A lot of the trouble with licensure is that it tends to ratchet upwards. If I'd been forced to spend $20,000 getting licensed as a barber, I'd be mad if a competitor opened across the street without having spent all that money. Repealing licensure requirements benefits everybody except the people who've already gotten licenses.
This is true. Part of the reason doctors have high salaries (and healthcare costs are high) is that the AMA issues licences and creates scarcity. In this sense, they perform a similar function to a union.
It does seem like an outdated way to see if a doctor is good or not. I'd personally find a recommendation from a friend or a bunch of positive reviews on yelp a lot more convincing than the mere fact they have a license to practice. It's pretty likely hospital administrators and others would be able to determine which doctors were good without a licensing practice (just like we find good programmers without licensing), and they have strong incentives to do so.
I'd personally find a recommendation from a friend
You would, but so would a bunch of stupid people with stupid friends. I think licensing doctors falls into the same category as mandatory school attendance, i.e., stopping people from hurting ourselves so they don't drag us down with them. To think we worry about doctors following decades-old traditions instead of evidence-based medicine, or being influenced by drug companies. Those are good worries to have! It could be a lot worse. Everyone knows you're supposed to see a doctor when you need medical care, got to take your kids to the doctor when they're sick, etc. That magic word "doctor" results in people actually getting competent medical care instead of going to a faith healer or an herbalist, which is what they'd do if anyone could call themselves a doctor and people had to discriminate for themselves.
Let people screw themselves all they want if it doesn't screw me, but we should take some measures to make sure people get more competent medical care than they would be able to choose for themselves, just like we force them to educate their kids instead of putting them to work full-time when they're eight.
Mandatory schooling has nothing to do with ensuring education and everything to do with ensuring dogma and a uniform and compliant citizenry. You need only look at the flag salute and the various rituals that have nothing to do with education to see it. Education is not mandatory, only schooling.
If mandatory schooling was about education then why can't parents take their education dollar to any certified provider?
Uhhh-huh. So if that's the case why do they waste so much time teaching you science and mathematics and ancient history and foreign languages and so forth when they could just be having four-hour flag-salutin' sessions?
Not everything needs to be a vast conspiracy, y'know. Some things are slightly screwy despite the best of intentions.
There are a couple encouraging signs in medicine. First, a lot of doctors advertise that they're board-certified. That's a voluntary, private certification that attests to the doctor's competence and has more rigorous requirements than state licenses do. Without licensure, there's every reason to think that private certifications would take on even more importance.
Second, the market is steadily routing around physician's monopoly on the practice of medicine. There's sverything from questionable stuff like acupuncture and chiropractic to nurses and PAs doing things that only doctors used to be allowed to do (e.g. prescriptions, minor procedures), and those trends seem to be accelerating.
> I'd personally find a recommendation from a friend
Plenty of people already use that method. And a lot of them go to see homeopaths and chiropractors based on that. Can you image what would happen to those people if they had to use recommendations from friends when they had actual medical problems that require actual doctors?
Just last month one of my friends with a debilitating back condition that forced her to spend many days in bed was told by medical doctors that she needed surgery to get rid of the pain. On the advice of friends, she went to a chiropractor and got immediate relief. The chiropractor solved her problem without surgery. Medical doctors have their place, but so do other healers.
But, there is going to be pressure on those that make the judgments. What happens when someone figures out how to game the doctor rating system? I'm just very risk averse when it comes to surgery (and I want my doctors to be vetted by experts in their field, as well as my social circle).
And you're absolutely right to be risk averse. That's why if you needed major surgery, you'd go to a reputable hospital and not to some clinic above a grocery store.
The hospital in this case is a middle man, and their role is vouching for the doctors they hire. When you buy a propane tank at Home Depot, the reason it doesn't blow up is that Home Depot's reputation depends on selling non-explodey propane tanks. When you buy meat at Whole Foods, why are you sure it's not rotten? Because the government checked that specific steak, or because you know Whole Foods wouldn't sell you rotten meat? Similarly, the reason people go to reputable hospitals is precisely because they know they can trust those places to hire competent staff.
While this isn't your central point, I'm pretty sure the reason Home Depot's propane tanks don't explode is not that Home Depot is concerned for their reputation and therefore takes all necessary measures required to avoid a rather infrequent problem, but that propane tanks and their handling are, in fact, regulated by government, and that those regulations codify best practices for infrequent events.
A purely free-market, reputation-based system of behavior works well for frequent events, but fails miserably for infrequent events, and that's why regulations are necessary.
