The Dark Side of Doctoring

I will say thought, that this is a really typical path in the US, at least:

* 4 years undergraduate ($200K debt, high competition/workload)

* 4 years medical school ($250K debt, high stress/workload, 50% odds of not being accepted)

* ~3 years residency (pay only $50K/yr, famously high stress/workload, possibility of being separated from loved ones or making hard choices in residency match)

So assuming starting undergrad at age 17, you have had a tough 11 years and are at least $300K in debt by the time you are 28 and getting your certification. This is ignoring specialties with fellowships. I don't have the time, but I'm sure it's possible to estimate the quality of the time sacrificed to education and lost compensation during that time and then amortize that over a typical career.

And the field is different... after all of that training they get to spend an inordinate amount of time doing paperwork/fighting with insurers, which (seems to be) leading to more group practices with workloads like those described in the article.

Yes, and this is a bug, not a feature. Food would be cheaper if this were not done. The "subsidies" are to the food producers, to artifically keep prices up. The equivalent for health care would be subsidies to health care providers.

> and food for the poor

Yes, with food stamps. But nobody tells the poor what they have to spend the food stamps on, and nobody regulates grocery stores up one side and down the other telling them what food items they have to provide if they accept food stamps and what they have to charge for every single item. So this regulation is nothing at all like US health care regulation.

The equivalent of food stamps for health care would be to give poor people a flat sum of money per month on a "health care spending card" that they could use at any health care provider they wanted, for any service they wanted. And then no other regulation of health care providers--no rules about what services they have to provide, no regulation of prices, etc. I personally think this would be a significant improvement over the current US system.

> food is cheap and plentiful to create

Yes, and it would be cheaper if the government did not subsidize producers, as above. The reason for this is, of course, that there is a free market in food (or at least much closer to one than the market in health care) and so producers are competing on price, therefore driving them to make food production more and more efficient. A century ago in the US, food was not cheap and plentiful to create. Technology and production processes improve over time if they are forced to by competition. I see no reason why the same would not apply to health care, if it were competitive the way food production is.

> food is easy to steal

This is an interesting point, but I'm not sure how much difference it makes in itself, because even the richest person in the world can only consume a limited quantity of food. So it makes no difference to rich people whether the poor can steal food or not; even if they do, the rich won't be the one to suffer, someone much further down the income ladder will (if anyone does).

A more interesting aspect is this:

> It's a lot harder to steal health care

I would rephrase this as: health care is much less fungible than food is. You and I can trade lunches, but we can't trade, say, gallbladder operations or physical exams. I agree that this is potentially a valid reason to treat health care different from food. What might be helpful is to look at other goods or services that are not fungible and see how they are handled in comparison with health care.

My wife is a pediatric emergency medicine physician and I get paid more than her because I'm in tech. Also, I started my career and began earning an income right after college, whereas she went to medical school and a fellowship before she could begin earning income.

I always joke with her that, in terms of income efficiency, my field is way more profitable than hers. And a lot less stressful too.

The reality is the unified vocational training and the court system and malpractice insurance system and fluidity of employee transfers and government licensing standards mean the variety in care available is more like the difference between McDonalds and Burger King and this aspect is extremely carefully avoided in the debates. Price competition simply will not happen in medical care, theres a lot more required to initiate it than merely messing with the insurance system, it goes very deep.

I think you miss the difficulty of walking out in mid treatment. Yes sure in theory its possible for people to get reservations at three restaurants and eat appetizers and drinks at one, the main meal at the second, and desert at the third. In practice roughly zero people do this even though in the restaurant marketplace they're hopefully not in pain or dying or semi-senile or some other medical distress, and their family isn't panicking. To get the restaurant marketplace analogy correct above, you'd have to use McDonalds, Burger King, and Wendys as your examples, so even if you wandered back and forth between restaurants, the bill would be about the same in the end if not higher on a system perspective from all the paperwork and increased transactional costs. The main, possibly only, effect of playing patient "hot potatoe" would be increasing suffering of sick people.