11 ms·

I agree with the three issues they identify driving up costs. But I fear “Medicare for All” won't fix all the issues, which go much deeper. For example, the US

I agree with the three issues they identify driving up costs. But I fear “Medicare for All” won't fix all the issues, which go much deeper. For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors and artificially driving up their demand. There is a need for standards, but perhaps the AMA has too much political influence. Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high. I fear the US medical system is becoming so insane the only fix will be to replace it entirely (It's not just about tearing down, but replacing institutions)

syops 5y ago
The bottleneck is not the number of people with an MD. The bottleneck is the number of residency programs. These are funded by Medicare and I believe they are not profitable for hospitals.
- tgb 5y ago
  There's some good reason to think that residencies are profitable: in 2019, 550 of them were auctioned off for $55 million in a controversial bankruptcy case. https://www.inquirer.com/business/hahnemann-university-hospital-residency-slots-55-million-20190809.html https://www.inquirer.com/business/hahnemann-university-hospi...
  - sjg007 5y ago
    So residences are basically taxi medallions. Interesting.
    - syops 5y ago
      They are taxi medallions to newly graduated MDs but not to the hospital. Without a residency slot MDs often times are relegated to a lifetime of med school debt servicing.
  - andrewlgood 5y ago
    It is not that the residencies themselves are profitable. It is that medical schools need to be able to provide residency slots to their students to have an effective program. Definitely an issue for newly formed for-profit medical schools.
- HEmanZ 5y ago
  I don't know how residencies could not be profitable for hospitals. Hospitals receive something like $120k/yr per resident, then work residents 80+ hours/week at $50k/yr pay, amounting to right around minimum wage (for my city). Residents do a tremendous amount of work in supporting the hospital, so much so that a single resident getting deathly ill and needing to stay home (e.g a surgery resident getting covid, which I witnessed) is enough to send a massive shock through a hospital and force other residents into 100+ hr/week schedules. I know this because my wife is a surgery resident and I'm describing a situation from this year. Edit: But there are still way too few residency spots. I think it has to do with the difficulty and administrative work around starting a new program or with getting federal funding for more spots.
  - ihsw 5y ago
    It sounds like we have a spending problem and not a funding problem.
  - EvanAnderson 5y ago
    The residency slots are so limited right now because the AMA lobbied hard against expanding them in the 1990s (fearing a "glut" of doctors). Edit: Every time this comes up I go down a rabbit hole of looking for an article from the mid-to-late 90s where a medical lobbyist spoke about how doctors would be forced to leave the profession and do "mundane" jobs like driving cabs if the residency slots weren't capped. It did not paint the lobby in a good light, and I've love to see it trotted out today. I never have been able to find the article online. If somebody with better search-engine-fu than me can find it I'd be greatful.
    - nradov 5y ago
      The AMA is actively lobbying for more residency slots. https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun...
      - EvanAnderson 5y ago
- rcpt 5y ago
  I don't think it's about the profit it's the fact that anything involving Medicare is a big political fight
- warmfuzzykitten 5y ago
  A helpful link on this subject. Apparently, medical schools in the US are now allowing more graduates. Not sure about profitability of residency programs, but certainly not all hospitals are teaching hospitals and the latter are federally subsidized. https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30 https://www.aamc.org/news-insights/us-medical-school-enrollm...
- kaitai 5y ago
  This is correct and needs to be upvoted more. The number of residency slots is artificially capped and already fails to serve the number of medical school graduates in the country. The Balanced Budget Act of 1997 is the basic vehicle for this cap. In Dec 2020 the first expansion in decades was passed, adding a whopping 1000 residency spots. Look up Graduate Medical Education program for more info. For more key words, see this document from the U of California system that has an agenda (increase capacity) but also effectively lists salient points: https://www.ucop.edu/federal-governmental-relations/_files/fact-sheets/fgr-health-factsheet-gme-f1.pdf https://www.ucop.edu/federal-governmental-relations/_files/f...
throwaway13337 5y ago
Agreed. Entrenched institutions are the general problem with America. It's the police unions protecting bad policing, the restricting of doctor supply via the residency bottleneck, and local governments preventing new building for burgeoning populations. They're all the same problem really. Beneficial to the incumbent group at the expense of those they service. It's kind of amazing.
