THE PROBLEM INCLUDES US: What, Us worry, perform or care?


Part 4—Journalistic/professorial fail:
Time magazine made a big mistake about film-maker Michael Moore.

Back in 2005, the list-making magazine honored Moore as one of the world's 100 most influential people. Two years later, the gentleman made a great film, and we all got to see that Time had been very wrong.

The film in question was Sicko, a humorous but highly pertinent look at the various health care systems of the developed nations. The film could have launched a great discussion, but we don't do discussion here—especially about the type of topic Moore attempted to tackle.

At the Washington Post, Stephen Hunter was called out of retirement to roll his eyes at Moore's film. "Ladies and gentlemen, I think we can agree on two things," he said as he started. "The American health-care system is busted and Michael Moore is not the guy to fix it."

In regular order, the Post's William Booth was more jocular in his own discussion of Moore's film. He described the way Moore had taken "his patented shtick to Canada, England and France...paint[ing] a very rosy picture, especially of the generosity of France."

At the New York Times, Moore's patented shtick was treated semi-fairly in an analysis piece by Philip Boffey. In this sardonic passage, he too mentioned France:
BOFFEY (7/5/07): After all these depressing tales, the second half of the film ushers us into a nirvana of humane and caring treatment supposedly provided to the citizens of Canada, France, Britain and even Cuba, a needlessly provocative choice that detracts from the main message.

While Mr. Moore could find almost nothing good to say about American health care, he can find almost nothing bad to say about the government-run national health systems abroad. There is no acknowledgement of the months-long waits to see specialists in Canada and Britain, of the sick people who fall through the cracks in every system or of rising costs in virtually all countries.

The French system comes off as best, where the government dispatches home aides to help new mothers do the laundry and American expatriates extol the quality and promptness of care. We are left with the impression that these foreign systems are geared up to provide care, while our insurance companies are motivated to deny it.
How strange! To think that viewers could have been left with an "impression" like that!

In fairness, the New York Times published a lengthy editorial, in which the editors made an admission against major corporate interest. "Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations," the editors noted. "France and Italy took the top two spots; the United States was a dismal 37th."

Say what? France had been found to have the world's best health care system? Could that possibly help explain why Moore had taken his shtick there?

Inevitably, Paul Krugman devoted yet another column to the attempt to explain that countries like France provide universal health care, with health care outcomes as good as ours, at less than half the per person cost.

That said, if there was anyone less influential than Moore, it had to be Krugman, who had committed the cosmic error of knowing whereof he spoke. Meanwhile, rather weirdly, the editors completely skipped the issue of per person cost in their 1300-word editorial.

They examined a range of ways in which the U.S. health system fell short of those in other lands. But they completely failed to mention the matter of per person costs.

Let's return to our basic point. Rather plainly, Michael Moore wasn't hugely influential as of 2007. His superb film came and went, producing little change in this nation's pitifully Potemkin discussion of health care.

In part as a result, we can once again show you the startling numbers from yesterday's award-winning post. Nine years after Michael Moore's film failed to ignite a real discussion, you can once again see the remarkable numbers we have posted below.

The numbers come from the OECD. They compare the per person health care spending of the United States and France:
Per person health care spending, 2015
United States: $9451
France: $4407
Say what? France spends less than half as much per person? The U.S., which doesn't have universal care, spends an extra $5000 per person per year?

In a word, those numbers are astonishing. In two more words, those numbers are never discussed. Thanks to the reliable silence of people like Maddow, Lilla and Rampell—we're naming just three in a cast of thousands—our standard gong-show pseudo-discussions roll along without anyone being asked to ponder the craziness of those blatantly crazy numbers.

Pretty amazing, isn't it? Five thousand dollars per person per year disappears into the maws of our "health care system," and we still can't provide the universal coverage achieved by a nation like France! Meanwhile, major news orgs break their backs to avoid discussing this state of affairs. Dearest darlings, it just isn't done!

Topics like these don't get discussed, not even by our own tribe. On the corporate channel which gets sold as "liberal," you see a great deal of mugging and clowning. But you never see the multimillionaire hosts discuss such looting at that.

What do we liberals do instead? When Sarah Kliff describes the fact that certain people in Kentucky can't afford to go to the doctor, we attack those people for their dumbness and, of course, for their presumed racism.

Skillfully, we doctor our facts, making their decisions seem more dumb than they actually are. We kick down at these average people as we maintain our well-paid silence about the looting conducted by the society's corporate interests and its professional swells.

