It was only a matter of time and I said (half) jokingly at the time that Uber is breaking the dam for everyone else to follow. Any regulated system will have its day in front of "disruptors" where the disruption is simply ignoring the regulation with some flimsy excuse, supported by the money and lack of morals of VCs and startup combinators.
Uber took an axe to taxi drivers which weren't a popular group to begin with so that was easy. With the "disruption" perfected, next up are doctors, nurses, lawyers, electricians, cooks, engineers, the sky is the limit.
Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
Some regulation is bad, some regulation is good. There's basically nothing at all that's good about guild systems and I will celebrate each of them facing open market competition.
> Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
You are defaulting to the US here (and I doubt Taxi regulation in the US is that homologous either tbh given the complexity of 50 states and then cities on top of that).
Taking the country I'm most familiar with (the UK), Taxis fall into two categories (only one of which is technically a taxi by law if not convention - Hackney and private hire vehicles) bothare licensed in different but similar ways by the licensing authorities (usually the local council but not always), some of those laws go back centuries.
Also worth noting, in the UK Uber does operate under the Private Hire Vehicle laws and does have to comply with applicable licensing same as any other "taxi" (private hire vehicle) operator.
They tried to argue otherwise and lost (at the UK Supreme Court so it's essentially settled case law) so they are classed as a PHV Operator and must ensure they only use a properly licensed PHV vehicle and drivers and can't pull the "but they are independent contractors" card out when it explodes in their faces.
It was a little more nuanced than that. The actual case was about whether a private hire operator accepting a booking had to contract with the customer as principal, rather than merely acting as an agent arranging a contract between the customer and driver (which was essentially Uber's argument).
The (UK) Supreme Court said "nah, it's you, nice try though".
They actually lost thrice - in 2017 TFL pulled their PHV licence because Uber London Limited wasn't considered to be a 'fit and proper person', Uber thought they could brazen it out only to find that TFL is beholden only to the Mayor and they ended up having to come back on bended knee, and then it was further refused in 2019 but returned on appeal - https://www.judiciary.uk/wp-content/uploads/2020/09/Uber-v-T...), which lists significant failings by Uber that they had since remedied.
The third outing with the Supreme Court was about employment rights - were the drivers workers, or genuine independent contractors for whom Uber are merely acting as a booking agent (which the Uber model relies almost entirely on).
The Employment Tribunal, The Employment Appeal Tribunal, The Court of Appeal and finally the Supreme Court all said "nah fam, you ain't fooling nobody" and the original ET was especially scathing:
> It seems to us that the Respondents' general case and the written terms on which they rely do not correspond with the practical reality. The notion that Uber in London is a mosaic of 30,000 small businesses linked by a common 'platform' is to our minds faintly ridiculous. In each case the 'business' consists of a man with a car seeking to make a living by driving it.
Aye, it's been interesting (by which I mean highly entertaining) to watch them run face first into the pole repeatedly since their attitude of "We got away with this elsewhere" worked until it didn't.
They did get away with it in London. They broke laws, argued unfaithfully in court, got denied a license, got an extended probationary period from a magistrate, and finally are operating in the clear.
Very very few other businesses get to act so brazenly and dangerously, then get an extended period of time and support to do the bare minimum to qualify as compliant.
> Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
Taxis have standardized rates set by the municipality and use standardized meters that are periodically inspected. Ride sharing apps have dynamic pricing and no transparency.
Taxis have (almost) no transparency. Outside of a few limited places where there are fixed fees for certain routes, you never know how much you're going to have to pay when you get in. With ride share apps the pricing is upfront and transparent.
Except when the "meter is broken" or they take the scenic route. My grandmother with dementia routinely got charged double or triple the expected rate for trips to medical appointments, until we figured out what was going on and started booking her rideshares.
Just curious what happens if there is a major event going on in the proximity of one of the doctors appointments?
It could turn out to be 2-3x the "normal" cost due to surge pricing. This often happens to people who go out drinking and think "I'll just grab an Uber later".
Recently heard someone complaining about the $45 cost to go 3 miles.
*Sidenote: people with dementia should probably have someone in the car with them to be sure they get to the appointments. That solves the issue of shady people taking advantage of them for the most part.
To clarify I was referring to her getting upcharged by unscrupulous taxi drivers, not rideshares. Rideshares were an improvement since we could book her a ride with a known up-front cost, and get pick-up/ drop-off notifications.
> *Sidenote: people with dementia should probably have someone in the car with them to be sure they get to the appointments. That solves the issue of shady people taking advantage of them for the most part.
Her dementia was still fairly mild at that point, she could easily manage taking a taxi from A to B, she just wouldn't push back if the guy said it was $30 when it should have been $10. It's tricky to figure out the right supports and boundaries at that stage, especially for elderly people used to being self-sufficient. Convincing her to stop driving was hard enough...
>To clarify I was referring to her getting upcharged by unscrupulous taxi drivers, not rideshares. Rideshares were an improvement since we could book her a ride with a known up-front cost, and get pick-up/ drop-off notifications.
Understood, IMHO...it is easier to find a reputable taxi company than it is to predict surge pricing. Or at least it used to be when you had a choice.
It has been my observation that the companies all had plans to "disrupt"...but it seems they never had a solid "profitable" plan past when the VC money ran out.
Aside from turning employees into contractors...most of which have not done the math on how much they are losing through having to use your own car with no employee benefits. Doordash/Uber start looking a lot less attractive if you figure in the $.65/mile costs (fuel, repairs, insurance, car purchase price) that you would be paid by most govt or "real" companies.
Almost everyone I know who does Doordash makes about $20/hr (which isn't good anyways) and they are not figuring in the costs of the vehicle.
Lots of people in the US need to own a car already and the vehicle still depreciates sitting in their driveway. The correct calculation there is the marginal cost (faster depreciation rate, gas) versus the income from a ride-sharing app. But yes buying a vehicle specifically to do delivery or ride-sharing is a bad decision.
Depreciation of the vehicle due to time is only a very small part of the costs. Mileage is way, way more important. (Of course Uber requires a certain age of car so that is a restriction).
Maintenance and fuel are a much larger part of the total costs. It is very easy to math out if you break down by the "recommended service intervals" which are largely based on mileage (fluids do require changing with time intervals but normal driving usually matches up with the mileage).
The myth that a car sitting still is losing money has been sold by the insurance companies. It is only cheaper to buy a new car vs fixing one if you account for the loss if someone runs into you and totals the car. My car which I have maintained and is 14 years old is worth way more to me than the amount that is placed on it by people who have it in their interest to say it is worthless due to age.
Sidenote: I tracked all my miles, costs and income while delivering pizzas many years ago. These costs vary greatly depending on the car. The 89 subaru justy I purchased to deliver was $.25/mile whereas my 93 mazda 626 was closer to $.60 (2004 pricing). My current car is ~$.60/mile also.
Currently, the IRS mileage rates for business is $.70/mile, do any of the gig economies pay this? [1]
You can go online and see what people are actually willing to pay for older, low-mileage cars. It's not much of a premium over similar cars with typical mileage. You can't really blame insurance companies when the valuations are determined by what people are actually paying for used vehicles. Sure, you might do an impeccable job of maintaining your car, but a future buyer has to go off of a mechanic's assessment, plus they won't have a manufacturer warranty to fall back on. There's also the issue that newer models generally have better fuel economy, more safety features, etc. Cars have actually gotten cheaper over time after accounting for new features and reliability improvements, which puts additional downwards pressure on the price of used vehicles.
> Currently, the IRS mileage rates for business is $.70/mile, do any of the gig economies pay this? [1]
I used to get paid that rate at my old job and it was an amazing deal, it was way over my actual costs for the vehicle. With a small fuel-efficient car I was covering my gas, insurance, and depreciation with a few trips each year. It was effectively my work paying for a free car I'd get to use the rest of the time.
That's the issue with using one number as a very rough estimate, it has to account for everything from contractors driving work trucks to someone commuting in a Model 3.
My wife volunteers during tax seasons to do tax returns for low income people. It always depresses her when people on the lower runs of the ladder come in and have been doing uber, lyft, doordash, etc or some combination and have nothing more than a hand wave estimate of how many miles they drove. She is the one who has to tell them just guesstimating is not allowed and what might have been a $1000 check back to them is instead a $2000 check they need to write to the government. 9 times out of ten they say, "but I don't have that money" and it crushes her. More than a few get mad at her for not being willing to just enter their guesstimate into the form.
I'm not sure if it is because uber (or whomever they work for) didn't make it clear enough to track it properly or if they simply didn't take it seriously.
This trend was started in health care by private equity with no inspiration from Uber. Check your local dentists, eye doctors, veterinarians, urgent cares, maybe even hospitals. You'll find very few that are not owned by some large private equity firm these days, who run everything at the highest margins possible. And once you eliminate any higher quality / higher paying positions in an area, moving to pricing on demand and getting rid of full time positions entirely comes next.