- mbg721 5y ago
  Institutional trust is certainly a huge problem right now.
- mycologos 5y ago
  > the restricting of doctor supply via the residency bottleneck Assuming that you're referring to the AMA here, their role is pretty unclear to me. They appear to have played a lobbying role to get Congress to freeze residency funding in 1997 to avoid having lots of doctors [1], but for several years now, the AMA has at least publicly claimed that they've been lobbying congress to increase funding for residency slots [2]. Maybe they're lying? But I for one don't actually know who is keeping residency funding low. [1] https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastating-doctor-shortage/ https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati... [2] https://www.ama-assn.org/press-center/press-releases/ama-builds-efforts-expand-funding-graduate-medical-education-0 https://www.ama-assn.org/press-center/press-releases/ama-bui...
  - smooth_remmy 5y ago
    AMA is a bad actor. They refuse to allow junior doctors (doctors who are MD school graduates but who have not completed residency) to practice medicine in ANY capacity. Common sense says that junior doctors should have the same practice rights as physician assistants - but the AMA refuses to let that happen. They are a medical cartel. A few states have allowed junior doctors to start practicing medicine in a limited capacity, because every other doctor so damn expensive. But the AMA does not support those states' decision.
    - 5y ago
chiefalchemist 5y ago
Demand is also "artificially" driven up by the American diet and lifestyle. If the preventables (e.g., Type 2 Diabetes) were prevented, otherwise mitigated (less sugar!) then the resources / system could focus on real disease. The issue with the USA is it wants its cake, it wants to eat it, and expects to pay less for consistently making unhealthy choices.
- nradov 5y ago
  Sure but most other countries are on track to have the same diet and lifestyle health problems as the USA. They're running a few years behind us but they'll catch up eventually.
  - djdjdjdjdj 5y ago
    Germany doesn't. I can think of plenty other European countries.
    - nradov 5y ago
      Germany has a high rate of obesity just like most comparable countries.
rscho 5y ago
> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world Rest of the world, yes. Rest of the developed world, not at all. The major difference is that becoming a doc in the US is much more expensive than pretty much anywhere else. You could also argue it's proportionally harder because of the more numerous competitors. But on an absolute level of knowledge and capability no, it's not harder than say, in western european countries.
- whiddershins 5y ago
  I believe it takes longer in the US, when all is said and done. It’s hard to casually verify this because each country uses different terms and has a different track but I think, when you include the various phases of training, starting from the bachelors degree, the US one is more total years. Edit: So for example the UK and France don’t appear to require any sort of bachelor’s degree as a prerequisite for medical. Which saves you 4 years on average. So their tracks may be longer but you can start sooner.
  - jimnotgym 5y ago
    Citation definitely needed here And just to be sure, I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine. I note this Wikipedia article that suggests 4 years messed school plus 1 year internship could get me a license in the US. That sounds like Western Europe to me. Or India... https://en.m.wikipedia.org/wiki/Medical_education_in_the_United_States https://en.m.wikipedia.org/wiki/Medical_education_in_the_Uni...
    - triceratops 5y ago
      > I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine. Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school. In the UK or India it's something like 5.5-6 years.[1] In the US it's 3-4 years of "pre-med", then 4 years of med school. That's from the article you referred. 1. https://en.wikipedia.org/wiki/Medical_school_in_the_United_Kingdom https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...
KoftaBob 5y ago
They state early in the article that this research details how to tackle those three issues without resorting to Medicare for All.
gumby 5y ago
> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors... Really? Can you give some examples? There are a lot of immigrant physicians in the USA. An anecdotal counter example: my mother is a physician with medical licenses from Australia, UK and the USA (obviously two have lapsed) and though she is quite critical of countries X and Y and positive about country Z she has never expressed any such opinion or said that one might be tougher than another, which is exactly the kind of thing she would point out.
- IG_Semmelweiss 5y ago
