My wife cut hair professionally for twenty years. Between COVID, the birth our first child and going back to school she stopped.
Now she wants to go back part time to make some extra money, but her license expired and that means she has to get her license back. That includes having to attend over 100 hours of class, for a slightly above minimum wage job many people do themselves, at home, with zero experience.
It's absurd. Maybe an hour or two refresher is justifiable, but I assure you she had not forgotten how to cut hair to the extent that she needs 100+ hours of retraining. It's deeply embedded in her psyche at this point.
My wife says she basically just needs to go hang out at a cosmetology school to make the hours but doesn't need to actually do anything while she is there.
It is absolutely a racket.
thijson 36 days ago [-]
I can think of so many examples of protectionism in society. In Canada the dairy industry is a quota system, not just anyone can sell milk or eggs. The article suggests that there should be government bodies to regulate these industries instead of self regulation, however that lends itself to regulatory capture. It probably would be better than self regulation though, similar to a school board.
I think that AI will fundamentally change health care, it's as good as a primary physician in a lot of cases. The barriers need to come down, that's what is driving the costs.
sarchertech 36 days ago [-]
> that's what is driving the costs.
Physicians salaries make up 8.6% of medical spending.
Kaiser did a study that found a 40% reduction in physician salaries would result in a 3% savings to consumers on medical costs.
thijson 36 days ago [-]
Where are the costs then? Is it the MRI that costs $1000?
sarchertech 36 days ago [-]
Equipment is heavily regulated and so it’s insanely expensive, drugs are heavily regulated and expensive to develop in general, infrastructure, malpractice insurance, non-physician labor, regulatory compliance, insanely expensive software, administrators etc…
Then you add in the profit that has to be extracted at every level.
Private equity buys up hospitals, physicians groups, and ambulance operators. They need to take their cut. Insurance companies need to take their cut.
The free market doesn’t work great for to keep rent seekers from extracting profits because of insurance and the very nature of healthcare which reduces the ability of customers to shop around.
hedora 36 days ago [-]
Last I checked (10 years ago?), 33% of US healthcare costs went to haggling between the insurance company and the administrative assistants the doctor has to hire.
I’d guess it’s higher now. It also seems really easy to fix:
Just have a standard price list, and auto accept/reject 99% of procedures at the time of administration. Also, have a billing system that lets the patient pay on discharge (like restaurants).
Edit: Concrete example. I needed some medicine. There are two interchangeable options. One retails for $30, and the other for $600.
The doctor chose the $600 version, and insurance rejected it. This wasted my afternoon, an hour of the pharmacist’s time, 15 minutes of insurance company time, and at least 45 minutes of time at the doctor’s office. On top of that, the doctor had to context switch back to my case to change the prescription.
If the doctor had a UI when writing the prescription that contained a price list, whether insurance covers which drug, and a “no really, we need the expensive one” button (there is already such an override that the insurance company honors), then all of this waste would have been avoided.
toast0 35 days ago [-]
> Also, have a billing system that lets the patient pay on discharge (like restaurants).
If we're wishing, let's wish for it to be like car repair. Where they have to give us a quote before they begin service. Need some allowance for billing for care when you were unable to consent, like when an ambulance picks you up for an emergency, or if something unexpected comes up during a surgery.
teruakohatu 35 days ago [-]
Wouldn’t a better regulation be that pharmacists can dispense cheaper generics with patient consent? If the doctor really wants something specific they can state no substitutes on the script.
Here in New Zealand I am pretty sure that’s the case.
zo1 35 days ago [-]
Here in South Africa, the pharmacist is obligated to offer a generic to you, irrespective of which medicine it is. Some days I just go sure, other times I specifically want the non-generic because it is slightly (at least to me) better.
hedora 33 days ago [-]
It works that way in the US too. These were different drugs, and there is no generic for the expensive one.
In my case, there was zero reason to prefer one over the other. That’s not true in all cases.
ssivark 35 days ago [-]
It's likely that inefficiencies like this contribute O(40%) to every slice of the pie, so fixing any one slice seems unimportant, but cumulatively they would make a big impact on the situation.
A second hypothesis is that the inefficiencies are fractal/recursive -- and that we might be able to squeeze out another one or two 40% savings in some slices even after the first one!
sarchertech 35 days ago [-]
>cumulatively the would make a big impact
Because of the nature of the healthcare market a reduction in physician salaries would be almost entirely captured by private equity and insurance companies.
The only realistic way a reduction in physician salaries leads to a significant reduction in costs is with a single payer system.
>fractal/recursive
This is just wishful thinking. I can think of zero mechanisms where paying physicians less has a compounding negative effect on prices.
I can think of several mechanisms for how it would have a compounding positive effect.
Decrease in quality, decrease in recruiting, acceleration of retirement etc…
gruez 36 days ago [-]
>Kaiser did a study that found a 40% reduction in physician salaries would result in a 3% savings to consumers on medical costs.
source?
snapplebobapple 35 days ago [-]
What was included in physician salaries? I suspect either specialists wernt included or they used take home salary rather than fees because fees by doctors and specialists is a lot more than 8% in canada
sarchertech 34 days ago [-]
8% is total physician compensation including specialities. If you look at total billed physician services it's closer to 14%.
The difference comes from revenue skimmed off by entities that employ or contract physicians.
A huge part of that is profit skimmed off by private equity buying out physician groups over the last 20 years or so.
Onavo 35 days ago [-]
In that case they shouldn't try to use Congress to obstruct training more doctors.
More to the point, vague and lazy arguments should have little, if any weight when it comes to policy debates. If a given policy has provable and material harms (ie. stifling the supply for hair cutters), and the only opposition is a vague "well it must be there for A Good Reason", then the proper response should be to repeal it, not "well I guess we can't conclusively prove that it wasn't there for a good reason so I guess we should keep it".
omgJustTest 36 days ago [-]
I hear you about the schooling requirement / hours. However if the "racket" were not there, the vast surplus of labor providing "slightly above minimum wage" services would depress wages down to the legal minimum.
The government would then be the only thing preventing a race-to-the-bottom in your wife making any money.
I have seen deregulation of industries decimate trucking, giving rise to subhuman organizations like Prime Trucking.
I would strongly advise anyone seeking deregulation to really consider... does this mean - literally - the only thing that one can offer as a competitive edge is how little money you are willing to take for this service?
Additionally, given the wrecking ball currently applied to the us govt, I would strongly advise that "no tax on tips" and "default gone regulations" may help some minimum wage people, but they have super nefarious implications for other parts of the govt. "Tips" for example are now legal to politicians, per the US Supreme Court [Snyder v US, 2024] and "no tax on tips" implies that politicians do not have to record those tips as income on their taxes... which was possibly one of the last ways in which they could have been documented in any way.
Aurornis 36 days ago [-]
> However if the "racket" were not there, the vast surplus of labor providing "slightly above minimum wage" services would depress wages down to the legal minimum.
> The government would then be the only thing preventing a race-to-the-bottom in your wife making any money.
Licensing is supposed to protect the consumer from bad practice, not to inflate wages and decrease competition for those who have licenses.
It’s not good. You might imagine it being good if you think it would protect yourself from competition, but if everyone practiced this way you’d be forced to pay inflated prices and wait excessively long for every service. It would be a net loss.
> I would strongly advise anyone seeking deregulation to really consider... does this mean - literally - the only thing that one can offer as a competitive edge is how little money you are willing to take for this service?
If there was literally nothing to distinguish your services other than price, then artificially inflating prices through excessive licensing would be nothing other than stealing from consumers through force of law.
In the real world, quality of service matters. People don’t go back to a hair stylist who does a bad job, though they may not immediately recognize one that doesn’t practice proper hygiene practices.
This is where licensing should apply: Teaching and enforcing the practices that are not obvious, but nevertheless important for societal benefit. Barbers need to practice proper hygiene to prevent spread of disease. Builders need to practice proper constriction to avoid dangerous buildings. There are numerous real problems that aren’t obvious at the point of purchasing a service, but must be enforced at a society level to avoid widespread problems.
These often go unappreciated in modern societies because we take them for granted. Spend some time in developing countries, though, and you’ll hear and experience a lot of negative stories from unregulated services.
RajT88 36 days ago [-]
I did not realize that last bit, but am not surprised.
Just about every time a politician champions some legislation for "the little guys" it turns out it overwhelmingly benefits monied and powerful interests more. Definitely a trend I have observed when you scratch beneath the surface of things.
donatj 36 days ago [-]
I disagree 100%, there is a big difference in quality between a haircut from an experienced stylist and your cousin Vinny. People right now go to fancy expensive salons when they could get a $15 haircut.
I think people would certainly pay more for a reliable and stylish haircut even if they could get a bottom barrel haircut from a high schooler. You just pay for the quality of work you want done.
What you call race to the bottom, I as a consumer call fair pricing not controlled by syndicates.
Controlling the market by limiting the job pool to just the people who can already afford the time let alone the licensing fees really just serves to keep people in poverty. How many people could be working right now but can't afford the time and money to get licensed?
omgJustTest 36 days ago [-]
In every industry there are creative people who make more than the average.
This is about policy for a group of nearly 600k people. If there were no 'racket' I think that most people who want to cut hair are capable of stylish and reliable - above the Great Clips standard.
"No regulation" could increase the labor pool a factor of 10x, given the propensity for these businesses to be 100% small $ transactions.
[Editted in response to your edit]
Every industry should have competition, but the national average for hair-cuts is near minimum wage. WTF are you smoking? Do you really believe if the minimum was gone there's a chance "fair pricing not controlled by syndicates" would be just above minimum wage? Is the govt minimum wage a "pricing controlled by syndicates"?
donatj 36 days ago [-]
Do these businesses really even need to exist? They themselves are a racket. They're just overhead.
Why can't my wife just cut hair out of our kitchen? Here at least it's illegal. I have no doubt she would have steady repeat clientele ready to pay for a good haircut.
I firmly believe the value of something is what someone else is willing to pay, and that artificially inflating the price by limiting supply will always be immoral and monopolistic.
Aurornis 36 days ago [-]
> Do these businesses really even need to exist? They themselves are a racket. They're just overhead.
They exist because people like convenience and ease of discovery.
They don’t “need” to exist. They exist because there’s demand and they’re filling it.
There are already many options from hair stylists operating out of their home. People can already choose one or the other.
omgJustTest 36 days ago [-]
People I know already do these home-haircuts as a business. They dont make money because its deregulated and every so mildly illegal, mostly from tax evasion.
andriesm 34 days ago [-]
Somebody's wife cut your hair in her kitchen and you paid in cash, no taxes. It's tax evasion, quick, let loose 1000s of new tax agents on the population to stop this travesty! Immediately!
