In Australia one doctors’ association was able to hire a retiring health minister as a lobbyist on a huge salary. I don’t think you could characterise the lobby there as politically weak, but GPs in Australia aren’t very well paid by international standards and have been lobbying unsuccessfully for increases in the government tariff for years.

Your French example depends for its success on knowledge of the degree of regulatory capture in that country which you haven’t presented (and I don’t know). You hit on the real reason for the US’s extreme costs in the last sentence – the govt has deliberately weakened its ability to negotiate prices, throwing it open to the private market and leaving hospitals to negotiate with a group of people (Doctors) who are very good at sticking together. This isn’t regulatory capture, it’s market power.

“France particularly excels in prenatal and early childhood care. Since 1945 the country has built a widespread network of thousands of health-care facilities, called Protection Maternelle et Infantile (PMI), to ensure that every mother and child in the country receives basic preventive care. Children are evaluated by a team of private-practice pediatricians, nurses, midwives, psychologists, and social workers. When parents fail to bring their children in for regular checkups, social workers are dispatched to the family home. Mothers even receive a financial incentive for attending their pre- and post-natal visits.”

Now, this isn’t utterly unknown in the U.S., but that mix of professionals is much more likely to be flattened into the usual American hierarchy of the doctor first. Midwives are very underused in the U.S., a notorious historical case of American doctors driving out a rival. This kind of pooling of skills is very hard to obtain when you have, as you do in the U.S., doctors associations that would see it as a threat, an encroachment on their professional turf.

To weaken doctors in the U.S. system would probably weaken healthcare, since the kind of preventive service presented in France depends on state funding. It won’t make a go of it if it depended on the private price system – that would soon price out a significant portion of the population. Unless the argument is, people shouldn’t have health care unless they can afford it out of their own pocket – which is the really honest conservative position, and one that would be overwhelmingly rejected by the population – a state supported system is preferable on every level.

Of course, the U.S. has one – the inefficiency of the U.S. system is caused by the runarounds and contortions that are necessary, purely on ideological grounds, to make the profit system and the public system (and public expenditure on health care is huge) both work. Bush’s pill bill is an example of this dysfunction – a huge public expenditure that is also designed as a gimme to big pharma, since, amazingly, the U.S. outlawed its own ability to negotiate drug prices. As so often, what is hailed as the triumph of free enterprise is actually the thinly disguised triumph of corruption.

Though, of course, there are many other variables, like specifics of the political system, etc. The US has a problem in this respect – no proportional representation and consequently no meaningful political parties.

I suppose he could hedge it further by saying that he didn’t mean it would imply a net cost increase relative to the “other developed countries” of which he spoke, but that’s just weasel words.

Your point is broader, true, but it is still contingent essentially on the differences between US and other nations’ professional associations’ power to enforce regulatory capture, and I am frankly unconvinced. The model of professional accreditation seems broadly similar across all of them, but there are some very very very big differences in other aspects of resource allocation and pricing. While it’s always good to look at things like this, it’s asking a bit much to expect it to be even a second-order concern when compared with the other major aspects of spending variation going on in modern health systems.

Certainly the health policy wags I have spoken to are aware of the way in which these professional associations skew the debate, but they at least partly value it, I think, because these associations have a lot of sensible and important things to say, and you just have to balance their positive role in the health system against their desire to protect their members’ interests.

Before I’d even dispute the claims, here, about the comparability of how nations stratify their medical talent sets, I’d have to say that you have to do your logic over, since as this sentence stands, it is certainly not an empirical proof of anything. Professional associations could, of course, still drive up costs, but nationalized health care could still be cheaper simply due to massive savings on getting rid of the intermediate insurance bureaucracy. To claim that labor is the only cost driving up health care prices is, of course, not my claim.

It isn’t stated very well. There are alternatives, so the question is whether there’s a better alternative. Is it better to leave things unregulated so the regulators won’t get captured? Will rich bad guys have less influence that way?

