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September 25, 2006

Farmworkers and Doctors

Yeah, I'm just going to quote this entire Dean Baker post. It's that good:

NPR had a piece this morning on the possibility that Medicare reimbursements for doctors will be cut. It told listeners that if this cut went into effect, then there may be a shortage of doctors who are willing to serve Medicare beneficiaries.

In other contexts, such as supplies of farm workers, custodians, and restaurant workers, NPR has told listeners that shortages meant that the country needed immigrant workers. No one interviewed for this segment mentioned the possibility of more immigrant doctors, even though doctors receive much higher pay in the United States than they do in the developing world, or even Europe. Surely, if the United States worked to eliminate the barriers that make it difficult for foreigners to train to U.S. standards and practice in the United States, there would be large numbers of foreign physicians who would be willing to do the work that NPR tells us American workers do not want to do.

The great thing about economic models is that you can use the same models for almost anything, you just have to change the words that appear on the axis. If getting immigrants, who will accept low pay, to work in our farms and factories makes economic sense, then getting foreign doctors, who are willing to accept low pay, also makes sense. Maybe NPR will one day get reporters who know economics, if we eliminate barriers to trade among journalists.

As a sidenote, who thinks a significant portion of farmhands are overpaid? How about doctors? Who thinks America pays too much for fruit? How about medical care? So why are we so quick to cut wages and labor costs for agriculture but so loathe to do the very same for the health industry?

September 25, 2006 in Health Care | Permalink


Incidentally this is exactly what is happening in the UK. Britain has bene importing doctors and nurses from the third and second world for years, but the flow has dramatically accelerated under Blair's government, to the extent that some countries have formally protested about the brain drain.

Posted by: Ginger Yellow | Sep 25, 2006 11:01:12 AM

Stealing one from Atrios, here is the easy answer to your easy question:

How much do agricultural employers donate to politicians? Doctors? Farmworkers? Patients?

Posted by: dmh | Sep 25, 2006 11:20:55 AM

The US is importing docs. The AAMC says almost 25% of practicing physicians in the US are from overseas already. Key Physician Data by State see Figure 2. The truth is that there hasn't been much expansion of Medical school capacity in years, with the exception of Osteopathic schools.

Docs who come to do further medical training in the US can get J1 visa waivers and stay here to practice if they agree to serve in shortage areas. These docs are a vital part of the safety net and couldn't be easily replaced if we stopped issuing the J1 waivers.

I have mixed feelings about IMGs. We are really poaching from the best minds of other, poorer countries that could really use those docs. But we couldn't easily replace the influx without a lengthy process of ramping up spots in med schools or opening new schools. But we're a rich country that has a huge population and we ought to be able to grow our medical personnel at home at our own expense.

Posted by: SteveH | Sep 25, 2006 11:21:19 AM

Hey hey, whoa whoa. I'm as progressive as the next guy, but these are lunchpail issues for me. As a poor religion grad student, I have cleverly enlisted the support of a soon-to-be-wealthy medical student in a simple sex for security scheme. I won't have you all mucking up this meal ticket with your reasonable questions of social justice.

Posted by: DivGuy | Sep 25, 2006 11:29:10 AM

Seems to me that making the educational path for doctors less nuts would have similar long-term effects. At my rather good undergrad university with an excellent med school, plenty of students that would have been great docs did other things largely because they didn't want to write off their 20's.

Oh, and nice, DivGuy. Somehow nobody believes me when I tell them that that's my goal.

Posted by: ptm | Sep 25, 2006 11:34:55 AM

NPR has told listeners that shortages meant that the country needed immigrant workers.

Oddly written piece. I don't think NPR has an editorial position on this. In stories I've heard, more than one view has been presented about how to deal with farm labor shortages. Some have suggested, of course, that we should just pay farm workers enough that we won't need to import the labor. A problem with that idea is that we would very likely discover that an apple a day is much less attractive at $2 each, and sales would drop. A fair amount of the industry might just collapse. That probably wouldn't be a good thing, on the whole. Sales for medical care aren't flexible in quite the same way, so the price constraints are different.