What kind of professoriate conducts itself this way? What kind of liberal rank and file gets conned by the mugging and clowning of a car salesman like Maddow? And of course, health care looting is only one area where the Maddows agree to avert their gaze from the looting conducted by the interests.

To cite one other remarkable area, you're also constantly kept from knowing the truth about domestic and international test scores. This lets the interests pursue their attacks on public schools and public school teachers in their headlong pursuit of privatization's sacks of cash.

Incredibly, we aren't even allowed to know about the large score gains achieved by our low-income kids. Rachel would jump off the Golden Gate Bridge before she's discuss such a topic. No one else gives the first flying fig either, as their silence makes clear.

Today, we find ourselves two weeks away from a visibly crazy president. But guess what? We liberals can't persuade The Others that they've been taken in by Trump, in large part because we've been taken in by the Maddows and the long list of silent professors.

They tell us which groups we should "want to protect." In turn, they drop dick jokes and R-bombs on the heads of The Others.

Dumbly, we get swept along, rarely failing to tell ourselves how brilliant and caring We are.

To our own non-professional eye, Donald J. Trump seems diagnosable. It isn't a moral failing when someone is crazy, but that doesn't mean that he isn't crazy, and it seems to us that Trump is.

In theory, it isn't easy to lose a race to a visible crackpot like Trump. But in part because of our professors and our mainstream and corporate-liberal "journalists," we've been working for twenty-five years to help this disaster occur.

We slept in the woods as the narratives grew. We were barefoot and happy, convinced of our manifest brilliance.

Persistently, we name-call The Others, while protecting the elites by whom they're getting looted. This is very much the way our pathetic tribe rolls.

As this month's disaster approaches, we keep pleasuring ourselves with our attacks on the dumbness and racism of Those People. It's the only play we seem to know, and we know it amazingly well.

As the disaster looms, we keep pleasing ourselves this way. Might we suggest that the problems which now surround us have, in some tiny small way, maybe perhaps come from Us?


  1. Michael Moore makes simplistic films that dumb down complex issues in order to present them as black and white, as are the solutions. His heart is in the right place but the world doesn't work that way.

    To take one example, French health care costs less because it pays its doctors less. It can do that because the doctors themselves have inexpensive training and thus no large student loans to pay for, no high malpractice insurance or practice costs, etc. The entire infrastructure for producing doctors is different. Access to becoming a doctor is different so the supply of trained physicians is less limited, no shortages. In short, there is no market economy operating for that job in France. That is just one part of their cost savings.

    Does Moore tell us that? Can we easily change the US higher education system and medical job market to emulate France? I don't see how.

    These across country comparisons are stupid and tell us nothing without comparing the larger context in which people live in those countries. Moore does point out that people are taxed more, but he says they can afford it because they pay less out of pocket for services. This applies to their entire economy, of which health care is only one piece. You cannot fix health care without fixing the rest.

    Simple answers are for Trump and his supporters. They aren't real and they don't work.

    1. To take one example, French health care costs less because it pays its doctors less....

      Er, that's exactly the point. This state of affairs arises from the fact that physicians have banded together for over a hundred years to pad their income in the United States through rent seeking. Sounds like a job for globalization- if we've taken care of the problem of American factory workers making too much money why not apply a similar approach to the issues surrounding the compensation of the professional elite in this country which, for some reason, the American neo-liberal political class has chosen to protect from market forces?

      Dean Baker says [LINK]

      [QUOTE] The first issue to examine is the extent to which there are differences in pay between the highly paid professionals in the United States and other wealthy countries....

      Physicians are a good place to start, since they are the highest paid of these professions and also there is a large number of practicing physicians in the United States. According to a recent analysis comparing physicians’ pay in the United States with that of other wealthy countries, there is a large gap which explains a substantial portion of the difference in per person health care costs (Laugesen and Glied 2008).

      This analysis finds large differences in pay for both general practitioners and orthopedic surgeons (the only area of specialization examined) between the United States and the other wealthy countries included in its reference group (Australia, Canada, France, Germany, and the United Kingdom). Average pre-tax earnings in the United States for primary care physicians was $186,600 compared to an (unweighted) average of $121,200 for the other five countries (in 2008 dollars). The average pre-tax earnings for orthopedic surgeons in the United States was $442,500, compared to an average of $215,500 in the reference countries....

      An analysis by the OECD (Fujisawa and Lafortune 2008) put the average compensation for general practitioners in the United States in 2004 at $146,000. This is more than 40 percent higher than the average for the other countries in the analysis, even excluding the Czech Republic as an outlier on the low side.

