30 Dec 2001

L bought me a DVD player for Christmas.  We got two DVDs:  Matrix and Shrek.   Love the Hallelujah song in Shrek (by Leonard Cohen).    For kicks, I tried to copy the Matrix DVD to VHS, but the copy was horrible:  apparently they are using the macrovision copy protection.    Some DVD players have secret menus to disable macrovision (and region protection) but our DVD player does not yet have any such secrets published on the web.

23 Dec 2001

Read The March of Folly (1984, B. Tuchman).   For a folly to be significant enough to be included in her book: (1) the folly must be perceived as foolish in its own time;  (2) There must be a feasible alternative; (3) More than one person (leader) must perpetrate the folly; and (4) The folly must last longer than a single person's political lifetime.

She tells the story of 6th century Athens:  the town elders begged wise man Solon to reform the corrupt government.   Solon created a fair, just set of laws, set up a fair system of taxes, and got the leaders to agree to leave these in place for 10 years.  He then left Athens for 10 years. 

If Othello and Hamlet's protagonists were switched, there would be no tragedies:   Hamlet would see right through Iago; and Othello would have killed King Claudius quickly

People will always band together to form governments, because chaos or anarchy is the least tolerable form of society.

I miss the old programming on Bravo and A&E TV networks:  I learned about some little-known artists (Laurie Anderson, Spaulding Grey, Still Life at the Penguin Cafe).   Ditto the World Cafe radio show.    Strangely, the internet, with a much broader reach, and hypothetically equal exposure for lesser known artists, does not reveal many to me.

Graham Greene (The Power and the Glory):   Hate is just a failure of imagination.

14 Dec 2001

Reading a four-book set How Things Work.   This is a very odd book:  originally from Germany, the book has no author or copyright information.  It is a bit more serious than some of the kid-friendly How Things Work books.  I wrote a review on Amazon:  http://www.amazon.com/gp/product/1114119512

Argentina is in the news this week:  People are losing confidence in their currency and it may get devalued soon.  Ecuador, a couple of years ago, gave up trying to maintain a currency and just adopted the US dollar.    I suppose that means they dont have a mint.   

This raises a question I've always wondered about:  How do countries manage the exchange of currency?  In other words, what is stopping, say, Ivory Coast's government bank from simply declaring "we have $4B in our account" and then using that money to, say, buy weapons from the US?   Does the US send auditors to every foreign bank to ensure that the books are accurate?    

If you want sympathy, look in the dictionary  between Shit and Syphilis  - Anon.

11 Dec 2001

Saw Fandango, a poignant coming-of age movie (1984?) starring Kevin Costner and Judd Nelson.   Reminds me of American Graffiti or Diner.   

1 Dec 2001

Read A Distant Mirror (B. Tuchman);  on the reformation:

In a culminating heresy, [Wyclif] transferred salvation from the agency of the Church to the individual: "For each man that shall be damned shall be damned by his own guilt, and each man that is saved shall be saved by his own merit".  Unperceived, here was the start of the modern world".   

She says the middle ages were when the Christian church perfected the doctrine that material wealth is evil.  Perhaps originating in the new testament instruction "It is easier for a camel to pass thru the eye of a needle than for a rich man to get into heaven".   Profit-making, especially charging interest became almost sinful.  This is one of the reasons that Jews became prominent money-lenders.

15 Nov 2001

Saw a neat piece of art by French artist Rousse (on the cruise ship Infinity).  The art is a photograph of a large, empty, industrial room.   

The room has been painted very carefully, so that, from the camera's viewpoint, you can see a particular checkerboard pattern.

28 Oct 2001

From the book The Proud Tower (B. Tuchman)

The painter Pillip Ernst, father of Max Ernst, when painting a picture of his garden omitted a tree, which spoiled the composition and then, overcome with remorse at this offense against realism, cut down the tree.

The five traditional fundamental machines are the lever, screw, inclined plane, pulley, and wedge.  The traditional five is  not very good list, because the wedge, screw, and inclined plane are all related, and because it omits others.  I would add crank and axel, toothed gears and hydraulic pump.    Maybe this would be a more interesting piece of furniture:  one that incorporates machines?   Or electromagnetism?  A hand crank that generates electricity? 

Read about a cool device to draw a perfectly straight line, even when you dont have a straight line to begin with.  It was invented by Peaucellier (french) around 1865.  It's really ingenious, because for a long time people believed it was impossible to generate a straight line from a circle.  Hmmm, since the periodic table has already been built, maybe I can build a table with Peaucellier device?   Some pictures are:

22 Oct 2001

Rome's leadership:   Ruled by kings (600 to 300 BC?);  then a republic ruled by a senate, without a king or emperor (although there were two consuls that administered the country; plus occasional dictators (a 6 month assignment during time of war)).  Then came Julius and the emperors.  Although I think Augustus, who followed Julius, was the first to actually have the title "emperor".   Julius was assassinated by senators that wanted a return to the republic.

17 Oct 2001

Remembrance of things Past - novel by Proust.  Never read it.  A new translation just out has a new title In Search of Lost Time, which I guess is more literal (the french is À la recherche du temps perdu).  The phrase "Remembrance of Things Past" is in a sonnet by Shakespeare (and apparently also in one of the apocryphal OT bible books (Wisdom of Solomon) although that wasnt written in english, so how can that be?).    My question is:  did Proust select his title from the Shakespeare sonnet?  Or is it just coincidence?