I say deregulate everything reasonable, stop trying to nake everything a nanny-society and micro-managing every last bit of compliance, and let the chips fall where they may! Let responsible adults live their lives. People self organise and figure most things out for themselves if you just let them.
If kitchen hairstylists outcompete hair chains, I would be surprised but also not too worried - hardly the end of civilization at risk. But locking people artificially out of jobs and artificially inflating almost all everyday expenses for consumers are pretty big enshittifications, in my opinion.
grugagag 35 days ago [-]
> My wife says she basically just needs to go hang out at a cosmetology school to make the hours but doesn't need to actually do anything while she is there.
While I agree there should be some kind of license - you don't want a random person become hair stylist for the day and then switch to something else - there probably should be some examinations of skills. The current racket is about making money and protecting incumbents from competition but it also wastes a lot of time in the process.
cookie_monsta 35 days ago [-]
> you don't want a random person become hair stylist for the day and then switch to something else
Considering that the stakes are fairly low (compared to say, surgeon for a day) and that there are plenty of jobs that obviously do not require a license and we are happy to let the employer apply the skills test, where exactly would the line sit between needs license and doesn't?
ssivark 35 days ago [-]
> you don't want a random person become hair stylist for the day and then switch to something else
Why though? The easier it is to switch in and out of careers, greater the likelihood that people will be well-matched to job opportunities. We will also have the least possible unemployment.
ein0p 35 days ago [-]
Why not? Why must I ask government permission and pay a fee to do anything at all? Is this America or North Korea?
_DeadFred_ 36 days ago [-]
At what point is the cutoff between a few hours and more hours? If someone stopped cutting hair 20 years ago versus let the license lapse 2 years ago?
How good is the record keeping? They might not log everything you do for 20 years, just 'if your license isn't lapsed you have completed everything currently required' and not have a mechanism for bringing someone with 1 year of no-compliance and someone with 20 years into compliance in a custom tailored manner.
_bin_ 35 days ago [-]
i get my hair cut by an unlicensed guy. he works out of a spare room in his house. good churchgoing man, upstanding member of the community, and gives the best haircuts i've ever had. he makes more money even though he only charges $17 for a cut.
ty6853 36 days ago [-]
Board differences in medical field have been interesting to watch.
For instance NP and PA have very similar skills, but the nursing board goes to bat for nurses allowing independent practice while doctors have chosen in some states to sabotage PAs as they live under the medical board fiefdom. There is little other explanation for the divergence in practice privileges.
If you are a licensed professional and your profession doesn't own the board, what often ends up happening is competing professions under the board sabotage each other.
Aurornis 36 days ago [-]
> but the nursing board goes to bat for nurses allowing independent practice while doctors have chosen in some states to sabotage PAs
The way Nurse Practitioners are allowed to practice independently now is a contentious topic in the field because they’re now operating essentially as doctors, but with much less education and hands-on training.
The original idea was that NPs could handle a subset of simple and routine issues and leave the more complex issues for fully trained doctors. The current situation has NPs and doctors performing the same functions but with very different training, while patients are mostly unaware that there’s a difference.
It’s a common complaint on forums like /r/medicine because doctors are seeing a rapidly growing number of patients who have gotten bad advice or prescriptions from overconfident NPs, especially in states where NPs can prescribe controlled substances. Going the NP route is also the preferred direction for people who want to practice alternative medicine but have a prescription pad, leading a lot of patients unknowingly into the hands of NPs who actually shun large parts of traditional medicine.
Common problems around here are NPs who prescribe antibiotics on demand, some times dangerously powerful ones for extended periods of time. NPs writing long-term benzo prescriptions as first line treatment for anxiety (very bad practice) has created a mess of dependent patients who didn’t know what they were getting into, who end up back at fully trained providers who need to taper them off for sometimes as long as a year.
So it’s not as simple as medical licensing boards being mean. There are some very real problems with the current double standard of training between NPs and doctors.
sarchertech 36 days ago [-]
NP education is basically the Wild West. Much of it is practical training under a doctor, but unlike residency there is very little oversight and standardization.
orwin 36 days ago [-]
In my country, you can be reimbursed on substance prescribed by a nurse (or any medical practitioner, including physical therapist) if its effect is proved, but only doctors can prescribe regulated substances, and this kind of prescription are typically monitored (and stats are made on those prescriptions. Why, i don't know yet, we set up the big data infrastructure like 5 years ago, so probably nothing yet).
And there is another tier of regulated substance that you can only be prescribed at a hospital (rarely-used antibiotics, you must stay under surveillance while you take them to avoid creating resistance), and another tier that can only be prescribed by a specialist (methadone, lithium, probably a ton of others), but i would hope this is the same in the US.
Aurornis 36 days ago [-]
> but only doctors can prescribe regulated substances
In the US this is determined at the state level, so it’s different depending on where you live.
In many states, NPs can prescribe controlled substances now. This has become a problem in some areas with certain NPs prescribing Adderall, Xanax, or Ketamine at alarmingly high rates.
We do have monitoring mechanisms and people can be flagged if their prescriptions are becoming a problem, but the system is slow to respond. The cases are publicly searchable and I spent some time reading my local cases last year. The reports were often unbelievable, with some NPs becoming locally known for prescribing certain drugs at high doses. You can even find tips about which NPs to go to on certain Reddits.
dpkirchner 36 days ago [-]
> It’s a common complaint on forums like /r/medicine because doctors are seeing a rapidly growing number of patients who have gotten bad advice or prescriptions from overconfident NPs, especially in states where NPs can prescribe controlled substances.
I wonder how much of this is simply because people are more able to afford (or even merely schedule!) medical care because NPs are available. There are certainly a lot of doctors that overprescribe and give bad advice after all.
amadeuspagel 35 days ago [-]
> If you are a licensed professional and your profession doesn't own the board, what often ends up happening is competing professions under the board sabotage each other.
From The System of Professions:
> By focusing on parallels in organizational development, students of the professions lost sight of a fundamental fact of professional life—interprofessional competition. Control of knowledge and its application means dominating outsiders who attack that control. Control without competition is trivial. Study of organizational forms can indeed show how certain occupations control their knowledge and its application. But it cannot tell why those forms emerge when they do or why they sometimes succeed and sometimes fail. Only the study of competition can accomplish that.
derbOac 36 days ago [-]
I'm a bit disturbed and/or upset about the way licensing issues in the US are often covered. Typically you see an article like this, in a news outlet that's aiming for financially motivated and/or well-off individuals, complaining about licensing for beauticians and doing a hand-wavy thing about medical professionals. The argument is "beauticians don't need licenses but all this other stuff is fine."
The problem with this is while it's true that beauticians don't cause the same damage as a medical provider (usually), they also don't have the same financial impact on the US economy as a whole. We don't hear people complaining about haircut costs, we hear people complaining about healthcare and higher education costs.
When it does get discussed, it seems like those discussions are always targeting those who threaten the status quo, and there's very little discussion of underlying issues.
So for example, you have pieces complaining about NP or PAs replacing doctors in clinics, ignoring the fact that it's not the NP or PA degrees necessarily, it's that you're taking people out of a 2 year program and putting them directly into practice with no residency or training program. Similar things play out with other provider types, where there's a lot of FUD and playing on stereotypes without discussing actual training backgrounds encountered within degrees, or the requirements that are actually necessary to complete tasks.
If you look at current MD programs, many of them are pushing hard to go to a 1.5 year coursework, 2.5 year clinical training model, followed by residency. Compare that to a PA program that is what? 1.5 years of coursework followed by clinical training. Many PA programs now also require licensed healthcare practice before you even enter the program too. So it's really hard for me to accept the argument that PAs + 6 years of supervised training aren't similar to an MD + 4 years of supervised training.
You can extend this to all sorts of aspects of the medical system. Many medications that are now prescribed really don't actually require prescriptions, especially some of those that someone has been taking for years. Others could be overseen by a pharmacist (probably better in many cases than a physician), or a psychologist, dentist, or optometrist with the right additional training.
The idea that provider skills in a given area are only ever possibly obtained by the MD degree model is preposterous to me. Sure, there are probably some domains where this is currently true, but there's a lot of domains where it's not. These discussions need to stop treating healthcare as if licensing is a totally different issue there — although it is probably in terms of risks but also in terms of costs, the fundamental problems are the same.
I could go on and on. Even among MDs, the specialty and subspecialty accreditation requirements can be grossly excessive and unnecessary. Conversely, there's also the fact that MDs sometimes are making decisions that they're not actually trained to deal with because their degree gives them a kind of blanket legal authority.
Everyone has anecdotes about poor care, but I can say the same just about any type of provider I've had contact with. I can think of grossly irresponsible care that I've had from physicians, where we've been saved in a sense by PAs, RNs, or NPs. I can also think of cases where the MDs were great, and the PAs, RNs, and NPs didn't know what they were talking about.
Healthcare licensing is a complete mess and it is a major unrecognized source of increased healthcare costs. Even with all of the push to deregulate, I don't see it being addressed effectively anytime soon because the discussion gets so distorted and because it often feels like the way it bubbles up into public consciousness is through bad actors leveraging deregulation for undesirable reasons.
sarchertech 36 days ago [-]
An MD or DO has 12-16k
clinical hours when the finish training. That is very regulated closely supervised training.
An NP can finish training with 500-750 hours and a PA with 2000.
And that training is nowhere near equivalent to resident training because NPs and PAs are handed the lower acuity and less complex patients. In the NP case there is also very little oversight over the kind of training they receive, so the quality is extremely variable (much more so than resident training).
After training the NP or PA could go on to work at minute clinic where they have almost zero direct supervision. Or they could go work at a doctor’s office where they handle low acuity and less complex patients.
After 6 years of running strep tests and overprescribing antibiotics in a minute clinic, they are by no means equivalent to an MD.
Residency is an intense 3-7 year 80-100 hour a week training program that includes academic components. In addition to being closely supervised, attendants are actively teaching them. They frequently go to lectures and have homework to complete. Residents are routinely evaluated by dozens of doctors and have to make significant progress or they are forced to repeat some or all of it. This is far more rigorous than “you showed up for work for 6 years and didn’t get fired.” 6 years working as an NP or PA is just not equivalent. To replace this, you’d need to force them to have a similar residency program.
Then you need to look at the scores of the average person coming into PA or NP programs vs MD or DO programs. And finally at the material covered. It is not equivalent. And it shouldn’t be. They do different jobs.
There are certainly long practicing PAs and NPs that have equivalent medical knowledge to many even most MDs.
But the only way to ensure that this is the case is to add a structured mandatory residency requirement, and increase the amount of information taught, and the number clinical hours during the program.
