overfunded bureaucracy where nobody ever says “no” to a funding request, not a sales team where our only goal is to sell a product.
If your doctor takes longer than 15 minutes in the exam, her emr system dings her for taking too long and her hospital system will penalize her for not seeing enough patients. Time is money and throughput is the only way we can get these people referred up to the real doctors who earn the hospital its money.
Also US lifestyles are bad. There are other factors in life expectancy beyond the healthcare system. I promise I don’t control how walkable anyone’s neighborhood is or set the price of junk food/alcohol.
I don't buy the junk food argument. Junk food also exists in the EU, and it is a cheaper option than healthy food there as well. However, I'm also used to having a long-standing relationship with our family doctor there with whom I have a chat every year, so if he thought my blood tests show that I'm not eating healthily, he would very forcefully let me know. (And he does do that from time to time.) Most Americans I know here don't do that type of doctor visits. (I mostly know people my age here, of course.)
I will give you the higher number of car accident deaths and the wider availability of guns as lifestyle reasons for shorter lifespans in the US though. However, I would expect you to concede that American doctors gave a lot of powerful opioids to people without appropriate supervision (my understanding is that you can't get this type of drugs with you at home where I come from) and that caused a lot of avoidable deaths here.
Fat but active is vastly better in terms of health outcomes than fat and inactive. Not quite as good as “not fat and active,” but within shouting distance.
European and Asian urban planning and transportation almost guarantee the former outcome even for people whose diets are unhealthy on the whole. American urban planning and transportation virtually assures the latter outcome for people not actively trying to avoid it.
I think its likely both sides somewhat overstate the impact here... I was doing some quick googling and it looks like Canada makes it quite a bit easier for foreign-educated doctors to practice (basically one year of residency + you have to take a test provided you went to one of the schools on their list). But Canada still has pretty high doctor salaries.
Biggest problem in the US seems like the US is overindexed on specialists vs. primary care, but that seems like a case where it'd essentially be a win-win: primary care doctors could help with the shortage but I don't think salaries would come down that much.
At least part of the specialist issue is demand, lots of people want to see dermatologists or gastroenterologists for things that might not get treatment in other countries. If we really wanted to disincentivize this we would probably need insurance companies (or the government) to deny more claims, which might be justified for things like back surgery that are expensive but useless. And even cancer screening programs are mostly controversial aside from a few clear-cut cases like colon cancer screening. But probably a tough lift politically so I think expanding supply is more realistic than telling Americans that prostate cancer screening doesn’t pass cost-benefit analysis
On the nursing shortage: a major contributor there is that a major educator of nurses are community colleges, and community college nursing instructors usually make less money than nurses who are qualified to teach.
Another way to promote growth is to add a lot more automation to seaports and freight rail. There is a lot of low-hanging fruit that automation would make more efficient. Of course that would mean fighting the unions.
Freight rail is mostly provided by (regulated) private companies who got way more profitable in recent years while quality of service has, if anything, deteriorated. Seems like regulators just got comfortable with way higher returns for the operators and that should be rethought.
By no means an expert and would love someone who is to chime in, but as I understand it one of the major issues that rail companies have pushed for over the last decade has been to have trains leave on time. Historically a lot of trains were delayed because companies wouldn't get their stuff loaded on time. Those delays required much looser scheduling to accommodate and were much less efficient. Moving to a - it has to ready on time or its not going - approach is definitely a change in the quality of service, but I don't know that its worse.
*they have also run their staff much more heavily which given that it appears the railroad workers might strike, is going to be bad for all of us.
Interesting and thanks for sharing! Be curious how that compares to historical averages. It does seem to echo what I've read elsewhere that they understaff and that has been a major driver in both poor service performance and in the labor issues where conductors are feeling overworked.
To be fair, just because management is being stupid in some way, doesn't exclude the unions from also being foolish. Tis sadly possible if not likely for both to happen.
You are correct that we should do more to expand the supply of healthcare services, but you kind of skipped over the reason why it’s so difficult to do. One reason why rent seeking is so common in medicine is because doctors are politically powerful. That’s not only because they are affluent and educated, but also because they are an extremely well trusted profession. If a doctor goes around telling their patients that some new healthcare rule is going to make it harder for them to give good care, then those patients will oppose the change, even if it’s a change that is beneficial for patients. If your doctor says something is bad and a politician says it’s good, most people will believe their doctor.
Was a big discovery when I did field work promoting ACA; that insurance companies were not actually the biggest villains in our bloated health care system. Attacking insurance companies as the "evil" ones* was probably smart politics because as much lobbying power as they had it was dwarfed by the lobbying power of doctors for the reasons you outlined.
Obama got a of flack for his "if you like your doctor, you can keep it" line as for a decent number of people it turned out to not be true. And I think it's fair for GOP (or other Progressives who want M4A) to point out that this wasn't strictly true. And yet if I could go back in time and advise Obama, I'd tell him to keep that line in his speeches and Town Halls because of the politics. You basically needed it to get it passed and I think this is one of those situations where the consequentialist framing is right (the end result justifies the "only most true" aspect of this line).
*not biggest villains doesn't mean they weren't or aren't villains. Insurance companies finding ways to deny claims that were seemingly part of someone's insurance plan was definitely a thing and they deserved the criticism that came their way.
Ah yes, Politifact's "Lie of the Year." I always wondered what the standard was for turning Obama's statement into a lie (or the Lie of the Year). If one single person hadn't been able to keep their plan, would that have been enough? Two? Thirty million? You use the term "a decent number of people" -- any idea what that translates to in actual numbers?