Get this:  The first four novels of this new translation were published, but the final 3 cannot be published until 2018 because of the Copyright Extension Act that Disney forced through congress.

The first volume is Swann's Way, which may be read by some people, but only real literature fanatics would read the entire 6 or 7 volumes.  Reminds me of James Joyce.

12 Oct 2001

Reading The Twelve Caesars (Seutonius) and The Annals of Rome (Tacitus).  Latter is the primary source of , Claudius (R. Graves).   The former is the source of many well-known phrases like "vine, vide, vince", and "the ides of march" and "even you, Brutus my child"; and the source of the "Caesar's wife" aphorism.    Shakespeare probably used these as his source for Julius Caesar [more likely was Plutarch]. 

Haymarket Square - 1886: four anarchists where hung for throwing dynamite and killing 7 policemen who were trying to break up a worker's protest (over the 8 hour day?) in Chicago.    

Homestead - City in Pennsylvania, site of an 1892 strike against Carnegie steel.  Carnegie and Pinkerton prevailed.

11 Oct 2001

Im looking forward to doing lots of science experiments with S.    Stuff like:

• Prism / spectrum / diffraction grating
• Rain-making by sudden pressure drops
• Gravitational acceleration same regardless of mass of object
• V = IR
• Water displacement
• Siphons
• Electromagnetism: inductance

27 Sept 2001

Read (again) The Path Between the Seas, and it attributes the quote "To each according to his needs, from each according to his means" to a Frenchman Rouvroy, not to Marx or Engels.

We were on vacation back in the states when the 9/11 disaster struck New York and the Pentagon.   Very tragic.   The attackers made it clear we were targeted because of our support of Israel ... but there was very little mention of that in the media.  When Bush talks, he says the attackers singled out the US because they hate freedom, or hate democracy.   Not true: If we were neutral on Israel, we would not have been attacked.  

10 Aug 2001

Recent headlines:

•  US P-3 plan is returned from china (where it made an emergency landing during a spy operation).
• Slavery reparations under discussion
• Human cloning is being planned in Italy
• Israel and Palestinians continue to duke it out

18 June 2001

Lots of protests about the US Navy bombing on the small island of Vieques, off Puerto Rico.  It is a bit annoying:  The island belongs to Puerto Rico, and they certainly have the right to cease the bombing.  But the only reason PR gets $20B a year in funding from the US is so the US can have the navy base and its bombing range.  So I say we should stop the bombing, vacate the navy base, and stop the payments to Puerto Rico.

Read Breakout (1999, Russ) a story about thee Chosin Reservoir battle in the Korean War (Nov - Dec 1950).   Not quite as good as Ambrose's D-Day book.   The courage and heroism of kids just out of high school is amazing.  Part of me feels I missed out on one of life's great adventures by being between wars; another part of me thinks it is just propaganda by the war machine to recruit more cannon fodder.

14 June 2001

Studying Tesla coils.  I've got to build one of these someday

16 May 2001

The physician lobby is flexing its muscle this month.  They are doing their best to maintain a monopoly on their turf, and keeping advanced practice nurses (APNs) out of business.  Clinton (whose mother was a CRNA) signed some resolution in his final months which permitted APNs to get reimbursed by Medicare (the states regulate the scope of practice, but the federal government regulates the Medicare rules).   But Bush, slave to campaign donations, did the physician's bidding and suspended the nurse-friendly rule.   

The cartel of physicians is exceedingly strong and active.  They go to great lengths to ensure that nurses can never compete with them or deprive them of their enormous income streams.  I found a couple of objective essays on this topic:

http://www.cato.org/pubs/pas/pa-246.html - Excellent summary from the CATO institue.

http://www.policyreview.com/fall95/thband.html - From Policy Review magazine.

Here are some extracts:

 THE MEDICAL MONOPOLY:
PROTECTING CONSUMERS OR LIMITING COMPETITION?

Sue A. Blevins is a writer and health policy consultant based in Boston.

Executive Summary
Nonphysician providers of medical care are in high demand in the United States. But licensure laws and federal regulations limit their scope of practice and restrict access to their services. The result has almost inevitably been less choice and higher prices for consumers.

Safety and consumer protection issues are often cited as reasons for restricting nonphysician services. But the restrictions appear not to be based on empirical findings. Studies have repeatedly shown that qualified nonphysician providers--such as midwives, nurses, and chiropractors--can perform many health and medical services traditionally per formed by physicians--with comparable health outcomes, lower costs, and high patient satisfaction.
Licensure laws appear to be designed to limit the supply of health care providers and restrict competition to physi cians from nonphysician practitioners. The primary result is an increase in physician fees and income that drives up health care costs.

At a time government is trying to cut health spending and improve access to health care, it is imperative to exam ine critically the extent to which government policies are responsible for rising health costs and the unavailability of health services. Eliminating the roadblocks to competition among health care providers could improve access to health services, lower health costs, and reduce government spending.

Introduction

I am myself persuaded that licensure has reduced both the quantity and quality of medical practice. . . . It has forced the public to pay more for less satisfactory medical service.
--Milton Friedman

Although broad-based health care reform has temporarily moved to the back of the public agenda, there remain serious problems of cost and access in the American health care system. The underlying reason for those problems is the lack of a functioning free market in health care in this country. There is privately owned health care, but there is not a living, vibrant free marketplace in health care like there is in other products and services.
Healthy markets have certain common characteristics. On the supply side, there is a choice of providers, in competition with one another, trying to gain customers on the basis of price and quality. And on the demand side, there are consumers seeking the best deal for their dollar. In today's health care system, neither of those conditions obtains.

