Transaction Costs Killed the Medical Stars

Transaction Costs Killed the Medical Stars

Send us Fan Mail [https://www.buzzsprout.com/2186249/fan_mail/new] We try to make sense of a real problem many of us feel: paying a lot for U.S. healthcare while still waiting months to see a doctor. We trace how engineered transaction costs, from the Flexner Report to modern residency caps, restrict physician supply and protect price power while leaving clinicians overworked and patients stuck.  • getting “fired” by a health system and what it reveals about access  • why shortages don’t clear when prices rise, and how transaction costs block entry  • the Flexner Report as quality reform and supply restriction  • evidence of conflicts of interest and rushed methods behind the Flexner narrative  • Ruben Kessel’s puzzle on persistent price discrimination in medicine  • hospital privileges and county medical societies as cartel discipline  • why advertising bans and professional norms can function as anti-competition tools  • how residency caps and accreditation keep the bottleneck in place today  • a listener letter on data center payments as compensation versus bribes  • book of the week recommendation and a few parting thoughts  ************************************** As I note in the episode, thanks to Dr. Lance Stell, Davidson College Department of Philosophy (emeritus).  Lance offered this note about the epidsode: There's a footnote to the Flexner report. It killed the Davidson medical college - NC"s first. The school was founded by a DC faculty as a proprietary school. After 10 years operating on campus, it moved to Charlotte where it had a clinical relationship w/ the Good Samaritan Hospital - a black hospital, becoming the first medical school in the country to have such a relationship. I can send you an article about it written by Dr. Eddie Hoover, MD, a surgeon and Editor of NC"s black medical journal. Flexner execrated proprietary medical schools and it was his goal to "close them." His damning review of the Davidson medical School, renamed The NC Medical College, was successful. Thanks, Lance, I did not know that!  I added that link, below.  **************************************** Links: * The infamous Flexner Report:  http://archive.carnegiefoundation.org/publications/pdfs/elibrary/Carnegie_Flexner_Report.pdf [http://archive.carnegiefoundation.org/publications/pdfs/elibrary/Carnegie_Flexner_Report.pdf] * Hiatt and Stockton on the Flexner Report:  "The Impact of the Flexner Report on the Fate of Medical Schools in North America After 1909" [https://www.researchgate.net/publication/242724640_The_Impact_of_the_Flexner_Report_on_the_Fate_of_Medical_Schools_in_North_America_After_1909] * Hiatt: "Around the Continent in 180 Days [https://pubmed.ncbi.nlm.nih.gov/10191645/]."  * Hiatt: "The Amazing Logistics of Flexner's Fieldwork [https://www.jpands.org/hacienda/hiatt.html]." * Kessell, Journal of Law and Economics, 1958:  "Price Discrimination in Medicine [https://www.journals.uchicago.edu/doi/abs/10.1086/466540]."  * Eddie L Hoover, Catherine R Lewis.  2006.  Journal of the National Medical Association. "Good Samaritan Hospital and the North Carolina Medical College circa early 1900: the first major affiliation between a black hospital and a white medical college [https://pubmed.ncbi.nlm.nih.gov/19397232/]." * Ernest Jones, "The God complex" in Essays in Applied Psycho-Analysis [https://en.wikipedia.org/wiki/God_complex].  Earliest source I could find for the TWEJ:  https://www.netfunny.com/rhf/jokes/old89/godplay.840.html [https://www.netfunny.com/rhf/jokes/old89/godplay.840.html] PA data center story: https://www.thecentersquare.com/pennsylvania/article_3b615fd8-5d36-45c4-bfb6-4a3162104f0b.html [https://www.thecentersquare.com/pennsylvania/article_3b615fd8-5d36-45c4-bfb6-4a3162104f0b.html] Book-o-da-week:  Daniel Hannan, Inventing Freedom, Broadside Press. https://www.amazon.com/Inventing-Freedom-English-Speaking-Peoples-Modern/dp/006223174X/ [https://www.amazon.com/Inventing-Freedom-English-Speaking-Peoples-Modern/dp/006223174X/] IF YOU HAVE QUESTIONS OR COMMENTS, OR WANT TO SUGGEST A FUTURE TOPIC, EMAIL THE SHOW AT TAITC.EMAIL@GMAIL.COM [taitc.email@gmail.com] ! You can follow Mike Munger on Twitter at @mungowitz  [https://twitter.com/mungowitz]

