On Doctor Pay, and Swedes
Noam Scheiber reports on our Bloggingheads back and forth, where in response to his argument that we could compensate doctors with prestige rather than money, I said:
We don't have a unified culture. There's no--Sweden can talk about having a Swedish culture, and to some extent a Swedish status hierarchy and Swedish values. That's just not true of America. Everyone's participating in about 97 different subcultures. So you can invent your own status hierarchy, but you can't get everyone to buy into the idea that we should pay our doctors $60,000 a year and then all love them a lot because they're doctors.
Scheiber writes:
I guess Megan's point is that Sweden has a more discernible status hierarchy because it's a much more homogeneous country. And it sorta sounds plausible (though I still think most people are inclined to respect doctors regardless of whether or not they belong to the same subculture--all the more so if they're satisfied with their health care).
But then, a day or two after all this, I stumbled across this item from Matt Yglesias:
An interesting fact about Sweden is that an extremely high proportion of its population is foreign born. It's not the highest in the world--Canada and Australia take the crown--but the foreign-born are a larger proportion of the population than in the United States.
A large number of those immigrants are from other European countries, but apparently Sweden has one of the world's largest Assyrian populations.
Hmmm. It turns out even Sweden doesn't have a Swedish culture.
I could be wrong--I'm certainly no expert on Sweden--but my understanding is that Sweden has a very high immigration rate because of its extraordinarily generous asylum policy. However, these immigrants are not particularly well assimilated, and are not really the people who become doctors in Sweden. Indeed, the non-Western immigrants to whom Matt refers seem to have a horrifically high unemployment rate. Second generation immigrants, particularly those who are not from Northern Europe, appear to have severe lagging income gaps with ethnic Swedes.
My impression is that the ethnic Nordics who have a higher probability of finding jobs as skilled professionals do in fact think of themselves as participating in a common Swedish culture in a way that is just not comprehensible in the United States. They talk about being Swedish in the way that an individual American might talk about being Jewish, or a Harvard grad.
In America, it's not just that we have a high percentage of immigrants right now; it's that all the previous generations of immigrants also created their own subcultures, as did the regional divides between north/south/west, the endlessly multiplying religious divides, and so forth. It's generally harder to substitute status for income outside of relatively closed and homogenous cultures, which is why small towns rely on volunteer firemen, and cities don't.
Matt Yglesias, who totally mangled what I said to interpret it as saying that income confers status on a profession--possibly true, but not what I argued--offers the Officer's Corps as an example of skilled profession that isn't particularly highly paid.
I'm not sure that it's an accident that the career military is so heavily drawn from hereditary military families, and white southerners, both of which place extraordinarily high status on joining the military. It's also true that officers have quite a lot of financial opportunities after they leave the military, but of course a lot of them are in it for honor rather than money. The thing is, being a high-ranking officer is so weird in so many ways that I'm not sure you can generalize it to any other profession--at least not unless you're willing to give successful doctors a few aides de camp, subsidized housing, and maybe a private plane.
But the main thing is that we can't just decide to offer doctors more status in exchange for lower pay. There's no one to "decide", and even if "we" did, a lot of people wouldn't go along with "we". Outside of the military, which seems to primarily recruit in a handful of subcultures, I'm not aware of a lot of professions which use status in lieu of pay to reward people who have many other opportunities. I mean, you can cite journalism or academia, but in fact, someone with a PhD in Comparative Literature is not foregoing scores of other lucrative job offers to take that tenured professorship. Academic specialties whose graduate students do have such opportunities, such as economics, law, and engineering, pay relatively well.
To expand that point a little bit, I think America's income inequality in general makes it harder to force down doctor pay. It's easy to deride this as saying that doctors are greedy--but the more relevant frame is opportunity cost. If people with strong science skills can earn, say, $150,000 in some other profession, you're asking them to sacrifice quite a lot for the privilege of becoming a doctor. Some of them will do it--just as some MBAs become journalists. But others will balk. So either you have to take lower-quality candidates with fewer other opportunities, or you end up with fewer doctors. In Europe, there aren't so many other lucrative opportunities, and status is arguably more valuable than it is here, since in many cases, only a minority of your fellow Americans will recognize the status you've so painstakingly acquired. When you're introduced to a pastor at a party in the rural south, you're meeting an important person. When you meet the same pastor at a dinner party on the Upper West Side, he's a freak who is at best possibly interesting. Multiply that a few hundred times, and it's little wonder that money is the dominant form of compensation in the US--at least, unless you can get God or professors to handle your recruiting.