BTW, I agree with you on the questionable singling out of insurance companies. That has always been Bernie's and Warren's go to move, including the other villains: "Big Pharma" and hospital administrators. Somehow, there's always one group that *never* gets mentioned. On the tip of my tongue . . . rhymes with "proctors" . . .
Yeah. Doctors aren’t mentioned in those attacks because it’s really obvious that the attack would backfire. People trust their doctors, and they especially trust their doctors more than they trust politicians. It misleads people a bit but the alternative is making healthcare reform ideas incredibly toxic because most people will refuse to think of their doctor as a bad guy in the situation.
The "'If you like your *health care plan*, you can keep it" [1] line really was a lie because part of the *purpose* of the ACA was to ban many types of plans. E.g. the ACA required all healthcare plans to cover a long list of things, so plans that didn't cover contraceptives were banned, and no one could keep them. I'm guessing that the vast majority of pre-ACA healthcare plans were not up to ACA standards (lifetime limits, which were also banned, were pretty common), so arguably, basically everyone lost their plan and got a different one in its place. (Probably a more expensive one given the expanded coverage.)
I think the mitigating factor is that HMOs suck, so I doubt anyone really liked their plan. At best, they just disliked it less than the alternatives... Was anyone unhappy that they could no longer get a plan with lifetime limits? I doubt it. Lifetime limits suck. Were some people unhappy that they could no longer get plans that didn't cover contraceptives? Absolutely. See Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania; Zubik v. Burwell; and Burwell v. Hobby Lobby Stores, Inc.
EDIT: [1] has an example of someone who was unhappy about the changes. I doubt she was the only person unhappy about expanded coverage:
"One example: PBS Newshour interviewed a woman from Washington, D.C., who was a supporter of the health care law and found her policy canceled. New policies had significantly higher rates. She told Newshour that the only thing the new policy covered that her old one didn’t was maternity care and pediatric services. And she was 58."
"The chance of me having a child at this age is zero. So, you know, I ask the president, why do I have to pay an additional $5,000 a year for maternity coverage that I will never, ever need?" asked Deborah Persico.
The fact that we don't have hard numbers for the number of people who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year". Its seems definitely more than a handful. But I can't seem to find just how many.
Regarding Bernie and Warren, I agree signaling Big Pharma or hospital administrators is mostly about politics as they make for good villains. But I'll semi-defend them in that there really are some terrible hospital administrator practices and insurance practices worth condemning. Centering your critique of the American health care system around these two entities is probably not entirely honest, but it's not entirely dishonest either if that makes any sense.
"who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year"."
The lie of the year had nothing to do with keeping doctors. The line was "If you like your **health care plan**, you can keep it" [1]. He did often mix healthcare plans and doctors together (e.g. "If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan." [2]), but only the health care plan part was the lie of the year. Serious, read [1]. The word "doctor" doesn't appear once. [1] Also notes that about 4 million people had their plans canceled. Granted, I have no idea how many of those people liked their plans, but surely some did.
Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state. Single parents of preschoolers are the biggest exception as the costs of child care swamp most younger peoples’ wages. Still, a solid 65% of adults do better by growing the economy than expanding benefits. This is the beating heart of center-right politics. The 35% who do better expanding benefits are numerically fewer and generally unproductive and often unsympathetic.
The main thing the welfare state can offer the median earner is security. I don’t trust an insurance company to take care of me if I get sick (I recall one claiming my wife’s cancer was a preexisting condition even though she’s had continuous coverage for years) and I sure as fuck don’t want my basic needs in old age to depend on the stock market.
>>Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state<<
That's undoubtedly true as far as it goes, but there are clearly very large numbers of people who would benefit from both. You know, a parent who does well by getting a better job AND sees a real benefit from affordable childcare, or the 22 year old who gets good education partly subsidized by wealthier people (so no burdensome student loans) but is is also helped by a robust job market upon graduation.
Also, I've been trying for years to find evidence of a tradeoff between A) size of a country's welfare state and B) the strength of its economy. And I can't find much. I mean, Denmark's pretty freaking rich!
I agree with your general point about economic *security*.
The median parent is better off with subsidized child care as long as said care is funded by a progressive income tax. If were funded with a flat tax or a sales tax, that would basically transfer income from the median parents late career to the early, child residing part of it. That might still be a good trade off, given that most people face more income constraints at 30 than at 50.
Yes, one of the things people don't understand about the case for public funding of child care is that it's essentially a form of income smoothing (allows people to spread payment for things that are really expensive in about 5 years of their life over a longer time period), which is particularly relevant for higher income professionals in paying for child care, since most are not able to save for it as for retirement, higher ed, etc. (And is obviously also an issue for lower income families who do not have the money to save for those things in any case)
I understand why we do it, but comparing the US to Denmark or any other small country seems weird to me. Its more comparable to Virginia - about the same size, though Denmark has 30% fewer people.
Could we step up the push to put tax-preparers out of work?
Legislation to have the IRS calculate your taxes and send you the bill. You verify it, or don't, and send them a check, or don't.
HR Block and Turbotax have to find new jobs.
I have no love for the lobbying efforts of H&R Block et al., but they're not the only problem here. The more social engineering gets layered onto the tax code (some advocated for by this very blog), the harder it is for the IRS to accurately calculate what you owe, and the IRS is not the most nimble IT service in the country.