If you do this, you’ve just recreated an MD program for no real reason.
Physicians salaries only make up 8.5% of healthcare spending. Even if you somehow manage to figure out a way to train NPs and PAs to completely replace doctors at half the salary, you’re telling a 4% reduction in spending. That’s a rounding error that will just end up being absorbed by the hedge funds that own the clinics, hospitals, and physicians groups.
Another thing worth noting is that when NPs and PAs start practicing independently their malpractice insurance premiums go way up, further down eating into the small savings you’ve made.
derbOac 35 days ago [-]
>If you do this, you’ve just recreated an MD program for no real reason.
If there was a dramatic increase in the number of medical schools, I'd see no reason maybe. But I think flexibility of educational tracks is another. My point is these are the kinds of discussions that need to happen. And it's also important to keep in mind the question of whether or not X training in Y field is actually necessary or if it's unnecessary overhead. We assume a certain educational model is necessary for safety but that's not clear at all, especially as you get into specialties. As some have pointed out, current residency practices might even decrease patient safety in a lot of ways.
Arguments about curriculum rigor also seem questionable to me if you consider, eg all the foreign medical school graduates and DO graduates practicing just fine. I'm not trying to cast aspersions on them, just they also tend to have lower scores etc and have long respectable practices.
>Physicians salaries only make up 8.5% of healthcare spending.
For what it's worth I don't think it's the salaries per se, it's the cost multipliers due to lack of options. I think NPs and PAs are just one example. The question is, if other service provision models were adopted, how would it decrease service costs? I don't think it's possible to extrapolate costs of service from physician salaries in this model to costs of service in a different model.
Let's say eg you required vaccines to be administered by a physician. There would be huge costs associated with that that wouldn't be represented by salaries alone. There would be delivery bottlenecks that could be leveraged by unscrupulous actors, an increase in price solely due to bottlenecks and so forth.
And that's not even getting into patient satisfaction due to increased choice, that might not be reflected in costs at all.
Also it's important to clarify I am not in favor of private equity run care, and in fact would prefer (single payer) public health care provided for all citizens.
I just think there's a lot that more types of providers could be providing now.
sarchertech 35 days ago [-]
>If there was a dramatic increase in the number of medical schools
The bottleneck for the number of doctors is residency slots, not med school slots. If you drastically increased the number of residency slots med schools could rapidly ramp up to fill them. If they couldn’t fill them foreign doctors wanting to work in the US would.
Beyond funding for residency slots. The real limiting factor is the number of doctors willing and able to train new doctors. Even if your plan is to product dozens of new kinds of practitioners, doctors are the only ones qualified to train the new practitioners today.
In a hypothetical world where you say “I want to create as many doctor equivalent practitioners as possible”, there’s no advantage to creating new types of doctors because existing doctors are still going to be the bottleneck. Essentially if you create a new PA program with a residency, past a certain point, you’ll just be competing with med schools and existing MD residencies for the same resources.
>whether or not X training in Y field is actually necessary or if it's unnecessary overhead
You know who spends far far more time thinking about this than you or I? Doctors like my wife who is the director of medical education for her division. Her and her colleagues are constantly evaluating resident’s performance and if anything they think that most of them could use more time not less. Her specialty is so overworked and understaffed that every doctor in that speciality would drop a year of residency if they thought it was feasible.
Doctors have strong a culture of service and the peer pressure to serve the community and put the needs of public health and medicine in general above their own is immense. I’ve never seen anything else like it in any other profession that I’ve encountered. I certainly don’t think that Doctors should be able to regulate every part of medicine with no oversight, but I can’t think of anyone more qualified and deserving to determine how much training is necessary to practice.
I’m not saying there are no inefficiencies here, but given the amount of time and effort regularly spent on resident education, I strongly suspect there are no large savings to be had here.
>current residency practices might even decrease patient safety in a lot of ways
Most of those claims have been debunked. Numerous high quality studies have shown that adding limitations to number of hours residents can work and limiting shift lengths did nothing to increase patient safety.
>just they also tend to have lower scores etc and have long respectable practice
Foreign medical schools that attract US students tend to have very low placement rates. If only the top 60% of your students match, you can’t look at the average student score and compare it to the average student score in a US school where 95% of students will match. If you look at actual residents who went to a foreign school as opposed to looking at average scores of everyone admitted, there isn’t a big difference.
As for DO scores. They are lower, but by a very small margin. Nowhere near the difference in scores between PA and NP students and med students.
It’s hard to compare them directly because PA applicants take the GRE not the MCAT. But the average med school student scored north of the 80th percentile on the MCAT, while the average PA student was right at the 50th percentile on the GRE. And college GPAs are much higher for med students.
>cost multipliers due to lack of options
I don’t know that this is the case. It could be but I suspect it’s not for a few reasons.
I’d expect any bottlenecks to already be reflected in the physicians salary. That is they would have captured a fairly large part of the increased price in their salaries because by becoming they bottleneck they are now more valuable.
We have been increasing the number of physicians per capita since 1960, but healthcare costs have been rising. If you look at list of developed countries by number of physicians per capita and compare it to a list of counties by healthcare expenditures per capita, there’s no correlation. if physical bottleneck was driving a significant chunk of healthcare costs, you’d expect to see a correlation.
>patient satisfaction due to increased choice
Patient satisfaction is so strongly correlated with whether or not a provider prescribes you something that it’s mostly a useless metric. It’s well documented that NPs and PAs are more likely to prescribe unnecessary antibiotics.
This leads directly into another issue I have with increasing the types of providers. Creating additional providers with their own governing bodies creates administrative overhead with significant costs.
Over prescribing antibiotics is a prime example. We’ve decided this is a problem, but now you need to convince med schools and residency programs to, np schools, pa, schools, and whatever new providers are created in this hypothetical world.
trillic 36 days ago [-]
Just last week I saw an NP, PA - someone with both degrees, didn’t understand why they’d have both. This makes sense now.
n8henrie 36 days ago [-]
Can you explain what you mean about doctors sabotaging PAs? In what way? And which doctors are to blame?
ty6853 36 days ago [-]
In some states dragging their feet on supporting independent practice and chaining them to more onerous doctor oversight/collaboration requirements vs NP. I'm referring to doctors with/of influence in the medical board.
NP are under the nursing board so doctors are less entrenched in their influence.
Aurornis 36 days ago [-]
Letting NPs practice independently as doctors is increasingly viewed as a mistake, not a model that should be emulated more widely.
There are a lot of problems coming out of the fact that NPs are now basically practicing medicine in parallel with doctors despite vastly different education and training experience.
Many patients don’t even understand the difference. It doesn’t matter for common things like a simple sprain or common cold usually, but cases of medication overprescribing (think antibiotics for colds, etc) are commonly traced back to NPs and specialists will complain about the deluge of incorrect referrals from NPs who don’t know what they’re doing.
One example: I heard a specialist explain that they had to stop taking referrals for Ehlers-Danlos evaluation from NPs because the local NPs were referring people at impossibly high rates due to misdiagnosis. Ehlers-Danlos has become a popular (though incorrect) TikTok diagnosis for vague symptoms and rather than push back, many local NPs were running with it. Social media is full of people who are convinced they have Ehlers-Danlos and a lot of NPs were leaning into the trend instead of realizing that it’s not real.
n8henrie 36 days ago [-]
> I'm referring to doctors with/of influence in the medical board.
So your unqualified statement refers to a specific and very small proportion of doctors.
I'm extremely grateful that APCs have independent practice in my system. There is way too much work to be done compared to the number of physicians available to do it.
The "working under a doctor" model seems to be mostly encouraged by the administrators, as this puts impossibly high liability on the physician (who is forced to "oversee" a dozen or more APCs).
No thank you.
ty6853 36 days ago [-]
I bypassed trades and engineering licensing to build my house, which is usually only legally possible if you do basically everything yourself ( at least in my state diy work and even owner/builder amateur structural engineering is exempted from licensing since there is no compensation involved). End results, costs <30% of anything comparable offered commercially.
spicyusername 36 days ago [-]
How much of that 30% is just labor costs?
If you total up the time you spent doing the work, and multiply that by what you could have been paid working doing something else, how does the savings change?
People should definitely build their own houses. Its custom fit to you and you get the satisfaction of doing it. But its also a lot of work, requires considerable time investment, and requires quite a bit of specialized knowledge.
ty6853 36 days ago [-]
Not sure. I lost about 4 months of work, rest was time where I didn't have other work offered to me so the opportunity cost was 0.
But consider if I hired someone, I would lose 30% of my earnings to taxes. And then 50% of what I pay others goes to insurance/licensing/taxes/transportation etc. So really your labor costs should be about 30% if you bill your own time since it is tax free both ways and no overhead.
potato3732842 35 days ago [-]
Back in the day (this century) I was an under the table laborer for someone building their own house. He said it costs less than half as much and takes 4x as long.
I.e. the majority of that 70% savings is not from labor.
Aurornis 36 days ago [-]
When I was on Reddit I browsed the /r/DIY subreddit every once in a while. It was amazing to see all of the self-built decks, sheds, and unpermitted home modifications that were death traps.
I’m sure you did your homework and did everything by the book, but I’ve seen enough both online and in my experience with old houses (commonly modified without permit) to have an appreciation for licensing and permitting requirements.
A few years ago my friends’ landlord tried to rebuild the house’s deck until it got shut down by an inspector driving by. I thought it was outrageous until I walked over and saw what was being built, which was a laundry list of engineering and design failures. After that I was thankful that the inspector noticed and stepped in.
Licensing (and permitting) doesn’t exist for the ideal case where people practice perfectly without licensing. It exists for the average case, where people like to guess and improvise.
> End results, costs <30% of anything comparable offered commercially.
If you did the work yourself I’d expect similar savings. I think this is an example of DIY labor, not the cost of licensing.
marcus0x62 35 days ago [-]
> It was amazing to see all of the self-built decks, sheds, and unpermitted home modifications that were death traps.
/r/DIY loves to harp on that kind of thing, but most of the "death trap" critiques I read there are for things like decks 12" above grade. People need to get a grip.
ty6853 35 days ago [-]
Codes and inspection were eliminated for owner/builders (but not landlords) decades ago in my county. None of the apocalyptic predictions came to fruition. It was mostly licensing contractors building death traps, not people that intend to live in something they build themself. And a death trap is often better than being homeless in any case, or coming short in healthcare/food/education.
potato3732842 35 days ago [-]
Mundane things aren't interesting. And this is representative. Reddit loves to circle jerk about how licenses, government permission and paying professionals.
Therefore the "crazy stuff" is what you wind up seeing it.