Parasites And Property Rights

Send us Fan Mail [https://www.buzzsprout.com/2186249/fan_mail/new] BIBLIOGRAPHICAL NOTE:  The information in this episode comes from Red Flags Press.  Their main web site [https://redflagspress.org/] is very useful for research purposes, and I recommend it! We follow the idea of the “social parasite” through socialist writing and show how it shifts from moral accusation to an enforceable legal category once society claims ownership over individual labor. We argue that the transaction costs of monitoring effort and assigning “socially useful” work push real-world socialism toward surveillance, coercion, and punishment. • socialist critique of wage labor as work or starve • transaction costs as defining, monitoring, and enforcing property rights • the property rights switch from self-ownership to society owning labor • “from each according to their ability” as an obligation backed by force • socialist writers labeling middlemen and many professions as parasites • the party as the decision-maker when prices are suppressed • Joseph Brodsky’s trial as a real anti-parasite enforcement example • why the parasite problem expands and becomes politically arbitrary • how similar labor-claim logic shows up in authoritarian socialism and fascism • why Scandinavian social democracy is capitalism, not classical socialism The book of the week is Lenin’s What Is to Be Done? Burning Questions of Our Moment, and I strongly recommend it. Links: Red Flags, "Why Socialism Says Slacking is Theft." [https://redflagspress.org/wp-content/uploads/Why-Socialism-Says-Slacking-Is-Theft.pdf] Moments in Soviet History: The Trial of Joseph Brodsky [https://soviethistory.msu.edu/1954/whats-a-woman-to-think/whats-a-woman-to-think-texts/trial-of-joseph-brodsky/] Leo Huberman, The ABCs of Socialism [https://stars.library.ucf.edu/prism/69/]. "Soviet Era 'Parasites'" https://www.themoscowtimes.com/2016/05/20/soviet-era-parasites-return-to-todays-russian-a52934 [https://www.themoscowtimes.com/2016/05/20/soviet-era-parasites-return-to-todays-russian-a52934] IF YOU HAVE QUESTIONS OR COMMENTS, OR WANT TO SUGGEST A FUTURE TOPIC, EMAIL THE SHOW AT TAITC.EMAIL@GMAIL.COM [taitc.email@gmail.com] ! You can follow Mike Munger on Twitter at @mungowitz  [https://twitter.com/mungowitz]

Books Don't Bet, They Match

Send us Fan Mail [https://www.buzzsprout.com/2186249/fan_mail/new] We break down how sportsbooks function as brokers that match contracts, set prices through the point spread, and earn their living through the vig. Kevin Braig joins us to explain how law, technology, and property rights shape whether sports betting markets stay clean or slide toward corruption and bad incentives. • five reasons people gamble, from dopamine to positive skewness • what a sports bet is as a contract and why a book exists as a broker • how the 11-to-10 price and the vig work in practice • why point spreads are a pricing technology and a marketing tool • how street-level enforcement and local political capture governed bookmaking • why Nevada legalized betting and how phones and smartphones changed everything • the Coasean case for clearly assigned property rights between leagues and books • how prop bets and inside information can erode trust in games • why extreme taxes and licensing fees raise transaction costs and distort markets Judge Kevin Braig's book, "Bookmakers vs. Ballowners [https://www.amazon.com/Bookmakers-Ball-Owners-Demolition-Bookmaking/dp/B0D79HT2N1]" RH Coase, "The Problem of Social Cost [https://www.law.uchicago.edu/lawecon/coaseinmemoriam/problemofsocialcost]" Gustavo Dudamel's opera, "Wealth of Nations [https://www.nyphil.org/concerts-tickets/2526/dudamel-and-david-langs-the-wealth-of-nations/]" IF YOU HAVE QUESTIONS OR COMMENTS, OR WANT TO SUGGEST A FUTURE TOPIC, EMAIL THE SHOW AT TAITC.EMAIL@GMAIL.COM [taitc.email@gmail.com] ! You can follow Mike Munger on Twitter at @mungowitz  [https://twitter.com/mungowitz]