      This analysis found an even larger gap between the pay of specialists in the United States and most other OECD countries. (It found specialists were paid even more in the Netherlands.)

      The average pay for specialists in the United States was $236,000 in 2003 (in 2003 dollars). By comparison, it was $159,000 in Canada, $153,000 in the United Kingdom, $144,000 in France, and just $93,000 in Denmark. The levels and gaps would be almost 30 percent higher in 2016 dollars....

      A slightly more recent analysis suggests that doctors’ pay in the United States is somewhat higher than indicated by these earlier studies....


    2. [QUOTE] ...continued

      There are two other points worth making about doctors’ compensation in the United States. First, the mix of doctors in the United States is much more skewed to specialists than in other wealthy countries. In most other wealthy countries close to two-thirds of physicians are general practitioners, with one-third specialists. In the United States the mix goes in the opposite direction.

      This implies that we pay more for physicians both because we pay more for each type of physician than in other wealthy countries, but also because we have a much larger share of expensive specialists and relatively fewer primary care physicians.

      It is beyond the scope of this paper to determine the extent to which the greater use of specialists in the United States results in better quality care, although there is certainly evidence for questioning whether this is the case (e.g. Sharp et al. 2002). However, the excessive use of specialists is certainly consistent with the presence of rents for specialists.

      It is also worth noting, that if specialists in the United States are spending much of their time doing tasks routinely performed by less highly trained general practitioners in other countries, then the gap in pay is effectively even larger than the raw data indicate. We are paying specialist wages in the United States for general practitioner work.

      The other point to be made about the data on doctors is that the United States ranks relatively low in overall density of physicians. According to the most recent data from the OECD, the United States has 2.6 physicians per 1,000 people (OECD 2014). By comparison, the density in the U.K. is 2.8, France 3.3, and in 4.0 in Germany.

      The relatively low density in the United States is a matter of deliberate policy. In 1997, the Accreditation Council on Graduate Medical Education decided to limit medical school enrollments in the United States, which had been growing more or less in step with population growth (Cooper 2008). More importantly, there was a cap placed on the number of residency slots that Medicare would support.

      This is a more binding constraint since a reduced number of medical school graduates in the United States can be offset by an increased inflow of medical school graduates from other countries.

      However, since having a U.S. residency is virtually a requirement for practicing medicine in the United States, the cap on residency positions effectively limited the number of practicing physicians in the country. According to Cooper, the United States is the only country that requires practicing physicians to complete a residency within the country.

      The result of these policies has been to limit the increase in physician density even as demand was growing both due to growing incomes and also the aging of the population.... [END QUOTE]

    3. We pay doctors (GPs and Specialists) way too much in the US, as compared to other OECD countries. We could drastically lower the cost of healthcare in the US if we paid our doctors in line with other OECD. Dean Baker of CEPR has written recent book where he discusses how we can get doctor's pay down. It is free to download and read.

    4. New physicians emerge with over $150K in debt. It costs them $80K per year for their malpractice insurance. They must pay their share of the overhead of a practice (overhead = office staff, rent, computer software, specialized equipment and supplies). Many doctors do not work directly for hospitals, HMOs or clinics. They worked for a shared practice that contracts with those entities, which may not be able to afford a full-time specialist in terms of patient need. That means a practice also hired attorneys and accountants. All of these things cost money that contributes to the amount specialists charge. Dean Baker needs to discuss how to lower all of these charges because lowering doctor pay without lowering their overhead is a non-starter.

    5. Physicians Assistants and nurses do as much of the non-specialist work as possible. Medical facilities long ago discovered the economy in this. Doctors don't mind because there is plenty left for them to do. Specialists in private practice work 60-80 hr weeks or more. There is a shortage of most specialists. This is not just because of limited access to the field, but because of the nature of the training. US students diligently avoid science and math and they arrive at graduation without the needed background in biology, physics, chemistry, the gpa to handle the coursework, or the motivation to put in the effort. These are the limiting factors, not access. Yes, lots of students would like to earn big bucks, but they don't want to do what it takes to qualify themselves. There is a kind of detail-oriented conscientiousness and hardiness that is required and there is no way to fake that. It eliminates many who think it might be nice to have such a career. Justifiably so, since you would not want a doctor without those characteristics.

      Becoming a GP requires 3 years beyond the B.S. degree. Becoming an internist requires a 1-year internship. Becoming any kind of specialist requires a 3-4 year residency following internship. Becoming certain kinds of specialists requires a fellowship beyond that (1-3 years). How do students support themselves during those years? Who pays for them to move to different parts of the country to do their internship, residency and fellowships? They do. Often they defer marriage, parenthood and home ownership to do this.