Many that haven't succumbed to PE yet know what it brings and appreciate the opportunity to speak to the issue themselves. Many of the best really wish more customers were paying attention and giving them credit for their choice not to sell out.
Meanwhile, many that haven't will either justify their corporate ownership or just kind of dodge the issue.
You can ask other providers for gossip and insight about ones you're curious about -- especially other providers in fields that are connected/adjacent but not directly competitive. The true locals are generally delighted to call out the sell outs.
TBF it’s also an engine to push for regulations review. Awful lot of regulations are written for an age that no longer exists and just as many are to make management easier therefore startups pushing the boundaries actually are a correcting mechanism.
Unfortunately some harm can be inflicted bur IMHO it’s better than the alternative.
There was an “Uber for X” wave that didn’t really amount to anything. Stuff like home repairs was a big one. My take was that driving (and delivery) is a rare service that above some basic competence (and I’d say below another) is a pure commodity. For most things, quality is a differentiator, and anyone good would never give up a percentage to an app, so only the worst providers would sign up. My intuition is that nursing would work this way.
I think your intuition about quality and who signs up is correct, but doesn't insulate as much as you're assuming. For one thing, corporations have a nearly unlimited appetite for converting employees to contractors. For another, the economy has produced a large number of desperate people willing to do pure commodity work.
One reason "Uber for X" appears not to have materialized is that the platforms themselves are commoditized, not just the labor. Retailers like Lowe's and Wayfair have built assembly/installation services behind a checkout upsell. They run portals distributing work to their "network of local contractors" .
I got a window into this world through an acquaintance. He has a truck and light trade skills, but mental and reputational legacies of past addiction lock him out of the "anyone good" market. He's on a half dozen platforms, trying to stitch a living doing sink or toilet installs for Lowe's and building bookcases for Wayfair. A negative review gets you demoted from the choice gigs, or even kicked from the platform entirely. It's bleak.
They aren’t attacking regulation but full time employment. They spent a tremendous amount of money in CA to pass a law that’s nearly unable to be repealed to avoid having their gig folks count as employees. That’s the attack - everyone being a 1099. Not regulated industries.
Uber "deregulating" everything, means Uber taxing everything... because everything will go through it... and you know the EEE thingy right? better prices until you kill industry, then rise prices...
The good thing is that we will not be fooled this time while checking the dead bird thing...
Not only were taxi drivers not popular but it also wasn't and isn't obvious to most people exactly how or why they were regulated. Especially to people outside of major urban areas.
Well, at least on case of taxi drivers "the flimsy excuse" phrasing applies more to existing regulation than not following it.
Not sure about the nurses, but my grandmothers were able to afford live-in caretakers in old age, without any government help or having much money, because these are completely unregulated (outside the US; or the regulation is not enforced)... We found good ones thru word of mouth, exactly the approach apps can scale
Being long degeneracy ( https://oldcoinbad.com/p/long-degeneracy ) really seems to be the correct market position. Turns out laws really are optional, if you're brazen enough.
To what degree is this just another symptom of the US healthcare system being flawed and in need of rework? To what degree would anyone use such a service if the costs remained high?
I used Zocdoc in the past to find a doctor and ended up with a doctor who just charged out-of-pocket instead of insurance, and it worked great. Would an app that shows up-front pricing be better for the consumer?
If you look carefully at the chart, US nurse salaries are high because US salaries are high. The ratio of US nurse salaries to average US salaries is nearly the same as the OECD average.
Yes, it’s not specific to nursing. Labor costs are often high in the US, which goes a long way to explain why labor-intensive services cost more in the US, relative to other goods and services.
Every serious analysis of the US healthcare system I've ever seen comes away with the takeaway "Americans consume a lot of healthcare services and the expensive part of that is the providers' salaries"
It’s pretty well known that vertical integration has been the issue with driving up costs. Salaries for physicians aren’t all that big of a cost, compared to all the administrative BS that hospitals and insurance companies drive up, and conveniently have agreements to heavily discount.
For example, on a roughly 400k surgery, maybe 4-5k of that goes to the providers (anesthesia and the surgeon), dependent one on the codes billed for the procedure.
There are private groups that purposely do not take insurance and bill purely out of pocket with a one time fee including all follow up’s and subsequent care, related to that procedure, and it is significantly lower (like 90%+ less) than what an average hospital is charging.
> There are private groups that purposely do not take insurance and bill purely out of pocket with a one time fee including all follow up’s and subsequent care, related to that procedure, and it is significantly lower (like 90%+ less) than what an average hospital is charging.
I would bet a LOT of money that it is 90% lower for a "typical" patient but not 90% lower (and very likely pretty comparable) on average.
To state it more plainly: every time you pay for medical care in the US, you are subsidizing a half dozen people who consume 5x the services you do and do not pay.
That's why "fee only" medical (which always conveniently has no emergency services, you'll notice) can offer such low rates.
Doctors and nurses in the US are in both the average and the median earning significantly more than their counterparts in Canada, the UK, France, Germany…
I'm in the Bay Area. There's a serious shortage of general practitioners because the patient:doctor ratio is so high. Even if their absolute pay is high, the amount they are paid to see me is minuscule. They can make more and have many fewer patients / appointments per day if they switch to a specialty.
On the other hand, specialists are more profitable for the "non-profit" healthcare networks we have around here, so they're easy to get appointments with.
Uber checked the first few digits of your debit card to filter out police officer credit unions to evade taxi regulation enforcement. They use your phone’s battery level as one factor to estimate your elasticity of demand. They have teams of economists to adjust personalized prices to as high as you can bear and pay for drivers as low as possible.
Among the things that need to give are 1) insurance companies should make no money because there's no margin left in the system for them, and 2) we should have several times as many doctors, which means breaking the protection racket that intentionally limits the supply.
What is the protection racket that intentionally limits supply? The primary bottleneck to producing more physicians is lack of available residency slots. Teaching hospitals are free to add more but for various reasons choose not to. In part I think they're waiting and hoping that Congress will kick in more subsidies through the Medicare program.
Even if financial constraints were removed, the notion that we could produce twice as many physicians is ludicrous. There simply aren't enough attendings able to supervise a lot more residents, nor are there enough patient cases coming through the teaching hospitals to give that many residents the practical training they would need.
Residency requirements are defined by ACGME. The AMA is a member of ACGME but ACGME operates independently. If you think that residency requirements should be changed then make a specific proposal instead of wasting our time with snarky, low-effort comments.
The physician protection racket case is put forward by Nobel Prize in Economics laureate Angus Deaton and his wife Princeton economist Anne Case in their 2020 book Deaths of Despair and the Future of Capitalism: https://press.princeton.edu/books/hardcover/9780691190785/de...
Discussion of physician protectionism is also found in the 2017 book by John Hopkins political science professor Steven Teles and Niskanen Center vice president Brink Lindsey The Captured Economy: https://global.oup.com/academic/product/the-captured-economy...
Did you even read through the website I linked above? Your references are badly outdated. While the AMA once lobbied Congress to limit Medicare funding for residency slots they reversed position years ago. And even back then, there was nothing stopping teaching hospitals from expanding residency programs using their own funds or other sources.
There are valid reasons to criticize the AMA but blocking the training of new physicians isn't one of them.
You're citing an AMA public relations campaign to retain public funding of residencies but I'm not sure anyone here is arguing that it should be cut. The AMA made public statements holding the same position about increasing funding and removing the 1997 residency caps in 2006. And yet notable academics since 2006 still have suggested (eg, the books in 2017 and 2020) that the profession, ie the membership of the AMA, presumably even with this formal position taken by their association body, is behaving in a protectionist manner. Either way, part of the argument is that physicians' documented earlier collective behavior (old boys club), suspected ongoing culture, and inherent economic interests, are still causing present and future problems.
Even if that was all true, so what? Congress is free to increase the Medicare budget for residency programs if that's what voters want. And teaching hospitals are free to expand their own residency programs regardless of whether Congress acts.
The AMA, and physicians in general, are obviously not the primary obstacle here. Complaining about their past actions won't solve any of the actual problems we have today
A much larger supply of doctors would presumably lower their pay significantly, right? Will people still want to put in the years and years of training to become a doctor if the pay drops significantly?
Given the NHS(and many other western countries) still has a surplus of med student to training places with much worse compensation than the US, the answer is yes.
Prestige and potential higher pay for specialisations will still attract people to the profession, although maybe not if the university costs for medicine remain as high as they currently are.
Germany has non-profit sickness funds (Bismarck model). So you don’t have to ban health insurance companies when rolling out universal healthcare. Their freewheeling excesses have to be reined in. Access is a right. Standardize coverage and prices on both the insurer and hospital/doctor ends. Once everyone is in the same risk pool, there will no longer be a perverse incentive to deny claims for profit. A single standard plan will also have the negotiation power to drive down prices.
Most hospitals (both for-profit and non-profit) are terribly inefficient. They burn up clinician time on administrative tasks that could be automated or performed by cheaper office staff or not done at all. And employees often waste a lot of time just waiting around because no one has optimized workflows to shorten queues or eliminate bottlenecks. The incentives are structured in a such a way that there's often little reason to improve.