Since you brought up a stupid anecdote I'll bring up my own stupid one. A friend of mine was out, mid thunderstorm, fixing the drainage ditch by the road he lives on as it was having problems and trying to go over the road. The state equivalent of the EPA happened to drive by and shut him down. Well, the road wound up getting washed out and the water found a new path of least resistance and caused tens of thousands of dollars of damage. Because the matter was on the state's radar everything took forever and more money to get fixed. To this day he regrets not handling the situation more aggressively.
potato3732842 35 days ago [-]
Mundane things aren't interesting. And this is representative. Reddit loves to circle jerk about how licenses, government permission and paying professionals.
Therefore the "crazy stuff" is what you wind up seeing it.
mhb 36 days ago [-]
Prerequisite of 1,000 hours of classroom instruction to qualify as a barber in Rhode Island. [216-RICR-40-05-4.4 C]:
"Students enrolled in programs of hairdressing/cosmetic therapy or barbering may enter into a work-study arrangement after they have completed at least one thousand (1,000) hours of classroom instruction."
"Key points about PPL classroom instruction:
Ground School:
In addition to flight hours, you must also complete a ground school course covering subjects like aerodynamics, weather, navigation, and regulations, which typically involves around 36-40 hours of dedicated classroom instructi"
dghlsakjg 35 days ago [-]
That is for just the private pilot license of the most basic type for clear conditions. This isn't the greatest comparison.
For one, the FAA allows you to take as much or as little classroom instruction as you need. There is no classroom requirement (kinda, there are other ways to get a pilots license). I had 0 hours of ground school, and did self study. I know people with 50+ hours of one on one tutoring. The FAA evaluates you on your knowledge, they don't care about your experience, except for meeting the minimum number of flight hours.
To get to the point where you can charge money for your skills you are looking at 8x the flight time to get to 250 hours as pilot in command, plus a litany of other courses to earn a commercial certificate, but even here, you are lucky to get a job, and it will likely be pretty un-glamorous flying.
To get to fly an airliner (in the US, Europe has much lower requirements), you need 1,500 hours minimum for the piece of paper, and its not like you are going to be flying an airliner alone.
tim333 35 days ago [-]
I think a private pilot license is probably of comparable or greater difficulty than being a barber. I have a PPL and have done my own barbering and flying is both trickier and has worse consequences if you screw up. I agree a PPL isn't close to enough to fly an airliner. But shaving and trimming hair?
dghlsakjg 35 days ago [-]
I agree, I think that barbering and haircutting shouldn’t take nearly what it does.
I was just pointing out that the pilots license hours comparison is not great. 1000 hours of classroom instruction at a cosmetics school is 6 months full time. 1000 hours in a cockpit takes years.
RajT88 36 days ago [-]
1000 hours is enough to grind out every activity in the original Destiny.
Destiny is designed to be as much a day job or more as cutting hair.
'Clifford Winston of the Brookings Institution argues for eliminating occupational licensing for lawyers entirely and replacing it with a system of voluntary certification. Government has a role to play by collecting information about service quality and making it easily accessible to the public. Databases like the NPDB should be improved and opened for many professions.
The medical profession is unlikely to be delicensed, but as Ms. Allensworth’s book shows, we shouldn’t let the AMA dictate the terms of medical education. Many European countries offer combined undergraduate and medical degree programs that take only six years, compared to the eight or more years required in the U.S.
Advances in artificial intelligence, which Ms. Allensworth doesn’t explore, may also catalyze reform. AI is already transforming fields such as legal research and medical diagnostics, automating tasks once reserved for licensed professionals. As these technologies advance, they can reduce reliance on rigid licensing systems by ensuring quality and safety through innovative tools.'
mjd 36 days ago [-]
In many cases, these licencing schemes are put in place by incumbent trade groups, to prevent comeptition.
For example, an association of funeral home owners will lobby their state representative for a law forbidding the sale of coffins by anyone other than a licensed funeral director. Ostensibly this somehow protects the public from unscrupulous coffin-sellers. In actuality, its main effect is to protect the profits of the funeral home oligopoly.
(Lest you think this is a fanciful example, see St. Joseph Abbey v. Castille.)
The AMA education requirements are of essentially the same sort, put in place by a compliant legislature to protect the profits of an incumbent cartel, at great cost to the public.
Advances in artificial intelligence will do nothing, absolutely nothing, to catalyze reform of what is essentially a problem of politics and greed.
> In many cases, these licencing schemes are put in place by incumbent trade groups, to prevent comeptition.
The worst is NAR and Realtors®. There's absolutely no professional instruction involved, just a morality test taken every few years that until the late-1940s early-1950s required that realtors maintain the racial character of neighborhoods (under penalty of disciplinary action.)
They managed to get themselves written into most state and local laws. Only the explosion of aspirational middlemen occasioned by the internet has recently managed to push back on that. Hopefully the recent antitrust case against them is catastrophic, but they spend $100M a year lobbying. Lobbying government is basically all the NAR actually does and all the real value that members are getting.
I would add too that these laws often serve the same interests of white supremacy that they have since the Civil War.
After the end of Reconstruction the Southern states instituted laws now called the “Black Codes”, forbidding blacks from being blacksmiths, or grocers, from owning property, or doing any sort of work other than, effectively, being sharecroppers - essentially slaves of the same white landowners as before.
Consider who is hurt most by laws requiring expensive and onerous licensing for independent hair-braiders. Are a lot of white hair-braiders suffering from this, do you suppose?
Same with minimum wage. Whites were tired of blacks underbidding them, so they just outlawed their jobs by making unskilled labor valued below X illegal.
eesmith 36 days ago [-]
"Minimum wage legislation emerged at the end of the nineteenth century from the desire to end sweatshops which had developed in the wake of industrialization.[17] Sweatshops employed large numbers of women and young workers, paying them what were considered non-living wages that did not allow workers to afford the necessaries of life." ...
"The earliest minimum wage laws in the United States were state laws focused on women and children.[25] These laws were struck down by the Supreme Court between 1923 and 1937.[25] The first federal minimum wage law, which exempted large parts of the workforce, was enacted in 1938 and set rates that became obsolete during World War II.[25]'
We know your scenario isn't true because there are plenty of white-owned businesses which knowing hire undocumented workers in order to pay them sub-market wages with poor working conditions.
ty6853 36 days ago [-]
Go back further. Minimums were applied to the railroad in 1909, pulling them up to the prevailing white wage when the Brotherhood of Locomotive Firemen became enraged blacks were working for cheaper.
eesmith 35 days ago [-]
Yes, a lot of those unions were racist and xenophobic.
I don't see anything about a minimum wage. I do see 'the arbitrators did rule that the railroad would be required to pay African American and white firemen the same wage' but nothing about how that minimum was set by law.
Minimums for a union job are not the same as minimum wage, which is the legal minimum set by law.
Union minimums predate the Civil War. For example, the Boston Journeymen Bootmaker's Society had a minimum price per shoe made, back in the 1830s, leading to Commonwealth v. Hunt.
pessimizer 36 days ago [-]
This is a strange theory. Since when did sub-minimum wage jobs become "their jobs?" And since when did poor whites get to create policy?
ty6853 36 days ago [-]
Well back in the early 20th century I'm afraid that was mostly what was available to discriminated minorities. It's not just theory, it goes back to railroadmen being pissed blacks were undercutting them. They could not just outright outlaw blacks so they just got the minimums set to the prevailing white wage.
pessimizer 36 days ago [-]
Since when did the lowest wage whites get to set minimum wage?
ty6853 35 days ago [-]
Suffrage in the early 20th century applied more to whites than blacks. And having low wage labor be black market without protections can in some cases benefit the upper classes.
sarchertech 36 days ago [-]
It’s hard to compare medical education between countries because some counties will have shorter medical school lengths but longer residency requirements.
And official durations are often different than the amount of time it actually takes students.
In Germany for example med school is 6 years, but the average student completes it in about 7.
A US student with some AP credits from high school and a few summer classes could easy finish university in 3 years and end up taking the same amount of time as the average German medical student.
But even looking at averages at the end of the day doctor’s salaries are a small fraction of overall medical costs so shaving a year off of the average training times isn’t going to make a dent.
The US also doesn’t have a national high school curriculum, so removing general education requirements from the university + medschool pipeline, which is essentially what countries with shorter total training times do, is a harder problem than it is in Europe.
ghaff 36 days ago [-]
At one point the US did have at least a couple of 6-year undergrad/medical school programs but they were discontinued I believe.
Machine learning has been talked up a lot in medicine especially in the context of radiology. I'm not sure to what degree it's really panned out to date. Legal discovery has been aided by automation of various sort for years.
psychlops 36 days ago [-]
Next time you get an x-ray, drop it in your favorite LLM and start asking it questions. It's eye-opening.
gorkish 36 days ago [-]
ChatGPT does not carry expensive malpractice insurance. The Radiologist is human in the loop for reasons other than their pattern recognition ability.
psychlops 36 days ago [-]
Not sure what concern you are addressing. I never said to replace radiologists with ChatGPT. My suggestion was to use it as a tool for further information.
That said, note that malpractice is in place for a reason. Everyone makes mistakes. We all have to go in to work even if we have a horrible hangover, doctors and radiologists included.
The trouble with giving doctors complete control over doctor education is that in the US they've used that control to restrict the supply of doctors to keep the price of doctors high.
sarchertech 36 days ago [-]
Right now it’s congress that is restricting the supply of doctors. The AMA’s (which only represents about 15% of doctors btw) current position is that we need more doctors and they have been actively lobbying congress to provide funding for more residency slots.
EvanAnderson 35 days ago [-]
The AMA lobbied for the freeze in slots in the 90s. Their change of heart today doesn't make them less responsible for creating the mess, in the name of protecting physician salaries, in the first place.
sarchertech 35 days ago [-]
The AMA lobbied for a freeze in slots because the rate of growth had was increasing and extrapolating from that it looked like more physicians would be graduating than there would be jobs for them to fill.
The number of physicians has been growing faster than population growth since the 60s. No one could have predicted that we’d be able to sustain the insane growth in medical spending and demand that allowed this to continue.
Because of the way medical training is funded, number of physicians isn’t not a free market phenomenon. Congress decides how many there are. In the 90s it looked like there were going to be too many. When that changed the AMAs position changed, it was a perfectly reasonable position.
But even if it weren’t a reasonable position. That was 30 years ago. No one who was in a position of power is around today, so it’s unclear to me how exactly the current AMA should bear responsibility.
It would be like if IEEE today called for a temporary freeze on the increase of H-1Bs. Then 30 years later something causes an explosion in demand for engineers and people started blaming these evil engineers.
hollerith 36 days ago [-]
OK I stand corrected.