Indeed. That this is an industry is a real failure. A huge anchor in terms of the opportunity cost stemming from smart people deployed in unnecessary activities and charging hilariously exorbitant fees. But then, tax avoidance is the one biggest way regular folk can do rent seeking...
Turbotax is a lot different then tax lawyers scheming with private bankers. Rich people paying tax professionals to reduce liabilities is inevitable, turbotax is not
"That this is an industry is a real failure."
Every tax-prep billionaire is a policy failure.
(Much easier to agree with than the generalized version.)
Eh, perhaps...then again, too-specific can be a bit much. See: “Can we step up the push to put tax preparers out of work?”
Or improve their service. Every year the same annoying edge cases don’t get fixed. And it’s gotten harder to see the underlying tax documents.
Don’t get me started!
Any politician who proposes that is going to find that their opponent in the next election is extremely well funded though.
Though I'm also guessing the AMA would fund the shit out of opponents to Matt's second proposal.
For low to middle income wage earners, taxes should absolutely be way simpler than they currently are. But there will still be plenty of jobs in business tax prep, because there is really no good way to make business taxes simple.
I've always wondered if open source tax software could ever take off to be a feasible challenger to killing these middlemen if Congress can't or won't.
Supposedly they are considering it again, but who knows if anything will result:
https://www.cnbc.com/2022/08/30/congress-explores-free-tax-filing-program-to-cut-out-middlemen.html
I’m more a fan of the “file our taxes on a postcard” plan, or just have everyone use the 1040EZ form. Get rid of deductions and raise the standard deduction. There is no reason we need things to be so complicated. We could lower tax rates substantially by eliminating deductions that only help a small percentage of the population. Get rid of capital gains and tax it all with the same rates, too. Withholdings would be easy to calculate so you wouldn’t have a big bill in April. We could put the accountants and tax lawyers to work doing something productive.
Even better replace it with something like the Fair Tax
"The origin of American zoning is largely in efforts to uphold racial segregation."
You see this claim a lot in progressive circles and it (a) doesn't really make sense and (b) is wholly unsupported by the linked studies and historiography. The paper linked in this work examines the use of zoning to enforce Racial Segregation in Southern Cities in the early 1900s. The idea that zoning would be used to uphold a de jure system of segregation that already existed is more or less unremarkable, horrific though it may be.
But "the origin of American zoning" is not found at all in the largely rural South. The paper you link to admits this in the second paragraph (!) saying "Benjamin Marsh championed zoning in the early 1900s in an effort to combat urban congestion and thereby improve the quality of working-class neighborhoods." Not only does this progressive, urban origin of zoning happen to be true, it also makes way more sense that an idea that originated in European urban renewal movements would first present itself in large, Northern American cities as opposed to smaller Southern ones.
This claim is akin to the ludicrous 1619 project claim that capitalism was invented in America (wrong) as a way to more efficiently facilitate the trade of enslaved people (also wrong). I don't understand why people feel the need to lie about this stuff, when it seems bad enough to me that the United States spend two centuries using otherwise anodyne or progressive advancements (urban renewal, ledger books) to facilitate the bondage and disenfranchisement of human beings. That is already bad! You don't need to pretend that Central Park is Jim Crow! IMHO it devalues the entire argument to make demonstrably false claims like this.
+1 from an urban planner. It's true that zoning has been *used* to facilitate segregation, but its orgins were related to the problems associated with urban growth and industrialization that you cite. And I superlike (tm) your point about undermining arguments with disingenuous false claims!
I am not sure this is such a big distinction, how long did it take for zoning to be used for racist ends? Like five years?
https://en.wikipedia.org/wiki/Zoning_in_the_United_States#Los_Angeles,_1904-1909
That said, I'm broadly sympathetic to the point that emphasizing the racist history of X is not going to be a very convincing argument since it's disconnected from the material consequences for voters you might be trying to persuade.
Well said, Ray. I understand that this was more of a throat-clearing comment by MY, but I think we would all be better off and more able to make real progress if we just dropped this point from the discourse. You will not guilt homeowners into supporting upzoning with the systemic racism argument.
I think it's worth unpacking a few things here. I think overall you're right to note that the origin story of zoning places much too much emphasis on a racist origin story, especially as you note that urban zoning began in Europe and migrated here.
But I think you might be overselling the case a bit too far in the other direction. Zoning became over time a backdoor way of upholding segregation. In some ways I think it might be worth breaking up history of zoning into pre and post WWII phases. But more to the point with modern times, when someone at a local board meeting complains that apartments will bring poverty to the town, it's hard not to see the very obvious racists origins of that claim. I'm aware that people have objections to multifamily projects for all sorts of reasons, including very basic ones as "I don't like how this building looks". But it's also undeniably true that enforcement of single family zoning is at least in part about keeping "those people" out of the neighborhood.
*Also not the point of your post, but in your 1619 project note I'm assuming you're referencing the Matthew Desmond essay? I bring this up because in the intellectual honest criticism of the 1619 project (unfortunately my feeling is most criticisms are intellectually dishonest...mostly along the lines of "how dare you say anything bad about Murica and it's founding. It's UnAmerican", really center around just two essays; Nicole Hannah Jones and Matthew Desmond's essays. Given that NHJ is basically the editor/creator of the project, there is a certain amount of fairness in expanding criticism of her essay as a criticism of the project overall. And I do think Matthew Desmond's essay is kind of garbage for the reasons you noted. But it is striking to me that criticism of the other (numerous) essays is almost non-existent. Like does anyone have any solid critiques of Jamelle Bouie or Kevin Kruse's essays? I'm sure they exist somewhere, but the lack of outrage directed at any of other essays seems really telling to me. Again, I for the most part agree with your comment about 1619 (although I'd quibble with using progressive as I think you're using a very late 19th early 20th century definition of the term that may not apply today), but just thought it worth noting.