During the 1994 health care reform debate, much atten tion was given to the demand side of the market.(1) That attention led to the development of ideas such as medical savings accounts to make health care consumers more cost conscious.(2)

However, true reform requires that the supply side of the health care market be addressed as well. Currently, a wide variety of licensing laws and other regulatory restric tions limits the scope of practice of nonphysician profes sionals and restricts access to their services. Moreover, at the same time that it is restricting the practices of nontraditional health care professionals, government is providing subsidies for the education and training of physi cians who fit the medical orthodoxy. The result has been the creation of a de facto medical monopoly, leading to less choice and higher prices for consumers.

Therefore, true health care reform must involve ending the government-imposed medical monopoly and providing con sumers with a full array of health care choices.


The Demand for Alternative Therapies

Every year millions of Americans seek providers who offer health care therapies that are neither widely taught in medical schools nor generally available in U.S. hospi tals. Researchers from Harvard Medical School studied the health care practices of U.S. adults and estimated that 22 million Americans sought providers of unconventional care in 1990. The study, reported in the New England Journal of Medicine, estimates that in 1990 Americans made more visits to providers who offered unconventional therapies than to all primary care physicians--425 million compared to 388 million visits.(3)

Researchers estimate that 34 percent of Americans used at least 1 of 16 unconventional therapies, such as chiro practic, herbal, and megavitamin therapies, in 1990.(4) Back problems were the most commonly reported "bothersome or serious" health problem for which consumers sought nontradi tional services.(5)

There is a great willingness to pay out-of-pocket for providers who offer unconventional health services. The Harvard researchers found that total projected expenditures on providers of unconventional care amounted to $11.7 bil lion in 1990. Nearly 70 percent--$8.2 billion--of that amount was paid by the consumer, rather than insurers or government. By contrast, only 17 percent of the bill for total physician services was paid out-of-pocket in 1990.(6)

According to U.S. Census data, receipts for nonphysi cian providers(7) grew by 83 percent--from $10.3 billion to $18.9 billion--between 1987 and 1992,(8) while physician receipts increased by 56 percent, from $90 billion to $141 billion. Census data show that employment by nonphysician establishments grew by 50 percent, while jobs in hospitals and physician offices increased less than 20 percent between 1987 and 1992.
Medical schools are responding to the consumer demand for unconventional health services. To date, 34 out of the 126 medical schools nationwide have started or are develop ing courses that focus on "alternative medical practices."(9)
It should be noted, however, that medical schools rely heavily on federal subsidies, while training for nonphysi cian providers is predominantly funded with private money. For example, all of the 17 chiropractic schools in the

The Rise of Medical Licensure

Although protection of the public is often cited as the reason for medical licensing and limiting access to uncon ventional therapies, history indicates that professional interest was more of an overriding concern in the early enactment of those laws. The latter theory reflects econo mist Paul Feldstein's perspective that health associations act like firms: they try to maximize the interests of their existing membership.(14)
Medical licensure was first introduced in England in 1442 when London barbers were granted charters to perform certain procedures. The charters authorized "barbers" to treat wounds, let blood, and draw teeth.(15)
In the United States, the earliest health professional licensure law was enacted by Virginia in 1639. That law dealt with the collection of physician fees, vaccination, the quarantine of certain diseases, and the construction and management of isolation hospitals. Other early colonial acts denied nonphysician practitioners any standing in civil courts to collect fees. In 1760 New York City became the first American jurisdiction to prohibit practice by unli censed physicians. Subsequently, many other cities and states introduced licensing requirements.(16)
During the early part of the 19th century, the United States experienced an era known as "free trade in medicine." A historical vignette in the Journal of the American Medical Association explains that during the mid-1800s, botanics and homeopathy were in great demand.(17) Those alternative health practices were a powerful counterforce to regular medicine. Most state licensure laws that granted special privileges to physicians were repealed because of the widespread consumer demand for botanicals. During the period, the United States was one of the healthiest nations, with the world's lowest infant mortality rate.(18)

However, the self-interest of physicians soon began to assert itself. The repeal of licensure laws "triggered a movement that led directly to the formation of the American Medical Association."(19) The AMA was determined to protect physicians from competition by nonphysician health care providers. Consequently, licensure laws arose again, begin ning about 1870. By 1895 nearly every state had created some type of administrative board to examine and license physicians.(20)

Another study of the early development of medical licensing laws in the United States reports that the goals of the AMA in supporting licensing appear to have been to (1) restrict entry into the profession and thereby secure a more stable financial climate for physicians, (2) destroy for-profit medical schools and replace them with nonprofit institutions, and (3) eliminate other medical sects such as homeopaths and chiropractors.(21)
History reveals that the AMA was influential in linking physician licensure with strict educational standards that (1) restricted entry into the health care marketplace and (2) increased the cost of medical education.(22)