      Who is going to do this without any prospect of paying back the loans out of their salary and without any way to establish a household at the end of that training? The European system for training and employing physicians is entirely different, beginning with free higher ed and a different attitude toward math, science and hard work.

      There are realities here that are not part of the discussion. Unless they are addressed, such discussions are going nowhere.

    6. The high out of pocket cost of medical education and the amount of time without compensation those in pursuit of that credential are expected to invest are two ways of preserving, to a significant extent, the practice of medicine as a legacy system for members of the upper middle class in the United States.

      Medical doctoring is the best compensated of the professions in the United States- that's after a practitioner's expenses, including those for (what was that?) the attorneys and accountant private practice doctors, themselves, have to hire; their malpractice insurance; the office space they buy or rent; the equipment they pay for; the staff they employ. How ridiculous to think Dean Baker was speaking of a general practitioner's or a specialist's gross income, not their yearly net income after expenses. The expected lifetime earnings to be derived from having a medical degree dwarf the up front costs the American system requires the medical student to bear through taking on debt or by tapping family resources.

    7. I read the two comments in reply to statement that GPs and Specialists are overpaid in the US. They clearly didn't read the chapter about doctors' pay in the US from Dean's book. If they did, they would be familiar with his responses to their points.

    8. What's odd around here, not just in this thread, is the number of commenters, in addition to David in Cal, who have the urge to defend economic inequality.

      It's a tough inclination to get past, I guess [LINK]:

      [QUOTE] This disposition to admire, and almost to worship, the rich and the powerful, and to despise, or, at least, to neglect persons of poor and mean condition... is... the great and most universal cause of the corruption of our moral sentiments.

      That wealth and greatness are often regarded with the respect and admiration which are due only to wisdom and virtue; and that the contempt, of which vice and folly are the only proper objects, is often most unjustly bestowed upon poverty and weakness, has been the complaint of moralists in all ages.

      We desire both to be respectable and to be respected. We dread both to be contemptible and to be contemned. But, upon coming into the world, we soon find that wisdom and virtue are by no means the sole objects of respect; nor vice and folly, of contempt. We frequently see the respectful attentions of the world more strongly directed towards the rich and the great, than towards the wise and the virtuous. We see frequently the vices and follies of the powerful much less despised than the poverty and weakness of the innocent. [END QUOTE]

    9. hardindr -- why not summarize them?

      CMike -- on what basis is someone who spends many years learning a specialty at personal expense being unfairly paid when they subsequently earn a large salary? I think it would be grossly unfair to pay a pulmonologist the same as a McDonalds cook -- no matter what the hourly wage was.

      Somerby doesn't provide the comparisons, but even fry cooks are not paid the same in European countries as in the USA. No jobs are paid the same. That's partly why these cross-country comparisons are specious.

    10. Dean's book is available for free as an eBook on Kindle and other platforms. You can read the chapter that contains the section in doctors' exhorbitant pay for yourself, rather than me trying to summarize it (badly). There is also this blog post by Dean on the subject:

    11. This comment has been removed by the author.

    12. Nobody is suggesting a "McDonalds cook" should be earning as much as a pulmonologist. As to whether fry cooks are not paid the same in European countries as they are in the USA- that's at the root of the discussion we're having.

      Should fiscal, monetary, immigration, labor, trade, child care, healthcare, and education policy in this country continue to aim at creating a glut of low and moderately skilled workers here who have no power when negotiating with employers for their wage rate? Meanwhile, should there continue to be policies in place to enhance the earning power of physicians and other professionals?

      What say ye, @6:25 PM?

    13. Professionals are workers too. What kind of movement pits less skilled workers against more skilled ones?

      There is a glut of low and moderately skilled workers because most people do not get the education needed to do professional jobs. Why blame those who do?

      Is there some reason you have singled out physicians while exempting engineers, computer scientists, chemists, and so on from scrutiny?

      To change health care we would have change a great deal more about how our economy works than simply the salaries of the workers in the health care industry. The problem isn't that doctors are overpaid but that we treat health care as an industry and apply all the same capitalist practices to it as in other industries. Cars cost too much here. Education costs too much. Housing is a problem. These are the faults of how our economy works, not the people who prepare themselves for the better paying jobs in a society that rewards some people more than others in order to encourage them to do difficult and unpleasant chores.