In other words, and more snarkily, the assumption that Home Depot hires competent staff is probably not sufficient to protect you from explosion.
Home Depot doesn't have to train their staff to inspect propane tanks, they only have to make sure they buy from a supplier who provides good propane tanks. But of course, since propane explosions can easily hurt bystanders, and "Fred's Discount Mailorder Propane" doesn't necessarily have as many incentives to ensure safety, so in this case I would say regulation is a good thing.
But there are cases where dangerous things aren't regulated by the government and it still works out pretty well, like roller coaster rides. In that case insurance companies actually play a big role in disseminating industry best practices.
In cases where companies produce danger for people other than their customers we shouldn't expect them to necessarily be responsible without government oversight - like with pollution. And in something like a hospital where people tend to die even when the hospital does everything right I wouldn't expect people to be able to differentiate between good and bad hospitals well enough - and the evidence I've seen is that people don't currently choose hospitals based on how good they are even with the government publishing statistics on the matter. I can easily imagine that in a totally unlicenced market the problem would be worse.
The government does regulate the safety of things like propane tanks, but major retailers, Home Depot included, usually have merchandise quality standards well above what the government mandates. That's suggestive (though not conclusive, I'll admit) that it's Home Depot, and not government safety standards, that keep you safe when you shop at Home Depot.
Are you really gonna rely on a bunch of reviews on yelp to tell you which doctors are competent? I don't even trust yelp reviews to tell me which restaurant to go to. Everything seems to have 3.8 stars...
"The average physician's net income declined 7 percent from 1995 to 2003, after adjusting for inflation, while incomes of lawyers and other professionals rose by 7 percent during the period."
"...none of this really matters, because doctors' salaries aren't a large enough chunk of health care spending in the United States to make a difference. According to Reinhardt, doctors' net take-home pay (that is, income minus expenses) amounts to only about 10 percent of overall health care spending. So if you cut that by 10 percent in the name of cost savings, you'd only save about $26 billion. That's a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors' offices, and advertising for drug companies. The real savings in health care will come from these expenses."
The rest of your comment is incorrect as well. The AMA does not license physicians, state governments do. Many physicians don't even belong to the AMA. The AMA lobbies for physicians, but it's not in any way like a union (not that there's anything wrong with unions).
Resident physicians in particular would probably lead better lives if in fact there were something like a union to limit hospitals and training programs that have traditionally worked these young physicians upwards of 100 hours a week for what amounts to minimum wage. Resident physician hours and primary care doc hours are still onerous, and most are paying education debut averaging $150,000.
Physicians can practice without any involvement with a hospital, and many do. In any event, the idea of using hospital CEOs or CFOs to determine "good" doctors is about as misguided as asking British Petroleum to determine "safe" drilling engineers.
There is a reason for (some) licensing. We tried the adolescent libertarian fantasy of letting the "free market" drive things like medical training and licensure back in the early days of the 20th century. You could characterize the vast majority of medical education in that era as training in quackery, before people like Abraham Flexner got involved:
The AMA is totally a guild and its primary mission is to limit the number of people able to practice of medicine, thereby driving up doctors' salaries. They don't need to organize as a formal union because the federal government actively sets the number of doctors in the U.S., so they can manipulate public policy instead.
I can tell you first-hand that AMA lobbied hard to reduce the number of medical school slots in America, there actually was an AMA-backed federal program in the mid-1990s that paid schools for the lost revenue from being forced to admit fewer students! The AMA also works to prevent nurses and midwives and the like from performing simple medicine and competing with doctors.
You're completely wrong.
"The average physician's net income declined 7 percent from 1995 to 2003, after adjusting for inflation, while incomes of lawyers and other professionals rose by 7 percent during the period."
http://www.nytimes.com/2006/06/22/business/22doctors.html
"...none of this really matters, because doctors' salaries aren't a large enough chunk of health care spending in the United States to make a difference. According to Reinhardt, doctors' net take-home pay (that is, income minus expenses) amounts to only about 10 percent of overall health care spending. So if you cut that by 10 percent in the name of cost savings, you'd only save about $26 billion. That's a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors' offices, and advertising for drug companies. The real savings in health care will come from these expenses."
http://www.slate.com/id/2227965/
Interesting data, but the question is if licensing scarcity increase salaries than without. The salary decrease in 1995 to 2003 doesn't tell us anything other than.....net income decrease.