Most software development shops (both for-profit and non-profit) are terribly inefficient. They burn up programmer time on administrative tasks that could be automated or performed by cheaper office staff or not done at all. And employees often waste a lot of time just waiting around because no one has optimized workflows to shorten queues or eliminate bottlenecks. The incentives are structured in such a way that there's often little reason to improve.
Ha ha, but it's a matter of degree. Every organization has some level of inefficiency but having seen how the sausage is made I can guarantee you that the average software development shop in a US tech company is significantly more efficient than the average hospital. It's not something that you can quantify in a directly comparable way but anyone familiar with the industry will tell you the same.
I manage a team of devs in the healthcare industry, I've worked in other regulated industries and healthcare is unique. I could go on forever but it comes down to the fact that healthcare is uniquely risk averse, for understandable reasons.
Risk tolerance is an orthogonal issue. The point I raised is about operational inefficiency which has no impact on risk (in terms of legal compliance or patient safety) one way or the other.
This is certainly true. With modern AI agents, it is entirely possible that the duty cycle of a software engineering enterprise is not actually the 8h/24h we have today but closer to a 24h/24h system. Certainly my ideal is to proceed software engineering organizations closer to the latter system.
It’s a complex problem because a lot of those hospitals are non profit, so they have zero incentives to have high margins because no shareholders to return money to. Higher salaries for executives though…
That's not entirely true and a misstatement of how these work, take Blue Cross of Michigan. It is a nonprofit, it's board is controlled by the members, essentially they are the share holders, they have a interest in lower prices and an efficient operation.
How the board gets approved to be elected is a bit self selected, but in theory it should be controlled by people that have incentives, the same as a public corporation.
Now this is an insurance company and not a provider network,some provider networks are more self owned.
It’s important to note that in most countries the law even states that they need to pay competitive salaries for these positions, so they can’t even pay them much lower amounts than their non profit counterparts
Traveling nurses make more than lots of doctors though, so I dont think they're being taken advantage of. However, Im sure this company is trying to take a piece of that traveling nurse pie.
The exact profit margins of hospitals as a whole doesn't matter. Hospitals are where health care happens but financially, they are simply a platform for a multitude of other private entities which make profits on top of the simple hospital fees - the "Uber For Nurses" thing is just one of many ways this happens, you have everything from data management companies to separately own MRI machines adding to the patient's bill and having a voice in the management of the hospital.
Yeah, maybe it's the idea that hospitals should make profit that should give?
Like, sorry, but not being from the US the whole idea of a "margin" when running a hospital is insane. Hospitals are paid from our ample taxes and the patient pays nothing - there is no room for profit there, not should there be one.
How much does your country’s medical professionals make, how long do patients wait for care and what is the level of care as measured by variety and efficacy? Seems hard to compare without normalizing these things.
Trying to compare national healthcare systems based on life expectancy is a total non sequitur. Most of the factors which limit US life expectancy relative to other developed countries have little or nothing to do with healthcare (or lack thereof). It's mainly other problems like car crashes, suicide, violence, substance abuse, and sedentary lifestyles.
It's happening everywhere. All these apps who try to be endless rent-seekers, injecting themselves in a process where they have very little to add.
I don't need a platform that takes 25% off of the handyman that I call. All that happens is that I pay 25% more. And if the platform becomes large enough it'll set policies that the handyman cannot offer lower prices outside of the platform...
Could I use this app to hire a nurse and get a diagnosis from home? If we can start getting even meagre medical treatment to skip insurance / other middle men, I could see this having a great impact on healthcare prices, especially since AI is such a good information extractor, which is 90% of the role doctors play anyway.
There are many types of nurses, for example Nurse Practitioners have masters or doctorates of nursing can do much or all of what a doctor could within their specific scopes.
Generally speaking nurses in the united states cannot provide a diagnosis, at least without jeopardizing their license. You can already find a doctor using a service like Zocdoc who may cut out middlemen, though regulatory capture has made it close to impossible to meaningfully reduce costs in this way. I would not recommend using AI to diagnose or treat yourself (https://www.nytimes.com/2026/10/27/well/ai-chatgpt-medicatio..., for instance) without the help of somebody highly trained to interpret this information and make good decisions.
Nurses don't really do diagnosis, but follow the ones doctors give.
(Except for trivial things)
Otherwise I unfortunately know plenty of doctors that could easily be replaced by an LLM, but for now I prefer a diagnosis from a real doctor (who may use AI as a tool).
If you really believe that information extraction is 90% of what doctors do then you're deeply ignorant about how healthcare actually works and not qualified to even have an opinion on this subject.
> A companion Roosevelt Institute brief found that some platforms "use data-brokers to determine nurse debt levels and offer lower wages to those with highest debt loads."
When something sounds too bad to be true, I think it's fair that we should ask for some kind of evidence to be produced. They cite a Roosevelt Institute article that says
"Gig nursing apps MAY [my caps] determine pay by what the firm knows about how much a nurse was willing to accept for a previous assignment, how often they bid for shifts, or how much credit card or other kinds of debt they might hold."
That kind of sounds like they are overselling a hypothetical. Even just an "insiders familiar with the matter have told us that it IS happening", would make me believe it more.
Everyone wants healthcare expenses to go down but the biggest healthcare expense is the salaries of providers. So, hard to give the masses what they want without making a smaller group of people who benefit from the status quo angry.
to be a bit pedantic, that says they account for only 15% of the excess healthcare spending, relative to other countries. It's not surprising given doctors in the united states have a higher level of training compared with many peer countries, and _all_ salaries are much higher in the united states compared with almost any country.
The 15% extra administrative cost of insurance and 15% extra administrative burden of applying care are the big culprits, in addition to extra costs on medicine and machinery. But it's interesting. Why is it that a comparatively deregulated and privatized system has so much extra pricing cost from bureaucracy?
Much like home prices. Everybody says they want homes to be more affordable, but all actions are designed to keep them high and if they did actually fall it would be treated as an emergency.
In Sweden we had this in the news: https://www.svt.se/nyheter/lokalt/uppsala/hon-pendlar-860-mi...
A US nurse moved to Sweden and preferred to fly to San Fransisco to work ten days at a time, then fly back to be off for six weeks, rather than taking a job as a nurse in Sweden. The salaries are very different.
Physician salary is only 9% of total healthcare cost. The rest of the labor pool is administrative - clerks, management, etc.
Physicians also make 2-3x more than physicians in other countries. Why? Their education cost is also 2-3x higher than in other countries.
Hospitals and procedures are expensive, in part because of insurance. Insurance is high because our society is too litigious. It's also expensive because of consolidated private healthcare systems that can control and mark up prices due to lack of competition.
Other countries spend half what we do on healthcare. And their people are often healthier.
The entire 'gig economy' model is exploitation. It only works because of income inequality. It requires a large pool of workers who don't make enough money to support themselves (due to insane healthcare and housing costs, and low wages and benefits) and thus will take any money they can get, despite the poor pay, long hours, and lack of benefits. It's taking a person slowly dying of thirst and offering them a thimble of water in exchange for knitting a sock.
Unfortunately it wouldn't fix anything. It would kill gig work because the model isn't sustainable with regular taxes and minimum wage (if it were, businesses would've already been doing that instead of independent contracting). It also wouldn't fix the income inequality that created gig work. People would be back to dying of thirst, without a thimble of water.
The real fix is to make it so their main job is hydrating enough, or the thing half the country hates the idea of (public fountains). IRS can't do either. Independent contracting is still a valuable mode of work, when the contractors are paid enough. So rather than ban forms of gig work, we need to provide good paying jobs and social services, and get the rich to pay their fair share.
While I do understand the importance of training, degrees and experience I see that people in the medical field beyond Doctors seem to have a very holier than thou attitude probably because they have 10 edge cases of how MRI can go wrong drilled into them (MRI technicians), not everyone is comfortable with needles and human body (nurses) and because it seems that only Pharmacists can sort and provide us the right medicines when in fact it can be easily done by some robots.
In before someone says that your reasoning is flawed because that is very incorrect perception of the field. All I see is that regulatory capture has worked very well here and is simply stopping totally novel and practical ideas which work on tradeoffs from even taking off
This sounds like pure insecurity with a sprinkle of Dunning Kruger. Unless I'm missing the joke somewhere? Nurses don't mind needles is the only difference? I must be missing the joke.
On the one hand, a good nurse is invaluable. They do the hard work that doctors won’t/don’t do, and can be so kind and generous during your time of need.