Not wanting apartments isn't necessarily about race.
Crime is strongly correlated with density and poverty
I think that the synthesis point for zoning is that it's just like a very powerful and very imprecise tool. Like, as our host likes to point out, what kind of buildings you allow where is a very big deal in both, uh, breadth and depth. That is: land and buildings are expensive, so allowing/forbidding/making changes to what kinds of buildings you can build hits people and businesses very deeply. It's not a minor speedbump that people can just sort of mostly handle and continue on with what they were doing, zoning makes and breaks ideas and projects and businesses and people. But also, it has really wide-ranging consequences, lots of important second-order effects.
And that's a dangerous combination. I think that lots of the people who supported zoning that we now understand limited the opportunities of black people probably did so without a single racist sentiment -- but because the impact of zoning is both so deep and so broad, it was easy to sneak in racially exclusionary zoning even as a second or third order consequence, and even as a second or third order consequence, its impact was deep enough that it was highly meaningful. And regardless of whether you, the hypothetical audiencemember, are personally animated by the racial framing, if it could be used that way, it can also be used to meaningfully impede goals that you do find compelling, or to accelerate projects that you personally find distasteful.
I think Matt Yglesias himself has complained when people claim that the origin of American *policing* is in the American slavery system, noting in his complaint the lack of global context -- other countries have broadly similar police systems and don't have a similar history around slavery.
It looks like he's making the same mistake himself here. (If there is some cross-country analysis that shows a strong link between housing restrictions and a history of segregation, please do correct me!)
There are a lot of things from the first three weeks of the URBS 1001: Introduction to Urban Studies curriculum that have been floating around the broader discourse for the past five or six years that could use a lot of the information from the other four years of the program...
We went over the early zoning cases in 1L Property Law. I remember at one point saying that these laws were designed to keep out poor black people and the professor correcting me with "No! These laws were designed to keep out all poor people, not just black people."
Euclidean zoning was more about anti-density and keeping the sounds and smells of industry (and the riffraff who worked in factories) away from nicer neighborhoods. Racial segregation was absolutely perpetuated by zoning, especially in the post-CRA era, but that was not the original intent.
Very much agreed.
And that's why I oppose density around my property
I’m not a knee-jerk defender of the doctor’s lobby and usually disagree with my specialty organization. But US training really is much better than what exists in many other countries, and also American tourists in many countries are often told to go to “the good hospital” and don’t just visit a random rural hospital when they’re sick.
If we want to intelligently deregulate (which I agree should be a goal), we should follow the example set by other countries like New Zealand, which don’t require a full residency but still require a couple years of supervised practice and a licensing exam before doctors set out on their own. And I totally agree that expanding NP practice is good, although we also have a nursing shortage so we should probably just expand that pipeline in general
>>But US training really is much better than what exists in many other countries<<
Sure, but not *all* countries. Seems nuts to require doctors trained in Canada, UK, France, Israel, etc to do a full residency. Can't the federal government certify the products of certain countries' medical training systems for fast-track status? (I agree with your idea re: the NZ system.)
Yeah I actually think dumb deregulation would backfire, because inevitably there would be horror stories about a poorly trained immigrant doctor providing bad medical care. And then US medical societies (which I 100% agree are all about rent-seeking) would say “see, all foreign-trained doctors should do residency” and we would be back where we started. I think something like what you are describing would be a better way to sustainably make this work.
I agree. But my guess would be that there aren't all that many French and British doctors who are interested in immigrating here.
They would be if salaries didn't crater. And they would probably continue to practice in large urban areas and continue to leave the rest of the country undersupplied.
Isn't there still a cap on the number of doctors able to train in the US? Really struggle to see how that's justified amid a physician shortage (and heavy restrictions on importing medical professionals).
You'll struggle indefinitely. There is no justification. It's rent-seeking, pure and simple.
HHS pays the wages of doctors in training. As far as I know, nothing would stop a private hospital from deciding to fund its own additional residency spots, but hospitals are penny pinchers and don’t do that. So the number of residency slots is determined by the budget Congress will allocate for them.
This is actually wrong.
While most residency spots are government funded (via many routes: CMS/Medicare & Medicaid, VA, HRSA), I have been at 3 institutions that either added residency spots with internal funding, or created entirely new residency programs from internal funding. It is pretty common.
There was a recent big boost to residency funding as well
https://www.cms.gov/newsroom/press-releases/cms-funding-1000-new-residency-slots-hospitals-serving-rural-underserved-communities
It's not a "cap" as in a set maximum decided somewhere. It's "the number we have collectively come to" via the independent and often competitive and contradictory decisions of ~200 US medical schools (MD+DO) who graduate new doctors (who really can't do anything) and literally thousands of residency programs of all types (who train doctors to have useful skills).
I agree with the NZ comments from Mark.
Allowing foreign physicians into the US to practice unrestricted if licensed there means one thing from EU countries, and something else entirely from many other places.
There is, because that is centrally set. If we went full unregulated capitalism here, I would argue we should scrap residency and even medical school requirements in general and just let hospitals hire whoever they want and train them the way they want to.
