Tag: american medical association

The US Has Become a Nursing Home Economy

by Bill Bonner – Bonner and Partners.com:

The key feature of age is that it happens no matter what you think.

What does this mean?

It means the “old countries” – their assets and their institutions, at least the ones that depend on population, income and credit growth – are “fastened to a dying animal” and are not likely to survive in their present form.

Today, these countries, including the US, are victims of demography. Older people get more money from the government. And they pay less in taxes. Old people also slow the rate of GDP, for obvious reasons: They are not adding to output; they are living on it.

As people age, the whole society – its institutions, its laws, its customs, its economy and its markets – ages, too. They all become as familiar, comfortable and shabby as a well-worn shoe.

An economy is not independent of the people in it. The economy ages with them. And when they reach retirement age, the economy gets arthritis.

A Nursing Home Economy

Even the Congressional Budget Office has noticed how government debt slows growth:

Increased borrowing by the federal government generally draws money away from (that is, crowds out) private investment in productive capital in the long term because the portion of people’s savings used to buy government securities is not available to finance private investment.

The result is a smaller stock of capital and lower output in the long term than would otherwise be the case all else held equal (CBO, July 2014, p. 72).

Why does the federal government need to borrow so much? Before the invention of the welfare state, almost all large borrowing was done for war. Since the end of World War II, however, most developed countries – with the exception of the US – have borrowed heavily only to pay for social programs.

But neither debt nor spending contributes to a dynamic, innovative and growth-oriented economy. Instead, they produce an economy that looks like the people in it – old, creaky and in need of around-the-clock care.

As people age, they begin fewer new businesses. “The Other Aging of America: The Increasing Dominance of Older Firms” is the title of a major study from the Brookings Institution. Done by Robert Litan and Ian Hathaway, it showed that American business was becoming “old and fat.”

Taken together, the data presented here clearly show a private sector where economic activity is sharply concentrating in older firms – a trend that is occurring in a nearly universal fashion across sectors, firm sizes and geographies…

An economy that is saturated with older firms is one that is likely to be less flexible, and potentially less productive and less innovative, than an economy with a higher percentage of new and young firms.

Young people try to create new wealth. Old people try to hold on to the wealth they believe they have in the bag. They are less entrepreneurial. They are also, perhaps, more eager to protect their businesses and professions from competition.

Part of the reason for fewer business start-ups is that it has gotten a lot harder to launch a new company in America.

That was the conclusion of a study by John W. Dawson and John J. Seater (“Federal Regulation and Aggregate Economic Growth”). What they found was that there has been a huge increase in economic regulation and restrictions in the US since World War II. They point out that these regulations have an economic cost. Like debt and demography, regulations reduce output.

In fact, they estimate that had the level of regulation remained unchanged since the year I was born – 1948 – today’s GDP would provide every man, woman and child in America with about $125,000 more in income per year.

A Glorified Ponzi Scheme

It was Alexis de Tocqueville who observed that democracy was doomed. He said it would soon degrade into tyranny. As soon as politicians realized that they could win elections by promising the voters more of other people’s money, it was just a matter of time until they overdid it.

Had he imagined how old people would get, he wouldn’t have been so optimistic.

As things developed, politicians noticed two important things: that young people (especially those who hadn’t been born yet) didn’t vote… and old people’s votes could be bought fairly cheaply, at least so it appeared at first.

When the US Social Security program was first put in place, for example, the typical American male could expect nothing from it. He was expected to live to 61. He’d be dead before benefits kicked in. But as the 20th century led to the 21st, his life expectancy increased, and so did the burden of old people.

Early Social Security participants paid in trivial amounts and got a very good return on their money. My mother, for example, only worked a few years at a low-paying job, from which she retired in 1986. She has been collecting Social Security ever since.

“Don’t you feel guilty about getting so much more than you put in?” I teased her.

“Not at all. That’s just the way the system works.”

The way the system works would be illegal for a private annuity plan. It would be labeled a Ponzi scheme. Its promoters would be fined or put in prison. The money that goes into the system is not locked away in wealth-producing investments so that the cash will be available to finance the retiree’s pension. Instead, the contributions of new participants are used to pay benefits to old ones.

This has the obvious and fatal flaw of all Ponzi schemes – eventually, there is not enough new money coming into the system to meet its obligations. This point was reached in the US system in 2010. Since then, the system has been running an annual deficit.

You’ll see why in the chart showing the retirement-age population.

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Everybody knows Social Security, the Affordable Care Act, veterans’ pensions and other support programs are dangerously underfunded. What is not appreciated is the effect that this has on GDP growth and stock market prices.

The crankshaft of age leads to the universal joint of social spending, which then goes to the axles of debt. Finally, where the rubber meets the road, the wheels turn more slowly.