On the other ones, there are so many who mail it in and are just milking the system
Healthcare is so expensive - some nurses are making 500k a year - their union contracts base vary from 200k to 300k for something like 32-36 hours per week
On top of that, they can pretty much work unlimited overtime with zero restrictions. They can work enough overtime hours such that they can nearly double their salary. And that’s how you come up with the 500k figure I posted
Granted, that’s at the top of the range, I’m talking about somewhere like the Bay Area, and does require a ton of overtime, but those extra 100s of thousands add up. These hours can’t be spread around to minimize the amount of time and a half or double pay paid out, per contract they go in order of seniority
This is just nurses and I imagine it’s something similar but with higher rates for specialists like anesthesiologists and still beyond that doctors and surgeons
I don’t begrudge anyone’s salaries, but it’s a zero sum game. There’s a reason why, aside from typical corporate profit maximization, you wind up with a 30k bill for a short visit. Even if you account for the lower rates insurance companies pay, it’s still in the thousands of dollars for treatment where you were seen for less than 30 minutes
Like I said, to be clear, I don’t begrudge anyone’s salaries - this is just an under discussed point when we talk about healthcare costs
Labor is generally reported as 60% of the costs of hospitals - so if you’d ever want to talk about making healthcare affordable you’d have to address this which I feel like is a bit of a taboo subject. Many nurses are in a union which makes it an even more difficult conversation
All that is to say, I can see the motivation behind stuff like this, even if I don’t agree with it
> Like I said, to be clear, I don’t begrudge anyone’s salaries - this is just an under discussed point when we talk about healthcare costs
You are begrudging someone’s salary. Nurses make 500k by working overtime. You know why they work overtime? Because it’s cheaper for the hospital than to hire 2 nurses. The problem isn’t the nursing salaries. It is the administrative costs that make your healthcare too expensive. Why do you think single payer reduces healthcare costs?
PS: median nursing salaries are still under a $100k. The numbers you pointed to are not the norm.
Not really, I just said they can’t spread out over time across staff because you have to move up the seniority ladder - so in this particular case, what any manager would do and does in other industries, is spread hours to limit the amount of the really expensive overtime. Instead of one person working and getting double time or more, you can have two people working regular overtime, but this isn’t always possible
I also said this was for the Bay Area - it’s not the norm but it’s not infrequent either
Labor costs are 60% or hospital expenses, I didn’t make that number up and you just glossed over.
And again, I said it was just an issue to be discussed. If discussion leads to it’s not worth discussing, that’s great and a great outcome
You did the thing where you just sort of read what you wanted to read in my comment vs addressing what it said
I am all for it, and hopefully seen in Canada soon too, the smug nurses are literally doing janitorial works and get paid 90k and above, always complaining, very bad attitudes, make it feels like they are doing all the work for free too.. hopefully doctors follow too, the healthcare mafia and their bureaucracy must end, these abysmal waiting times aren’t because of low resources or whatever BS excuses, it’s intentional from doctors/healthcare staff supply all the way to the actual process you get to deal with while being treated or going to ER, it is designed that way.
Nurses already deserve higher wages than what they already get, but introducing "dynamic pricing" and competition to under-bid each other is just disgusting.
Nurses form the backbone of healthcare. Treat them as such.
Edit: To those downvoting me, talk to a real nurse and I bet you wouldn't take twice the pay to do half the work they have to deal with.
There's no concept of "deserving higher wages". It's a popular online meme but what on Earth does it even capture? If you value the work higher, then pay them more and you'll win the market for that labour.
There's a good argument to say that sufficiently aggregated marketplaces can launder price collusion, and if we were in such an aggregated marketplace then you could make that argument. But we're not in that situation right now.
The 'Edit:' is even more confusing. If I talk to someone in a profession and I wouldn't take twice the pay they receive to do half the work they do then they deserve higher wages? But that list is huge. Congressmen, Senators, many CEOs, Wagner-group mercenaries, ICE officers, drone pilots. In fact, almost every profession has this 4x effective slippage you're talking about.
Thanks for leaving a comment rather than just drive by downvoting.
One movie that made me change my perspective on nursing as a field was the Swiss movie Late Shift. It really opened my eyes to what nurses have to deal with. Yes the US might be different in having lower patient to nurse ratios but at the end of the day I think it's still applicable.
There's no way for me to tell you that I am well aware of this without it sounding like some braggadocious detailing of events of my life, so perhaps it will suffice to say that my parents are surgeons and we lived in rural and urban India at various points in our lives.
I still think their monetary compensation should be provided by market valuation of the utility of the work they do.
Go ahead and downvote me for this, but the medical field in the US especially when it comes to RNs needs a shake up. This is going to sound very crass, but the only skill that your average person on the street doesn’t have that nurses have is to stick a needle in a vein and that’s something that can be taught to a lay person over a week. Pretty much everything else are skills that any person off the street possesses and we would do well to have a lower bar for entry for it.
Nurses change dressings. Insert catheters. Move heavy patients without hurting themselves. Prepare equipment for surgery. Ensure the sterile field is maintained. Operate specialized equipment. Triage medical emergencies.
And about a million other things that the average person doesn't know how to do.
Yeah, I was relying on anecdotal experience so I went and looked it up and they do an incredible amount. Well, it’s too late though I can’t modify or delete my comment anymore.
It was only a matter of time and I said (half) jokingly at the time that Uber is breaking the dam for everyone else to follow. Any regulated system will have its day in front of "disruptors" where the disruption is simply ignoring the regulation with some flimsy excuse, supported by the money and lack of morals of VCs and startup combinators.
Uber took an axe to taxi drivers which weren't a popular group to begin with so that was easy. With the "disruption" perfected, next up are doctors, nurses, lawyers, electricians, cooks, engineers, the sky is the limit.
Don't confuse "regulation" with "guild systems".
Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
Some regulation is bad, some regulation is good. There's basically nothing at all that's good about guild systems and I will celebrate each of them facing open market competition.
> Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
You are defaulting to the US here (and I doubt Taxi regulation in the US is that homologous either tbh given the complexity of 50 states and then cities on top of that).
Taking the country I'm most familiar with (the UK), Taxis fall into two categories (only one of which is technically a taxi by law if not convention - Hackney and private hire vehicles) both are licensed in different but similar ways by the licensing authorities (usually the local council but not always), some of those laws go back centuries.
Also worth noting, in the UK Uber does operate under the Private Hire Vehicle laws and does have to comply with applicable licensing same as any other "taxi" (private hire vehicle) operator.
They tried to argue otherwise and lost (at the UK Supreme Court so it's essentially settled case law) so they are classed as a PHV Operator and must ensure they only use a properly licensed PHV vehicle and drivers and can't pull the "but they are independent contractors" card out when it explodes in their faces.
It was a little more nuanced than that. The actual case was about whether a private hire operator accepting a booking had to contract with the customer as principal, rather than merely acting as an agent arranging a contract between the customer and driver (which was essentially Uber's argument).
The (UK) Supreme Court said "nah, it's you, nice try though".
They actually lost thrice - in 2017 TFL pulled their PHV licence because Uber London Limited wasn't considered to be a 'fit and proper person', Uber thought they could brazen it out only to find that TFL is beholden only to the Mayor and they ended up having to come back on bended knee, and then it was further refused in 2019 but returned on appeal - https://www.judiciary.uk/wp-content/uploads/2020/09/Uber-v-T...), which lists significant failings by Uber that they had since remedied.
The third outing with the Supreme Court was about employment rights - were the drivers workers, or genuine independent contractors for whom Uber are merely acting as a booking agent (which the Uber model relies almost entirely on).
The Employment Tribunal, The Employment Appeal Tribunal, The Court of Appeal and finally the Supreme Court all said "nah fam, you ain't fooling nobody" and the original ET was especially scathing:
> It seems to us that the Respondents' general case and the written terms on which they rely do not correspond with the practical reality. The notion that Uber in London is a mosaic of 30,000 small businesses linked by a common 'platform' is to our minds faintly ridiculous. In each case the 'business' consists of a man with a car seeking to make a living by driving it.
Aye, it's been interesting (by which I mean highly entertaining) to watch them run face first into the pole repeatedly since their attitude of "We got away with this elsewhere" worked until it didn't.
They did get away with it in London. They broke laws, argued unfaithfully in court, got denied a license, got an extended probationary period from a magistrate, and finally are operating in the clear.
Very very few other businesses get to act so brazenly and dangerously, then get an extended period of time and support to do the bare minimum to qualify as compliant.
> Taxi drivers were not more "regulated" in any meaningful way, in fact oversight of them was significantly worse than the community-driven Uber rating system (not that that doesn't also have flaws).
Taxis have standardized rates set by the municipality and use standardized meters that are periodically inspected. Ride sharing apps have dynamic pricing and no transparency.
Taxis have (almost) no transparency. Outside of a few limited places where there are fixed fees for certain routes, you never know how much you're going to have to pay when you get in. With ride share apps the pricing is upfront and transparent.
Except when the "meter is broken" or they take the scenic route. My grandmother with dementia routinely got charged double or triple the expected rate for trips to medical appointments, until we figured out what was going on and started booking her rideshares.
Just curious what happens if there is a major event going on in the proximity of one of the doctors appointments?
It could turn out to be 2-3x the "normal" cost due to surge pricing. This often happens to people who go out drinking and think "I'll just grab an Uber later".
Recently heard someone complaining about the $45 cost to go 3 miles.
