[HN Gopher] 'The Licensing Racket' Review: There's a Board for That
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'The Licensing Racket' Review: There's a Board for That
Author : Bostonian
Score : 53 points
Date : 2025-02-08 12:43 UTC (10 hours ago)
(HTM) web link (www.wsj.com)
(TXT) w3m dump (www.wsj.com)
| Bostonian wrote:
| https://archive.is/Tcc1J
|
| 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.'
| mjd wrote:
| 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.
|
| https://ij.org/case/saint-joseph-abbey-et-al-v-castille-et-a...
| mjd wrote:
| 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?
|
| https://en.wikipedia.org/wiki/Black_Codes_(United_States)
| ty6853 wrote:
| 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 wrote:
| "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]'
|
| - https://en.wikipedia.org/wiki/Minimum_wage_in_the_Unite
| d_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.
| ty6853 wrote:
| 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 wrote:
| Yes, a lot of those unions were racist and xenophobic.
|
| 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.
| pessimizer wrote:
| 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 wrote:
| 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 wrote:
| Since when did the lowest wage whites get to set minimum
| wage?
| ty6853 wrote:
| 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.
| pessimizer wrote:
| > In many cases, these licencing schemes are put in place by
| incumbent trade groups, to prevent comeptition.
|
| The worst is NAR and Realtors(r). 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...
| ghaff wrote:
| 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 wrote:
| Next time you get an x-ray, drop it in your favorite LLM and
| start asking it questions. It's eye-opening.
| gorkish wrote:
| ChatGPT does not carry expensive malpractice insurance. The
| Radiologist is human in the loop for reasons other than
| their pattern recognition ability.
| psychlops wrote:
| 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.
| senkora wrote:
| The UMKC 6-year one seems to still exist as far as I can
| tell: https://med.umkc.edu/academics/degree-and-certificate-
| progra...
| sarchertech wrote:
| 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.
| luma wrote:
| 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.
| willis936 wrote:
| 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 wrote:
| 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 wrote:
| They are getting something for that money: exclusive access
| to the legal system. That is power they wouldn't sell.
| pseingatl wrote:
| 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 wrote:
| 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.
|
| 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.
| beacon294 wrote:
| Can you provide more details on why they and not doctors can
| resist?
| nickdothutton wrote:
| For licensing see medieval guilds.
| ddgflorida wrote:
| We also have the "Continuing Education" racket.
| pseingatl wrote:
| 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.
| spicyusername wrote:
| 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.
| BlandDuck wrote:
| 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" ?
| bryanlarsen wrote:
| 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 wrote:
| 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.
| spicyusername wrote:
| 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
| ori_b wrote:
| Milton Friedman died in 2006. He was two years old when the
| WWI started.
| spicyusername wrote:
| 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 wrote:
| > 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 wrote:
| 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?
| Aurornis wrote:
| > 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.
| krapp wrote:
| 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.
|
| [0]https://www.huffpost.com/entry/elon-musk-regulations-
| default...
| amanaplanacanal wrote:
| Maybe check first, before removing? Instead of waiting for
| people to be killed, then add back.
|
| As they say: First, do no harm.
| ty6853 wrote:
| 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 wrote:
| 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 wrote:
| 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 wrote:
| 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 wrote:
| 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.
| ty6853 wrote:
| 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 wrote:
| 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.
| potato3732842 wrote:
| 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.
| ty6853 wrote:
| 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.
| trillic wrote:
| 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 wrote:
| Can you explain what you mean about doctors sabotaging PAs? In
| what way? And which doctors are to blame?
| ty6853 wrote:
| 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 wrote:
| 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 wrote:
| > 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.
| Aurornis wrote:
| > 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 wrote:
| 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 wrote:
| 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 wrote:
| > 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 wrote:
| > 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.
| derbOac wrote:
| 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 wrote:
| 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.
| neonate wrote:
| https://archive.is/Tcc1J
| bryanlarsen wrote:
| 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.
| mhb wrote:
| 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."
|
| https://rules.sos.ri.gov/regulations/part/216-40-05-4
| gosub100 wrote:
| Contrast that to flying a plane:
|
| "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 wrote:
| 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.
| RajT88 wrote:
| 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.
| donatj wrote:
| 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.
| omgJustTest wrote:
| 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.
| donatj wrote:
| 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 wrote:
| 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 wrote:
| 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.
| omgJustTest wrote:
| 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.
| Aurornis wrote:
| > 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.
| RajT88 wrote:
| 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.
| Aurornis wrote:
| > 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.
| thijson wrote:
| 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 wrote:
| > 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 wrote:
| Where are the costs then? Is it the MRI that costs $1000?
| sarchertech wrote:
| 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 wrote:
| 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.
| teruakohatu wrote:
| 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.
| gruez wrote:
| >Kaiser did a study that found a 40% reduction in physician
| salaries would result in a 3% savings to consumers on
| medical costs.
|
| source?
| Onavo wrote:
| In that case they shouldn't try to use Congress to obstruct
| training more doctors.
| sarchertech wrote:
| The AMA (less than 15% of physicians are members btw) has
| been lobbying congress to fund more residency spots
| (which is the bottleneck) for 20 years.
|
| The number of doctors has grown far faster than the
| population has since 1960 (the number of doctors per
| capita has grown).
|
| In the 90s the last time the AMA recommended we slow the
| _growth_ in training new doctors, the rate of growth in
| new doctors graduating was accelerating. Extrapolating
| based on the change in rate of growth it looked like
| there would be more new doctors than available jobs.
|
| No one could have predicted that we'd increase medical
| spending even faster such that we could absorb all those
| new doctors. The growth in demand would be really
| shocking to anyone looking at the numbers back then.
|
| A few years after the AMA realized what was happening
| they changed their recommendation to increase the rate of
| growth again.
|
| Because of the way medical education is funded the number
| of doctors available is never going to be purely market
| driven. There's also only so much you can do without
| reducing standards.
| brador wrote:
| Chestertons fence:
| https://en.m.wiktionary.org/wiki/Chesterton%27s_fence
| gruez wrote:
| Thought-terminating cliche:
| https://en.wikipedia.org/wiki/Thought-
| terminating_clich%C3%A...
|
| 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".
| _DeadFred_ wrote:
| 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_ wrote:
| 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.
| stogot wrote:
| 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 wrote:
| Yeah, probably depends a bit on the specific publisher but 250
| pages+ at any rate.
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