The Health Care System and the Guilds

There can be no question that the American health-care system has tremendous problems. We spend almost as much per capita in public funds as do the Europeans, but we do not have universal service. We spend a greater amount in private funds, yet we do not have free market in medical care. It is almost as if someone deliberately designed a system that combined the worst features of socialism and capitalism into one Rube Goldberg operation. We spend more than any other country in the world on medical services, yet the results are near third-world levels.

The debates on this issue usually take place within this framework of “free market” vs. “socialized” medicine, yet the system we have is neither and both. It cannot be a free market system because the supply of medicine and medical services are limited by licenses and patents. Milton Friedman advocated abolishing the licensing of doctors altogether. Friedman argued that medical licenses restrict the supply of doctors and thereby raise the cost. He believed that the free market would judge medical competence better than any license board, rewarding the competent doctors and punishing the incompetent.

The problem with Friedman's argument is that we have already tried that. Right into the early 20^th century, doctors were unlicensed; they took perhaps one to two years at a local medical college, usually a for-profit institution run by local doctors who lectured at the college. After their course of lectures, and without ever having touched a microscope or a cadaver, they set up as doctors. The results were disastrous, as became evident in the great Spanish Influenza pandemic of 1918. After that, the move to improve education and require licenses gained public support to produce the system we have today, a system largely controlled by the American Medical Association (AMA).

Further, a free market solution depends on the availability of information and the ability to judge that information. In comparing doctors, information about them is hard come by, and even if I had such information, I would not be able to make an informed judgment. And if I am having a heart attack, I am in no position to do the comparison shopping that a free market requires.

Yet for all that, Friedman has a point. By limiting the number of doctors, we restrict the supply and raise the cost. Further, the education of a doctor is long, arduous, and expensive. New doctors are frequently burdened with huge education loans, and setting up a practice requires a huge capital investment. This forces doctors to act more like businessman than medical professionals; they have to turn a large profit just to break-even on both their costs and the amount of income forgone while they were getting their educations. And it has frequently been charged that the AMA restricts the number of “slots” in medical schools so as to further restrict supply.

I have previously dealt with the problem of licenses (see Sicko-phancy). Instead of a single license requiring many years, and hundreds of thousands of dollars, I propose a series of licenses: midwife, nurse practitioner, medical practitioner, medical doctor, medical specialist. This would vastly expand the supply of medical personnel and thereby lower the cost. However, this can only be a partial solution. Doctors, whatever their license level, still face tremendous problems with medical insurance. And likewise the public faces similar problems. The cost of medical care is so high that nearly everyone needs insurance, but the insurance companies do their best to limit the claims they will pay. And there is still the problem of who gets to grant the licenses, no matter how many levels there are. Would not the AMA exercise its influence on governmental agencies to keep the supply as low as it is today, and the price as high as possible? And how to address the problems of the high cost of medicine and medical equipment, like MRIs?

Can we take away the power from government and still have an effective medical system? Must we be mired in socialism, or should we return to the free-market chaos of the 19^th century? I believe that there is a better way. I believe that the answer lies in a well-tested institution from out past, and that institution is the guild. The guilds were associations of professionals in a given field who took responsibility for the training of their members and the quality and price of their products and services. They were the sole judge of the qualifications of their members, and had the power to set both standards and prices. What I propose is that we allow medical professionals to form guilds with the power to grant various licenses. They would be the sole judge of the qualifications required, and they would set the practice standards and prices. But most importantly, the guild would stand surety for its members. That is to say, when a patient had a complaint, he would sue not the doctor but the guild. The guild would be responsible for the competence and good conduct of its members.

You might ask, “why would one doctor stand surety for another?” But in fact, this is what already happens in malpractice insurance. Insurance is merely cost averaging. If the losses go up for one doctor, the rates for every other doctor in that insurance pool goes up. But doctors have no control over who is in their insurance pool; the quack and the competent get thrown in the same insurance system, with the later required to pay for the former. In a guild system, the guild would have a strong incentive to ensure the competence of their members and monitor their practice standards; they would want to weed out the incompetent or downgrade their licenses. The guild would purchase insurance for all its members, or even provide the insurance itself, thereby removing the profit motive and lowering the cost.

Since the guild would be the sole judge of the qualifications and practices of its members, there would be a greater diversity of practical approaches. The Guild of St. Luke, for example, might favor one approach to medicine, the Galen Guild might favor another, and natural competition and practical experience would be sufficient to discover the superior approach. And while it might be difficult for the public to judge one doctor against another, it would be easier to judge the performance of one guild versus another. Further, this also provides space for “alternative medicine.” I have no way to judge whether such things as acupuncture or Chinese herbalism are medically valid. But when joined in a guild and required to stand surety for each of their members, practices which do have some value would likely thrive, even if traditional medicine does not, as yet, recognize their value. And if they have no value, it is likely that such practices would simply disappear because the insurance claims would bankrupt them. Likely the government would still have some minimal role to prevent outright quackery; they would not likely allow a Guild of Peach Pit cure-alls.

The guild would also provide a career path for its members. As it is now, student spends the better part of their youth and a great part of their future earnings in getting an MD. But with a guild with a multiple license structure, they could enter as nurse or medical practitioners, practice medicine at some level while continuing their training for higher levels. This would give them both an income stream and practical experience in their trade. It would be a kind of “apprentice” program.

In addition to insuring their doctors, the guild could offer insurance to the public. That is, they could offer to treat people for a fixed annual fee. This would give the guilds an income stream, but also a great incentive to insure that small problems do not go untreated to become big problems. In other words, such health insurance would actually be concerned with insuring health rather than denying claims. Further, the guilds could be required to devote a certain amount of their resources to free or low-cost care for the impoverished or indigent. The government might play a role here in qualifying people as eligible for such reduced-cost treatment.

The guild would be empowered to establish its own clinics, its own training and education programs, its own pharmacies, labs, administrative structures, and whatever else is necessary to medical practice. This would also make it easier for medical professionals to enter practice without worrying about setting up the business and administration that consumes so much of doctor's time today.

Of course, the complete solution to the problem cannot be found without breaking the monopoly power of prescription drugs and medical equipment. I have already outlined an approach to this in the aforementioned Sicko-phancy. But I believe that the guilds can also play an important role here, especially in the testing new drugs and negotiating prices. Drug companies would no longer have an incentive to “bribe” doctors to prescribe their patent medicines, since it would be the guild and not the individual doctor who establishes standards for medicines and judges their effectiveness. The collective judgment of the guild is likely to be superior to the individual judgment of any given doctor, especially when that individual judgment is influenced by “gifts” from the drug companies, as it is now.

Now, I will not pretend to my long-suffering readers that I am an expert in medical economics. I welcome any critiques or refinements that those more qualified than I am can offer on these matters. But I will assert that there are some principles which hold no matter what the system, one of these being that the incentives will dictate the outcomes. And the current incentives—for doctors, insurance companies, the AMA, and others—are all wrong and cannot be repaired in the current system. Every solution now on the table in the public debate will likely only make the problems worse.

What I will assert is that sometimes our best future is in our long past; that methods that have been tried and worked, but for some reason were abandoned, can be re-worked to answer current conditions. I believe that it is the essence of both the progressive and the traditional to find what has worked, and to adapt it to the present moment.