      Doctors confront life and death every day as part of their work. Who else has to tell relatives that their loves have died, who else struggles with trying to extend life while knowing it is a losing battle. Who else gets sued regularly for outcomes beyond their control? Who else must inflict pain to cure? And who works on call for days on end and must be alert and competent despite fatigue, emotional upset, and personal concerns? There are a few other jobs like this and they are similarly high paid because this isn't a fun occupation. It is one requiring dedication, a service orientation, a thick skin coupled with continued ability to care about others, and a detachment from life-and-death struggles. It is a hard job and it deserves to be well paid.

    14. Physicians are the most overpaid professionals, so that is why Baker focuses on them. He also discusses dentists and lawyers, but they are not as overpaid as doctors. You didn't really discuss any of his economic arguments about why doctors shouldn't be subject to market forces like automobile and textile workers.

      You know the AMA limits the number of people who can be admitted to medical school in the US, correct? Also, doctors from foreign countries (regardless of their education or professional attainment) have to complete a 3-year residency in order to practice medicine in the US.

      Just to be clear, Baker does not say that doctors (and others who put in years of training to attain professional competency) deserve to be paid the same as other workers with less education. There just is no economic (or policy) argument for why they should be paid as well as they are.

    15. I see no reason why someone from another country should not complete a 3-year residency, just as US internists and specialists would. Residency is hands-on training in medical settings like those doctors will work in. Someone from another country needs to learn how things are done in the US. A residency permits them to do so under supervision and in a systematic way, with assessment of their knowledge and skills. That is a better way to qualify them than giving them a written test. Medicine varies across countries because different medications are approved for use, different equipment is available, and there are different laws protecting patients, different standards of care. This needs to be learned. Baker thinks this is just protectionism but he is wrong.

      I think doctors are already subject to market forces. It is also possible for US students to go to foreign countries to be trained then return for residency, so limiting the admissions of US medical schools isn't as big a factor as Baker claims. It is conflated with needs to regulate the quality of US medical education, which Baker doesn't discuss (at least in that article). Medical schools are not just classrooms but include a practicing medical research faculty and access to hands-on training in medical facilities. How do you scale that up when those resources are themselves limited in number.

      Doctors on the faculties of medical schools are paid a lot less than those in practice. Their salaries are higher than other professors but nowhere near what other doctors earn. They work as faculty because they are interested in research. Many have MD/PhDs. How do you get more students to go down that track in order to staff up more medical schools? I doubt Baker has given any thought to it.

      Students select their majors and careers based on market forces. The bright ones with the ability to do the work will go elsewhere because there are certainly easier ways for science-oriented students to earn a living if you make medicine just another career.

    16. Why should doctors in other OECD who are qualified to practice medicine in their own countries be required to have a 3-year residency in the US? Are doctors in France less qualified to practice medicine than doctors in the US? Why is the US the only OECD country to require a 3-year residency. Baker in his book says that it is reasonable to require doctors who are trained in developing countries to have some kind of additional training before being allowed to practice medicine in the US, but that there is no justification for a 3-year residency.

      According to the Dean bakers' books, the AMA states that 25% of the doctors practicing in the US graduated from a foreign medical school, with 5% being US citizens who get their degrees from medical schools in Caribbean countries and the 20% rest being foreign doctors who emigrated tot the US. 5% is not a lot. Why does the AMA (with help from the federal government) limit the number of openings in medical school, when the US has so few doctors compared to other OECD countries?

      Medical school professors are some of the best paid professionals in academia (the highest paid public employee in New York State is the chair of a department in a public medical school). Being a professor at a medical school is both a highly paid job and one with high prestige. I am sure that more people could be attracted to fill the positions needed to train more doctors in the US.

    17. @10:59: What kind of movement pits less skilled workers against more skilled ones?

      If we were to revise that to read, "What kind of movement pits less skilled workers against a favored class of corporate executives, professionals, and owners?" the answer would be an all together rancid one. Those in the United States not trying to hide their embrace of these objectives call this particular movement American neo-liberalism.

      @10:59: There is a glut of low and moderately skilled workers because most people do not get the education needed to do professional jobs. Why blame those who do?

      In the 21st century it is a fallacy to hold on to the notion that the more educated the population becomes the more high paying jobs there will be in the economy. If everyone keeps getting better credentials you won't end up with more professional work for PhDs, you'll need a PhD to get hired as a cashier at Wal-Mart. Even if it were true that most any low skilled worker could improve their economic prospects with more of the right kind of education or specialized training, it is not true that a large segment of the population together can improve their economic prospects by acquiring more education or specialized training. The private sector can not produce enough high paid, high skilled job opportunities to match the number of diligent aspirants who want one.