Midwifery
At least 36 states restrict or outright prohibit the practice of lay midwifery.(46) Consequently, only 5 percent of all births are attended by midwives in this country,(47) compared with 75 percent of all births in European coun tries.(48) Americans' low usage of midwifery does not corre late with high-quality birth outcomes: the United States has the second highest caesarean rate in the world(49) and the fifth highest infant mortality rate among Western industri alized nations.(50)
There are an estimated 10,000 midwives in this country who fall into two categories: the certified nurse-midwife and the lay midwife (or "direct-entry" midwife). Certified nurse-midwives are registered nurses with two years of advanced training who most often work under the supervision of a physician and practice in clinic or hospital settings. Certified nurse-midwives represent approximately 4,000 of the 10,000 midwives nationwide.
By contrast, lay midwives enter the profession directly from independent midwifery schools or through apprentice ship. They are trained to meet individual state require ments for licensure, registration, or certification. But unlike certified nurse midwives, most lay midwives practice independently in consultation with physicians, not under
direct physician supervision. About half the 6,000 lay midwives are associated with religious groups,(51) and a ma jority of home births in the United States are attended by lay midwives.(52)


Nurse Practitioners

Particularly in underserved areas and long-term care facilities, registered nurses with advanced training--nurse

practitioners--are able to provide most basic health servic
es provided by physicians, and at lower costs. The American Nurses Association estimates that of the 2.1 million regis tered nurses nationwide, approximately 400,000 deliver primary care.(73) Many of them are practicing in managed-care organizations under the supervision of physicians. Some 21,000 nurses have received advanced training at graduate schools of nursing and are licensed nurse practitioners.
Research shows that between 75 and 80 percent of adult primary care, and up to 90 percent of pediatric primary care, services could be safely provided by nurse practi tioners.(74) A study by the Office of Technology Assessment found that the outcomes of nurse practitioner care were equivalent to those of services provided by physicians, and that nurse practitioners were actually more adept in commu nication and preventive care. The Office of Technology Assessment study also indicates that increasing access to nurse practitioner services could be especially advantageous for the home-bound elderly.(75)

Another study examined the outcomes of a nurse-managed clinic that was opened to provide primary care services to more than 2,000 low-income children and their families in an underserved Texas community. Research shows that after the clinic was opened in 1991, emergency room visits by pediat ric Medicaid recipients decreased by 27 percent at the largest emergency room in the county. In addition, the pregnancy-induced hypertension rate was reduced from 7 to 3.3 percent over a three-year period, preventing costly hospitalizations.(76)
The economic loss from inefficient use of primary care nurse practitioners is estimated to be between $6.4 billion and $8.75 billion.(77) A meta-analysis conducted by the Amer ican Nurses Association in 1993 showed that nurse practi tioner care resulted in fewer hospitalizations, higher scores on patient satisfaction, and lower cost per visit- $12.36 compared to $20.11 for physicians.(78) In addition to projected savings on direct health services, the taxpayer burden for training nurse practitioners is approximately one-fifth the cost of training physicians.(79)
Despite empirical evidence that nurse practitioners can safely provide primary care, many states impose scope-of practice regulations that prevent nurses from practicing independently as primary care providers. Nurse practi tioners derive their authority from various state nurse practice acts.(80) However, some states give their medical boards regulatory control over boards of nursing. That gives one profession full veto power over the rules and regulations of its competitors.

Moreover, scope-of-practice regulations often dictate that nurses must work in coordination with physicians. For example, 48 states grant nurse practitioners prescriptive authority but mandate that nurses must have a written prac tice agreement or work in collaboration with a physician.
As of January 1995, only 10 states granted nurse prac titioners the legal right to prescribe drugs independent of a physician.(81) Moreover, even some of those states limited the independent nurse practitioner's prescription authority by law to 72 hours.(82) What that means for competition is that consumers--for example, elderly Medicare recipients who live in rural areas--would have to visit independent nurse practitioners every three days to renew prescriptions. Barbara Safriet, associate dean of Yale Law School, argues,

Medical practice acts remain overly broad and indeterminate, with concomitant and unnecessary restrictions in the licensure and practice acts of nonphysician providers. If we are to achieve our goal of offering high-quality care, at an afford able cost, to everyone who needs it, we must en sure that all health care providers are able to practice within the full scope of their profes sional competencies.(83)
States' scope-of-practice regulations shield the full market demand for nurse practitioner services because nurses are not legally free to compete in the health care market. A 1993 Gallup poll found that 86 percent of consumers would be willing to use nurse practitioners for basic health care services. Only 12 percent stated that they would be unwill ing to see a nurse practitioner.(84)
This analysis does not in any manner call for increased government regulations that would force Medicaid or Medicare recipients to substitute nurse practitioner care for physi cian services. Instead, it argues that Americans should not be restricted from choosing low-cost alternative practition ers and forced to subsidize an oversupply of highly spe cialized physicians. Let nurse practitioners legally com pete in the health care market and allow consumers to choose among qualified health providers on the basis of quality and cost.

Protecting Consumers or Limiting Competition?