But if we have higher standards for US grads and the more competitive foreign applicants (who will still do a US residency), and lower standards for less competitive foreign doctors from countries with much lower standards for their own residency systems, then you end up with a system where only desperate rural hospitals hire foreign-trained doctors.
This is incorrect. There is no centrally set cap on either physician grads from medical schools (AAMC, LCME), nor one for residencies (ACGME). Each program can adjust size--within existing guidelines and funding sources, which are complex--on their own.
Realistically though, programs generally only increase slots if they get Medicare funding, so we have a defacto shortage. This is exacerbated by the fact specialist residents/fellows are worth more to hospitals than generalists, so if they are going to self fund it's not for the generalists they need.
I'm in the military and have interacted with/have colleagues that interact with the European system. The consensus is that Britain's residencies are as rigorous as the US, but most European residencies don't produce doctors capable of independent practice (in part owing to hour restrictions that reduce training they can get in a set time). My boss said in Italy he'd frequently see docs 10 years out of residency deferring to a super senior doctor on management issues we'd expect a fresh grad to make.
I also was told that care east of Germany (Poland) was severely substandard to the US, even citing OR cleanliness issues.
Data on the US system shows we grade the best for most issues (trauma, heart disease cancer etc.) Controlling for health when you get in trouble. The non US advantage is better population health and management/screening that nips more issues in the bud.
Basically, you need to improve compensation for general practitioners and ramp up their supply. That will reduce the supply of train wreck patients that make our numbers look bad.
I mean yes and no, I've been a part of entirely new and self-funded residency and fellowship programs in a large non-academic hospital system. Most of the medicare spots were basically frozen decades ago until recently. https://www.cms.gov/newsroom/press-releases/cms-funding-1000-new-residency-slots-hospitals-serving-rural-underserved-communities
I am totally for expanding med schools, residency spots, and importing doctors with appropriate credentials--I appreciate your insights above on European training.
My colleague did months of rotations in Australia and came away horrified at their training for what that's worth....
I am not a member of the AMA, or generally a fan of most specialty society positions on "business and workforce" issues.
I only exist here to correct the misperceptions that there is a set cap of some meaningful sort in the way that people commonly use the term "cap" to mean.
I agree, there isn't a cap, the same way there isn't a cap on housing. However the way the system is set up you generate a shortage and residency is where the shortage manifests. The easiest way to fix that is probably some increased Medicare funding for primary care residencies in undeserved areas.
I'd also say a lot of mid-level proliferation is a work around on this. Whatever you think of foreign trained docs, they're better than an online NP grad heading straight into independent practice.
To be honest, I *would not* visit a random rural hospital here *in* the US...
They are good for some things like fishing-related or farming-related injuries, but I would definitely get my cancer care (or more specialized care in general) elsewhere. Primary care is probably more or less equivalent, there are a lot of good rural family doctors
"...fishing-related or farming-related injuries, but I would definitely get my cancer care..."
I originally wanted to do a residency in oncology, but wound up doing five years of fish-hook removal.
When I play golf with the other docs, they make a lot of barbed comments.
I think you're trolling . . . .
And they fell for it, hook line and sinker!
I cheer all attempts at humor in SB comments. Even ones that flounder about. :-)
"I cheer all attempts at humor..."
I'm glad you liked it! I'm not above fishing for compliments.
I don't know. Obviously there is selection bias skewing this but the amount of "oh my god, this medicine hasn't been the standard of care for this problem since the 90s" or "how could they have never considered to run this test or treatment when the chart indicates that the patient has been complaining of this problem for years?" I hear from my wife about patients ending up in the urban hospital she works at after having their care mismanaged doesn't make me feel great about the quality of care in a lot of rural settings.
I accept many patients transferred to the big fancy university hospital from small rural critical-access hospitals. Some for clear good reasons (complexity) some because the small hospital is just failing to do what they clearly need to do. Yes, there is often a knowledge deficit in the small places--I don't think they see enough, do enough to keep up their knowledge and practice with anything but the most very common things they care for.
For me though, my hesitation is more based on the limited resources in case of something going wrong, something new and bad found, or just general lack of 24/7 coverage for important things (it's often ~12/5).
COVID made all this 10x worse.
I would allow primary and outpatient care. But that is not *hospital* care.
Agreed. At the same time, NPs who aren’t doctors at all are increasingly replacing doctors. And the trend continues. Now you have nurse anesthesiologists etc. You’re telling me that an EU trained doctor would on average give you less qualified treatment than an American np? As others commented, o think a rigorous regulation that very much cuts hurdles for doctors trained in. *specific countries* only would be a good thing. Not goin as far as MY but not accepting the untenable status quo either.
US training is indeed better than what exists in many other countries, but is it better than the EU, for example? I’m very skeptical having lived both in the EU and the US. I would only go to an American doctor for an emergency, and I always wait to go back home on vacation for doctor visits I can schedule.
"I would only go to an American doctor for an emergency"
Because of the quality of the doctor or the quality of the health care system? I feel like the latter is 90% of what's important or more but doctor training only impacts that other 10% that is doctor quality.
Good question. I only have anecdotal evidence to offer. My American experience says that doctors will spend as little time with you as possible and try to do as many tests as possible so that they can charge you. I view them more as salesmen than doctors to be honest. I’m used to the doctor taking her time to listen to you before anything, and then also taking the time to explain to you in detail what’s going on, and I haven’t seen that in the US at the times I needed to go to a doctor. I also know that American residencies tend to be more brutal than the ones back home, and you end up with doctors that are more sleep deprived than normal. I don’t want a sleep deprived doctor!
