Author: Andrew Sullivan

Richard Gunderman argues in favor of concierge medicine, a system in which patients pay hefty fees to spend more time with their doctors:

The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness….

Of course, there are drawbacks to concierge practice. For one thing, some patients cannot afford it, and others will choose not to pay the fee. Critics also see such models as promoting a two-tiered system of healthcare, in which those with more money get better care.

“But we have always had a two-tiered system,” [internist Frederic] Becker counters, “and it is better to care for 600 patients well than just adequately for three or four times that number. Someday patients, physicians, and healthcare payers will recognize that slower-paced but truly high-quality medical care is a better value than the fast medicine many physicians feel pressured to practice today.”

Meanwhile, Christopher Flavelle fears the rise of specialists who demand cash payments:

The slice of the population that’s willing and able to pay for specialty care in cash is small; the share of physicians in cash-only practices was just 6 percent last year. But that’s double the level from 2011. And if the income gap keeps growing, so will the number of doctors who can find enough cash-only patients to stop taking insurance. …

If the trend accelerates, it may call for new guidelines from the American Medical Association. The AMA now says doctors moving to cash-only practices must “facilitate the transfer of their non-participating patients to other physicians” – for instance, not charging for the transfer of medical records. If no other physicians are available in the community, the doctor “may be ethically obligated to continue caring for such patients.” The AMA also reminds doctors of their “professional obligation to provide care to those in need.” Those guidelines may start to look too vague if the best specialists drop out of the insurance system altogether.

Previous Dish on concierge medicine here.

Pointing to a new study showing that income inequality is rapidly declining at the global level, Tyler Cowen argues that the redistribution favored by egalitarian movements in the US would end up hurting international prosperity:

Although significant economic problems remain, we have been living in equalizing times for the world — a change that has been largely for the good. That may not make for convincing sloganeering, but it’s the truth. … Many egalitarians push for policies to redistribute some income within nations, including the United States. That’s worth considering, but with a cautionary note. Such initiatives will prove more beneficial on the global level if there is more wealth to redistribute. In the United States, greater wealth would maintain the nation’s ability to invest abroad, buy foreign products, absorb immigrants and generate innovation, with significant benefit for global income and equality.

Mark Perry backs up Cowen’s thesis with the above chart. But Daniel Little criticizes Cowen’s “Panglossian” picture of global inequality:

Cowen bases his case on what seems on its face paradoxical but is in fact correct: it is possible for a set of 100 countries to each experience increasing income inequality and yet the aggregate of those populations to experience falling inequality. And this is precisely what he thinks is happening.

Incomes in (some of) the poorest countries are rising, and the gap between the top and the bottom has fallen. So the gap between the richest and the poorest citizens of planet Earth has declined. The economic growth in developing countries in the past twenty years, principally China, has led to rapid per capita growth in several of those countries. This helps the distribution of income globally — even as it worsens China’s income distribution.

But this isn’t what most people are concerned about when they express criticisms of rising inequalities, either nationally or internationally. They are concerned about the fact that our economies have very systematically increased the percentage of income and wealth flowing to the top 1, 5, and 10 percent, while allowing the bottom 40% to stagnate. And this concentration of wealth and income is widespread across the globe.

Ryan Avent pushes back as well:

There is an alternative hypothesis, however, which Mr Cowen mostly disregards: that redistribution provides insurance against economic dislocation and therefore softens resistance to globalisation. It’s worth pointing out that the world has experienced two great eras of globalisation. The first combined minimal redistribution with minimal political power for non-elites. The second combined universal suffrage with substantial redistribution. I don’t think it’s unreasonable to conclude that redistribution is the price democracies pay for globalisation.

And that makes perfect sense! Reducing barriers to trade generates net gains, but those gains will occasionally be distributed in highly unequal fashion. If gains are concentrated and no provision is made for redistribution, then a voting majority might well conclude that openness is a losing proposition. Mr Cowen seems to want voters to recognise that whether or not they personally are made better off by globalisation it is a good thing to support, because it enables the enrichment of poor areas of the globe. But few voters are content to have their economies run as charities (and a good thing for economists that they aren’t, as that would make a baseline assumption of rational self-interest look pretty absurd).