*Sidenote: people with dementia should probably have someone in the car with them to be sure they get to the appointments. That solves the issue of shady people taking advantage of them for the most part.
To clarify I was referring to her getting upcharged by unscrupulous taxi drivers, not rideshares. Rideshares were an improvement since we could book her a ride with a known up-front cost, and get pick-up/ drop-off notifications.
> *Sidenote: people with dementia should probably have someone in the car with them to be sure they get to the appointments. That solves the issue of shady people taking advantage of them for the most part.
Her dementia was still fairly mild at that point, she could easily manage taking a taxi from A to B, she just wouldn't push back if the guy said it was $30 when it should have been $10. It's tricky to figure out the right supports and boundaries at that stage, especially for elderly people used to being self-sufficient. Convincing her to stop driving was hard enough...
>To clarify I was referring to her getting upcharged by unscrupulous taxi drivers, not rideshares. Rideshares were an improvement since we could book her a ride with a known up-front cost, and get pick-up/ drop-off notifications.
Understood, IMHO...it is easier to find a reputable taxi company than it is to predict surge pricing. Or at least it used to be when you had a choice.
It has been my observation that the companies all had plans to "disrupt"...but it seems they never had a solid "profitable" plan past when the VC money ran out.
Aside from turning employees into contractors...most of which have not done the math on how much they are losing through having to use your own car with no employee benefits. Doordash/Uber start looking a lot less attractive if you figure in the $.65/mile costs (fuel, repairs, insurance, car purchase price) that you would be paid by most govt or "real" companies. Almost everyone I know who does Doordash makes about $20/hr (which isn't good anyways) and they are not figuring in the costs of the vehicle.
Isn't the business model of uber dependent on people not figuring in the costs of their vehicle?
Lots of people in the US need to own a car already and the vehicle still depreciates sitting in their driveway. The correct calculation there is the marginal cost (faster depreciation rate, gas) versus the income from a ride-sharing app. But yes buying a vehicle specifically to do delivery or ride-sharing is a bad decision.
Depreciation of the vehicle due to time is only a very small part of the costs. Mileage is way, way more important. (Of course Uber requires a certain age of car so that is a restriction).
Maintenance and fuel are a much larger part of the total costs. It is very easy to math out if you break down by the "recommended service intervals" which are largely based on mileage (fluids do require changing with time intervals but normal driving usually matches up with the mileage).
The myth that a car sitting still is losing money has been sold by the insurance companies. It is only cheaper to buy a new car vs fixing one if you account for the loss if someone runs into you and totals the car. My car which I have maintained and is 14 years old is worth way more to me than the amount that is placed on it by people who have it in their interest to say it is worthless due to age.
Sidenote: I tracked all my miles, costs and income while delivering pizzas many years ago. These costs vary greatly depending on the car. The 89 subaru justy I purchased to deliver was $.25/mile whereas my 93 mazda 626 was closer to $.60 (2004 pricing). My current car is ~$.60/mile also. Currently, the IRS mileage rates for business is $.70/mile, do any of the gig economies pay this? [1]
[1] https://www.irs.gov/tax-professionals/standard-mileage-rates
You can go online and see what people are actually willing to pay for older, low-mileage cars. It's not much of a premium over similar cars with typical mileage. You can't really blame insurance companies when the valuations are determined by what people are actually paying for used vehicles. Sure, you might do an impeccable job of maintaining your car, but a future buyer has to go off of a mechanic's assessment, plus they won't have a manufacturer warranty to fall back on. There's also the issue that newer models generally have better fuel economy, more safety features, etc. Cars have actually gotten cheaper over time after accounting for new features and reliability improvements, which puts additional downwards pressure on the price of used vehicles.
> Currently, the IRS mileage rates for business is $.70/mile, do any of the gig economies pay this? [1]
I used to get paid that rate at my old job and it was an amazing deal, it was way over my actual costs for the vehicle. With a small fuel-efficient car I was covering my gas, insurance, and depreciation with a few trips each year. It was effectively my work paying for a free car I'd get to use the rest of the time.
That's the issue with using one number as a very rough estimate, it has to account for everything from contractors driving work trucks to someone commuting in a Model 3.
Uber is an easy way for a cash-strapped person to convert vehicle depreciation into cash.
The people driving Uber have mostly figured this out by now.
If you set yourself up as an LLC for your uber driving, can you take the standard mileage rate as an expense?
My wife volunteers during tax seasons to do tax returns for low income people. It always depresses her when people on the lower runs of the ladder come in and have been doing uber, lyft, doordash, etc or some combination and have nothing more than a hand wave estimate of how many miles they drove. She is the one who has to tell them just guesstimating is not allowed and what might have been a $1000 check back to them is instead a $2000 check they need to write to the government. 9 times out of ten they say, "but I don't have that money" and it crushes her. More than a few get mad at her for not being willing to just enter their guesstimate into the form.
I'm not sure if it is because uber (or whomever they work for) didn't make it clear enough to track it properly or if they simply didn't take it seriously.
Uber gives drivers tax summaries with miles driven.
https://help.uber.com/en/driving-and-delivering/article/wher...
I'd be surprised if they all didn't. They certainly have that information.
She's a tax preparer. It is not her job to police their miles, if they say 100k then that's not on her to go put and check the odometer.
Sadly she is just another poor tax. Highly paid tax preparers are happy to fudge numbers. I've seen it personally - every year.
"The Sleaze"... indeed you are.
Yeah. I won't say my nicely-paid tax preparer checks every minor charitable deduction but he certainly wants documentation for everything material.
You don’t need an LLC to do this. Just filing a Schedule C will do.
so either people aren't mathing or the frictionless experience is actually of value...
This trend was started in health care by private equity with no inspiration from Uber. Check your local dentists, eye doctors, veterinarians, urgent cares, maybe even hospitals. You'll find very few that are not owned by some large private equity firm these days, who run everything at the highest margins possible. And once you eliminate any higher quality / higher paying positions in an area, moving to pricing on demand and getting rid of full time positions entirely comes next.
Is there some way to tell whether a local company is owned by PE?
You can start by asking.
Many that haven't succumbed to PE yet know what it brings and appreciate the opportunity to speak to the issue themselves. Many of the best really wish more customers were paying attention and giving them credit for their choice not to sell out.
Meanwhile, many that haven't will either justify their corporate ownership or just kind of dodge the issue.
You can ask other providers for gossip and insight about ones you're curious about -- especially other providers in fields that are connected/adjacent but not directly competitive. The true locals are generally delighted to call out the sell outs.
It's not foolproof, but it's an effective start.
TBF it’s also an engine to push for regulations review. Awful lot of regulations are written for an age that no longer exists and just as many are to make management easier therefore startups pushing the boundaries actually are a correcting mechanism.
Unfortunately some harm can be inflicted bur IMHO it’s better than the alternative.
There was an “Uber for X” wave that didn’t really amount to anything. Stuff like home repairs was a big one. My take was that driving (and delivery) is a rare service that above some basic competence (and I’d say below another) is a pure commodity. For most things, quality is a differentiator, and anyone good would never give up a percentage to an app, so only the worst providers would sign up. My intuition is that nursing would work this way.
I think your intuition about quality and who signs up is correct, but doesn't insulate as much as you're assuming. For one thing, corporations have a nearly unlimited appetite for converting employees to contractors. For another, the economy has produced a large number of desperate people willing to do pure commodity work.
One reason "Uber for X" appears not to have materialized is that the platforms themselves are commoditized, not just the labor. Retailers like Lowe's and Wayfair have built assembly/installation services behind a checkout upsell. They run portals distributing work to their "network of local contractors" .
I got a window into this world through an acquaintance. He has a truck and light trade skills, but mental and reputational legacies of past addiction lock him out of the "anyone good" market. He's on a half dozen platforms, trying to stitch a living doing sink or toilet installs for Lowe's and building bookcases for Wayfair. A negative review gets you demoted from the choice gigs, or even kicked from the platform entirely. It's bleak.
They aren’t attacking regulation but full time employment. They spent a tremendous amount of money in CA to pass a law that’s nearly unable to be repealed to avoid having their gig folks count as employees. That’s the attack - everyone being a 1099. Not regulated industries.
Uber "deregulating" everything, means Uber taxing everything... because everything will go through it... and you know the EEE thingy right? better prices until you kill industry, then rise prices...
The good thing is that we will not be fooled this time while checking the dead bird thing...
Not only were taxi drivers not popular but it also wasn't and isn't obvious to most people exactly how or why they were regulated. Especially to people outside of major urban areas.
I do not think this will hold with nursing.
I have heard a couple of times -- Uber, but for prostitution.
Well, at least on case of taxi drivers "the flimsy excuse" phrasing applies more to existing regulation than not following it.
Not sure about the nurses, but my grandmothers were able to afford live-in caretakers in old age, without any government help or having much money, because these are completely unregulated (outside the US; or the regulation is not enforced)... We found good ones thru word of mouth, exactly the approach apps can scale
Being long degeneracy ( https://oldcoinbad.com/p/long-degeneracy ) really seems to be the correct market position. Turns out laws really are optional, if you're brazen enough.