There is little actual evidence that medical licensing improves quality or protects the public.(106) Medical econo mist Gary Gaumer, reviewing all the available literature on medical licensing, concluded,

Research evidence does not inspire confidence that wide-ranging systems for regulating health profes sionals have served the public interest. Though researchers have not been able to observe the consequences of a totally unregulated environment, observation of incremental variations in regulato ry practice generally supports the view that tigh ter controls do not lead to improvements in the quality of service.(107)
Even the Federal Trade Commission has concluded that "occupational licensing frequently increases prices and imposes substantial costs on consumers. At the same time, many occupational licensing restrictions do not appear to realize the goal of increasing the quality of professionals' services."(108)
Licensing laws may actually put the public more at risk by lulling consumers into a false sense of security. Terree Wasley points out in What Has Government Done to Our Health Care? that most state licensing laws permit all licensed physicians to perform all types of medical services, even those for which they are not specifically trained.(109) For example, in Massachusetts physicians are licensed to perform acupuncture even though they may not have received special training.(110) That situation disturbs nonphysician acupunc turists who receive more hours of acupuncture training than do most licensed physicians.(111)

Feldstein points out that licensure laws focus at the point of entry into the medical profession, not on continu ous monitoring. Once medical professionals are licensed, there are no requirements for proving that they are fully trained to perform the most up-to-date procedures.(112) Some states do not require continuing education, so there is no guarantee that a physician is current with the most recent techniques and information.(113) Feldstein points out that

state licensing boards are responsible for moni toring physicians' behavior and for penalizing physicians whose performance is inadequate or whose conduct is unethical. Unfortunately, this approach for assuring physician quality and compe tence is completely inadequate. . . . Monitoring the care provided by physicians through the use of claims and medical records data would more direct ly determine the quality and competence of a phy sician.(114)

In his 1987 Cato Institute book, The Rule of Experts: Occupational Licensing in America, S. David Young, a profes sor of accounting and finance at Tulane University, reviewed the literature on a wide variety of occupational licensing restrictions, including medical licensing, and found that "licensing has, at best, a neutral effect on quality and may even cause harm to consumers."(115)
While the public safety benefits of medical licensure are clearly questionable, nearly all economists recognize that professional licensure laws act as a barrier to entry
that decreases competition and increases price. As Victor Fuchs wrote in 1974, "Most economists believe that part [of physician's high incomes] represents a monopoly return to physicians from restrictions on entry to the profession and other barriers to competition."(116)
One of the earliest studies of the impact of licensure on physician income was done in 1945 by Nobel Prize-winning economist Milton Friedman and Simon Kuznets. Friedman and Kuznets found that the difference in income between profes sional and nonprofessional health care workers was larger than could be explained by the extra skill and training of the professionals. A large portion of the variation, they concluded, was due to licensing restrictions. In addition, they concluded that the difference in mean income of physi cians and dentists was caused by greater difficulty of entry into medicine than into dentistry.(117)

Friedman and Kuznets's conclusions have been confirmed by numerous other studies. For example, William White examined the effect of licensure on the income of clinical laboratory personnel and found that in cities with stringent licensing restrictions income was 16 percent higher than in cities with less stringent restrictions, with no variation in the quality of testing.(118)

Lawrence Shepard examined the fees of dentists in states that recognized out-of-state licenses and those that did not. He found that in states that did not recognize out-of-state licenses, dental fees were 12 to 15 percent higher.(119) A study of Canadian health care indicated that occupational licensing, combined with mobility restrictions and advertising restrictions, increased health care costs by as much as 27 percent.(120) Gaumer found that both fees and provider incomes were higher in states with more restrictive licensure requirements.(121)

Interesting confirmation that physician licensure is related more to a desire to increase physician incomes than to concern over public health and safety can be found in a 1984 study by medical economist Chris Paul, who found that the year that a state enacted physician licensing was relat ed to the number of AMA members in the state.(122) Paul con cluded that decisions by states to require licensing of physicians were more likely a result of special interests than of the public interest.
As the Friedmans note, "The justification [for licen sure] is always the same: to protect the consumer. However, the reason is demonstrated by observing who lobbies at the
state legislatures for imposition or strengthening of licen sure. The lobbyists are invariably representatives of the occupation in question rather than its customers."(123)

Subsidies and the Medical Monopoly

In addition to using government to restrict competi tion, the medical monopoly also turns to government for subsidies. For example, most physician training is subsi dized by the federal government.

In 1927 student fees accounted for 34 percent of medi cal school revenues.(124) Today less than 5 percent of medi cal school revenues comes from tuition and fees. Instead, medical schools rely heavily on federal and state sup port.(125) In 1992 total medical school revenues amounted to $23 billion.(126) State and local governments provided $2.7 billion.(127) The federal government paid at least $10.3 billion to medical schools and hospitals for medical educa tion and training (Table 3). Additional revenues were obtained from charges for services, endowments, and private grants.



Medicare payments to hospitals represent the largest source of federal funding for medical education and train ing.(128) Medicare pays for physician education and training in two ways: First, hospitals receive direct payments from Medicare based on the number of full-time-equivalent resi dents employed at each hospital. Second, Medicare increases a hospital's diagnostic-related group payments according to an "indirect" medical education factor, based on the ratio of residents to hospital beds.(129)
The average Medicare payment to hospitals was more than $70,000 per resident for both direct and indirect education subsidies in 1992. An estimated 69,900 full-time-equivalent interns, residents, and fellows were eligible for Medicare reimbursement in 1991.(130)