      @10:59: Doctors confront life and death every day as part of their work. Who else has to tell relatives that their loves have died, who else struggles with trying to extend life while knowing it is a losing battle. Who else gets sued regularly for outcomes beyond their control? Who else must inflict pain to cure? And who works on call for days on end and must be alert and competent despite fatigue, emotional upset, and personal concerns?

      Just about all of this is wrong. Most doctors do not confront life and death every day as part of their work. Those who do, like emergency medicine practitioners, are not among the highest paid. Orthopedic surgeons who perform necessary but what are essentially elective procedures are among the best paid of all doctors. Those particular doctors are almost entirely insulated from dealing with patients during their painful recoveries and rehabilitations- those challenges are jobs left to be performed by lower paid medical personnel.

      Among the lowest paid doctors are the ones dealing with what I would think is the most emotionally challenging work, pediatrics. Pediatric oncology and pediatric emergency medicine doctors are lower paid than those practicing the same specialties for the adult population, in fact this is true of almost every pediatric specialty. I don't know the reason for this pay discrepancy but I would suspect it is because children are more likely to be on Medicaid.

      The working for days on end while needing to be alert and competent is a vestige of a ridiculous residency regime which at this late date is nothing more than an entirely unnecessarily rite of passage by hazing and dangerous to patients.

    18. The working for days on end while needing to be alert is part of the call system that persists for those who work in hospitals. My daughter has four board certifications (internal medicine, critical care, pulmonary, sleep medicine). She is an intensivist -- the person who answers when someone codes anywhere in the hospital. She typically works ICU, a week at a time, on call 24 hrs, which means you can be called out after working all day, and you have to monitor some of the most critical patients. She tells me that the requirement to be alert despite lack of sleep is not a vestige or rite of passage but is needed to train residents to see the course of a developing disease in a patient in crisis. Staying with someone until they stabilize is needed and handing patients off in the middle of that period can be fatal to the patient. She thinks the restrictions on work schedules are a big mistake, and she is not an old curmudgeon or legacy of older times.

      The working for days on end also occurs in emergency rooms during major accidents involving multiple hospitals, in a whole hospital during flu and other infectious disease epidemics which can affect staff as well as patients, and during strikes, severe weather or other periods of disruption of services. Doctors don't take sick days. The same is not true for nurses or other medical staff as a job expectation, although they frequently are equally dedicated.

      Pediatric services are lower paid because women go into them.

      An orthopedic surgeon can encounter death too whenever general anesthesia is involved. Diabetics often die in the course of foot amputations but the cause of death may be listed as diabetes. Yes, there are specialties where doctors deal with less death, but even dermatologists diagnose melanomas. Obstetricians, dealing with the happiest of life outcomes, also have the births that go very wrong.

      The major part of the job for an emergency room doctor is dealing with the addicted people who come in seeking pain meds (because they don't take "no" very well) and the overdoses -- by far the most frequent occurrence.

      The complaints being put forward by Dean Baker and others need to be balanced by the testimony of those who work in the field. Nurses, physical therapists, technicians of various types, all believe they do what doctors do (or could have done it), but they don't see the whole job. While what they do is essential, it isn't the same contribution to health care -- they don't make the decisions and they don't bear the responsibility.

    19. Answer to hardindr about why foreign doctors should be a 3-year residency:
      1. Medicine is not practiced in the same way worldwide. They need to learn the specifics of how it is practiced in the US.
      2. Standard of care does not refer to competence -- it refers to the specific protocol established to treat each condition and disease. It changes with new knowledge and differs across hospitals or HMOs or practices, not just countries.
      3. The English vocabulary used to discuss illness and body symptoms is not taught in classroom courses in English. Someone may be very fluent but not know that language and need to learn it.
      4. Traditional beliefs about illness and alternative treatments among people are very different across cultures. These are part of the medicine in that region, including the US. There are differences in folk beliefs and treatment expectations just between the US and Mexico, Asia and the West, Eastern Europe and Western Europe. These need to be learned/relearned.
      5. Practices and drugs illegal in Europe are used in the US and vice versa. People go to other countries to get treatments forbidden here, for example. The differences need to be learned.
      6. The US has laws governing patient privacy and record-keeping (HIPAA) and other regulations that need to be learned.
      7. It is easier to verify the competence and knowledge of someone by supervising them on the job than by giving them a written test.
      8. The three-year requirement is to enable someone to practice without supervision.