Hayley Tsukayama urges consumers to be honest with themselves about their reading habits before signing up for Amazon’s new literary service:

Kindle Unlimited is $9.99 per month. So you’ll be paying Amazon, whose chief executive Jeffrey Bezos owns The Washington Post, around $120 per year for the unfettered e-book access. If you’re habitually spending money on more than one book per month, then it’s a service to think about. It has its perks for big book buyers – namely that don’t have to worry about spending money on a book you end up hating.

But, chances are, you aren’t reading more than one book per month. In January, the Pew Internet and American Life Project asked how many books the typical American had read in the past year.

The answer? Five.

Maria Bustillos contends that “it shouldn’t cost a thing to borrow a book”:

For a monthly cost of zero dollars, it is possible to read six million e-texts at the Open Library, right now. On a Kindle, or any other tablet or screen thing. You can borrow up to five titles for two weeks at no cost, and read them in-browser or in any of several other formats (not all titles are supported in all formats, but most offer at least a couple): PDF, .mobi, Kindle or ePub (you’ll need to download the Bluefire Reader—for free—in order to read ePub format on Kindle.) I currently have on loan Alan Moore’s Watchmen, Original Sin by P.D. James, and The Dead Zone by Stephen King.

Alison Griswold concentrates on the business angle:

Kindle Unlimited will add a new layer of complexity to negotiations between Amazon and publishers. So far, it seems that most of the big-name publishers haven’t agreed to let their titles onto the subscription platform. Books published by HarperCollins and Simon & Schuster aren’t offered and those from Penguin Random House are notably absent. Amazon has not said how authors and publishers will be paid for participating in Kindle Unlimited, but it’s unlikely that the models currently used for e-book sales through its store will do the trick.

Brian Heater is concerned that writers like him will get screwed:

We’ve all heard the horror stories of the fractions of cents being doled out by Spotify, with the justification that many musicians make their mint touring anyway. For one thing, that’s hardly a universal and for another, where’s the author’s analog to touring? Unless you’re, say, Hillary Clinton pulling in $200,000 per speaking engagement, no one’s paying big bucks to watch you read. You’re there to sell more books.

The other justification for music-streaming services is the notion that people who really love a record will go out and buy it. Perhaps I’ve just become too immersed in the world of e-books too quickly, but I’m having difficulty imagining a scenario in which I run out and buy a hard copy of a book after reading the electronic version. It certainly hasn’t happened to me yet – I also haven’t found myself going back and re-reading too many e-books to this point.

Joshua Gans fears that Amazon’s new service will discourage the creation of long books:

Amazon’s payment to authors is similar to its payment to them for the Kindle Owner’s Lending Library. There is a fund (amount = F) that is set monthly by Amazon. If there are a certain number of books downloaded that month (N) and your book is downloaded n times, you receive (n/N)*F in payments that month. That’s for lending. For books under the Unlimited plan, they have to be at least 10% ‘read’ (on the assumption that flipping 10% of the pages is the same as reading them). And so your share is based on how often your book is minimally read. Basically, people can try before they buy with their attention.

Now this plan isn’t all rosy because while it rewards books that are readable, it does so asymmetrically. For instance, Piketty’s recent book has 696 pages whereas mine most recent one has 93. Suffice it to say, Piketty will receive the same payment for another book read this month beyond 70 pages as I would get for 10. That strikes me as amiss.

Konnikova, meanwhile, looks at the impact digital devices have on the reading experience:

When Ziming Liu, a professor at San Jose State University whose research centers on digital reading and the use of e-books, conducted a review of studies that compared print and digital reading experiences, supplementing their conclusions with his own research, he found that several things had changed. On screen, people tended to browse and scan, to look for keywords, and to read in a less linear, more selective fashion. On the page, they tended to concentrate more on following the text. Skimming, Liu concluded, had become the new reading: the more we read online, the more likely we were to move quickly, without stopping to ponder any one thought.

The online world, too, tends to exhaust our resources more quickly than the page. We become tired from the constant need to filter out hyperlinks and possible distractions. And our eyes themselves may grow fatigued from the constantly shifting screens, layouts, colors, and contrasts, an effect that holds for e-readers as well as computers.