Medicare paid hospitals $1.6 billion for direct medical education expenses and dispensed $3.6 billion for indirect medical education adjustments in 1992.(131) Of the total $5.2 billion that Medicare paid to hospitals for training, ap proximately $0.3 billion was appropriated for training nurses and allied health professionals.(132)
Medical schools and teaching hospitals receive addi tional federal funding from the National Institutes of Health, the Department of Veterans Affairs, the Department of Defense, and the Health Resources and Services Adminis tration (Title VII) program. Federal funding for research, training, and teaching amounted to at least $5.1 billion in 1992.(133) That money was awarded to medical schools and affiliated hospitals in the form of grants and contracts. Supporting biomedical research in medical schools is one way the federal government supports medical education without appearing to do so directly.(134)
As Feldstein has pointed out, "There is no reason why medical students should be subsidized to a greater extent than students in other graduate or professional schools."(135) That point has also been suggested by Uwe Reinhardt, a professor of political economy at Princeton University, who recently noted,


Conclusion
What should government do if it is serious about cut ting health spending and improving access to affordable health care? The first step should be to eliminate the anti-competitive barriers that restrict access to low-cost providers, namely licensure laws and federal reimbursement regulations. Americans should not be forced to substitute providers against their will; rather, they should be free to choose among all types of health care providers.

Instead of imposing strict licensure laws that focus on entry into the market but do not guarantee quality control, states should hold professionals equally accountable for the quality of their outcomes. That will reduce the need for strict licensure laws and other regulations that are pur ported to protect the public at large.

The time is right for eliminating barriers to nonphysi cian health care providers. Many Americans are seeking low cost nontraditional providers and even choose to pay out-of pocket for their services. Breaking the anti-competitive barriers of licensure laws and federal reimbursement regula tions will provide meaningful health reform, increase con sumer choice, and reduce health care costs.

M.D. Monopoly:

How Nurses Can Help Relieve Spiraling Heath-Care Costs

Doug Bandow
Policy Review
Fall 1995, Number 74

Medicare isn't the only part of America's health-care system where costs are spiraling out of control. Doctors have created a cartel by confining the delivery of treatment solely to M.D.s and by regulating the number and activities of M.D.s. This suppresses the supply of health-care professionals, raising costs and reducing choice. State governments could significantly lower both public and private health-care costs by reducing physicians' stranglehold over medical care and moving towards a freer market. For its part, the federal government could, if it is willing to use its vast power under the commerce clause of the Constitution, preempt state rules that hamper the cost-effective delivery of medical services.

The Clinton administration recognized the problem of supply, but sought to remedy it by manipulating federal funding to force more doctors to become general practitioners. Similarly, the Council on Graduate Medical Education has urged educational changes to change the ratio of primary-care physicians to specialists from 30:70 to 50:50 by the year 2040.

The critical question, however, is not what percentage of doctors should provide primary care, but who should be allowed to provide primary care. Doctors are not the only professionals qualified to treat patients, yet most states needlessly restrict the activities of advanced-practice nurses (A.P.N.s) (who include nurse practitioners, nurse-midwives, clinical nurse specialists, and nurse anesthetists), registered nurses (R.N.s), licensed practical nurses (L.P.N.s), physicians assistants (P.A.s), nurse's aides, and similar professionals. Even today, these providers dramatically outnumber doctors-there are 2.2 million R.N.s, three times the number of M.D.s, and nearly 1 million L.P.N.s alone, while the number of A.P.N.s, at well over 100,000, is about half the number of physicians providing primary care. Ellen Sanders, a vice-president of the American Nurses Association, estimates that 300,000 R.N.s could become A.P.N.s with an additional year or tw o of training.

Although A.P.N.s, R.N.s, and L.P.N.s are capable of handling many simple and routine health care procedures, most states, at the behest of physicians, allow only M.D.s to perform "medical acts." According to Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota, "You have highly trained people doing things that could be done by others." Doctors perform what A.P.N.s could do, A.P.N.s do what registered nurses could handle, and registered nurses handle what nurse's aides could perform. "I can take care of a patient who has broken an arm," complains Maddy Wiley, a nurse practitioner in Washington state, "treat them from top to bottom, but I can't give them an adequate painkiller." Instead, patients can receive such treatment only through the government-created doctors' oligopoly, into which entry is tightly restricted. Observes Michael Tanner of the Cato Institute: "In most states, nurse practitioners cannot treat a patient without direct physician supervision. Chiropractors cannot order blood tests or CAT scans. Nurses, psychologists, pharmacists, and other practitioners cannot prescribe even the most basic medications."

The problem is exacerbated by the nature of the medical marketplace, where the expansion of services is expensive. Much of the necessary capital already exists -- there are, for instance, a lot of unfilled hospital beds. The practice of medicine, however, has become increasingly labor intensive. The National Center for Policy Analysis figures that, because of the high cost of training medical personnel, "moving capital and labor from other sectors requires a price increase for medical services that is six times higher than that needed to expand other goods and services." As a result, the NCPA estimates, 57 cents of every additional dollar in U.S. medical expenditures is eaten away by higher prices rather than added services.

Physicians have shown unyielding resistance to alternative professionals. Medical societies have tried to prev ent chiropractors, for instance, from gaining privileges at local hospitals. M.D.s have similarly opposed osteopaths and podiatrists. Working through state legislatures, physicians have won statutory protection from competition. Many states ban midwives from handling deliveries. Optometrists are usually barred from such simple acts as prescribing eye drops. Half of the states permit only physicians to perform acupuncture. Overregulation of pharmaceuticals, which prevents patients from self-medicating, also acts as a limit on health-care competition. Allowing over-the-counter sales of penicillin, for instance, could save patients about $1 billion annually.