I bet the situation is quite complicated, and I now regret offering a one-sentence explanation.
36 days ago [-]
betaby 35 days ago [-]
In Quebec about 80% of all occupations require licensing.
We are well past useful regulations.
Such situation makes people poor. Since everything needs license, people can't practice jobs that they are perfectly capable doing.
stogot 36 days ago [-]
I’d like to read books about random topics and this one is interesting, but 304 pages? It seems publishers demand most nonfiction to be that page length
ghaff 36 days ago [-]
Yeah, probably depends a bit on the specific publisher but 250 pages+ at any rate.
amadeuspagel 35 days ago [-]
A counter example to this is food. Anyone can open a restaurant. Even though the risks, like food poisoning, are much bigger then a bad haircut.
bryanlarsen 36 days ago [-]
Canada might see significant movement on licensing restrictions soon. There's a big movement to reduce inter provincial trade barriers in the face of potential American tariffs. It's a good political sound bite: replace American trade with Canadian trade.
But in physical goods almost all of the barriers have already been demolished. Liquor is the maon exception.
But the service industry is now bigger than the physical goods industry and there are lots of barriers in it, licensing being perhaps the biggest. Licensing is a provincial responsibility. Hopefully the rare unity the country has experienced since Trump's inauguration can be harnessed to unify and rationalize licensing country wide.
36 days ago [-]
pseingatl 36 days ago [-]
This subject was addressed comprehensively in Milton Friedman's Capitalism and Freedom.
BTW, Friedman makes DOGE look life a fearful, cautious agency. He would have eliminated dozens of federal agencies; perhaps 80% of them.
Aurornis 36 days ago [-]
> He would have eliminated dozens of federal agencies; perhaps 80% of them.
Most licensing is state level. That’s why you so often hear that someone is only licensed to practice in a certain state.
Eliminating federal agencies wouldn’t change anything about how, for example, your barber is licensed.
Friedman also wrote for an entirely different era. The world has changed a lot since he was active, and even more since he died almost two decades ago.
tim333 35 days ago [-]
We have some enthusiastic elimination going on from a Friedman fan in Argentina
>Furthermore, we have a deregulation ministry, where basically every day we eliminate between one and five regulations. (from https://youtu.be/8NLzc9kobDk?t=666)
so there's a real world experiment to see how it goes.
spicyusername 36 days ago [-]
The world Milton Friedman lived in was very different than the world we have now. Much of what he had to say no longer applies, today. Its analogous to reading philosophy from pre-enlightenment or pre-naturalist philosophers. Academically interesting, but totally irrelevant.
Economists like to masquerade as hard-scientists, but once you get past supply and demand and behavioral economics, its just academics making things up that sound good.
The world we live in is globally interconnected with civilization and planet-sized problems. The actors squabbling in today's world are no longer small local groups, focused on community-sized problems, as they mostly were pre-1900. They are impossibly large, country-spanning, corporate entities with huge reach and influence.
Public institutions need to be sized appropriately to solve modern problems and to properly contend with their corporate competitors.
Tiny pre-WWI-sized governments are not going to cut it with post-WWII-sized problems.
tim333 35 days ago [-]
>The world Milton Friedman lived in was very different than the world we have now.
How so in any meaningful way?
I was alive when he was popular and things don't seem very different on the economics front.
ori_b 36 days ago [-]
Milton Friedman died in 2006. He was two years old when the WWI started.
spicyusername 36 days ago [-]
Yea, but he was born in 1916 and, like most other humans, the world that he group up in shaped him for the rest of his life.
Most of his popular works were published in the early 60's, before many of our modern problems were obvious and the outcome of many of the expansionary policies of that period had time to take root.
ori_b 36 days ago [-]
> Most of his popular works were published in the early 60's
A significant portion of his writing postdates 1995. Very little predates 1965.
dghlsakjg 35 days ago [-]
Sure, but what worldview is his thinking rooted in.
I can write about Kant's ideas in 2025, but it doesn't make them new ideas.
Did he evolve his views past where he was in the mid-century era?
Does thinking from the late 1990s really apply well to the world we live in today?
BlandDuck 36 days ago [-]
Interesting ideas. I respectfully disagree with all of them.
Do you have any evidence to back them up, or are you yourself "just [...] making things up that sound good" ?
spicyusername 36 days ago [-]
The outcomes of public policy throughout the 1900s, particularly pre-Reagan and post-FDR. Quite expansionary, but nearly all of the bedrock institutions most people have come to rely on and take for granted materialized in this period.
- The GI Bill
- Medicare / Medicaid
- Social Security
- Unemployment Insurance
- Regulatory institutions / policies like the SEC, FDIC, OSHA, and the EPA.
- The Civil Rights Act
None of this stuff just happens by accident, and these kinds of things definitely don't magically fall out of unregulated free-markets. And they DEFINITELY don't fall out of markets where the participants are massive corporate interests.
You need institutions whose focus is solely on social / economic wellbeing and who have the power and authority to provide it.
There are also plenty of modern academics, making things up themselves, who articulate similar points.
- Joseph Stiglitz
- Thomas Piketty
- Ha-Joon Chang
- Mariana Mazzucato
- Robert Reich
- etc
bryanlarsen 36 days ago [-]
Perhaps Friedman's most widely known saying is that "inflation is a monetary phenomenon". In the last 30 years the correlation between money supply expansion and inflation has been low. OTOH the correlation between supply shocks and inflation has been high.
A real science would update in the face of contradictory evidence. Some economists have, but most haven't.
zdragnar 36 days ago [-]
We did see massive inflation in subsectors of the broader economy, though, and there were a lot more monetary policy levers moving than just supply expansion.
krapp 36 days ago [-]
For what it's worth, Musk has said his goal is to eliminate all regulations[0] (and, one assumes, all federal agencies except DOGE, assuming it even counts) and then add each regulation back one at a time if they deem it necessary.
Maybe check first, before removing? Instead of waiting for people to be killed, then add back.
As they say: First, do no harm.
grugagag 35 days ago [-]
I wonder if China is going to step up to the plate and swipe all that American influence under their umbrella. They can print out yuan the same way we print dollars except that theirs are backed by being the world's factory.
luma 36 days ago [-]
Lawyers have organized their licensing so well that they are the ONLY profession in America not being overrun by PE consolidation because they had to foresight to not allow it. The capital class was eventually going to run up against them to try and break down that wall.
pseingatl 36 days ago [-]
Accenture, E&Y, PWC and Deloitte all have a law division; not as much in the US but overseas and slowly creeping here because these firms are joined at the top and fueled by public money. The consolidation was set back by more than a decade because of Enron and the prosecution of Andersen, but now they're back. These hybrid firms, because of the requirement of annual tax filings, offer something big law firms simply cannot. Very few law firms have set up consulting arms and those who have done so have stumbled, e.g. Greenberg Traurig.
luma 36 days ago [-]
None of the orgs you listed provide direct "lawyers for hire" style legal services in the United States. They'll have partner orgs which are lead by lawyers, they'll have international arms with international lawyers, they'll offer legal-adjacent services, but show me and example where, say, Deloitte will put a lawyer into a US courtroom who is directly being paid on W2 by Deloitte.
You can't, because they can't legally operate like that in the US.
> The Deloitte US firms do not practice law or provide legal advice. Deloitte Legal refers to the legal practices of Deloitte Touche Tohmatsu Limited member firms (or their respective affiliates) that provide legal services outside of the United States.
> PwC US does not provide legal advice or opinion in the United States
Lawyers in the US, through the state Bar Associations, have done a damn fine job of protecting their industry against capital. Doctors in the US now answer to MBAs, Lawyers only answer to other Lawyers.
beacon294 36 days ago [-]
Can you provide more details on why they and not doctors can resist?
willis936 36 days ago [-]
What would the motivation be for them to do that? Restricting access to law & order to the wealthy is working out great for them.
Ekaros 36 days ago [-]
Extracting money. Delta between billed rate and minimum wage is pretty massive. There is lot of money to be extracted from that gap. And from pushing the billable rate and hours up at same time.
willis936 36 days ago [-]
They are getting something for that money: exclusive access to the legal system. That is power they wouldn't sell.
Now she wants to go back part time to make some extra money, but her license expired and that means she has to get her license back. That includes having to attend over 100 hours of class, for a slightly above minimum wage job many people do themselves, at home, with zero experience.
It's absurd. Maybe an hour or two refresher is justifiable, but I assure you she had not forgotten how to cut hair to the extent that she needs 100+ hours of retraining. It's deeply embedded in her psyche at this point.
My wife says she basically just needs to go hang out at a cosmetology school to make the hours but doesn't need to actually do anything while she is there.
It is absolutely a racket.
I think that AI will fundamentally change health care, it's as good as a primary physician in a lot of cases. The barriers need to come down, that's what is driving the costs.
Physicians salaries make up 8.6% of medical spending.
Kaiser did a study that found a 40% reduction in physician salaries would result in a 3% savings to consumers on medical costs.
Then you add in the profit that has to be extracted at every level.
Private equity buys up hospitals, physicians groups, and ambulance operators. They need to take their cut. Insurance companies need to take their cut.
The free market doesn’t work great for to keep rent seekers from extracting profits because of insurance and the very nature of healthcare which reduces the ability of customers to shop around.
I’d guess it’s higher now. It also seems really easy to fix:
Just have a standard price list, and auto accept/reject 99% of procedures at the time of administration. Also, have a billing system that lets the patient pay on discharge (like restaurants).
Edit: Concrete example. I needed some medicine. There are two interchangeable options. One retails for $30, and the other for $600.
The doctor chose the $600 version, and insurance rejected it. This wasted my afternoon, an hour of the pharmacist’s time, 15 minutes of insurance company time, and at least 45 minutes of time at the doctor’s office. On top of that, the doctor had to context switch back to my case to change the prescription.
If the doctor had a UI when writing the prescription that contained a price list, whether insurance covers which drug, and a “no really, we need the expensive one” button (there is already such an override that the insurance company honors), then all of this waste would have been avoided.
If we're wishing, let's wish for it to be like car repair. Where they have to give us a quote before they begin service. Need some allowance for billing for care when you were unable to consent, like when an ambulance picks you up for an emergency, or if something unexpected comes up during a surgery.
Here in New Zealand I am pretty sure that’s the case.
In my case, there was zero reason to prefer one over the other. That’s not true in all cases.
A second hypothesis is that the inefficiencies are fractal/recursive -- and that we might be able to squeeze out another one or two 40% savings in some slices even after the first one!