That will only happen until they step on the wrong toes.
I can't wait until they disrupt something a cartel or the mafia are in on.
... funny thing, that. How about Uber for Amazon? Literally just gigwork in the warehouses at this point, in four hour shift chunklets.
https://hiring.amazon.com/promotions/anytime-shifts
American Tech Firms: fucking over society one segment at a time.
To what degree is this just another symptom of the US healthcare system being flawed and in need of rework? To what degree would anyone use such a service if the costs remained high?
I used Zocdoc in the past to find a doctor and ended up with a doctor who just charged out-of-pocket instead of insurance, and it worked great. Would an app that shows up-front pricing be better for the consumer?
The costs are not high. It's the prices that are too high.
I don't really know, but according to one graph, US nursing salaries are second only to Luxembourg:
https://www.oecd.org/en/publications/2025/11/health-at-a-gla...
Red herring; high salaries are fine for people who actually directly interact with patients https://hmpi.org/2026/07/10/the-growth-in-healthcare-adminis...
Breaking: Richest Country has higher wages.
Overall US salaries are also second only to Luxembourg (https://www.statista.com/chart/13093/the-countries-with-the-...)
Ratio to average wages is 0.9 last with Switzerland.
US not UK
If you look carefully at the chart, US nurse salaries are high because US salaries are high. The ratio of US nurse salaries to average US salaries is nearly the same as the OECD average.
Yes, it’s not specific to nursing. Labor costs are often high in the US, which goes a long way to explain why labor-intensive services cost more in the US, relative to other goods and services.
Evidence?
Every serious analysis of the US healthcare system I've ever seen comes away with the takeaway "Americans consume a lot of healthcare services and the expensive part of that is the providers' salaries"
It’s pretty well known that vertical integration has been the issue with driving up costs. Salaries for physicians aren’t all that big of a cost, compared to all the administrative BS that hospitals and insurance companies drive up, and conveniently have agreements to heavily discount.
For example, on a roughly 400k surgery, maybe 4-5k of that goes to the providers (anesthesia and the surgeon), dependent one on the codes billed for the procedure.
There are private groups that purposely do not take insurance and bill purely out of pocket with a one time fee including all follow up’s and subsequent care, related to that procedure, and it is significantly lower (like 90%+ less) than what an average hospital is charging.
> There are private groups that purposely do not take insurance and bill purely out of pocket with a one time fee including all follow up’s and subsequent care, related to that procedure, and it is significantly lower (like 90%+ less) than what an average hospital is charging.
I would bet a LOT of money that it is 90% lower for a "typical" patient but not 90% lower (and very likely pretty comparable) on average.
To state it more plainly: every time you pay for medical care in the US, you are subsidizing a half dozen people who consume 5x the services you do and do not pay.
That's why "fee only" medical (which always conveniently has no emergency services, you'll notice) can offer such low rates.
The costs are too high, but the health care workers are paid too little.
To see how this is possible, enumerate all the other people getting paid, and then compare to a country with a working health care system.
The most obvious difference is that the US spends an absurd amount of money administering health insurance.
Doctors and nurses in the US are in both the average and the median earning significantly more than their counterparts in Canada, the UK, France, Germany…
https://www.oecd.org/en/publications/2025/11/health-at-a-gla...
I'm in the Bay Area. There's a serious shortage of general practitioners because the patient:doctor ratio is so high. Even if their absolute pay is high, the amount they are paid to see me is minuscule. They can make more and have many fewer patients / appointments per day if they switch to a specialty.
On the other hand, specialists are more profitable for the "non-profit" healthcare networks we have around here, so they're easy to get appointments with.
Maybe we'd have more money to fix the problem if "nursing at home" wasn't one of the main medicare fraud schemes that has persisted for years now.
> another symptom of the US healthcare system
You know the videos of those couriers eating your food and claiming that it was delivered?
see also: https://en.wikipedia.org/wiki/Hippocratic_Oath
This is marketed to hospitals to fill shifts rather than nurse-to-consumer which has been available for a long time.
> To what degree is this just another symptom of the US healthcare system being flawed?
100%.
Nobody living in a country with healthcare for all with no out of pocket costs would ever care about such a thing.
I spend as much time thinking about “fixing” my healthcare as I do thinking about fixing the supermarket or the roads around here.
Ie not one second because they work perfectly.
It’s the symptom of a system where more and more wealth goes to few people and the rest has to fight for the rest of wealth
> found that some platforms "use data-brokers to determine nurse debt levels and offer lower wages to those with highest debt loads."
We can assume all gig economy companies do this? Brave new world indeed.
Uber checked the first few digits of your debit card to filter out police officer credit unions to evade taxi regulation enforcement. They use your phone’s battery level as one factor to estimate your elasticity of demand. They have teams of economists to adjust personalized prices to as high as you can bear and pay for drivers as low as possible.
Wondering if regular companies are doing this as well.
yes
Apparently most hospitals make low margins. If this is true, and the goal is to make healthcare more affordable, something has to give, no?
https://www.kff.org/health-costs/key-facts-about-hospitals/?...
It is also unclear how this is any different than traveling nurses which operate similarly.
What is the solution that doesn’t result in at least some large group of people making less money?
Among the things that need to give are 1) insurance companies should make no money because there's no margin left in the system for them, and 2) we should have several times as many doctors, which means breaking the protection racket that intentionally limits the supply.
What is the protection racket that intentionally limits supply? The primary bottleneck to producing more physicians is lack of available residency slots. Teaching hospitals are free to add more but for various reasons choose not to. In part I think they're waiting and hoping that Congress will kick in more subsidies through the Medicare program.
https://savegme.org/
Even if financial constraints were removed, the notion that we could produce twice as many physicians is ludicrous. There simply aren't enough attendings able to supervise a lot more residents, nor are there enough patient cases coming through the teaching hospitals to give that many residents the practical training they would need.
> What is the protection racket that intentionally limits supply?
It's the AMA.
"Free to add more" is hiding a LOT of important nuts and bolts of the guild system that discourages new entrants.
Nonsense. The AMA doesn't limit the number of residency slots. Did you even read through the website I linked above?
The website you linked above is quite literally rent-seeking for government funds to fund the residency requirements defined by the AMA.
Can you imagine if that website were for programmers?
"Waaaah we need more Staff Engineers at OpenAI but we just can't afford training them due to Congress not doling out enough for it, boo hoo".
Residency requirements are defined by ACGME. The AMA is a member of ACGME but ACGME operates independently. If you think that residency requirements should be changed then make a specific proposal instead of wasting our time with snarky, low-effort comments.
https://www.acgme.org/
State medical boards are the entities which ultimately decide on physician licensing criteria.
The physician protection racket case is put forward by Nobel Prize in Economics laureate Angus Deaton and his wife Princeton economist Anne Case in their 2020 book Deaths of Despair and the Future of Capitalism: https://press.princeton.edu/books/hardcover/9780691190785/de...
This AMA/ACGME protection theory is covered by Yascha Mounk at https://www.persuasion.community/p/deaton and elsewhere.
Discussion of physician protectionism is also found in the 2017 book by John Hopkins political science professor Steven Teles and Niskanen Center vice president Brink Lindsey The Captured Economy: https://global.oup.com/academic/product/the-captured-economy...
The New York Times covered the AMA's lobbying in this 1986 article: https://www.nytimes.com/1986/06/14/us/ama-board-studies-ways...
There's also the 1970 article by University of Chicago economics professor Reuben A. Kessel, The A.M.A. and the Supply of Physicians: https://scholarship.law.duke.edu/lcp/vol35/iss2/4/
Did you even read through the website I linked above? Your references are badly outdated. While the AMA once lobbied Congress to limit Medicare funding for residency slots they reversed position years ago. And even back then, there was nothing stopping teaching hospitals from expanding residency programs using their own funds or other sources.
There are valid reasons to criticize the AMA but blocking the training of new physicians isn't one of them.
You're citing an AMA public relations campaign to retain public funding of residencies but I'm not sure anyone here is arguing that it should be cut. The AMA made public statements holding the same position about increasing funding and removing the 1997 residency caps in 2006. And yet notable academics since 2006 still have suggested (eg, the books in 2017 and 2020) that the profession, ie the membership of the AMA, presumably even with this formal position taken by their association body, is behaving in a protectionist manner. Either way, part of the argument is that physicians' documented earlier collective behavior (old boys club), suspected ongoing culture, and inherent economic interests, are still causing present and future problems.
Even if that was all true, so what? Congress is free to increase the Medicare budget for residency programs if that's what voters want. And teaching hospitals are free to expand their own residency programs regardless of whether Congress acts.
The AMA, and physicians in general, are obviously not the primary obstacle here. Complaining about their past actions won't solve any of the actual problems we have today
A much larger supply of doctors would presumably lower their pay significantly, right? Will people still want to put in the years and years of training to become a doctor if the pay drops significantly?