The rest of your comment is incorrect as well. The AMA does not license physicians, state governments do. Many physicians don't even belong to the AMA. The AMA lobbies for physicians, but it's not in any way like a union (not that there's anything wrong with unions).
Would it be possible that AMA effectively limits licensing rate through their lobbying?
There is a reason for (some) licensing. We tried the adolescent libertarian fantasy of letting the "free market" drive things like medical training and licensure back in the early days of the 20th century. You could characterize the vast majority of medical education in that era as training in quackery, before people like Abraham Flexner got involved:
Interesting data, but not enough details to support your statement. We need more details on what kind of reforms were made, privately or governmental.
Logjam's comments on the Flexner repor are widely accepted to be true. If you're not familiar with it, it's worth reading the wikipedia article on the subject. Pre-Flexner, it was a dangerous, anything-goes world.
It's interesting that you mention Friedman, in his series Free to Choose he outlines the AMA position against paramedics. It seems quite funny now but if you think about it it really outlines a larger issue with the AMA and the Hippocratic Oath. If you read most of the oath it's really about dividing up healthcare into monopolies.
Actually, Milton Friedman famously (and impressively persuasively) did oppose mandatory licensure of doctors.
Can you summarize what his argument is? Can't we count on some upfront testing that will weed out the people who clearly cannot call themselves doctors? Is testing the same as licensure?
He argues that private certification organizations (think Consumer Reports, but for doctors) are a more reliable and versatile way to see how competent a doctor is, and also that hospitals and clinics have an incentive to only hire competent people.
The rebuttal would be "Fine, but certainly state licensure can't hurt. It's just a backup." He says that it does in fact hurt, by allowing the AMA to control the supply of people who get to practice medicine. This limits patients' options w/r/t how, from whom, and for what price they can get medical care.
E.g. suppose I find a competent, well-trained nurse to remove a mole for me. The nurse and I agree to go ahead for $100. Friedman says that it's a) morally wrong and b) inefficient for the government to barge in and say, "No, for your own safety, you're not allowed to make this voluntary agreement. You have to have a doctor do this. Oh, and it'll cost $300." That's the effect of a law that says only licensed physicians are allowed to remove moles.
My rebuttal: private certification organizations that, over time, reduce the effectiveness (strictness) of their testing because they are (e.g.) afraid of getting sued (libel, slander, discrimination, etc) by people that have been denied.
Also, there's a countervailing ratchet effect where if anyone is harmed by someone with a licence who should have known better the standards become more strict. We've seen a lot of this in medicine over the years.
And, because they're paid by those they certify, they have an economic incentive to have certification standards as low as they can without the public rejecting them completely; not a good idea.
We have much the same situation with examinations boards for school leavers in the UK. A competitive market for examinations providers and schools incentivised to maximise pass rates has unsurprisingly led to grade inflation as each board tries to 'best serve their customers'....
But, as the Wall Street Journal has doggedly pointed out,
America’s Licence Raj has extended its tentacles into
occupations that pose no plausible threat to health or
safety—occupations, moreover, that are governed by
considerations of taste rather than anything that can be
objectively measured by licensing authorities. The list
of jobs that require licences in some states already
sounds like something from Monty Python—florists, handymen,
wrestlers, tour guides, frozen-dessert sellers, firework
operatives, second-hand booksellers and, of course, interior
designers—but it will become sillier still if ambitious
cat-groomers and dog-walkers get their way
Handymen, frozen-dessert sellers, and firework operatives all plausibly involve health or safety concerns.
Where in the US do second-hand booksellers need a license?
I suspect that they may be counting for some of these requirements to have a business license, rather than any license tied specifically to the occupation. They may also be mixing up requirements to be licensed with requirements to be bonded.
"Even in this age of Amazon.com and impersonal warehouse bookstores, many people still appreciate the intimacy and service of a local and independent used bookshop. Unfortunately, they are a dying breed, and Los Angeles is doing everything in its power to make them extinct. Used bookshops—or “secondhand book dealers,” as they are referred to in the municipal code—are among the 53 categories of business that require a police permit. [109]"
"In addition to complying with the general police permit regulations—e.g., submitting to fingerprinting, paying the applicable permit fee ($263), etc.—they must comply with occupation-specific regulations that create administrative nightmares for purveyors of used paperbacks. [110] For example, every time a used bookshop purchases or receives books in exchange, it is required to “ascertain that the person selling or exchang[ing]” the books “has a... legal right to do so,” then execute a consecutively numbered bill of sale for the purchase or exchange. [...] The Police Commission, in turn, has its own set of rules governing used bookshops. Amazingly, they require that bookshops thumbprint every person from whom they receive a book and file a daily report with the Police Department describing all books taken in that day. They also require used bookshops to hold books for at least 30 days before selling them. [112] Apparently on an ad hoc basis, these requirements are waived for some shops. [113]"
IIRC, In the early 90's, a Columbus, Ohio (OSU Campus) textbook seller named SBX (Student Book Exchange) was referred to by students as the "Stolen Book Exchange". Snatching a student's backpack and selling his books to a used textbook store was a simple, profitable form of crime.