Because of the nature of the healthcare market a reduction in physician salaries would be almost entirely captured by private equity and insurance companies.
The only realistic way a reduction in physician salaries leads to a significant reduction in costs is with a single payer system.
>fractal/recursive
This is just wishful thinking. I can think of zero mechanisms where paying physicians less has a compounding negative effect on prices.
I can think of several mechanisms for how it would have a compounding positive effect.
Decrease in quality, decrease in recruiting, acceleration of retirement etc…
source?
The difference comes from revenue skimmed off by entities that employ or contract physicians.
A huge part of that is profit skimmed off by private equity buying out physician groups over the last 20 years or so.
I think we understand the reasoning pretty well. Protectionism.
In the UK I don't think we have licensing required for hairdressers or egg sellers and we still have ok haircuts and eggs.
More to the point, vague and lazy arguments should have little, if any weight when it comes to policy debates. If a given policy has provable and material harms (ie. stifling the supply for hair cutters), and the only opposition is a vague "well it must be there for A Good Reason", then the proper response should be to repeal it, not "well I guess we can't conclusively prove that it wasn't there for a good reason so I guess we should keep it".
The government would then be the only thing preventing a race-to-the-bottom in your wife making any money.
I have seen deregulation of industries decimate trucking, giving rise to subhuman organizations like Prime Trucking.
I would strongly advise anyone seeking deregulation to really consider... does this mean - literally - the only thing that one can offer as a competitive edge is how little money you are willing to take for this service?
Additionally, given the wrecking ball currently applied to the us govt, I would strongly advise that "no tax on tips" and "default gone regulations" may help some minimum wage people, but they have super nefarious implications for other parts of the govt. "Tips" for example are now legal to politicians, per the US Supreme Court [Snyder v US, 2024] and "no tax on tips" implies that politicians do not have to record those tips as income on their taxes... which was possibly one of the last ways in which they could have been documented in any way.
Licensing is supposed to protect the consumer from bad practice, not to inflate wages and decrease competition for those who have licenses.
It’s not good. You might imagine it being good if you think it would protect yourself from competition, but if everyone practiced this way you’d be forced to pay inflated prices and wait excessively long for every service. It would be a net loss.
> I would strongly advise anyone seeking deregulation to really consider... does this mean - literally - the only thing that one can offer as a competitive edge is how little money you are willing to take for this service?
If there was literally nothing to distinguish your services other than price, then artificially inflating prices through excessive licensing would be nothing other than stealing from consumers through force of law.
In the real world, quality of service matters. People don’t go back to a hair stylist who does a bad job, though they may not immediately recognize one that doesn’t practice proper hygiene practices.
This is where licensing should apply: Teaching and enforcing the practices that are not obvious, but nevertheless important for societal benefit. Barbers need to practice proper hygiene to prevent spread of disease. Builders need to practice proper constriction to avoid dangerous buildings. There are numerous real problems that aren’t obvious at the point of purchasing a service, but must be enforced at a society level to avoid widespread problems.
These often go unappreciated in modern societies because we take them for granted. Spend some time in developing countries, though, and you’ll hear and experience a lot of negative stories from unregulated services.
Just about every time a politician champions some legislation for "the little guys" it turns out it overwhelmingly benefits monied and powerful interests more. Definitely a trend I have observed when you scratch beneath the surface of things.
I think people would certainly pay more for a reliable and stylish haircut even if they could get a bottom barrel haircut from a high schooler. You just pay for the quality of work you want done.
What you call race to the bottom, I as a consumer call fair pricing not controlled by syndicates.
Controlling the market by limiting the job pool to just the people who can already afford the time let alone the licensing fees really just serves to keep people in poverty. How many people could be working right now but can't afford the time and money to get licensed?
This is about policy for a group of nearly 600k people. If there were no 'racket' I think that most people who want to cut hair are capable of stylish and reliable - above the Great Clips standard.
"No regulation" could increase the labor pool a factor of 10x, given the propensity for these businesses to be 100% small $ transactions.
[Editted in response to your edit] Every industry should have competition, but the national average for hair-cuts is near minimum wage. WTF are you smoking? Do you really believe if the minimum was gone there's a chance "fair pricing not controlled by syndicates" would be just above minimum wage? Is the govt minimum wage a "pricing controlled by syndicates"?
Why can't my wife just cut hair out of our kitchen? Here at least it's illegal. I have no doubt she would have steady repeat clientele ready to pay for a good haircut.
I firmly believe the value of something is what someone else is willing to pay, and that artificially inflating the price by limiting supply will always be immoral and monopolistic.
They exist because people like convenience and ease of discovery.
They don’t “need” to exist. They exist because there’s demand and they’re filling it.
There are already many options from hair stylists operating out of their home. People can already choose one or the other.
I say deregulate everything reasonable, stop trying to nake everything a nanny-society and micro-managing every last bit of compliance, and let the chips fall where they may! Let responsible adults live their lives. People self organise and figure most things out for themselves if you just let them.
If kitchen hairstylists outcompete hair chains, I would be surprised but also not too worried - hardly the end of civilization at risk. But locking people artificially out of jobs and artificially inflating almost all everyday expenses for consumers are pretty big enshittifications, in my opinion.
While I agree there should be some kind of license - you don't want a random person become hair stylist for the day and then switch to something else - there probably should be some examinations of skills. The current racket is about making money and protecting incumbents from competition but it also wastes a lot of time in the process.
Considering that the stakes are fairly low (compared to say, surgeon for a day) and that there are plenty of jobs that obviously do not require a license and we are happy to let the employer apply the skills test, where exactly would the line sit between needs license and doesn't?
Why though? The easier it is to switch in and out of careers, greater the likelihood that people will be well-matched to job opportunities. We will also have the least possible unemployment.
How good is the record keeping? They might not log everything you do for 20 years, just 'if your license isn't lapsed you have completed everything currently required' and not have a mechanism for bringing someone with 1 year of no-compliance and someone with 20 years into compliance in a custom tailored manner.
For instance NP and PA have very similar skills, but the nursing board goes to bat for nurses allowing independent practice while doctors have chosen in some states to sabotage PAs as they live under the medical board fiefdom. There is little other explanation for the divergence in practice privileges.
If you are a licensed professional and your profession doesn't own the board, what often ends up happening is competing professions under the board sabotage each other.
The way Nurse Practitioners are allowed to practice independently now is a contentious topic in the field because they’re now operating essentially as doctors, but with much less education and hands-on training.
The original idea was that NPs could handle a subset of simple and routine issues and leave the more complex issues for fully trained doctors. The current situation has NPs and doctors performing the same functions but with very different training, while patients are mostly unaware that there’s a difference.
It’s a common complaint on forums like /r/medicine because doctors are seeing a rapidly growing number of patients who have gotten bad advice or prescriptions from overconfident NPs, especially in states where NPs can prescribe controlled substances. Going the NP route is also the preferred direction for people who want to practice alternative medicine but have a prescription pad, leading a lot of patients unknowingly into the hands of NPs who actually shun large parts of traditional medicine.
Common problems around here are NPs who prescribe antibiotics on demand, some times dangerously powerful ones for extended periods of time. NPs writing long-term benzo prescriptions as first line treatment for anxiety (very bad practice) has created a mess of dependent patients who didn’t know what they were getting into, who end up back at fully trained providers who need to taper them off for sometimes as long as a year.
So it’s not as simple as medical licensing boards being mean. There are some very real problems with the current double standard of training between NPs and doctors.
And there is another tier of regulated substance that you can only be prescribed at a hospital (rarely-used antibiotics, you must stay under surveillance while you take them to avoid creating resistance), and another tier that can only be prescribed by a specialist (methadone, lithium, probably a ton of others), but i would hope this is the same in the US.
In the US this is determined at the state level, so it’s different depending on where you live.
In many states, NPs can prescribe controlled substances now. This has become a problem in some areas with certain NPs prescribing Adderall, Xanax, or Ketamine at alarmingly high rates.
We do have monitoring mechanisms and people can be flagged if their prescriptions are becoming a problem, but the system is slow to respond. The cases are publicly searchable and I spent some time reading my local cases last year. The reports were often unbelievable, with some NPs becoming locally known for prescribing certain drugs at high doses. You can even find tips about which NPs to go to on certain Reddits.
I wonder how much of this is simply because people are more able to afford (or even merely schedule!) medical care because NPs are available. There are certainly a lot of doctors that overprescribe and give bad advice after all.
From The System of Professions:
> By focusing on parallels in organizational development, students of the professions lost sight of a fundamental fact of professional life—interprofessional competition. Control of knowledge and its application means dominating outsiders who attack that control. Control without competition is trivial. Study of organizational forms can indeed show how certain occupations control their knowledge and its application. But it cannot tell why those forms emerge when they do or why they sometimes succeed and sometimes fail. Only the study of competition can accomplish that.
The problem with this is while it's true that beauticians don't cause the same damage as a medical provider (usually), they also don't have the same financial impact on the US economy as a whole. We don't hear people complaining about haircut costs, we hear people complaining about healthcare and higher education costs.
When it does get discussed, it seems like those discussions are always targeting those who threaten the status quo, and there's very little discussion of underlying issues.
So for example, you have pieces complaining about NP or PAs replacing doctors in clinics, ignoring the fact that it's not the NP or PA degrees necessarily, it's that you're taking people out of a 2 year program and putting them directly into practice with no residency or training program. Similar things play out with other provider types, where there's a lot of FUD and playing on stereotypes without discussing actual training backgrounds encountered within degrees, or the requirements that are actually necessary to complete tasks.
If you look at current MD programs, many of them are pushing hard to go to a 1.5 year coursework, 2.5 year clinical training model, followed by residency. Compare that to a PA program that is what? 1.5 years of coursework followed by clinical training. Many PA programs now also require licensed healthcare practice before you even enter the program too. So it's really hard for me to accept the argument that PAs + 6 years of supervised training aren't similar to an MD + 4 years of supervised training.
You can extend this to all sorts of aspects of the medical system. Many medications that are now prescribed really don't actually require prescriptions, especially some of those that someone has been taking for years. Others could be overseen by a pharmacist (probably better in many cases than a physician), or a psychologist, dentist, or optometrist with the right additional training.
The idea that provider skills in a given area are only ever possibly obtained by the MD degree model is preposterous to me. Sure, there are probably some domains where this is currently true, but there's a lot of domains where it's not. These discussions need to stop treating healthcare as if licensing is a totally different issue there — although it is probably in terms of risks but also in terms of costs, the fundamental problems are the same.
I could go on and on. Even among MDs, the specialty and subspecialty accreditation requirements can be grossly excessive and unnecessary. Conversely, there's also the fact that MDs sometimes are making decisions that they're not actually trained to deal with because their degree gives them a kind of blanket legal authority.