Here’s an example I know a little bit about. It used to be there were “small loan” companies. My father explained that it was a good thing to have them because the alternative was people would borrow from the Mafia at something like 20% interest a week. These companies provided loans mostly to lower-middle-class people who needed a little extra money. Like, a man needed surgery and he’d be out of work for a couple of weeks without pay, so he needed a few hundred dollars to tide his family over. After he was back at work he could scrimp and pay off the loan. The system was heavily regulated. They couldn’t charge more than a set interest rate, for example.

But the regulation also carefully limited the number of small loan companies that could set up shop in a particular area. Small loan companies were pretty much guaranteed to be profitable because they were an oligopoly. They competed for customers with advertising etc, but there was guaranteed to be more than enough business to go around.

When it wasn’t regulated you got the Mafia. When it was regulated you got something that was supposed to protect customers and lenders both. How well did it do?

Well, at one point there was a financial crisis and the prime rate went above the legal rate for small loans to lend money. They did better to put their money into CDs than lend it out. Bad times. I guess that small loan companies were just not rich enough to do enough regulatory capture enough to survive.

Instead, these days I think that the well-documented problem of regulatory capture is just an argument in favor of designing good oversight systems, monitoring them, updating as necessary, and being as consistent as possible with punishments that count. (Like what I’m told is practice in some Scandinavian countries, of fines defined in terms of fractions of annual income.) And this would be true in any system where honesty is valued.

But in that case I notice I like you a lot better.

Any industrialized society would “…require.. a [more] advanced infrastructure in order for it to work…” than an agrarian one. I am sure that GOSPLAN and its associated state enterprises were sufficiently more elaborate than whatever the Inka empire had that one could assert a difference in kind, rather than a difference in degree. If you believe that a certain “advancedness” of a certain type of political, judicial and administrative infrastructure is what distinguishes one ism from the other, then we would have to say that people are being anachronistic when they say that the Inkas had “central planning” .

If we are going to apply present day categories to the past at all, then Temin’s approach towards defining a market economy seems reasonable to me: Of three forms of provision and distribution – (i) reciprocity; (ii) redistribution; and (iii) exchange – did exchange predominate? Is the test that Temin sets up what you do not find convincing? Or is that you do not believe the evidence he has marshalled supports his conclusion?

Macchiavelli also advocated a virtuous society. Practically everybody does. It takes a special kind of mind to claim that society is better off when we all go after our own short-term best interest and lie about it.

So how do you create a virtuous society? The thing I’ve seen that works best is to start up some great goal that people buy into. That works for awhile. Like, NASA had a bunch of people knocking themselves out to get results. They got results. But now NASA is a bunch of old guys waiting for their retirements, trying not to rock the boat, making sure they’ve done enough review and testing that if anything goes wrong it won’t be their fault. They still do pretty competent work but the spark is dimmed.

For a little while the USSR had people working very hard for little immediate reward because they wanted to create a great society for their grandchildren. Once they saw it wasn’t working they pretty much gave up.

You do a lot better toward creating a virtuous society by inspiring people with a great goal than you do by killing the worst offenders. But nothing seems to work reliably.

You say that dentistry would be improved by opening up the market to non-dentists but again, it’s not that simple. Dentistry in Japan is done by dentists and it is very cheap. In the UK dentistry is available to the poor and middle class on the NHS, so if they aren’t getting it (an assertion I would suggest is unsupportable in fact) then the reasons probably aren’t much related to a closed shop system.

This claim about costs being driven up by the “closed shop” of professional associations is just empirically wrong. Every country with nationalised healthcare has these associations, and every country with nationalised healthcare pays less than the US for its healthcare – considerably less. Within these nations there are variations in spending and quality of healthcare which just cannot be explained away by the very small differences in doctor monopolies which exist between them. Even in the UK the amount spent by PCTs (English health authorities) on particular specialties can vary threefold, and isn’t well explained by differences in disease prevalence.

You need to find a better explanation for the problem than that.