However, nothing here is data. The only data I’m aware of say that the US has unusually short life expectancies for the wealth it exists here. But that could point to problems at many areas of healthcare other than doctor training.
My anecdotal experience with GPs has been really good - they've always taken a lot of time to listen and answer questions - but maybe I've just gotten lucky.
With other care I find that I have to wait a long time and barely see the doctor. It just seems like there's staffing shortages across the board, at least that's my explanation but I don't really know or have a point of comparison.
"unusually short life expectancies for the wealth" - I'm skeptical of healthcare explanations for that gap. Or at least I'm skeptical healthcare is the majority of the explanation. There's too much geographic and demographic variation in LE between counties, states and demographics within the US for healthcare to be the main driver. It could be one driver, but other cultural or lifestyle factors most be at work, too.
Why so skeptical? US stands out in western world for low and decreasing life expectancy. It also is *unique* in the terrible healthcare system and lack of any kind of universal coverage. I see no other potentially relevant factor in which the US stands out so clearly from peer countries. Why wouldn't you think this is extremely plausible a priori as at least one significant factor explaining the phenomenon?
“Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer’s disease) account for 86% and 67% of American men’s and women’s life expectancy shortfall, respectively.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9154274/
American Exceptionalism isn’t just the good stuff, you know.
As a relevant factor, I'm not quite so skeptical as I must have sounded. But I'm very skeptical that it's the major or only factor.
One part I didn't mention is that I'm just somewhat skeptical of our healthcare systems ability to treat non-acute issues. If I have an appendicitis or a heart attack, I'll be glad I live near an ER. But if I needed a plan to lose weight or eat healthy I'm not expecting a doctor to prescribe that for me. And in between the acute stuff and the lifestyle stuff there's a huge volume of elective procedures and diagnostics that I have a very skeptical view of. I just don't think they move the needle much and can do as much harm as good.
I don't have great evidence for this latter POV other than "lived experience". And I may be entirely ignorant of how much better Western Europe is on one of those 3 areas of healthcare: lifestyle, acute, elective/diagnostic. A good source of evidence that I may dig through at some point is mortality data during covid when hospitals stopped doing elective and diagnostic work: many editorials predicted people would die of cancers, etc.. due to lack of screening but as far as I can see that never happened.
The part I did state above, though, is there's so much non-healthcare variation in American Health. Non-college degreed people live many years fewer than the degreed, but in general we all go to the same hospitals for acute stuff and are left to our own devices wrt to lifestyle (and as I said I don't think the elective stuff does much anyway) so lifestyle is probably what explains the gap.
I'm glad about your GP experiences! I mostly have that type of visits when I go home on vacation, so I really only use the medical system here for relatively urgent staff. For the lifestyle conversation, check my answer to Mark below.
The time limits are set by insurance companies and the government, and probably influenced by low supply of doctors (it’s still hard to get an appointment). The excessive testing is dumb but a separate issue - lots of medical training here is based on highly conscientious people who think you need to test for every rare disease under the sun. And insurance companies/Medicare will always reimburse, so it’s never challenged.
If this was driven by doctor greed, then academic hospitals that pay on salary would have lower costs of care than community hospitals that pay more based on incentives, but we don’t see that pattern. It still leads to excessive costs either way, but assuming all doctors are bad people isn’t any more useful than saying that all academics are bad people because tuition at US universities is too high
And I think a lot of people *want* a bunch of tests/meds, so for doctors that can be the path of least resistance. I know a lot of people in my middle-aged cohort and older who are convinced that they're sick a lot of the time...
Good insight.
Academic hospital cost >> community hospital cost.
Academic hospital care ?? community hospital care...depends on the issue for; for some complex stuff there just isn't much comparison (since it doesn't happen at community hospitals, but for other things (particularly routine things) a great community hospital could be far better.
I'm at a big academic place and my income changes based on the number of patients I see is <10-15%, and it is not affected whatsoever based on tests, consults, whatever that I actually order/do (I am not a proceduralist).
First, I'm not saying that all American doctors are bad people! I'm saying that from my anecdotal evidence (and not data) I would describe my interactions with doctors here as mediocre at best. I said that I'm not sure that points to training issues even. The only direct knowledge of a problem with doctor training I have from the US is that the residents I know here are far more overworked than the ones back home, and I don't want a tired doctor.
However, I find it rather implausible that American doctors are such an outlier in conscientiousness. If insurers paid providers (hospitals, clinics, etc) a fixed amount of money every month regardless of the number of tests they did, I suspect that American conscientiousness would go to European levels.
Didn’t mean to imply that, but the relationship between money and healthcare implied by the salesman model is wrong. The difference between US and Euro doctors isn’t that we’re paid more for doing tests, otherwise you would see that relationship based on practice setting, and academic doctors would spend less since we are on salary. It’s that nobody tells us “no”, so we assume/feel that all tests are justified (as opposed to Europe where cost control exists). We also have a very human bias that the work we do is useful - not always true! And external cost control can fix that.
The better analogy is an overfunded bureaucracy where nobody ever says “no” to a funding request, not a sales team where our only goal is to sell a product.
If your doctor takes longer than 15 minutes in the exam, her emr system dings her for taking too long and her hospital system will penalize her for not seeing enough patients. Time is money and throughput is the only way we can get these people referred up to the real doctors who earn the hospital its money.