Everyone has anecdotes about poor care, but I can say the same just about any type of provider I've had contact with. I can think of grossly irresponsible care that I've had from physicians, where we've been saved in a sense by PAs, RNs, or NPs. I can also think of cases where the MDs were great, and the PAs, RNs, and NPs didn't know what they were talking about.
Healthcare licensing is a complete mess and it is a major unrecognized source of increased healthcare costs. Even with all of the push to deregulate, I don't see it being addressed effectively anytime soon because the discussion gets so distorted and because it often feels like the way it bubbles up into public consciousness is through bad actors leveraging deregulation for undesirable reasons.
An NP can finish training with 500-750 hours and a PA with 2000.
And that training is nowhere near equivalent to resident training because NPs and PAs are handed the lower acuity and less complex patients. In the NP case there is also very little oversight over the kind of training they receive, so the quality is extremely variable (much more so than resident training).
After training the NP or PA could go on to work at minute clinic where they have almost zero direct supervision. Or they could go work at a doctor’s office where they handle low acuity and less complex patients.
After 6 years of running strep tests and overprescribing antibiotics in a minute clinic, they are by no means equivalent to an MD.
Residency is an intense 3-7 year 80-100 hour a week training program that includes academic components. In addition to being closely supervised, attendants are actively teaching them. They frequently go to lectures and have homework to complete. Residents are routinely evaluated by dozens of doctors and have to make significant progress or they are forced to repeat some or all of it. This is far more rigorous than “you showed up for work for 6 years and didn’t get fired.” 6 years working as an NP or PA is just not equivalent. To replace this, you’d need to force them to have a similar residency program.
Then you need to look at the scores of the average person coming into PA or NP programs vs MD or DO programs. And finally at the material covered. It is not equivalent. And it shouldn’t be. They do different jobs.
There are certainly long practicing PAs and NPs that have equivalent medical knowledge to many even most MDs.
But the only way to ensure that this is the case is to add a structured mandatory residency requirement, and increase the amount of information taught, and the number clinical hours during the program.
If you do this, you’ve just recreated an MD program for no real reason.
Physicians salaries only make up 8.5% of healthcare spending. Even if you somehow manage to figure out a way to train NPs and PAs to completely replace doctors at half the salary, you’re telling a 4% reduction in spending. That’s a rounding error that will just end up being absorbed by the hedge funds that own the clinics, hospitals, and physicians groups.
Another thing worth noting is that when NPs and PAs start practicing independently their malpractice insurance premiums go way up, further down eating into the small savings you’ve made.
If there was a dramatic increase in the number of medical schools, I'd see no reason maybe. But I think flexibility of educational tracks is another. My point is these are the kinds of discussions that need to happen. And it's also important to keep in mind the question of whether or not X training in Y field is actually necessary or if it's unnecessary overhead. We assume a certain educational model is necessary for safety but that's not clear at all, especially as you get into specialties. As some have pointed out, current residency practices might even decrease patient safety in a lot of ways.
Arguments about curriculum rigor also seem questionable to me if you consider, eg all the foreign medical school graduates and DO graduates practicing just fine. I'm not trying to cast aspersions on them, just they also tend to have lower scores etc and have long respectable practices.
>Physicians salaries only make up 8.5% of healthcare spending.
For what it's worth I don't think it's the salaries per se, it's the cost multipliers due to lack of options. I think NPs and PAs are just one example. The question is, if other service provision models were adopted, how would it decrease service costs? I don't think it's possible to extrapolate costs of service from physician salaries in this model to costs of service in a different model.
Let's say eg you required vaccines to be administered by a physician. There would be huge costs associated with that that wouldn't be represented by salaries alone. There would be delivery bottlenecks that could be leveraged by unscrupulous actors, an increase in price solely due to bottlenecks and so forth.
And that's not even getting into patient satisfaction due to increased choice, that might not be reflected in costs at all.
Also it's important to clarify I am not in favor of private equity run care, and in fact would prefer (single payer) public health care provided for all citizens.
I just think there's a lot that more types of providers could be providing now.
The bottleneck for the number of doctors is residency slots, not med school slots. If you drastically increased the number of residency slots med schools could rapidly ramp up to fill them. If they couldn’t fill them foreign doctors wanting to work in the US would.
Beyond funding for residency slots. The real limiting factor is the number of doctors willing and able to train new doctors. Even if your plan is to product dozens of new kinds of practitioners, doctors are the only ones qualified to train the new practitioners today.
In a hypothetical world where you say “I want to create as many doctor equivalent practitioners as possible”, there’s no advantage to creating new types of doctors because existing doctors are still going to be the bottleneck. Essentially if you create a new PA program with a residency, past a certain point, you’ll just be competing with med schools and existing MD residencies for the same resources.
>whether or not X training in Y field is actually necessary or if it's unnecessary overhead
You know who spends far far more time thinking about this than you or I? Doctors like my wife who is the director of medical education for her division. Her and her colleagues are constantly evaluating resident’s performance and if anything they think that most of them could use more time not less. Her specialty is so overworked and understaffed that every doctor in that speciality would drop a year of residency if they thought it was feasible.
Doctors have strong a culture of service and the peer pressure to serve the community and put the needs of public health and medicine in general above their own is immense. I’ve never seen anything else like it in any other profession that I’ve encountered. I certainly don’t think that Doctors should be able to regulate every part of medicine with no oversight, but I can’t think of anyone more qualified and deserving to determine how much training is necessary to practice.
I’m not saying there are no inefficiencies here, but given the amount of time and effort regularly spent on resident education, I strongly suspect there are no large savings to be had here.
>current residency practices might even decrease patient safety in a lot of ways
Most of those claims have been debunked. Numerous high quality studies have shown that adding limitations to number of hours residents can work and limiting shift lengths did nothing to increase patient safety.
>just they also tend to have lower scores etc and have long respectable practice
Foreign medical schools that attract US students tend to have very low placement rates. If only the top 60% of your students match, you can’t look at the average student score and compare it to the average student score in a US school where 95% of students will match. If you look at actual residents who went to a foreign school as opposed to looking at average scores of everyone admitted, there isn’t a big difference.
As for DO scores. They are lower, but by a very small margin. Nowhere near the difference in scores between PA and NP students and med students.
It’s hard to compare them directly because PA applicants take the GRE not the MCAT. But the average med school student scored north of the 80th percentile on the MCAT, while the average PA student was right at the 50th percentile on the GRE. And college GPAs are much higher for med students.
>cost multipliers due to lack of options
I don’t know that this is the case. It could be but I suspect it’s not for a few reasons.
I’d expect any bottlenecks to already be reflected in the physicians salary. That is they would have captured a fairly large part of the increased price in their salaries because by becoming they bottleneck they are now more valuable.
We have been increasing the number of physicians per capita since 1960, but healthcare costs have been rising. If you look at list of developed countries by number of physicians per capita and compare it to a list of counties by healthcare expenditures per capita, there’s no correlation. if physical bottleneck was driving a significant chunk of healthcare costs, you’d expect to see a correlation.
>patient satisfaction due to increased choice
Patient satisfaction is so strongly correlated with whether or not a provider prescribes you something that it’s mostly a useless metric. It’s well documented that NPs and PAs are more likely to prescribe unnecessary antibiotics.
This leads directly into another issue I have with increasing the types of providers. Creating additional providers with their own governing bodies creates administrative overhead with significant costs.
Over prescribing antibiotics is a prime example. We’ve decided this is a problem, but now you need to convince med schools and residency programs to, np schools, pa, schools, and whatever new providers are created in this hypothetical world.
NP are under the nursing board so doctors are less entrenched in their influence.
There are a lot of problems coming out of the fact that NPs are now basically practicing medicine in parallel with doctors despite vastly different education and training experience.
Many patients don’t even understand the difference. It doesn’t matter for common things like a simple sprain or common cold usually, but cases of medication overprescribing (think antibiotics for colds, etc) are commonly traced back to NPs and specialists will complain about the deluge of incorrect referrals from NPs who don’t know what they’re doing.
One example: I heard a specialist explain that they had to stop taking referrals for Ehlers-Danlos evaluation from NPs because the local NPs were referring people at impossibly high rates due to misdiagnosis. Ehlers-Danlos has become a popular (though incorrect) TikTok diagnosis for vague symptoms and rather than push back, many local NPs were running with it. Social media is full of people who are convinced they have Ehlers-Danlos and a lot of NPs were leaning into the trend instead of realizing that it’s not real.
So your unqualified statement refers to a specific and very small proportion of doctors.
I'm extremely grateful that APCs have independent practice in my system. There is way too much work to be done compared to the number of physicians available to do it.
The "working under a doctor" model seems to be mostly encouraged by the administrators, as this puts impossibly high liability on the physician (who is forced to "oversee" a dozen or more APCs).
No thank you.
If you total up the time you spent doing the work, and multiply that by what you could have been paid working doing something else, how does the savings change?
People should definitely build their own houses. Its custom fit to you and you get the satisfaction of doing it. But its also a lot of work, requires considerable time investment, and requires quite a bit of specialized knowledge.
But consider if I hired someone, I would lose 30% of my earnings to taxes. And then 50% of what I pay others goes to insurance/licensing/taxes/transportation etc. So really your labor costs should be about 30% if you bill your own time since it is tax free both ways and no overhead.
I.e. the majority of that 70% savings is not from labor.
I’m sure you did your homework and did everything by the book, but I’ve seen enough both online and in my experience with old houses (commonly modified without permit) to have an appreciation for licensing and permitting requirements.
A few years ago my friends’ landlord tried to rebuild the house’s deck until it got shut down by an inspector driving by. I thought it was outrageous until I walked over and saw what was being built, which was a laundry list of engineering and design failures. After that I was thankful that the inspector noticed and stepped in.
Licensing (and permitting) doesn’t exist for the ideal case where people practice perfectly without licensing. It exists for the average case, where people like to guess and improvise.
> End results, costs <30% of anything comparable offered commercially.
If you did the work yourself I’d expect similar savings. I think this is an example of DIY labor, not the cost of licensing.
/r/DIY loves to harp on that kind of thing, but most of the "death trap" critiques I read there are for things like decks 12" above grade. People need to get a grip.
Therefore the "crazy stuff" is what you wind up seeing it.
Since you brought up a stupid anecdote I'll bring up my own stupid one. A friend of mine was out, mid thunderstorm, fixing the drainage ditch by the road he lives on as it was having problems and trying to go over the road. The state equivalent of the EPA happened to drive by and shut him down. Well, the road wound up getting washed out and the water found a new path of least resistance and caused tens of thousands of dollars of damage. Because the matter was on the state's radar everything took forever and more money to get fixed. To this day he regrets not handling the situation more aggressively.
