Eugene: You say: "Maybe everyone already knew this but it just occured to me that medicine is analagous to labor intensive industries, like hair dressing. It is a one-to-one experience, so for the basic hands-on work it is difficult to make productivity gains. Of course productivity gains are not impossibe, just more difficult than for, say, stock brokering, where a security analysis by one individual can be sold to thousands without much extra expense than selling it to one."
Perhaps physicians in primary care have the possibility of engaging one-on-one as the 'owner' of a small industry. However most of them are like hair dressers, however perhpas not in the sense you appear to state. They are both are in a petit bourgeois situation. They have some control and may even employ a couple of people, but are not 'big' employers. But, many have over the decades recently, been transformed into a situation analagous to that of a worker in that their decisions are subject to intense oversight and their work conditions are out of their control. Of course their salary in these HMO situations is higher... however they are not in control. Most physicians in tertiary care are definitely not in control, being subject to oversight by their universities or hospital administration. Nonetheless they have a degree more freedom - because they are perhpas more 'qualified-degreed', and they are fewer. Objectively their situation, in my view, still reflects the more general petit bourgeois position of being pushed into a lower class, but their 'sensitivities' and their (for the time being) salaries pull them subjectively to a higher class viewpoint. Eugene goes on to say: "With medicine, doctors are sort of a priest or guild class, and with a tight control over entry, wages have been kept high. For nurses, and more generally nursing care, similarly a mostly one worker to one customer experience, the cachet of a priest didn't keep pay up." I do not know what you mean by a "sort of priest class". That old nexus you are referring to between a patient and doctor, I was still familiar with 30 years ago. It is not readily seen these days. Just as Marx pointed out the old relations of professions like the doctor's, are torn asunder by the bourgeois order. And you then ask: "So, for those thinking deeper into the medical business than I am, what is the model going forward? There is a demand for medical care that holds up, especially when you want to keep yourself alive. And lots of technological advances in drugs and electronics. But how to pay for nursing and doctoring? Or is that becoming a shrinking part of total cost?" As Virchov pointed out long ago, and as the bioengineers in Victorian England understood: the big pay-off is in prevention. For my part, I think this is still true. There is so much in this old truism that cannot be quickly brushed off. The Scandinavian systems have an abundance of concrete examples. Ther are both reformist and revolutionary extensions to this strand of thinking. As for "costs".... Cost of drugs? The answer seems clear to me: nationalisation (under a capitalist system); and reorganisation of the FDA that currently appear to favour the drugs industry; Cost of High Tech medicine: Demand proof of efficacy before (i) making services widely available and (ii) making any of them reimbursable. Cost of labour power needed to run the system? It seems to me that this is under control in various countries that I am familiar with such as the UK, Germany and Canada. Again there are reformist and revolutionary extensions of these lines of thought. I here refer to Jim's reply to you, that doctors know a lot about the medicines they prescribe etc. Regrettably that is not true in my view. the practice of what has come to be called Evidence Baed medicine is still somewhat rudimentary when confronted with teeh daily practical difficulties faced by a busy clinician. By the way I still have major difficulty with so many of the writers on this list who simply decry the piteously small steps of the current reform. I must also repsectfully disagree with the PNHP - for whom I have the utmost respect. Sure - the current tiny steps are far from a single payer situation. But I still find it inconcievable that they are not of some benefit to the people who are currently not covered. As for the cost to the family, what is being painted out transparently as a true cost, is in Western Europe hidden as a non-transparent tax. As for the wail that somehow Obama is 'betraying; his mandate - tell me if anyone expected this lackey of the ruling class to do otherwise? You are calling for a reformist to perform a revolutionary act. I think that is akin to what in an older jargon, was termed an 'impossibilist' demand. To get single payer is in fact, I think - having watched the shennanigans for the last couple of years, a demand that requires a mass movement and is in the USA, almost - if not fully - a revolutionary demand. Respectfully, Hari Kumar
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