The planet pays doctors much less than the USA does. They still have doctors.
The USA doesn't recognize those other doctors (in more ways than 1 apparently) and that is an aspect of the issue.
Given the NHS(and many other western countries) still has a surplus of med student to training places with much worse compensation than the US, the answer is yes.
Prestige and potential higher pay for specialisations will still attract people to the profession, although maybe not if the university costs for medicine remain as high as they currently are.
#1 seems like a feature, not a bug. The real problem is that health insurers in their current form exist at all.
Germany has non-profit sickness funds (Bismarck model). So you don’t have to ban health insurance companies when rolling out universal healthcare. Their freewheeling excesses have to be reined in. Access is a right. Standardize coverage and prices on both the insurer and hospital/doctor ends. Once everyone is in the same risk pool, there will no longer be a perverse incentive to deny claims for profit. A single standard plan will also have the negotiation power to drive down prices.
We are saying the same thing: I was stating what the desirable state would be.
Most hospitals (both for-profit and non-profit) are terribly inefficient. They burn up clinician time on administrative tasks that could be automated or performed by cheaper office staff or not done at all. And employees often waste a lot of time just waiting around because no one has optimized workflows to shorten queues or eliminate bottlenecks. The incentives are structured in a such a way that there's often little reason to improve.
Most software development shops (both for-profit and non-profit) are terribly inefficient. They burn up programmer time on administrative tasks that could be automated or performed by cheaper office staff or not done at all. And employees often waste a lot of time just waiting around because no one has optimized workflows to shorten queues or eliminate bottlenecks. The incentives are structured in such a way that there's often little reason to improve.
Ha ha, but it's a matter of degree. Every organization has some level of inefficiency but having seen how the sausage is made I can guarantee you that the average software development shop in a US tech company is significantly more efficient than the average hospital. It's not something that you can quantify in a directly comparable way but anyone familiar with the industry will tell you the same.
I made a lot of sausage, including for US companies. My personal preference is smoked, not dried.
I manage a team of devs in the healthcare industry, I've worked in other regulated industries and healthcare is unique. I could go on forever but it comes down to the fact that healthcare is uniquely risk averse, for understandable reasons.
Risk tolerance is an orthogonal issue. The point I raised is about operational inefficiency which has no impact on risk (in terms of legal compliance or patient safety) one way or the other.
This is certainly true. With modern AI agents, it is entirely possible that the duty cycle of a software engineering enterprise is not actually the 8h/24h we have today but closer to a 24h/24h system. Certainly my ideal is to proceed software engineering organizations closer to the latter system.
It’s a complex problem because a lot of those hospitals are non profit, so they have zero incentives to have high margins because no shareholders to return money to. Higher salaries for executives though…
That's not entirely true and a misstatement of how these work, take Blue Cross of Michigan. It is a nonprofit, it's board is controlled by the members, essentially they are the share holders, they have a interest in lower prices and an efficient operation.
How the board gets approved to be elected is a bit self selected, but in theory it should be controlled by people that have incentives, the same as a public corporation.
Now this is an insurance company and not a provider network,some provider networks are more self owned.
It's REALLY important to understand that non profits have just as much incentive to maximize their income as for profits.
They have no stock holders to pay, but the people running them will pay themselves multi million dollar wages if they can!
It’s important to note that in most countries the law even states that they need to pay competitive salaries for these positions, so they can’t even pay them much lower amounts than their non profit counterparts
check the admin headcount vs healthcare worker last time I looked up admin grew exponentially
Traveling nurses make more than lots of doctors though, so I dont think they're being taken advantage of. However, Im sure this company is trying to take a piece of that traveling nurse pie.
The exact profit margins of hospitals as a whole doesn't matter. Hospitals are where health care happens but financially, they are simply a platform for a multitude of other private entities which make profits on top of the simple hospital fees - the "Uber For Nurses" thing is just one of many ways this happens, you have everything from data management companies to separately own MRI machines adding to the patient's bill and having a voice in the management of the hospital.
Yeah, maybe it's the idea that hospitals should make profit that should give?
Like, sorry, but not being from the US the whole idea of a "margin" when running a hospital is insane. Hospitals are paid from our ample taxes and the patient pays nothing - there is no room for profit there, not should there be one.
How much does your country’s medical professionals make, how long do patients wait for care and what is the level of care as measured by variety and efficacy? Seems hard to compare without normalizing these things.
>How much does your country’s medical professionals make
Let's assume UK. Less. US physicians earn about twice what their UK peers do, US RNs about 1.5x https://www.commonwealthfund.org/publications/issue-briefs/2...
>how long do patients wait for care
About the same or longer, in general UK consumes less healthcare per person, but...
>what is the level of care
Better outcomes in the UK https://www.pgpf.org/article/how-does-the-us-healthcare-syst... and longer UK life expectancy https://www.oecd.org/en/publications/2025/11/health-at-a-gla... (and of course US has higher levels of chronic illness https://www.healthsystemtracker.org/chart-collection/how-has...
All for far less (share of GDP) than US https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locat...
Trying to compare national healthcare systems based on life expectancy is a total non sequitur. Most of the factors which limit US life expectancy relative to other developed countries have little or nothing to do with healthcare (or lack thereof). It's mainly other problems like car crashes, suicide, violence, substance abuse, and sedentary lifestyles.
mhm
It's happening everywhere. All these apps who try to be endless rent-seekers, injecting themselves in a process where they have very little to add.
I don't need a platform that takes 25% off of the handyman that I call. All that happens is that I pay 25% more. And if the platform becomes large enough it'll set policies that the handyman cannot offer lower prices outside of the platform...
Could I use this app to hire a nurse and get a diagnosis from home? If we can start getting even meagre medical treatment to skip insurance / other middle men, I could see this having a great impact on healthcare prices, especially since AI is such a good information extractor, which is 90% of the role doctors play anyway.
There are many types of nurses, for example Nurse Practitioners have masters or doctorates of nursing can do much or all of what a doctor could within their specific scopes.
Generally speaking nurses in the united states cannot provide a diagnosis, at least without jeopardizing their license. You can already find a doctor using a service like Zocdoc who may cut out middlemen, though regulatory capture has made it close to impossible to meaningfully reduce costs in this way. I would not recommend using AI to diagnose or treat yourself (https://www.nytimes.com/2026/10/27/well/ai-chatgpt-medicatio..., for instance) without the help of somebody highly trained to interpret this information and make good decisions.
Nurses don't really do diagnosis, but follow the ones doctors give. (Except for trivial things)
Otherwise I unfortunately know plenty of doctors that could easily be replaced by an LLM, but for now I prefer a diagnosis from a real doctor (who may use AI as a tool).
Nurse is a very broad term with education ranging from under two years of vocational training to a doctorate in nursing.
If you really believe that information extraction is 90% of what doctors do then you're deeply ignorant about how healthcare actually works and not qualified to even have an opinion on this subject.
Lord have mercy. The last thing you want is under paid, lower quality nurses. If you're for that, you've never had a hospital stay.
I cant even afford a hospital stay.
Seems like illegal wage fixing collusion by employers with the extra step of technology.
To be fair US health care system is sort of similar to old NYC taxi driver cartels before Uber. Just try to get price quote ahead of procedure...
Ripe for disruption!
> A companion Roosevelt Institute brief found that some platforms "use data-brokers to determine nurse debt levels and offer lower wages to those with highest debt loads."
thanks free market
I'm investing in guillotines. I have a feeling they're going to be hot.
When something sounds too bad to be true, I think it's fair that we should ask for some kind of evidence to be produced. They cite a Roosevelt Institute article that says
"Gig nursing apps MAY [my caps] determine pay by what the firm knows about how much a nurse was willing to accept for a previous assignment, how often they bid for shifts, or how much credit card or other kinds of debt they might hold."
That kind of sounds like they are overselling a hypothetical. Even just an "insiders familiar with the matter have told us that it IS happening", would make me believe it more.
Everyone wants healthcare expenses to go down but the biggest healthcare expense is the salaries of providers. So, hard to give the masses what they want without making a smaller group of people who benefit from the status quo angry.
Physician and nurse salaries account for only 15% of healthcare spending.
https://www.commonwealthfund.org/publications/issue-briefs/2...
to be a bit pedantic, that says they account for only 15% of the excess healthcare spending, relative to other countries. It's not surprising given doctors in the united states have a higher level of training compared with many peer countries, and _all_ salaries are much higher in the united states compared with almost any country.
The 15% extra administrative cost of insurance and 15% extra administrative burden of applying care are the big culprits, in addition to extra costs on medicine and machinery. But it's interesting. Why is it that a comparatively deregulated and privatized system has so much extra pricing cost from bureaucracy?
Much like home prices. Everybody says they want homes to be more affordable, but all actions are designed to keep them high and if they did actually fall it would be treated as an emergency.
I’m sure there is some savings to be found within the insurance industry who regularly reports earnings in the billions.