  all those immigrant physicians went thru the same programs as the non-immigrants. In fact, I hear this is continuously a problem for well qualified , practicing, and established physicians to migrate to the US. They are fed up with their own home countries lack of security, opportunities for their children, freedom etc, but they cannot imagine going back to medical school to be accredited to practice in the US. This does not apply to every country. Notably, 4, all here: https://www.theabfm.org/become-certified/i-am-certified-country-outside-united-states https://www.theabfm.org/become-certified/i-am-certified-coun... While many foreign physicians will have years of experiences diagnosing, treating patients, and administering medicine, in order to practice as a US doctor, it essentially requires them to start all over again academically, especially when the curriculum differs from overseas qualifications. [1] https://www.fnu.edu/foreign-physicians-work-healthcare-practitioners/ https://www.fnu.edu/foreign-physicians-work-healthcare-pract...
  - dublin 5y ago
    No, they most certainly did not. I've spent a large chunk of my career in healthcare technology, and one thing I can say for sure is that with very few exceptions, foreign doctors are no where close to the knowledge and capability of those educated in the US. I'm not going to specify to avoid slamming particular countries, but I would definitely refuse to be treated by doctors from several major countries that crank out tons of doctors, many of whom worm their way into US practice. (This isn't based on race, etc, at all just competency, and I have a much larger exposure to this than most people. These people kill way too many patients with their incompetence, but (especially lately) they cannot be criticized for fear of being branded racist. My body, my choice.)
podgaj 5y ago
The bottleneck is the cost of medical school. That cost is linked to the colleges raising prices because they can. Medicare for All will surely help this, but free college will help as well. The U.S. is like a dysfunctional family where the parents will not pay for the kids college even though they have the money.
- nradov 5y ago
  The cost of medical school is not a bottleneck. Lower prices would be nice, but even with current high prices all accredited medical schools have essentially full enrollment. The real bottleneck is in lack of federal funding for residency programs. Every year students graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency slot.
heymijo 5y ago
I just realized Physician Assistants (PAs) and Nurse Practitioners (NPs) have been forgotten in this equation. 126,000 practicing PAs [0] 325,000 licensed NPs [1] 985,000 practicing physicians (MDs and DOs) [2] I know that nurse practitioners are not under the same artificial residency constraints of MDs/DOs. I'm not sure about physician assistants. For someone not in the U.S., NPs and PAs often do the same role as general practitioners/family doctors e.g. see patients, prescribe medicine, etc. They can also specialize. [0] https://www.thepalife.com/physician-assistant-stats/ https://www.thepalife.com/physician-assistant-stats/ [1] https://www.aanp.org/about/all-about-nps/np-fact-sheet https://www.aanp.org/about/all-about-nps/np-fact-sheet [2] https://en.wikipedia.org/wiki/Physicians_in_the_United_States https://en.wikipedia.org/wiki/Physicians_in_the_United_State...
- tryptophan 5y ago
  PA/NA education is a complete joke compared to what your average MD gets. They are not qualified to practice as general doctors at all. However, they are really cheap, which is why corporations are pushing them so hard. Substandard care in the name of profits.
  - deleted 5y ago
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  - weasel_words 5y ago
    Wow I was about to gush about how much I LOVE my NP compared to my old crappy, braindead MDs. I could share stories of how bad MDs are...and the horrors of insurance. She is sharp as a whip. Smarter and more motivated than ANY MD I've EVER had. Anything she doesn't know about, she researches (on her own time/dime). She prescribes everything - dirt cheap. Lets me text/call/email ANY time. Refers me to a specialist for anything beyond her expertise (just like any MD would!) DIRT CHEAP (eg: MRI for $300, scheduled within a day or two down the street). A single, cheap, monthly fee ($65/mo!) lets me see her any time day and night, ask anything, discuss as long as I like...and I do all these things! No MD going through standard insurance would allow anything even remotely similar. ...I could go on... imo the NP model is FAR superior than the traditional insurance+MD crap model we have right now. It's one of those things "they" don't want people learning about since it'll crush the traditional way of doing things once people realize how amazing that model is. Yes I have basic insurance since it's required. And, just in case - she obviously doesn't have an emergency room.
pessimizer 5y ago
It's not that the standards are high, it's that they are protectionist. I think one of the biggest hurdles is the US residency requirements. Everything you say is true, though.
sct202 5y ago