I have heard on NPR some talk about importing more doctors, in any case. As Steve points out, the US does import doctors already, as it does workers in most technical fields; it just isn't something most people know much about. It's more noticeable in poor and rural areas.

An obvious difference between farm workers and doctors is that it's impossible to work illegally as a doctor. Fortunately. I don't think it's a good idea to lower the standards for becoming a doctor.

Posted by: Sanpete | Sep 25, 2006 12:05:21 PM

Yeah, the best way to help the doctor situation is to make med school less expensive. If we also would go ahead and make the system to become a doctor less insane, that would help as well.

I understand the desire to have highly educated, trained and tested doctors. However, the system that we have is one that values rote memorization skills, short-term memory and simple endurance rather than critical-thinking and abilities to find what they need to know to treat all the various illnesses and conditions we have.

On another note, DivGuy, are you getting an M.Div, hence the moniker? And am I to take it that ptm is also following that route? How weird, I just finished my M.Div this year.

Posted by: Stephen | Sep 25, 2006 12:07:30 PM

I would be very interested to see how the average US medical/medicare dollar gets spent (and how that has changed over the past 10-20 years).

Many doctors (family practice), no longer make huge salaries. The average salaries for doctors have fallen over the past 15 years, relative to the cost of becoming a doctor (med-school, insurance etc.), I call it the HMO squeeze.

Posted by: disdaniel | Sep 25, 2006 12:08:21 PM

An apple every eight hours keeps away three doctors.

Posted by: Jimmm | Sep 25, 2006 12:19:05 PM

What about government subsidies to put people through med school with a contractual obligation to work in high need areas, free clinicsh or for medicaid/medicare patients for a predetermined amount of time after graduation? It seem to me that this would be a way to both encourage more kids to go to med school and would help cover shortages.

Posted by: DuWayne | Sep 25, 2006 12:26:16 PM

The constant battle between insurance companies (including Medicare and other govt. programs) and doctors should make America's physicians natural allies with those of us seeking single-payer healthcare in this country.

Unfortunately, single-payer would probably mean a guaranteed reduction in doctors' salaries, at least in the short term, and most docs seem to think that they will be able to beat back the insurance companies and their continual efforts to reduce the payments they make. It's the old gambling problem we humans have; we're willing to accept a worse outcome if it means that there is a chance, no matter how small, that we will win.

But the system is stacked against doctors and patients. Patients need insurance in order to pay for our healthcare, and doctors need to accept it - and the "negotiated rates" - in order to get enough patients for a sustainable practice.

A nationalized healthcare system, the funds of which by law would not be able to be used for any other purpose, would allow doctors to make decent money off each payment and for normal increases in payments as new and more expensive treatments are developed. Then it would be up to the doctors, as it is now, to determine how much money they would like to make by how many patients they decide to accept.

There are doctors' groups springing up around the country that charge $30-40 for an office visit but don't accept any insurance whatsoever. Most doctors, I believe, will get closer to $100/visit between co-pays and insurance payments. The rationale behind the reduced payments is that they don't have to hire as many office workers or deal with as many headaches from all the paperwork and foot-dragging from the insurance companies.

Posted by: Stephen | Sep 25, 2006 12:49:44 PM

DuWayne, there are already special schemes for student loans and such for people taking medical training (that includes nurses etc).
There most certainly were (not sure if there still are) payments to medical schools for them to reduce the number they trained. Evidence of, as Atrios points out, the power of the AMA in reducing competition. But then this would be the classical liberal thought anyway. As Dean says, you use the same models, just changing the names.
The doctor's union has used its power to keep high the incomes of doctors. As does the schoolteacher's unions and so on. At, note, the expense of everyone else, just like the doctors.
But to the larger point, sure, I agree. The economics of bringing in fruit pickers is exactly the same as that of doctors: if we accept near open borders for one we should indeed for the other.

Posted by: Tim Worstall | Sep 25, 2006 1:15:18 PM

The doctor's union has used its power to keep high the incomes of doctors. As does the schoolteacher's unions and so on.

HA HA HA. Damn those fatcat teachers!

Damn them all to hell!