      The limiting factor on the availability of more doctors is not medical school seats but residency positions. It means there are too few doctors at teaching hospitals available to supervise more residents. Such doctors are on the lower end of the physician pay scales because the hospitals are associated with universities and they are paid as academics. Getting more doctors to abandon higher paying jobs is difficult.

    20. None of the things you brought up justifies a 3-year residency to become a doctor. Again, I agree along with Baker that there needs to be some additional training for foreign doctors. Curiously, are you a doctor yourself?

    21. PhD not MD. I have done medical reseach. Retired now. My adult children are doctors.

      My daughter has supervised residents and fellows. Some of the foreign students have been excellent and some shouldn't be anywhere near patients.

      I see no reason why Baker and not the professionals who do the job should decide how much training is needed.

    22. @5:58 PM: An orthopedic surgeon can encounter death too whenever general anesthesia is involved.

      Funny you would say this. I have been the caregiver in the past several weeks for a patient who had a reverse total shoulder replacement. Because of a particular concern I had for how the patient would handle the anesthesia during and after surgery, in the immediate post-op consult I asked the surgeon how that aspect of the procedure went and he told me it's not his job to pay attention to any of that, he's focused on other matters. Then he showed me the pictures on his phone of the joint he had removed. (True story.)

      @5:58 PM: Pediatric services are lower paid because women go into them.

      Well that solves that mystery in this, the best (and fairest) of all possible worlds.

      @5:58 PM: My daughter has four board certifications (internal medicine, critical care, pulmonary, sleep medicine). She is an intensivist -- the person who answers when someone codes anywhere in the hospital. She typically works ICU, a week at a time, on call 24 hrs, which means you can be called out after working all day, and you have to monitor some of the most critical patients.

      She tells me that the requirement to be alert despite lack of sleep is not a vestige or rite of passage but is needed to train residents to see the course of a developing disease in a patient in crisis. Staying with someone until they stabilize is needed and handing patients off in the middle of that period can be fatal to the patient.

      She thinks the restrictions on work schedules are a big mistake, and she is not an old curmudgeon or legacy of older times.

      That's interesting, but I refuse to believe it is in the patient's best interest for the attending physician to be sleep deprived. In the matter of the "hand-off" I can see where if one doctor checks out at 5:00 PM at the moment the next doctor checks in, that that would be a problem. But I can't believe the relief doctor can't get up to speed on a patient in the course of several hours before the original doctor takes an adequate break. Of course your daughter, who from the sounds of it has very impressive credentials, speaks with far more authority on this subject than I do.

    23. hardindr: If you suggest a shorter period of training then a separate training program would need to be established instead of incorporating foreign doctors into an existing program. It might be that some foreign doctors would need varying lengths of training. That is sounding unrealistic for an admittedly short-handed discipline.

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  2. "That said, if there was anyone less influential than Moore, it had to be Krugman....."

    Bob Somerby

    That said, Bob, aren't you the guy who just day before yesterday whined.....

    "We started in March 1999, in the very week when the attacks against Candidate Gore began.

    For the next ten years, we tried to get career journalists to discuss the phenomenon..."

    Seems to me I'd nominate you for being infinitely less influential that either person you disparaged here.

    1. Do you think Somerby is criticizing Moore for not being influential? He is criticizing everyone else for not listening and not discussing Moore's points.

      You are way too eager to bash Somerby. Any stick to beat a dead horse here.

    2. You seem to be saying Somerby is a dead horse.
      That may explain why Ed thinks he is without influence.

    3. @12:55 PM, I understand what you're trying to do but how about waiting until you've got an actual two cents worth to contribute?

    4. I'm sure Somerby would agree he is not at all influential. Clearly he is not. He has said as much before. And after all, Trump is now our president elect and the feral madness of our journalistic elite rumbles on unabated, everyone toasting glasses and getting a piece of the action.

    5. So you imply someone who has no influence should be telling liberals how to win friends and influence voters?

    6. Better leave it to someone influential like Donna Brazile then.

    7. Influence or no Somerby called the Trump presidency and showed how liberal media self absorption, ineptitude and laziness helped make it happen. What I hope to happen is that he would become influential based on his track record and they less so based on theirs.

    8. Are you implying people with influence are the only ones to which we should listen?

  3. Somerby thinks you can look up the wholesale price of a pill or bandage, compare it to the what the patient is billed, and the difference is gouging. It doesn't work that way because hospitals must use such billing to recover unreimbursed costs of treating people who do not pay at all.