The supply of doctors in a lot of primary care roles is supplemented by Nurse Practitioners and Physicians Assistants who have less restricted licensing bodies. Like NPs and PAs aren't required to go thru residency and can switch specialties more easily than a doctor.
mbesto 5y ago
You just conflated two partners in the whole mix of what we call "healthcare" in the US. Payers = Medicare for All, UNH, Aetna, etc. Providers = Hospitals, doctors, medical supplies, etc. It's entirely possible to have one payer and then having a governing body regulate a free market[0] comprised of providers in the market. [0] - I'm using the word free market not in its purest form (which rarely exists) but rather in a more colloquially way.
tw04 5y ago
>Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high. I can tell you for a fact this simply isn't true. The reason manufacturers of medical supplies operate as a monopoly is because they have turned to acquiring everyone and anyone in the medical supply/device business and there's been 0 opposition to it. https://www.beckersspine.com/orthopedic-a-spine-device-a-implant-news/item/50526-medtronic-acquires-7th-company-in-2020-9-device-company-notes.html https://www.beckersspine.com/orthopedic-a-spine-device-a-imp... https://mergr.com/abbott-laboratories-acquisitions#cma-tab https://mergr.com/abbott-laboratories-acquisitions#cma-tab https://www.greenlight.guru/blog/top-100-medical-device-companies https://www.greenlight.guru/blog/top-100-medical-device-comp... You can go through the last link which is a list of device manufacturers and look at their acquisitions. They just eat up every small player that shows even a hint of providing competition. Some of them have been averaging an acquisition a month for years.
UncleOxidant 5y ago
If we do medicare for all or some other kind of universal healthcare in the US we're also going to need to train doctors way more cheaply than we do now. At the least we're going to need to offer free or heavily subsidized education to incentivize more people to go into medicine without graduating with debt higher than many mortgages.
King-Aaron 5y ago
The United State's healthcare don't even appear in any "Top-10 global healthcare" rankings available anywhere, and are consistently overshadowed by many European countries, Singapore, Australia, Japan etc. I don't think you can use "extremely high standards restricting who can practice medicine" as reasoning when it doesn't appear to impact the quality of care at all.
jjav 5y ago
> limiting the supply of doctors Possibly, but the cost of doctors (+nurses, technicians, etc) is in the noise, just a distraction. The vast majority of the cost of medical care in the US goes to the middlemen who contribute no value at all, just extract profit. A 15 minute session with a general practicioner here (CA) costs around $300. That doctor isn't making $1200/hr ($2.5M/yr). That doctor is likely only making a bit over 200K: https://www.salary.com/research/salary/benchmark/family-physician-salary/ca https://www.salary.com/research/salary/benchmark/family-phys... The other $2M+ are going hangers-on who're not contributing to health care, just inserting themselves into the chain to get rich. Take a look at the billions in revenue collectively by all insurance companies. That's all a tax on health care that provides no value.
- rland 5y ago
  Huh? You'd need to look at billions in profit, not revenue, since insurance does pay out for the cost of care. When you look at that, the margin is actually lower than most industries. It is true that there are a lot of middlemen with hands in the pot but it's not quite that simple. The biggest driver of healthcare is that Americans just consume a lot of it. We get surgeries, we opt for long, expensive treatments at the end of our lives, we use extremely sophisticated and expensive medical equipment a lot, we pay people to take care of our old people exorbitant sums of money. Like, in other countries, when your lungs and kidneys start going, you don't go to the hospital for a multiple surgery. When you fall and you can't move around and wipe your own ass, you don't get moved into a facility where people are paid to take care of you, you move in with your family. And, if you don't have those options, you die. I'm with you that the system is fucked but the underlying reason doesn't _really_ have anything to do with greed in medicine and everything to do with the way that we treat medicine culturally: the duty that children (don't, in this country) have to care for their elders, the attitude we have about prolonging death. That every part of the medical system says: we will never, ever make the decision to let someone pass away, even when "fixing" their problem (of death!) with all the technology and labor we've got turns out to be ludicrously expensive.
  - jjav 5y ago
    > profit, not revenue No, because profit is substracting all the operating costs of the insurance company, including salaries of hundreds of thousands of paper pushers and multi-million dollar bonuses to their executives. All of this is just overhead that provides no health-care value and can be eliminated.