A recent episode in Georgia illustrates the arbitrariness of most occupational licensure regulations. According to Tanner, state legislation was introduced at the behest of dentists to prevent dental hygienists from cleaning teeth. Then an amendment was added for the ophthalmologists to bar optometrists from performing laser eye surgery. In the end, the bill prohibited anyone but physicians, veterinarians, podiatrists, and dentists from performing any procedure that pierced the skin, effectively outlawing nurses from drawing blood or giving injections. This unintended outcome would have brought most hospitals to a halt, and a court had to block its enforcement. Examples abound of legal restrictions promoted by self-serving professionals and harmful to consumers. In general, professional licensure has reduced the number of potential caregivers, cut the time spent with patients, and raised prices.

The second manifestation of physicians' monopoly power is the anticompetitive restrictions that the profession places upon itself. The doctors' lobby has helped drive proprietary medical schools out of business, reduced the inflow of new M.D.s, and for years prevented advertising and discouraged members of local medical associations from joining prepaid plans. Until the early 1980s, the American Medical Association attempted to restrict walk-in clinics that adv ertised themselves as providing "emergency" or "urgent" care. Explained John Coury, who was then chairman of the AMA, "Some of these facilities were set up by nonmedical people as money-making propositions" -- as if doctors don't seek to make money. Moreover, federal immigration law and state requirements limit the entry of foreign doctors into the country and often prevent them from finding work. None of these rules has much to do with consumer protection.

Allowing nurses to provide services for which they are qualified would expand people's options, allowing patients to decide on the more cost-effective course of their treatment. Some states have begun to allow greater competition among health-care providers. Mississippi does not regulate the practice of P.A.s. Nearly half the states, including New York, already allow nurse practitioners to write at least some prescriptions, while a handful, such as Oregon and Washington, give A.P.N.s significant autonomy. The Florida Department of Health and Rehabilitative Services is encouraging the training of nurse-midwives.

In this area, at least, the Clinton administration wanted to move in the right direction, pledging to "remove inappropriate barriers to practice." The Clinton proposal would have eliminated state laws that ban A.P.N.s from offering primary care-prenatal services, immunizations, prescription of medication, treatment of common health problems, and management of chronic but standard conditions like asthma -- and to receive insurance reimbursement for such services. Even these modest efforts did not go unchallenged: The California Medical Association attacked the Clintons' proposal as "dangerous to the public's health," and an AMA report argued that expanding the role of nurses would hurt patients, fragment the delivery of care, and even raise costs.

There is, however, no evidence that the public health would be threatened by allowing non-M.D.s to do more. Professionals should be allowed to perform work for which they are well trained -- witho ut direct supervision by a doctor. At the very least, states should relax restrictions in regions, particularly rural areas, that have difficulty in attracting physicians. In this way, those with few health-care options could choose to seek treatment from professionals with less intensive training. A recent Gallup poll found that 86 percent of Americans would accept a nurse as their primary-care practitioner. Why not give them that option? Says Leah Binder of the National League of Nursing, "Let the 'invisible hand' determine how much it should cost to get a primary-care checkup."

Physicians assistants, for instance, receive two years of instruction to work directly for doctors and could perform an estimated 80 percent of the primary-care tasks conducted by doctors, such as taking medical histories, performing physical exams, and ordering tests. Similarly, the Office of Technology Assessment figures that nurses with advanced practices could provide 60 to 80 percent of the clinical services now reserved for doctors. Explains Arthur Caplan of the University of Minnesota, nurse practitioners are "an underutilized, untapped resource that could help reduce the cost of health care significantly." Len Nichols, a Wellesley economist, estimates that removing restrictions on A.P.N.s could save between $6.4 billion and $8.8 billion annually. Mary Mundinger, the dean of Columbia University's School of Nursing, contends that nurse practitioners have been providing primary care for decades and no research, even that conducted by doctors, has ever documented any problems.

Lonnie Bristow, the chairman of the AMA, admits as much, but responds that those nurses were working under a doctor's supervision. But that supervision is often quite loose. Nurses regularly perform many simple aspects of primary care far more often than doctors and, as a result, are better qualified to handle them in the future, with or without the supervision of an M.D.

None of the AMA's arguments withstands analysis. For instance, the officia l AMA report claims that because nurses want to serve all populations and not just "underserved" groups in rural and inner-city areas, "there is virtually no evidence to support" the claim that empowering other medical professionals would improve access to care. But increasing the quantity of primary health-care providers would necessarily make additional medical professionals available to every area. Moreover, poor rural communities would likely be better able to afford the services of A.P.N.s, whose median salary nationwide is $43,600, than a general-practice M.D.s, with a median salary of $119,000. Even if allowing nurses to do more increased competition only in wealthier areas, it would thereby encourage some medical professionals, including doctors, to consider moving to underserved regions where the competition is less intense.

The most compelling argument against relaxing restrictions on nurses is that Americans' health care might somehow suffer. "A nurse with four to six years of education after high school does not have the same training, experience, or knowledge base as a physician who has 11 to 16 years," complains Daniel Johnson, the Speaker of the AMA's House of Delegates. True enough, but so what? No one is suggesting that nurses do anything but the tasks nurses are trained to do. In fact, the OTA study judged A.P.N. care in a dozen medical areas to be better than that of M.D.s.