Therefore the "crazy stuff" is what you wind up seeing it.
"Students enrolled in programs of hairdressing/cosmetic therapy or barbering may enter into a work-study arrangement after they have completed at least one thousand (1,000) hours of classroom instruction."
https://rules.sos.ri.gov/regulations/part/216-40-05-4
"Key points about PPL classroom instruction: Ground School: In addition to flight hours, you must also complete a ground school course covering subjects like aerodynamics, weather, navigation, and regulations, which typically involves around 36-40 hours of dedicated classroom instructi"
For one, the FAA allows you to take as much or as little classroom instruction as you need. There is no classroom requirement (kinda, there are other ways to get a pilots license). I had 0 hours of ground school, and did self study. I know people with 50+ hours of one on one tutoring. The FAA evaluates you on your knowledge, they don't care about your experience, except for meeting the minimum number of flight hours.
To get to the point where you can charge money for your skills you are looking at 8x the flight time to get to 250 hours as pilot in command, plus a litany of other courses to earn a commercial certificate, but even here, you are lucky to get a job, and it will likely be pretty un-glamorous flying.
To get to fly an airliner (in the US, Europe has much lower requirements), you need 1,500 hours minimum for the piece of paper, and its not like you are going to be flying an airliner alone.
I was just pointing out that the pilots license hours comparison is not great. 1000 hours of classroom instruction at a cosmetics school is 6 months full time. 1000 hours in a cockpit takes years.
Destiny is designed to be as much a day job or more as cutting hair.
Excerpted and discussed at https://marginalrevolution.com/marginalrevolution/2025/02/th...
The book site is https://www.hup.harvard.edu/books/9780674295421
'Clifford Winston of the Brookings Institution argues for eliminating occupational licensing for lawyers entirely and replacing it with a system of voluntary certification. Government has a role to play by collecting information about service quality and making it easily accessible to the public. Databases like the NPDB should be improved and opened for many professions.
The medical profession is unlikely to be delicensed, but as Ms. Allensworth’s book shows, we shouldn’t let the AMA dictate the terms of medical education. Many European countries offer combined undergraduate and medical degree programs that take only six years, compared to the eight or more years required in the U.S.
Advances in artificial intelligence, which Ms. Allensworth doesn’t explore, may also catalyze reform. AI is already transforming fields such as legal research and medical diagnostics, automating tasks once reserved for licensed professionals. As these technologies advance, they can reduce reliance on rigid licensing systems by ensuring quality and safety through innovative tools.'
For example, an association of funeral home owners will lobby their state representative for a law forbidding the sale of coffins by anyone other than a licensed funeral director. Ostensibly this somehow protects the public from unscrupulous coffin-sellers. In actuality, its main effect is to protect the profits of the funeral home oligopoly.
(Lest you think this is a fanciful example, see St. Joseph Abbey v. Castille.)
The AMA education requirements are of essentially the same sort, put in place by a compliant legislature to protect the profits of an incumbent cartel, at great cost to the public.
Advances in artificial intelligence will do nothing, absolutely nothing, to catalyze reform of what is essentially a problem of politics and greed.
https://ij.org/case/saint-joseph-abbey-et-al-v-castille-et-a...
The worst is NAR and Realtors®. There's absolutely no professional instruction involved, just a morality test taken every few years that until the late-1940s early-1950s required that realtors maintain the racial character of neighborhoods (under penalty of disciplinary action.)
They managed to get themselves written into most state and local laws. Only the explosion of aspirational middlemen occasioned by the internet has recently managed to push back on that. Hopefully the recent antitrust case against them is catastrophic, but they spend $100M a year lobbying. Lobbying government is basically all the NAR actually does and all the real value that members are getting.
edit: https://www.notus.org/money/national-realtors-lobbying-polit...
After the end of Reconstruction the Southern states instituted laws now called the “Black Codes”, forbidding blacks from being blacksmiths, or grocers, from owning property, or doing any sort of work other than, effectively, being sharecroppers - essentially slaves of the same white landowners as before.
Consider who is hurt most by laws requiring expensive and onerous licensing for independent hair-braiders. Are a lot of white hair-braiders suffering from this, do you suppose?
https://en.wikipedia.org/wiki/Black_Codes_(United_States)
"The earliest minimum wage laws in the United States were state laws focused on women and children.[25] These laws were struck down by the Supreme Court between 1923 and 1937.[25] The first federal minimum wage law, which exempted large parts of the workforce, was enacted in 1938 and set rates that became obsolete during World War II.[25]'
- https://en.wikipedia.org/wiki/Minimum_wage_in_the_United_Sta...
We know your scenario isn't true because there are plenty of white-owned businesses which knowing hire undocumented workers in order to pay them sub-market wages with poor working conditions.
You are, I believe, referring to https://en.wikipedia.org/wiki/1909_Georgia_Railroad_strike ?
I don't see anything about a minimum wage. I do see 'the arbitrators did rule that the railroad would be required to pay African American and white firemen the same wage' but nothing about how that minimum was set by law.
Minimums for a union job are not the same as minimum wage, which is the legal minimum set by law.
Union minimums predate the Civil War. For example, the Boston Journeymen Bootmaker's Society had a minimum price per shoe made, back in the 1830s, leading to Commonwealth v. Hunt.
And official durations are often different than the amount of time it actually takes students.
In Germany for example med school is 6 years, but the average student completes it in about 7.
A US student with some AP credits from high school and a few summer classes could easy finish university in 3 years and end up taking the same amount of time as the average German medical student.
But even looking at averages at the end of the day doctor’s salaries are a small fraction of overall medical costs so shaving a year off of the average training times isn’t going to make a dent.
The US also doesn’t have a national high school curriculum, so removing general education requirements from the university + medschool pipeline, which is essentially what countries with shorter total training times do, is a harder problem than it is in Europe.
Machine learning has been talked up a lot in medicine especially in the context of radiology. I'm not sure to what degree it's really panned out to date. Legal discovery has been aided by automation of various sort for years.
That said, note that malpractice is in place for a reason. Everyone makes mistakes. We all have to go in to work even if we have a horrible hangover, doctors and radiologists included.
The number of physicians has been growing faster than population growth since the 60s. No one could have predicted that we’d be able to sustain the insane growth in medical spending and demand that allowed this to continue.
Because of the way medical training is funded, number of physicians isn’t not a free market phenomenon. Congress decides how many there are. In the 90s it looked like there were going to be too many. When that changed the AMAs position changed, it was a perfectly reasonable position.
But even if it weren’t a reasonable position. That was 30 years ago. No one who was in a position of power is around today, so it’s unclear to me how exactly the current AMA should bear responsibility.
It would be like if IEEE today called for a temporary freeze on the increase of H-1Bs. Then 30 years later something causes an explosion in demand for engineers and people started blaming these evil engineers.
I bet the situation is quite complicated, and I now regret offering a one-sentence explanation.
Such situation makes people poor. Since everything needs license, people can't practice jobs that they are perfectly capable doing.
But in physical goods almost all of the barriers have already been demolished. Liquor is the maon exception.
But the service industry is now bigger than the physical goods industry and there are lots of barriers in it, licensing being perhaps the biggest. Licensing is a provincial responsibility. Hopefully the rare unity the country has experienced since Trump's inauguration can be harnessed to unify and rationalize licensing country wide.
BTW, Friedman makes DOGE look life a fearful, cautious agency. He would have eliminated dozens of federal agencies; perhaps 80% of them.
Most licensing is state level. That’s why you so often hear that someone is only licensed to practice in a certain state.
Eliminating federal agencies wouldn’t change anything about how, for example, your barber is licensed.
Friedman also wrote for an entirely different era. The world has changed a lot since he was active, and even more since he died almost two decades ago.
>Furthermore, we have a deregulation ministry, where basically every day we eliminate between one and five regulations. (from https://youtu.be/8NLzc9kobDk?t=666)
so there's a real world experiment to see how it goes.
Economists like to masquerade as hard-scientists, but once you get past supply and demand and behavioral economics, its just academics making things up that sound good.
The world we live in is globally interconnected with civilization and planet-sized problems. The actors squabbling in today's world are no longer small local groups, focused on community-sized problems, as they mostly were pre-1900. They are impossibly large, country-spanning, corporate entities with huge reach and influence.
Public institutions need to be sized appropriately to solve modern problems and to properly contend with their corporate competitors. Tiny pre-WWI-sized governments are not going to cut it with post-WWII-sized problems.
How so in any meaningful way?
I was alive when he was popular and things don't seem very different on the economics front.
Most of his popular works were published in the early 60's, before many of our modern problems were obvious and the outcome of many of the expansionary policies of that period had time to take root.
A significant portion of his writing postdates 1995. Very little predates 1965.
I can write about Kant's ideas in 2025, but it doesn't make them new ideas.
Did he evolve his views past where he was in the mid-century era?
Does thinking from the late 1990s really apply well to the world we live in today?
Do you have any evidence to back them up, or are you yourself "just [...] making things up that sound good" ?
- The GI Bill
- Medicare / Medicaid
- Social Security
- Unemployment Insurance
- Regulatory institutions / policies like the SEC, FDIC, OSHA, and the EPA.
- The Civil Rights Act
None of this stuff just happens by accident, and these kinds of things definitely don't magically fall out of unregulated free-markets. And they DEFINITELY don't fall out of markets where the participants are massive corporate interests.
You need institutions whose focus is solely on social / economic wellbeing and who have the power and authority to provide it.
There are also plenty of modern academics, making things up themselves, who articulate similar points.
- Joseph Stiglitz
- Thomas Piketty
- Ha-Joon Chang
- Mariana Mazzucato
- Robert Reich
- etc
A real science would update in the face of contradictory evidence. Some economists have, but most haven't.
[0]https://www.huffpost.com/entry/elon-musk-regulations-default...
As they say: First, do no harm.
You can't, because they can't legally operate like that in the US.
Deloitte: https://www2.deloitte.com/us/en/pages/tax/solutions/legal-bu...
> The Deloitte US firms do not practice law or provide legal advice. Deloitte Legal refers to the legal practices of Deloitte Touche Tohmatsu Limited member firms (or their respective affiliates) that provide legal services outside of the United States.
PWC: https://www.pwc.com/us/en/services/tax/legal-business-soluti...
> PwC US does not provide legal advice or opinion in the United States
Lawyers in the US, through the state Bar Associations, have done a damn fine job of protecting their industry against capital. Doctors in the US now answer to MBAs, Lawyers only answer to other Lawyers.