syops 5y ago

The bottleneck is not the number of people with an MD. The bottleneck is the number of residency programs. These are funded by Medicare and I believe they are not profitable for hospitals.

tgb 5y ago
There's some good reason to think that residencies are profitable: in 2019, 550 of them were auctioned off for $55 million in a controversial bankruptcy case. https://www.inquirer.com/business/hahnemann-university-hospital-residency-slots-55-million-20190809.html https://www.inquirer.com/business/hahnemann-university-hospi...
- sjg007 5y ago
  So residences are basically taxi medallions. Interesting.
  - syops 5y ago
    They are taxi medallions to newly graduated MDs but not to the hospital. Without a residency slot MDs often times are relegated to a lifetime of med school debt servicing.
- andrewlgood 5y ago
  It is not that the residencies themselves are profitable. It is that medical schools need to be able to provide residency slots to their students to have an effective program. Definitely an issue for newly formed for-profit medical schools.
HEmanZ 5y ago
I don't know how residencies could not be profitable for hospitals. Hospitals receive something like $120k/yr per resident, then work residents 80+ hours/week at $50k/yr pay, amounting to right around minimum wage (for my city). Residents do a tremendous amount of work in supporting the hospital, so much so that a single resident getting deathly ill and needing to stay home (e.g a surgery resident getting covid, which I witnessed) is enough to send a massive shock through a hospital and force other residents into 100+ hr/week schedules. I know this because my wife is a surgery resident and I'm describing a situation from this year. Edit: But there are still way too few residency spots. I think it has to do with the difficulty and administrative work around starting a new program or with getting federal funding for more spots.
- ihsw 5y ago
  It sounds like we have a spending problem and not a funding problem.
- EvanAnderson 5y ago
  The residency slots are so limited right now because the AMA lobbied hard against expanding them in the 1990s (fearing a "glut" of doctors). Edit: Every time this comes up I go down a rabbit hole of looking for an article from the mid-to-late 90s where a medical lobbyist spoke about how doctors would be forced to leave the profession and do "mundane" jobs like driving cabs if the residency slots weren't capped. It did not paint the lobby in a good light, and I've love to see it trotted out today. I never have been able to find the article online. If somebody with better search-engine-fu than me can find it I'd be greatful.
  - nradov 5y ago
    The AMA is actively lobbying for more residency slots. https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun...
    - EvanAnderson 5y ago
rcpt 5y ago
I don't think it's about the profit it's the fact that anything involving Medicare is a big political fight
warmfuzzykitten 5y ago
A helpful link on this subject. Apparently, medical schools in the US are now allowing more graduates. Not sure about profitability of residency programs, but certainly not all hospitals are teaching hospitals and the latter are federally subsidized. https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30 https://www.aamc.org/news-insights/us-medical-school-enrollm...
kaitai 5y ago
This is correct and needs to be upvoted more. The number of residency slots is artificially capped and already fails to serve the number of medical school graduates in the country. The Balanced Budget Act of 1997 is the basic vehicle for this cap. In Dec 2020 the first expansion in decades was passed, adding a whopping 1000 residency spots. Look up Graduate Medical Education program for more info. For more key words, see this document from the U of California system that has an agenda (increase capacity) but also effectively lists salient points: https://www.ucop.edu/federal-governmental-relations/_files/fact-sheets/fgr-health-factsheet-gme-f1.pdf https://www.ucop.edu/federal-governmental-relations/_files/f...

throwaway13337 5y ago

Agreed. Entrenched institutions are the general problem with America. It's the police unions protecting bad policing, the restricting of doctor supply via the residency bottleneck, and local governments preventing new building for burgeoning populations. They're all the same problem really. Beneficial to the incumbent group at the expense of those they service. It's kind of amazing.