The problem of occupational licensure is not confined to doctors. The nursing profession behaves the same way when it has a chance. Under severe cost pressures, hospitals have increasingly been relying on L.P.N.s, nurse's aides, and "patient-care assistants." The cost savings can be great: Nurses typically receive two to four times as much training as licensed practical nurses and command salaries 50 percent greater. Yet in many hospitals they still bathe and feed patients. Stanford University Hospital has saved $25 million over the last five years by reducing the share of R.N.s among patient-care employees from 90 percent to 60 percent. The consulting firm of APM, Inc. claims that, since 1987, it has assisted 80 hospitals in saving some $1 billion. Alas, professional groups like the American Nurses Association have opposed these efforts.

To bring competition to the medical profession, patients should also be allowed greater access to practitioners of unorthodox medicine. In 1990, a tenth of Americans -- primarily well-educated and middle- to upper-income -- went to chiropractors, herbal healers, massage therapists, and the like. Health insurance covered few such treatments. Some of these procedures may seem spurious, but then, practices like acupuncture were once regarded similarly before gaining credibility. The most important principle is to allow patients free choice to determine the medical treatments they wish to receive. This means relaxing legal restrictions on unconventional practitioners and creating a health-insurance system that would allow those inclined toward alternative treatments to acquire policies tailored to their preferences.

Most important, states should address the obstacles to becoming and practicing as an M.D. This nation suffers from an artificial limit on physicians. Observes Andrew Dolan of the University of Washington, the argument that occupational licensing is necessary "to protect patients against shoddy care" is "unproven by almost any standard." Experience suggests that licensure reflects professional rather than consumer interests.

At the least, states should eliminate the most anti-competitive aspects of the licensing framework, particularly barriers to qualifying as doctors and to competition. These include that power of doctors to control entry into their own profession and to restrict competitive practices. As the National Center for Policy Analysis's John Goodman and Gerald Musgrave explain, "Virtually every law designed to restrict the practice of medicine was enacted not on the crest of widespread public demand but because of intense pressure from the political repres entatives of physicians." Although licensure is defended as necessary to protect patients, local medical societies spent years fighting practices (such as advertising, discounting, and prepaid plans) that served patients' interests, as well as imposing fixed-fee schedules on their members. No existing licensing requirement should escape critical review.

More far-reaching reform proposals include substituting institutional licensure of hospitals and establishing a genuine free market in health care (backed by private certification and testing and continuing malpractice liability). Such approaches seem shocking today only in the context of the vast regulatory structure that has been erected over the years. If we are serious about increasing access to and reducing the expense of medical care, we should give careful consideration to full deregulation. Such steps would do much to achieve the Clinton administration's goal of encouraging more primary-care physicians and more physicians from racial minorities.

The federal government shares some of the blame for clogging the pipeline of medical professionals, because its Medicaid and Medicare reimbursement rules encourage needlessly large and over-trained medical staffs. Medicare, for instance, requires hospitals to use only licensed laboratory and radiological technicians, and engage a registered nurse to provide or supervise the nursing in every department. Only nurse practitioners operating in nursing homes or rural areas can be reimbursed under Medicare. Only 18 states allow Medicaid reimbursement for A.P.N.s. Non-hospital facilities such as community health centers, which play a particularly important role in poor and rural areas, also face tough staffing requirements. These sort of restrictions hamper the shift to less expensive outpatient services. With enough political will, the federal government could play a role in easing state licensure, just as the Federal Trade Commission fought professional strictures against advertising. 

25 Mar 2001

Learning about the Starker 1031 IRS provision:  a way to avoid capital gains taxes when selling something.   The notion is that you can buy a house (or any capital object) and depreciate it; then exchange the house (buy/sell) for another one and you don't have to pay capital gains on the original house.   But it is a complex process: you have to hire an intermediary (kind of like an escrow company) for about $1,000 to do all the paperwork and hold the sale proceeds;  then you have to buy the replacement house within 2 months of selling the first house (either before or after);  and you cannot personally get control of the sale proceeds between the two transactions.  A reverse Starker is when the purchase happens before the sale.

4 Mar 2001

Napster finally shut down this weekend after a long battle with Hollywood.   

US submarine Greenville was taking 16 civilians on a Puerto Rico joyride near Hawaii and it killed 9 Japanese when it recklessly surfaced under their fishing boat.  The captain will be court martialled, of course.  Will the Japanese ask for compensation?  Ironic since the accident happened so close to Pearl Harbor.

Clinton gave a pardon to a criminal in his last week in office:  the criminal defrauded lots of innocent victims, and is now living in Switzerland with his wealth.   The criminal is a jew whose family has donated lots of $$ to Clinton.  

On the other hand, Clinton did take some good steps to preserve open space by establishing some national monuments in his final month in office.

4 Feb 2001

Read The Killer Angels (1974, Michael Shaara).   Excellent historical novel about Gettysburg.  A very enjoyable way to learn history.  

Read A Very Long Engagement ( 1991, Sebastian Japrisot).   French novel set in WW I and its aftermath.  Very original plot structure:  half mystery, half love story, half anti-war polemic.   

Read The Loss of the Ship Essex, Sunk by a Whale (18??, Chase and Nickerson).  A collection of true narrative accounts written by survivors of a ship sunk in the Pacific.

Read The Voyage of the Narwhale (1998, Andrea Barrett).   A mediocre novel about an artic expedition.  Seems like a poor  imitation of Angels and Insects.