Posted by: Stephen | Sep 25, 2006 1:20:41 PM


Yes, the K-Fed career track is a fine one. About your point educating doctors, you're right-- it takes too long. Back in the day, a medical school grad would do a one year internship and then start practicing. Now new MD's go through residencies that last three (for internal medicne ) to five years (for surgery) and if you want to a specialists, like say a cardiologists or neurosurgeon, you do additional years of training after the initial residency. Even if you start med school right after college, you've just written off your 20's as either a student or as an overworked, underpaid resident.

I don't think anyone wants their brain surgeon to skimp on his advanced traning, so we need to look at the front end on the process. If you cut the summer breaks out of med school and switch to trimesters (many Carribean med schools do it this way), you can complete the 4 years of medical school in 3 years. Or we could look at the European system of combining undergrad and med school into one 6 year program.

During World War II, as I've mentioned in another thread here a few months ago, medical schools sort of did both. Students completed 2 years of undergrad premed (no doubt they didn't get to read much poetry). With no summer breaks, this was done in a year and a half, and then went straight to medical school for three years. So in 4 and half years, they could pump out doctors ready to take the same medical boards as graduates who had taken 4 years of college and 4 years of medical school.

I think the war ended and the program canceled before any students came all the way through the pipeline, but its not the worst idea in the world. It would let new docs go through all their additional years of training and then start a career (and a family) at a young age.

Posted by: beowulf | Sep 25, 2006 1:27:24 PM

I agree strongly with Dean Baker, but there's another step that also needs to be taken: medicine needs to be de-skilled. That doesn't mean less skilled doctors; it means more "sort-of doctors"--more midwives, more nurse practitioners with some prescription ability, more GP's--and it means thinking about what skill level is really needed to do various jobs? Could we have an optional training program for RN's that took, say, an additional year and let them prescribe the safest group of prescription medications? (Antibiotics, cortisone cream, etc.)

There are things that need a doctor with 15 years of training, but things that require that much training will always be expensive; one key to controlling medical costs, to me, is figuring out what things can be done with 4 years of training, and letting those things be done with 4 years of training.

Posted by: SamChevre | Sep 25, 2006 3:26:52 PM

On another note, DivGuy, are you getting an M.Div, hence the moniker? And am I to take it that ptm is also following that route? How weird, I just finished my M.Div this year.

Working on the doctorate, now, but I'm still at the div school, and will be for a while. I picked the moniker in part because it seemed like no one on the liberal blogs had the faintest understanding of the modern study of religion and critiques of imperialist secularism, but between the comments here and my discovery of The Weblog, I'm realizing my initial assumption was a bit off.

Posted by: DivGuy | Sep 25, 2006 4:35:47 PM

The US should not be importing doctors from poor countries. That's theft. They need those doctors way more than we do.

By contrast, importing unskilled agri workers helps poor countries, who send remittances back home.

Brain drains hurt poor countries, "brawn drains" don't. Is that really so hard to understand?

Posted by: tyronen | Sep 26, 2006 1:02:12 PM


My medical school didn't have summer breaks. The three month interval between 1st and 2nd year was counted as a "break" for student loan purposes, but in practice any students who didn't already have a postgraduate degree had to spend that time in a research lab in order to finish their (required for graduation) research project. The summers between 2nd and 3rd year and 3rd and 4th year were spent doing clinical rotations. I suspect my school's typical in this regard. Unlike college, there's really not much time savings to be had in the medical school schedule.

Restructuring medical education along European lines would indeed save two years - but until our high school students emerge from school with an educational experience equal to their European peers, I'm not sure that's such a good idea. And in any case, the savings may well be offset by the longstanding general trend of increasing lengths of residency/fellowship training. I think SamChevre's approach of training more paraprofessionals is the one we'll likely see adopted.

Posted by: dlnevins | Sep 26, 2006 4:45:13 PM

Sounds like a job market, with the farm one beeing more of a free-market and the doctor being favored by the Socialists.

Posted by: Guy Montag | Sep 26, 2006 8:27:53 PM

I'm fine with it if doctor pay goes down due to market forces. I'm also fine with government deciding how much it will pay for Medicare procedures. Just so long as private care remains legal and doctors can opt out of Medicare.

Posted by: Adam Herman | Sep 27, 2006 3:36:52 PM

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