mbg721 5y ago
Institutional trust is certainly a huge problem right now.
mycologos 5y ago
> the restricting of doctor supply via the residency bottleneck Assuming that you're referring to the AMA here, their role is pretty unclear to me. They appear to have played a lobbying role to get Congress to freeze residency funding in 1997 to avoid having lots of doctors [1], but for several years now, the AMA has at least publicly claimed that they've been lobbying congress to increase funding for residency slots [2]. Maybe they're lying? But I for one don't actually know who is keeping residency funding low. [1] https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastating-doctor-shortage/ https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati... [2] https://www.ama-assn.org/press-center/press-releases/ama-builds-efforts-expand-funding-graduate-medical-education-0 https://www.ama-assn.org/press-center/press-releases/ama-bui...
- smooth_remmy 5y ago
  AMA is a bad actor. They refuse to allow junior doctors (doctors who are MD school graduates but who have not completed residency) to practice medicine in ANY capacity. Common sense says that junior doctors should have the same practice rights as physician assistants - but the AMA refuses to let that happen. They are a medical cartel. A few states have allowed junior doctors to start practicing medicine in a limited capacity, because every other doctor so damn expensive. But the AMA does not support those states' decision.
  - 5y ago

chiefalchemist 5y ago

Demand is also "artificially" driven up by the American diet and lifestyle. If the preventables (e.g., Type 2 Diabetes) were prevented, otherwise mitigated (less sugar!) then the resources / system could focus on real disease. The issue with the USA is it wants its cake, it wants to eat it, and expects to pay less for consistently making unhealthy choices.

nradov 5y ago
Sure but most other countries are on track to have the same diet and lifestyle health problems as the USA. They're running a few years behind us but they'll catch up eventually.
- djdjdjdjdj 5y ago
  Germany doesn't. I can think of plenty other European countries.
  - nradov 5y ago
    Germany has a high rate of obesity just like most comparable countries.

rscho 5y ago

> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world Rest of the world, yes. Rest of the developed world, not at all. The major difference is that becoming a doc in the US is much more expensive than pretty much anywhere else. You could also argue it's proportionally harder because of the more numerous competitors. But on an absolute level of knowledge and capability no, it's not harder than say, in western european countries.

whiddershins 5y ago
I believe it takes longer in the US, when all is said and done. It’s hard to casually verify this because each country uses different terms and has a different track but I think, when you include the various phases of training, starting from the bachelors degree, the US one is more total years. Edit: So for example the UK and France don’t appear to require any sort of bachelor’s degree as a prerequisite for medical. Which saves you 4 years on average. So their tracks may be longer but you can start sooner.
- jimnotgym 5y ago
  Citation definitely needed here And just to be sure, I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine. I note this Wikipedia article that suggests 4 years messed school plus 1 year internship could get me a license in the US. That sounds like Western Europe to me. Or India... https://en.m.wikipedia.org/wiki/Medical_education_in_the_United_States https://en.m.wikipedia.org/wiki/Medical_education_in_the_Uni...
  - triceratops 5y ago
    > I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine. Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school. In the UK or India it's something like 5.5-6 years.[1] In the US it's 3-4 years of "pre-med", then 4 years of med school. That's from the article you referred. 1. https://en.wikipedia.org/wiki/Medical_school_in_the_United_Kingdom https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...

KoftaBob 5y ago

They state early in the article that this research details how to tackle those three issues without resorting to Medicare for All.

gumby 5y ago

> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors... Really? Can you give some examples? There are a lot of immigrant physicians in the USA. An anecdotal counter example: my mother is a physician with medical licenses from Australia, UK and the USA (obviously two have lapsed) and though she is quite critical of countries X and Y and positive about country Z she has never expressed any such opinion or said that one might be tougher than another, which is exactly the kind of thing she would point out.