Hereditary Monarchy: At Least You Know Which Idiot Is Next

Send us Fan Mail [https://www.buzzsprout.com/2186249/fan_mail/new] Hereditary monarchy seems like a ridiculous way to pick a leader, yet it dominates most of human political history. We argue the reason is transaction costs: succession systems survive when they settle “who rules next” cheaply enough to prevent recurring civil war.  • Why hereditary monarchy is historically prevalent compared with democracy and universal suffrage  • Why “divine right” stories often rationalize a choice people already find tolerable  • Thomas Paine’s critique of hereditary succession and what it misses  • Hobbes on the state of nature as what happens when sovereignty is contested  • Succession as the master coordination problem of political order  • Transaction costs applied to elections, enforcement, legitimacy, and rent seeking  • Why elective monarchy can become an armed auction for total power  • Bright line rules versus discretionary selection and why speed can beat “better”  • How constitutional design lowers the cost of leadership transition when it works  • The legitimacy problem and why dynasties converge on endogamy  • The genetic consequences of endogamy and the Habsburg cautionary tale  • Twedges, book recommendation, and a listener letter on board game “math trades”  LINKS: Thomas Paine, Common Sense, February 1776 [https://www.gutenberg.org/files/147/147-h/147-h.htm] Michael Munger, The Ugly Pig, 20224 [https://www.econlib.org/library/columns/y2024/mungercapitalism.html] A.P. Martinich, Thomas Hobbes:  A Biography, 1999 [https://www.amazon.com/Hobbes-Biography-P-Martinich/dp/0521495830]. Thomas Hobbes, Leviathan, 1651. [https://www.gutenberg.org/files/3207/3207-h/3207-h.htm] Neal Schultz, Suicide Kings: Hereditary Monarchy, 2025 [https://substack.com/home/post/p-167221802] Tbadel Barter App [https://www.tbadelapp.com/] Cosmos Institute, Coasian Bargaining at Scale, 2025 [https://blog.cosmos-institute.org/p/coasean-bargaining-at-scale] https://www.tbadelapp.com/ UPDATE: An interesting, and more clearly articulated, application of the reasoning here.... https://aminga.substack.com/p/how-transaction-cost-economics-explains [https://aminga.substack.com/p/how-transaction-cost-economics-explains] IF YOU HAVE QUESTIONS OR COMMENTS, OR WANT TO SUGGEST A FUTURE TOPIC, EMAIL THE SHOW AT TAITC.EMAIL@GMAIL.COM [taitc.email@gmail.com] ! You can follow Mike Munger on Twitter at @mungowitz  [https://twitter.com/mungowitz]

Swollen Permits? Call Chile!

Send us Fan Mail [https://www.buzzsprout.com/2186249/fan_mail/new] Permits feel like “just paperwork”, until they quietly become the biggest barrier to building, investing, and even basic economic growth. We use Chile’s fight with “permisologia” to show how bureaucracy creates delay, uncertainty, and political risk even when the stated goal is safety or environmental protection.  • permits as transaction costs that quietly tax projects and entrepreneurship  • why bureaucracy is not the same thing as government and why it crowds out market coordination  • “permisologia” in Chile and how a one-stop shop becomes many counters  • parallels to India’s license raj and the logic of rent seeking choke points  • Dominga as a case study in shifting rules, scandal, and investment held hostage  • documented GDP and jobs costs from permitting delay and collapsed processing capacity  • Chile’s LMAS reform plan including deadlines, digitization, and sworn declarations with sanctions  • Parkinson’s Law, bike shedding, and why committees obsess over trivial items  • listener letter on commune life and how transaction costs show up inside “one big firm”  Links: What is  "Permisología"? https://comentarista.emol.com/2294117/27242033/Emol-Social-Facts.html [https://comentarista.emol.com/2294117/27242033/Emol-Social-Facts.html] Framework Law (LMAS):  https://www.bluefieldresearch.com/research/chile-takes-another-step-towards-mining-reform/ [https://www.bluefieldresearch.com/research/chile-takes-another-step-towards-mining-reform/] Parkinson's Law and the "Law of Triviality":  https://fs.blog/parkinsons-law/ [https://fs.blog/parkinsons-law/] Twin Oaks Community:  https://www.twinoaks.org/ [https://www.twinoaks.org/] IF YOU HAVE QUESTIONS OR COMMENTS, OR WANT TO SUGGEST A FUTURE TOPIC, EMAIL THE SHOW AT TAITC.EMAIL@GMAIL.COM [taitc.email@gmail.com] ! You can follow Mike Munger on Twitter at @mungowitz  [https://twitter.com/mungowitz]