Perhaps LA subjects used bookstores to regulations similar to those imposed upon pawn shops?
[Note that I'm not arguing either in favor or against these regulations. I'm merely suggesting that they are more rational than they might at first appear.]
I can learn programming on my own (through books or Internet) and get a employment as a programmer working on business critical systems and I do not need to get any license from anyone. But hey, if I want to cut someone's hair, I need to pay my dues to the state?
I think for non medical businesses, the licensing requirements should be removed. We save tax payer's money and there could be more competition in the market place which will benefit the consumer. [And don't worry about protecting the consumer, once you get a bad hair cut from a salon, you will announce it to the world (thanks to the Internet) that the hair salon is bad and you will never visit that place again. Market forces will take care of the crappy businesses.]
Barbers are actually one of the traditional license-requiring occupations going back centuries, because one of their main jobs used to be shaving men with straight razors, which carried a risk of injury or disease if the barber was poorly trained, or if the equipment was poorly disinfected. It might admittedly be a bit obsolete now.
While modern clippers are less likely to draw blood, that only means they're less likely to transmit bloodborne illnesses. But there are plenty of other diseases that they can transmit.
Wait, what diseases? And are the risks worse than those involved with food preparation or janitorial work (both unlicensed)?
EDIT: Lice, obviously, but that's both treatable and not particularly dangerous.
Here in Washington state you do need a food handlers license just to wash dishes in a restaurant. It's not especially onerous, something like $15 to take a fairly simple test. (And even for the lowest-wage employees I imagine most Restaurants will eat the cost of licensing without complaint.)
And I think it's the general assumption that you don't need to worry about disease in a salon that merits the higher barrier of entry to getting a license than a Janitor, where everyone knows that if there's a bunch of human-sourced fluid on the ground, you need to be careful.
Barbers still use straight razors these days (at least mine does! If yours doesn't, find one that does, it's a treat!), and other implements that can cut you.
I was under the impression barbers/hair salons needed licensing for the disease transmission aspects of that job, which can actually be fairly serious.
Whereas a florists license in Louisiana was defended with:
"The state now maintains that regulation is necessary because consumers often phone in orders for third parties and never get to see what they've paid for." [1]
I'm not sure how anyone could defend something like that with a straight face.
This is a frequent pattern in many contexts. A wave of immigrants gets demonized, they integrate over the course of a few generations, and then they turn around and demonize the next wave of immigrants. A school of art or literature survives the scoffing of the old guard, only to become the old guard themselves, et cetera.
I'm not sure why wrestlers, tour guides and handymen need to be licensed, but many of the professions the author highlights genuinely should be licensed.
The main profession the article picks on - interior designers - seems to be misunderstood by the author.
He incorrectly insinuates interior designers only choose fabrics and colors. In fact, interior designers are professionals who have completed training in space management, ergonomics and architecture. They are able to recommend structural changes that could, if designed incorrectly, cause structural damage. Interior Decorators, who in fact are NOT licensed, are limited to choosing fabrics and colors (so to speak). More info: http://www.schools-of-interior-design.com/Interior-Design-vs...
Some of his other examples:
Frozen desert sellers - I hate to bring out the '...but think of the children argument,' but seriously, do you know if the grungy dude in the van selling ice-cream to your kids knows how to handle food safely? Has a criminal record? Has 12 DUIs?
Firework Operators - their job is to set off large explosions close to large crowds, occasionally indoors. I, for one, don't have a problem making sure they know what they're doing.
So the author may have a valid point, but his poor choice of examples does not support his case well in my opinion.
It seems clear that if someone is going to recommend putting holes through walls, they should be appropriately educated and licensed. But I clicked through to your link, and it appears that the biggest difference is that interior designers are required to be familiar with various building codes and the like.
> Frozen desert sellers - I hate to bring out the '...but think of the children argument,' but seriously, do you know if the grungy dude in the van selling ice-cream to your kids knows how to handle food safely? Has a criminal record? Has 12 DUIs?