IG_Semmelweiss 5y ago
all those immigrant physicians went thru the same programs as the non-immigrants. In fact, I hear this is continuously a problem for well qualified , practicing, and established physicians to migrate to the US. They are fed up with their own home countries lack of security, opportunities for their children, freedom etc, but they cannot imagine going back to medical school to be accredited to practice in the US. This does not apply to every country. Notably, 4, all here: https://www.theabfm.org/become-certified/i-am-certified-country-outside-united-states https://www.theabfm.org/become-certified/i-am-certified-coun... While many foreign physicians will have years of experiences diagnosing, treating patients, and administering medicine, in order to practice as a US doctor, it essentially requires them to start all over again academically, especially when the curriculum differs from overseas qualifications. [1] https://www.fnu.edu/foreign-physicians-work-healthcare-practitioners/ https://www.fnu.edu/foreign-physicians-work-healthcare-pract...
- dublin 5y ago
  No, they most certainly did not. I've spent a large chunk of my career in healthcare technology, and one thing I can say for sure is that with very few exceptions, foreign doctors are no where close to the knowledge and capability of those educated in the US. I'm not going to specify to avoid slamming particular countries, but I would definitely refuse to be treated by doctors from several major countries that crank out tons of doctors, many of whom worm their way into US practice. (This isn't based on race, etc, at all just competency, and I have a much larger exposure to this than most people. These people kill way too many patients with their incompetence, but (especially lately) they cannot be criticized for fear of being branded racist. My body, my choice.)

podgaj 5y ago

The bottleneck is the cost of medical school. That cost is linked to the colleges raising prices because they can. Medicare for All will surely help this, but free college will help as well. The U.S. is like a dysfunctional family where the parents will not pay for the kids college even though they have the money.

nradov 5y ago
The cost of medical school is not a bottleneck. Lower prices would be nice, but even with current high prices all accredited medical schools have essentially full enrollment. The real bottleneck is in lack of federal funding for residency programs. Every year students graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency slot.

heymijo 5y ago

I just realized Physician Assistants (PAs) and Nurse Practitioners (NPs) have been forgotten in this equation. 126,000 practicing PAs [0] 325,000 licensed NPs [1] 985,000 practicing physicians (MDs and DOs) [2] I know that nurse practitioners are not under the same artificial residency constraints of MDs/DOs. I'm not sure about physician assistants. For someone not in the U.S., NPs and PAs often do the same role as general practitioners/family doctors e.g. see patients, prescribe medicine, etc. They can also specialize. [0] https://www.thepalife.com/physician-assistant-stats/ https://www.thepalife.com/physician-assistant-stats/ [1] https://www.aanp.org/about/all-about-nps/np-fact-sheet https://www.aanp.org/about/all-about-nps/np-fact-sheet [2] https://en.wikipedia.org/wiki/Physicians_in_the_United_States https://en.wikipedia.org/wiki/Physicians_in_the_United_State...

tryptophan 5y ago
PA/NA education is a complete joke compared to what your average MD gets. They are not qualified to practice as general doctors at all. However, they are really cheap, which is why corporations are pushing them so hard. Substandard care in the name of profits.
- deleted 5y ago
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- weasel_words 5y ago
  Wow I was about to gush about how much I LOVE my NP compared to my old crappy, braindead MDs. I could share stories of how bad MDs are...and the horrors of insurance. She is sharp as a whip. Smarter and more motivated than ANY MD I've EVER had. Anything she doesn't know about, she researches (on her own time/dime). She prescribes everything - dirt cheap. Lets me text/call/email ANY time. Refers me to a specialist for anything beyond her expertise (just like any MD would!) DIRT CHEAP (eg: MRI for $300, scheduled within a day or two down the street). A single, cheap, monthly fee ($65/mo!) lets me see her any time day and night, ask anything, discuss as long as I like...and I do all these things! No MD going through standard insurance would allow anything even remotely similar. ...I could go on... imo the NP model is FAR superior than the traditional insurance+MD crap model we have right now. It's one of those things "they" don't want people learning about since it'll crush the traditional way of doing things once people realize how amazing that model is. Yes I have basic insurance since it's required. And, just in case - she obviously doesn't have an emergency room.

pessimizer 5y ago

It's not that the standards are high, it's that they are protectionist. I think one of the biggest hurdles is the US residency requirements. Everything you say is true, though.

sct202 5y ago

The supply of doctors in a lot of primary care roles is supplemented by Nurse Practitioners and Physicians Assistants who have less restricted licensing bodies. Like NPs and PAs aren't required to go thru residency and can switch specialties more easily than a doctor.