Also US lifestyles are bad. There are other factors in life expectancy beyond the healthcare system. I promise I don’t control how walkable anyone’s neighborhood is or set the price of junk food/alcohol.
I don't buy the junk food argument. Junk food also exists in the EU, and it is a cheaper option than healthy food there as well. However, I'm also used to having a long-standing relationship with our family doctor there with whom I have a chat every year, so if he thought my blood tests show that I'm not eating healthily, he would very forcefully let me know. (And he does do that from time to time.) Most Americans I know here don't do that type of doctor visits. (I mostly know people my age here, of course.)
I will give you the higher number of car accident deaths and the wider availability of guns as lifestyle reasons for shorter lifespans in the US though. However, I would expect you to concede that American doctors gave a lot of powerful opioids to people without appropriate supervision (my understanding is that you can't get this type of drugs with you at home where I come from) and that caused a lot of avoidable deaths here.
Fat but active is vastly better in terms of health outcomes than fat and inactive. Not quite as good as “not fat and active,” but within shouting distance.
European and Asian urban planning and transportation almost guarantee the former outcome even for people whose diets are unhealthy on the whole. American urban planning and transportation virtually assures the latter outcome for people not actively trying to avoid it.
I think its likely both sides somewhat overstate the impact here... I was doing some quick googling and it looks like Canada makes it quite a bit easier for foreign-educated doctors to practice (basically one year of residency + you have to take a test provided you went to one of the schools on their list). But Canada still has pretty high doctor salaries.
Biggest problem in the US seems like the US is overindexed on specialists vs. primary care, but that seems like a case where it'd essentially be a win-win: primary care doctors could help with the shortage but I don't think salaries would come down that much.
At least part of the specialist issue is demand, lots of people want to see dermatologists or gastroenterologists for things that might not get treatment in other countries. If we really wanted to disincentivize this we would probably need insurance companies (or the government) to deny more claims, which might be justified for things like back surgery that are expensive but useless. And even cancer screening programs are mostly controversial aside from a few clear-cut cases like colon cancer screening. But probably a tough lift politically so I think expanding supply is more realistic than telling Americans that prostate cancer screening doesn’t pass cost-benefit analysis
yeah I agree with that, create more primary care folks rather than getting rid of specialists.
On the nursing shortage: a major contributor there is that a major educator of nurses are community colleges, and community college nursing instructors usually make less money than nurses who are qualified to teach.
I like Supply-Side Matt.
If repeal of the Jones Act were on the list, this essay would be a winner.
Jones Act delenda est
Another way to promote growth is to add a lot more automation to seaports and freight rail. There is a lot of low-hanging fruit that automation would make more efficient. Of course that would mean fighting the unions.
Freight rail is mostly provided by (regulated) private companies who got way more profitable in recent years while quality of service has, if anything, deteriorated. Seems like regulators just got comfortable with way higher returns for the operators and that should be rethought.
By no means an expert and would love someone who is to chime in, but as I understand it one of the major issues that rail companies have pushed for over the last decade has been to have trains leave on time. Historically a lot of trains were delayed because companies wouldn't get their stuff loaded on time. Those delays required much looser scheduling to accommodate and were much less efficient. Moving to a - it has to ready on time or its not going - approach is definitely a change in the quality of service, but I don't know that its worse.
*they have also run their staff much more heavily which given that it appears the railroad workers might strike, is going to be bad for all of us.
The industry appears to admit service quality is bad at the moment, e.g. https://www.trains.com/trn/news-reviews/news-wire/railroads-report-on-time-performance-to-federal-regulators-for-first-time/
Interesting and thanks for sharing! Be curious how that compares to historical averages. It does seem to echo what I've read elsewhere that they understaff and that has been a major driver in both poor service performance and in the labor issues where conductors are feeling overworked.
Right...which runs pretty contrary to blaming the unions, as the OP of this little threat did.
To be fair, just because management is being stupid in some way, doesn't exclude the unions from also being foolish. Tis sadly possible if not likely for both to happen.
Freight and longshoreman unions fight tooth and nail against automation. Heck, freight unions fight against one-conductor trains.
You are correct that we should do more to expand the supply of healthcare services, but you kind of skipped over the reason why it’s so difficult to do. One reason why rent seeking is so common in medicine is because doctors are politically powerful. That’s not only because they are affluent and educated, but also because they are an extremely well trusted profession. If a doctor goes around telling their patients that some new healthcare rule is going to make it harder for them to give good care, then those patients will oppose the change, even if it’s a change that is beneficial for patients. If your doctor says something is bad and a politician says it’s good, most people will believe their doctor.
Was a big discovery when I did field work promoting ACA; that insurance companies were not actually the biggest villains in our bloated health care system. Attacking insurance companies as the "evil" ones* was probably smart politics because as much lobbying power as they had it was dwarfed by the lobbying power of doctors for the reasons you outlined.
Obama got a of flack for his "if you like your doctor, you can keep it" line as for a decent number of people it turned out to not be true. And I think it's fair for GOP (or other Progressives who want M4A) to point out that this wasn't strictly true. And yet if I could go back in time and advise Obama, I'd tell him to keep that line in his speeches and Town Halls because of the politics. You basically needed it to get it passed and I think this is one of those situations where the consequentialist framing is right (the end result justifies the "only most true" aspect of this line).
*not biggest villains doesn't mean they weren't or aren't villains. Insurance companies finding ways to deny claims that were seemingly part of someone's insurance plan was definitely a thing and they deserved the criticism that came their way.