This is not just a problem for government finance. Companies make money by putting out products and selling them. But when people grow old or population growth declines, so do both supply and demand.

Then, companies earn less money. Their shares are worth less. Personal incomes go down. Capital gains retreat. And tax revenues fall, too.

When this happens in an economy that is already deeply in debt, it triggers a crisis.

Article originally posted at Bonnerandpartners.com.

The American Medical Association Restricts Medical Care

excerpt from The Left, the Right, and the State by Llewellyn H. Rockwell Jr.:american medical association building

Restricting the supply of medical care has a long history. Hippocrates built a thriving medical center on the Greek island of Cos in the fourth century B.C., and taught any student who could pay the tuition. But when the great man died, there was fierce competition for students and patients, and the doctors sought to cartelize the system with the Hippocratic Oath.

The oath pledged devoted care to the sick, but also that “I will hand on” my “learning to my sons, to those of my teachers, and to those pupils duly apprenticed and sworn, and to none others.”

In the modern world, England’s Royal College of Physicians (RCP)—a state-approved licensing agency—has long been the model medical monopoly, exercising iron control over its members’ economic conduct. But this guild-like system wasn’t salable in laissez-faire America.

In 1765, John Morgan tried to start an intercolonial medical licensing agency in Philadelphia, based on the RCP. He failed, thanks to bitter infighting among the doctors, but did begin the first American medical school, where he established the “regular mode of practice” as the dominant orthodoxy. Those who innovated were to be punished.

After the Revolution, said historian Jeffrey Lionel Berlant, “a license amounted to little more than a honorific title.” In Connecticut and Massachusetts, for example, unlicensed practitioners were prohibited only from suing for fees. And in the free market 1830s, one state after another repealed penalties against unlicensed practice.

By the mid-nineteenth century, there were virtually no government barriers to entry. As economist Reuben A. Kessel noted, “Medical schools were easy to start, easy to get into, and provided, as might be expected in a free market, a varied menu of medical training that covered the complete quality spectrum.” Many were “organized as profit-making institutions,” and some “were owned by the faculty.”

From time to time, doctors attempted to issue tables of approved fees—with price-cutting called unprofessional—but they failed, because price-fixing cannot long survive in a competitive environment.

Organized medicine’s lobbying against new doctors and new therapies began to be effective in the middle of the century, however. The official reason was the need to battle “quackery.” But as historian Ronald Hamowy has demonstrated in his study of state medical society journals, doctors were actually worried about competition lowering their incomes.

The American Medical Association (AMA) was formed in 1847 to raise doctors’ incomes. Nothing wrong with that, if it had sought to do it through the market. Instead, its strategy, designed by Nathan Smith Davis, was the establishment of state licensing boards run by medical societies. He attacked medical school owners and professors who “swell” the number of “successful candidates” for “pecuniary gain,” fueled by the “competition of rival institutions.” These men advance “their own personal interests in direct collision” with “their regard for the honor and welfare of the profession to which they belong.” The answer? “A board of examination, to sit in judgment” to restrict entry and competition, which he did not point out could only have a pecuniary motive.

As philosopher William James told the Massachusetts legislature in 1898: “our orthodox medical brethren” exhibit “the fiercely partisan attitude of a powerful trade union, they demand legislation against the competition of the ‘scabs.’” And by 1900, every state had strict medical licensure laws.

The Flexner Report of 1910 further restricted entry into the profession, as legislatures closed non-AMA-approved medical schools. In 1906, there were 163 medical schools; in 1920, 85; in 1930, 76; and in 1944, 69. The relative number of physicians dropped 25 percent, but American Medical Association membership zoomed almost 900 percent.

During the great depression, as Milton Friedman notes, the American Medical Association ordered the remaining medical schools to admit fewer students, and every school followed instructions. If they didn’t, they risked losing their AMA accreditation.

Today, with increasing government intervention in medicine — often at the AMA’s behest— the organization exercises somewhat less direct policy control. But it still has tremendous influence on hospitals, medical schools, and licensing boards.

It limits the number of medical schools, and admission to them, and makes sure the right to practice is legally restricted. The two are linked: to get a license, one must graduate from an AMA-approved program. And there is a related AMA effort to stop the immigration of foreign physicians. The American Medical Association also limits the number of hospitals certified for internships, and licensure boards will accept only AMA-approved internships.

The licensure boards—who invariably represent medical societies—can revoke licenses for a variety of reasons, including “unprofessional conduct,” a term undefined in law. In the past, it has included such practices as price advertising.

Medical licensure is a grant of government privilege. Like all such interventions, it harms consumers and would-be competitors. It is a cartelizing device incompatible with the free market. It ought to be abolished.