Hospital administration costs are 20-30% of healthcare costs. [1]
[1] https://www.trillianthealth.com/market-research/studies/hosp...
In Sweden we had this in the news: https://www.svt.se/nyheter/lokalt/uppsala/hon-pendlar-860-mi... A US nurse moved to Sweden and preferred to fly to San Fransisco to work ten days at a time, then fly back to be off for six weeks, rather than taking a job as a nurse in Sweden. The salaries are very different.
The whole ecosystem of companies trying to make a profit from each thing along the way isnt efficient. Other countries just nationalize instead
How about we gut the insurance companies that are blowing the price of everything in healthcare and not leverage the desperation of nurses?
We just need to educate a lot more doctors and nurses. That would lower salaries and provide a lot more care.
Last I heard the AMA controls how many doctors can be educated.
Physician salary is only 9% of total healthcare cost. The rest of the labor pool is administrative - clerks, management, etc.
Physicians also make 2-3x more than physicians in other countries. Why? Their education cost is also 2-3x higher than in other countries.
Hospitals and procedures are expensive, in part because of insurance. Insurance is high because our society is too litigious. It's also expensive because of consolidated private healthcare systems that can control and mark up prices due to lack of competition.
Other countries spend half what we do on healthcare. And their people are often healthier.
The entire 'gig economy' model is exploitation. It only works because of income inequality. It requires a large pool of workers who don't make enough money to support themselves (due to insane healthcare and housing costs, and low wages and benefits) and thus will take any money they can get, despite the poor pay, long hours, and lack of benefits. It's taking a person slowly dying of thirst and offering them a thimble of water in exchange for knitting a sock.
In the case of Uber it's bring your own thimble too
Could not the IRS fix this in one swoop by declaring that "gig workers" are employees?
Presumably, but what do you think the lobbyists are for?
Unfortunately it wouldn't fix anything. It would kill gig work because the model isn't sustainable with regular taxes and minimum wage (if it were, businesses would've already been doing that instead of independent contracting). It also wouldn't fix the income inequality that created gig work. People would be back to dying of thirst, without a thimble of water.
The real fix is to make it so their main job is hydrating enough, or the thing half the country hates the idea of (public fountains). IRS can't do either. Independent contracting is still a valuable mode of work, when the contractors are paid enough. So rather than ban forms of gig work, we need to provide good paying jobs and social services, and get the rich to pay their fair share.
While I do understand the importance of training, degrees and experience I see that people in the medical field beyond Doctors seem to have a very holier than thou attitude probably because they have 10 edge cases of how MRI can go wrong drilled into them (MRI technicians), not everyone is comfortable with needles and human body (nurses) and because it seems that only Pharmacists can sort and provide us the right medicines when in fact it can be easily done by some robots.
In before someone says that your reasoning is flawed because that is very incorrect perception of the field. All I see is that regulatory capture has worked very well here and is simply stopping totally novel and practical ideas which work on tradeoffs from even taking off
This sounds like pure insecurity with a sprinkle of Dunning Kruger. Unless I'm missing the joke somewhere? Nurses don't mind needles is the only difference? I must be missing the joke.
I feel really conflicted on nurses
On the one hand, a good nurse is invaluable. They do the hard work that doctors won’t/don’t do, and can be so kind and generous during your time of need.
On the other ones, there are so many who mail it in and are just milking the system
Healthcare is so expensive - some nurses are making 500k a year - their union contracts base vary from 200k to 300k for something like 32-36 hours per week
On top of that, they can pretty much work unlimited overtime with zero restrictions. They can work enough overtime hours such that they can nearly double their salary. And that’s how you come up with the 500k figure I posted
Granted, that’s at the top of the range, I’m talking about somewhere like the Bay Area, and does require a ton of overtime, but those extra 100s of thousands add up. These hours can’t be spread around to minimize the amount of time and a half or double pay paid out, per contract they go in order of seniority
This is just nurses and I imagine it’s something similar but with higher rates for specialists like anesthesiologists and still beyond that doctors and surgeons
I don’t begrudge anyone’s salaries, but it’s a zero sum game. There’s a reason why, aside from typical corporate profit maximization, you wind up with a 30k bill for a short visit. Even if you account for the lower rates insurance companies pay, it’s still in the thousands of dollars for treatment where you were seen for less than 30 minutes
Like I said, to be clear, I don’t begrudge anyone’s salaries - this is just an under discussed point when we talk about healthcare costs
Labor is generally reported as 60% of the costs of hospitals - so if you’d ever want to talk about making healthcare affordable you’d have to address this which I feel like is a bit of a taboo subject. Many nurses are in a union which makes it an even more difficult conversation
All that is to say, I can see the motivation behind stuff like this, even if I don’t agree with it
> Like I said, to be clear, I don’t begrudge anyone’s salaries - this is just an under discussed point when we talk about healthcare costs
You are begrudging someone’s salary. Nurses make 500k by working overtime. You know why they work overtime? Because it’s cheaper for the hospital than to hire 2 nurses. The problem isn’t the nursing salaries. It is the administrative costs that make your healthcare too expensive. Why do you think single payer reduces healthcare costs?
PS: median nursing salaries are still under a $100k. The numbers you pointed to are not the norm.
If admin costs concern you, and you live in California. You should vote for Prop 44.
Not really, I just said they can’t spread out over time across staff because you have to move up the seniority ladder - so in this particular case, what any manager would do and does in other industries, is spread hours to limit the amount of the really expensive overtime. Instead of one person working and getting double time or more, you can have two people working regular overtime, but this isn’t always possible
I also said this was for the Bay Area - it’s not the norm but it’s not infrequent either
Labor costs are 60% or hospital expenses, I didn’t make that number up and you just glossed over.
And again, I said it was just an issue to be discussed. If discussion leads to it’s not worth discussing, that’s great and a great outcome
You did the thing where you just sort of read what you wanted to read in my comment vs addressing what it said
I am all for it, and hopefully seen in Canada soon too, the smug nurses are literally doing janitorial works and get paid 90k and above, always complaining, very bad attitudes, make it feels like they are doing all the work for free too.. hopefully doctors follow too, the healthcare mafia and their bureaucracy must end, these abysmal waiting times aren’t because of low resources or whatever BS excuses, it’s intentional from doctors/healthcare staff supply all the way to the actual process you get to deal with while being treated or going to ER, it is designed that way.
Nurses already deserve higher wages than what they already get, but introducing "dynamic pricing" and competition to under-bid each other is just disgusting.
Nurses form the backbone of healthcare. Treat them as such.
Edit: To those downvoting me, talk to a real nurse and I bet you wouldn't take twice the pay to do half the work they have to deal with.
There's no concept of "deserving higher wages". It's a popular online meme but what on Earth does it even capture? If you value the work higher, then pay them more and you'll win the market for that labour.
There's a good argument to say that sufficiently aggregated marketplaces can launder price collusion, and if we were in such an aggregated marketplace then you could make that argument. But we're not in that situation right now.
The 'Edit:' is even more confusing. If I talk to someone in a profession and I wouldn't take twice the pay they receive to do half the work they do then they deserve higher wages? But that list is huge. Congressmen, Senators, many CEOs, Wagner-group mercenaries, ICE officers, drone pilots. In fact, almost every profession has this 4x effective slippage you're talking about.
Thanks for leaving a comment rather than just drive by downvoting.
One movie that made me change my perspective on nursing as a field was the Swiss movie Late Shift. It really opened my eyes to what nurses have to deal with. Yes the US might be different in having lower patient to nurse ratios but at the end of the day I think it's still applicable.
There's no way for me to tell you that I am well aware of this without it sounding like some braggadocious detailing of events of my life, so perhaps it will suffice to say that my parents are surgeons and we lived in rural and urban India at various points in our lives.
I still think their monetary compensation should be provided by market valuation of the utility of the work they do.
Uber for talk therapy / psychology is dog shit, I’m sure this will be too.
Does this mean that as a customer I can select only nurses that don't have fake degrees?
You'll only get that option on the Premium tier.
Another torment nexus banger.
Tech bros: "It's Uber and Doge for nursing!"
Like nurses are just an expense.
Go ahead and downvote me for this, but the medical field in the US especially when it comes to RNs needs a shake up. This is going to sound very crass, but the only skill that your average person on the street doesn’t have that nurses have is to stick a needle in a vein and that’s something that can be taught to a lay person over a week. Pretty much everything else are skills that any person off the street possesses and we would do well to have a lower bar for entry for it.
I don't think you know what nurses do.
Nurses change dressings. Insert catheters. Move heavy patients without hurting themselves. Prepare equipment for surgery. Ensure the sterile field is maintained. Operate specialized equipment. Triage medical emergencies.
And about a million other things that the average person doesn't know how to do.
Yeah, I was relying on anecdotal experience so I went and looked it up and they do an incredible amount. Well, it’s too late though I can’t modify or delete my comment anymore.
Many industries (medicine, law, engineering, etc.) need huge "deregulation" shakeups; massive expensive legal and financial grifts going on