Ah yes, Politifact's "Lie of the Year." I always wondered what the standard was for turning Obama's statement into a lie (or the Lie of the Year). If one single person hadn't been able to keep their plan, would that have been enough? Two? Thirty million? You use the term "a decent number of people" -- any idea what that translates to in actual numbers?
BTW, I agree with you on the questionable singling out of insurance companies. That has always been Bernie's and Warren's go to move, including the other villains: "Big Pharma" and hospital administrators. Somehow, there's always one group that *never* gets mentioned. On the tip of my tongue . . . rhymes with "proctors" . . .
Yeah. Doctors aren’t mentioned in those attacks because it’s really obvious that the attack would backfire. People trust their doctors, and they especially trust their doctors more than they trust politicians. It misleads people a bit but the alternative is making healthcare reform ideas incredibly toxic because most people will refuse to think of their doctor as a bad guy in the situation.
Yup.
The "'If you like your *health care plan*, you can keep it" [1] line really was a lie because part of the *purpose* of the ACA was to ban many types of plans. E.g. the ACA required all healthcare plans to cover a long list of things, so plans that didn't cover contraceptives were banned, and no one could keep them. I'm guessing that the vast majority of pre-ACA healthcare plans were not up to ACA standards (lifetime limits, which were also banned, were pretty common), so arguably, basically everyone lost their plan and got a different one in its place. (Probably a more expensive one given the expanded coverage.)
I think the mitigating factor is that HMOs suck, so I doubt anyone really liked their plan. At best, they just disliked it less than the alternatives... Was anyone unhappy that they could no longer get a plan with lifetime limits? I doubt it. Lifetime limits suck. Were some people unhappy that they could no longer get plans that didn't cover contraceptives? Absolutely. See Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania; Zubik v. Burwell; and Burwell v. Hobby Lobby Stores, Inc.
EDIT: [1] has an example of someone who was unhappy about the changes. I doubt she was the only person unhappy about expanded coverage:
"One example: PBS Newshour interviewed a woman from Washington, D.C., who was a supporter of the health care law and found her policy canceled. New policies had significantly higher rates. She told Newshour that the only thing the new policy covered that her old one didn’t was maternity care and pediatric services. And she was 58."
"The chance of me having a child at this age is zero. So, you know, I ask the president, why do I have to pay an additional $5,000 a year for maternity coverage that I will never, ever need?" asked Deborah Persico.
[1] https://www.politifact.com/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/
The fact that we don't have hard numbers for the number of people who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year". Its seems definitely more than a handful. But I can't seem to find just how many.
Regarding Bernie and Warren, I agree signaling Big Pharma or hospital administrators is mostly about politics as they make for good villains. But I'll semi-defend them in that there really are some terrible hospital administrator practices and insurance practices worth condemning. Centering your critique of the American health care system around these two entities is probably not entirely honest, but it's not entirely dishonest either if that makes any sense.
"who couldn't keep their doctors speaks volumes as to the absurdity of Politfact calling it "Lie of the Year"."
The lie of the year had nothing to do with keeping doctors. The line was "If you like your **health care plan**, you can keep it" [1]. He did often mix healthcare plans and doctors together (e.g. "If you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan." [2]), but only the health care plan part was the lie of the year. Serious, read [1]. The word "doctor" doesn't appear once. [1] Also notes that about 4 million people had their plans canceled. Granted, I have no idea how many of those people liked their plans, but surely some did.
[1] https://www.politifact.com/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/
[2] https://www.politifact.com/obama-like-health-care-keep/
Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state. Single parents of preschoolers are the biggest exception as the costs of child care swamp most younger peoples’ wages. Still, a solid 65% of adults do better by growing the economy than expanding benefits. This is the beating heart of center-right politics. The 35% who do better expanding benefits are numerically fewer and generally unproductive and often unsympathetic.
The main thing the welfare state can offer the median earner is security. I don’t trust an insurance company to take care of me if I get sick (I recall one claiming my wife’s cancer was a preexisting condition even though she’s had continuous coverage for years) and I sure as fuck don’t want my basic needs in old age to depend on the stock market.
>>Almost any working age, non-disabled person has more to gain from growing the economy than further expanding the welfare state<<
That's undoubtedly true as far as it goes, but there are clearly very large numbers of people who would benefit from both. You know, a parent who does well by getting a better job AND sees a real benefit from affordable childcare, or the 22 year old who gets good education partly subsidized by wealthier people (so no burdensome student loans) but is is also helped by a robust job market upon graduation.
Also, I've been trying for years to find evidence of a tradeoff between A) size of a country's welfare state and B) the strength of its economy. And I can't find much. I mean, Denmark's pretty freaking rich!
I agree with your general point about economic *security*.
The median parent is better off with subsidized child care as long as said care is funded by a progressive income tax. If were funded with a flat tax or a sales tax, that would basically transfer income from the median parents late career to the early, child residing part of it. That might still be a good trade off, given that most people face more income constraints at 30 than at 50.
Yes, one of the things people don't understand about the case for public funding of child care is that it's essentially a form of income smoothing (allows people to spread payment for things that are really expensive in about 5 years of their life over a longer time period), which is particularly relevant for higher income professionals in paying for child care, since most are not able to save for it as for retirement, higher ed, etc. (And is obviously also an issue for lower income families who do not have the money to save for those things in any case)
I understand why we do it, but comparing the US to Denmark or any other small country seems weird to me. Its more comparable to Virginia - about the same size, though Denmark has 30% fewer people.