I fail to see the relevance of criminal records and DUIs to handling ice cream.
Criminal background checks are a common concern when licensing adults who work with children.
DUI history is a common concern when licensing occupations that involve driving niche equipment under challenging circumstances, such as a truck in a throng of tiny jaywalking pedestrians.
I see. Your definition of "working with children" is miles wider than mine. I take it you're also in favor of licensure and criminal background checks for people working in children's clothing stores?
If the law allows you to have a driver's license even though you have 12 DUIs, I can't see any reason why you shouldn't be allowed to drive a van.
As a counterpoint, here's the pro-licensing argument for interior designers from a friend's mother who is an interior designer in Florida: interior designers are distinct from interior decorators in that they often propose structural changes to buildings that, if done improperly, could compromise the integrity of the structure. Licensing interior designers is another layer of safety akin to a building permit for someone renovating their home.
but presumably you would still need to actually hire carpenters/architects and get a building permit to implement the structural changes. I don't think you should need to be licensed to make a recommendation.
I think that the implication is that the designer is acting as the architect, and just directly hiring the carpenters/etc. I don't know if this is true or not though.
Though not professional licensing, we had an example of the unintended consequences of licensing here (Minneapolis) when there was a proposal to license community gardens. Though the licensing would not be particularly expensive it would also mean gardens would require insurance, because the city would have liability if something happened at a licensed location (but as long as the city simply wasn't involved no one could sue the city). The result of course would simply halt these otherwise entirely non-commercial efforts, as much out of bureaucratic overhead as financial.
Thank goodness any form of licensing or certification never caught on in the tech community. Way too libertarian to let any of that sort of stuff stand.
On the flip side the worst that can happen in the vast majority of cases is that programs won't work (or maybe they'll even lose your data or leak it to the world). It's pretty rare that a programming error can kill someone.
There have been some interesting comments here since I posted this article just before I took my son to his soccer tournament. Now that I'm back, I see some commenters have suggested that some of the occupations identified in the submitted article as probably not needing state licenses (as indeed they don't need in many states) do need licenses. Those suggestions by my fellow HN participants are often made on the basis of hypothetical examples or imagined worst cases.
My own sister has formal training in interior design from a baccalaureate program at a state university, and she has pursued that occupation since graduation for more than two decades. I am aware from my sister's work in commercial interior design in a big city with skyscraper office buildings that some interior designers have somewhat of an influence on the safety of public spaces. But it's ludicrous to think that Florida's pattern of regulation of interior designers is in any sense motivated by public safety concerns. If there are such huge public safety concerns from interior designers not being state licensed, why do we not hear news stories from other states with different patterns of regulation about all the people who die from entering buildings that are owned by owners who hired unlicensed interior designers?
The experiment in federalism that has been going on in the United States offers a wonderful comparative laboratory of policies. Unfortunately, for reasons well explored by public choice theory,
lobbyists who divert attention from real-world experience to focus on hypothetical harms that could (maybe) happen if they don't obtain their favorite kind of special treatment. So I would respectfully suggest to my fellow HN participants that if someone wants to make a case that some occupation (e.g., hacking to build web-based SaaS businesses?) should be regulated by state-issued licenses, the persuasive way to make that case is to refer to detailed statistics about actual benefits or harms to the general population, rather than referring to imagination or common fears.
P.S. The one time I had to shop for a surgeon, for my wife, I asked my mom, an operating room nurse who has worked with some world-famous surgeons, to help me find the best doctors in town. That she was readily able to do. People always work the best network they can for the other people they care about most, and life will always be this way, regulation or no regulation. My wife had a completely uneventful and full recovery from her surgery.
What the British author of the article should point out is that the US states determine how and what professions are licensed. Some US federal laws and regulations require licensure in a profession in federal domain, but those requirements are determined by the state (e.g, Arizona CPA licensure has greater school credit requirements than a Georgian CPA).
IIRC in Ontario (Canada), you need a license to serve alcohol, though I believe it's basically just a series of classes to make sure that people all have a baseline level of competency in things like "determining if someone is too drunk" or stuff like that.
Actually, Milton Friedman famously (and impressively persuasively) did oppose mandatory licensure of doctors.
http://www.fff.org/freedom/0194e.asp
A lot of the trouble with licensure is that it tends to ratchet upwards. If I'd been forced to spend $20,000 getting licensed as a barber, I'd be mad if a competitor opened across the street without having spent all that money. Repealing licensure requirements benefits everybody except the people who've already gotten licenses.