    Homeless and mentally ill people are allowed to refuse medical treatment in the US, as opposed to those Socialist Democracies. They do not take care of chronic illnesses and wind up in crisis in the emergency room. They are stabilized and released, where they do not take care of themselves (don't take medication or follow procedures) and wind up back in crisis again in the emergency room. This cycle continues every few days as their conditions worsen and they eventually die after expensive treatment. These costs are added to the cost of those pills and band aids.

    Some communities try to support the indigent, homeless and mentally ill outside the hospital to prevent such visits, but the extent to which cities do this varies considerably. Some do nothing. ACA helped with this by providing the insurance to keep people out of emergency rooms and give them preventive care. That reduction in costs is invisible to everyone not working in medicine.

    To fix medical care costs you have to fix how our society deals with people and you would have to revise freedoms we consider important here. In those other democracies, someone diagnosed with a mental illness would be given a living stipend and required to undergo treatment and also be forbidden to work. I've met people who resent this because they feel their problems are sufficiently controlled that they could work, but are not permitted to do so. These are social tradeoffs Somerby never talks about.

    1. @12:54 PM tells us it's not gouging:

      [QUOTE] ...[H]ospitals must use such billing to recover unreimbursed costs of treating people who do not pay at all. [END QUOTE]

      Oh really? [3:38 VIDEO] [LONG ARTICLE]

      [QUOTE] When I asked MD Anderson to comment on the charges on Recchi’s bill, the cancer center released a written statement that said in part, “The issues related to health care finance are complex for patients, health care providers, payers and government entities alike … MD Anderson’s clinical billing and collection practices are similar to those of other major hospitals and academic medical centers.”

      The hospital’s hard-nosed approach pays off. Although it is officially a nonprofit unit of the University of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26% on revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.

      The president of MD Anderson is paid like someone running a prosperous business. Ronald DePinho’s total compensation last year was $1,845,000. That does not count outside earnings derived from a much publicized waiver he received from the university that, according to the Houston Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical companies.” DePinho’s salary is nearly triple the $674,350 paid to William Powers Jr., the president of the entire University of Texas system, of which MD Anderson is a part.

      This pay structure is emblematic of American medical economics and is reflected on campuses across the U.S., where the president of a hospital or hospital system associated with a university — whether it’s Texas, Stanford, Duke or Yale — is invariably paid much more than the person in charge of the university.

      I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business.

      In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.... [END QUOTE]

    2. Public universities also pay their Presidents like CEOs of corporations. Does that mean professors are overpaid? Not exactly. Are these large sprawling places with lots of buildings? You bet. This is a crazy argument.

      There are a lot of sick people. MD Anderson is a cancer center that attracts people from all over the place because they do cancer research and treat people with leading edge treatments. It isn't the neighborhood hospital. So there is some cherry-picking here. The guys says the pricing is complicated. It is.

    3. There's no cherry picking, Brill discussed what piqued his interest early on in his research into the subject. If you're satisfied you can't learn anything from him, don't read the article- I could care less if you do, but not very much less.

    4. My point is simply that MD Anderson is not typical of hospitals or medical centers.

      You like to quote things as if that made your argument. I think you should try to put your thoughts into your own words. You will be more succinct and we will understand your points better.

    5. Brill did not confine his discussion to MD Anderson, which he specified as being in a special class of the centers like those at "Texas, Stanford, Duke or Yale."

      I sometimes paste, what for this forum are relatively long passages, because I, myself, have no expertise in these areas. Some people prefer comments to be a series of paragraph or two dismissals of one another delivered impatiently off the top of the head by people who are here to argue or show off what they see in themselves as some sort of verbal prowess. That style of discussion doesn't interest me much.

      However, as a variation on what you're recommending, maybe I should be extending the length of my comments to include an explicit statement of the conclusions I am drawing from whatever grafs I'm pasting.

    6. I think that would be helpful. Thank you.

  4. Who is name-calling today? Why Mr Krugman is calling Trump voters "rubes." Is that an effective way to win votes?

    Somerby doesn't just avert his eyes, he pretends that Krugman is the kind of advocate liberals need.

  5. "Best health care" doesn't mean what it sounds like. From wiki
    The rankings are based on an index of five factors:[2]

    Health (50%) : disability-adjusted life expectancy
    Overall or average : 15%
    Distribution or equality : 35%
    Responsiveness (25%) : speed of service, protection of privacy, and quality of amenities
    Overall or average : 12.5%
    Distribution or equality : 12.5%
    Fair financial contribution : 25%

    I would have thought that "best health care" addressed the effectiveness of the health care. But, effectiveness of the health care system is only a small portiong of the score. 47.5% of the score is based on two types of equality and 25% is based on "fair financial contribution."

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