mbesto 5y ago

You just conflated two partners in the whole mix of what we call "healthcare" in the US. Payers = Medicare for All, UNH, Aetna, etc. Providers = Hospitals, doctors, medical supplies, etc. It's entirely possible to have one payer and then having a governing body regulate a free market[0] comprised of providers in the market. [0] - I'm using the word free market not in its purest form (which rarely exists) but rather in a more colloquially way.

tw04 5y ago

>Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high. I can tell you for a fact this simply isn't true. The reason manufacturers of medical supplies operate as a monopoly is because they have turned to acquiring everyone and anyone in the medical supply/device business and there's been 0 opposition to it. https://www.beckersspine.com/orthopedic-a-spine-device-a-implant-news/item/50526-medtronic-acquires-7th-company-in-2020-9-device-company-notes.html https://www.beckersspine.com/orthopedic-a-spine-device-a-imp... https://mergr.com/abbott-laboratories-acquisitions#cma-tab https://mergr.com/abbott-laboratories-acquisitions#cma-tab https://www.greenlight.guru/blog/top-100-medical-device-companies https://www.greenlight.guru/blog/top-100-medical-device-comp... You can go through the last link which is a list of device manufacturers and look at their acquisitions. They just eat up every small player that shows even a hint of providing competition. Some of them have been averaging an acquisition a month for years.

UncleOxidant 5y ago

If we do medicare for all or some other kind of universal healthcare in the US we're also going to need to train doctors way more cheaply than we do now. At the least we're going to need to offer free or heavily subsidized education to incentivize more people to go into medicine without graduating with debt higher than many mortgages.

King-Aaron 5y ago

The United State's healthcare don't even appear in any "Top-10 global healthcare" rankings available anywhere, and are consistently overshadowed by many European countries, Singapore, Australia, Japan etc. I don't think you can use "extremely high standards restricting who can practice medicine" as reasoning when it doesn't appear to impact the quality of care at all.

jjav 5y ago

> limiting the supply of doctors Possibly, but the cost of doctors (+nurses, technicians, etc) is in the noise, just a distraction. The vast majority of the cost of medical care in the US goes to the middlemen who contribute no value at all, just extract profit. A 15 minute session with a general practicioner here (CA) costs around $300. That doctor isn't making $1200/hr ($2.5M/yr). That doctor is likely only making a bit over 200K: https://www.salary.com/research/salary/benchmark/family-physician-salary/ca https://www.salary.com/research/salary/benchmark/family-phys... The other $2M+ are going hangers-on who're not contributing to health care, just inserting themselves into the chain to get rich. Take a look at the billions in revenue collectively by all insurance companies. That's all a tax on health care that provides no value.

rland 5y ago
Huh? You'd need to look at billions in profit, not revenue, since insurance does pay out for the cost of care. When you look at that, the margin is actually lower than most industries. It is true that there are a lot of middlemen with hands in the pot but it's not quite that simple. The biggest driver of healthcare is that Americans just consume a lot of it. We get surgeries, we opt for long, expensive treatments at the end of our lives, we use extremely sophisticated and expensive medical equipment a lot, we pay people to take care of our old people exorbitant sums of money. Like, in other countries, when your lungs and kidneys start going, you don't go to the hospital for a multiple surgery. When you fall and you can't move around and wipe your own ass, you don't get moved into a facility where people are paid to take care of you, you move in with your family. And, if you don't have those options, you die. I'm with you that the system is fucked but the underlying reason doesn't _really_ have anything to do with greed in medicine and everything to do with the way that we treat medicine culturally: the duty that children (don't, in this country) have to care for their elders, the attitude we have about prolonging death. That every part of the medical system says: we will never, ever make the decision to let someone pass away, even when "fixing" their problem (of death!) with all the technology and labor we've got turns out to be ludicrously expensive.
- jjav 5y ago
  > profit, not revenue No, because profit is substracting all the operating costs of the insurance company, including salaries of hundreds of thousands of paper pushers and multi-million dollar bonuses to their executives. All of this is just overhead that provides no health-care value and can be eliminated.