Valid frame challenge, especially with NYC. Yes, increasing regulation may be one of the underlying themes. Regarding doctors' cartels and public/private salary gaps: That hasn't changed though.

For DB at least privatization is a major culprit of the decline. That is the CEOs optimized for share holder value and did so by cutting innovation and investment. That worked for a few years before it almost inevitably started falling apart... Didn't the same 1% pro manager philosophy also ruin Boeing, which moved from an engineer driven company delivering state of the art products to a business driven company being a major health hazard? Also a healthcare that you can't afford is no healthcare at all.

It is a good point though that people are getting older and that thus necessary jobs have shifted. Also health care jobs aren't really able to be streamlined or the other way around doing that usually leads to abysmal performances with regards to what they are meant to accomplish so there is an inherent problem that the market can't solve or not in desirable ways. Also yes the expectations have also risen, so what would have been acceptable in the 70-80s is nowadays 40-50 years behind the standard...

Also with regards to restricted spots for medical doctors, where are the other solutions offered. Like a comment mentions entry level tests, but those are already a thing where an above average level Abitur/Matura/A-Level is required to study restricted disciplines, apparently the English Wikipedia lists the high school diploma as less challenging than the formerly mentioned so additional aptitude tests are required. Still the same concept you limit the spots by putting up a threshold for acceptance.

Also what are "cartels" in your mind? Like unions? The fact that many occupations are professions rather than jobs, so that they require several years of training to become a certified professional rather than something you could pick up as an amateur? That you're trained on the job and that therefore you need to find a company that trains you? Also a major problem for craftsmen right now is inflation and the fact that things get more expensive than planned and that they can't plan ahead what their material will cost.

I think this answer doesn't explain why additional demand is not matched by additional supply. If there is more geriatric medicine, then why aren't there more medics, and why isn't the work more routine (so instead of seeing a GP, you go to a knee doctor or a hip doctor)? Why aren't more hospitals opening rather than closing and concentrating?

@haxor789: I'm not too familiar with Germany, but reports are that you need two years of specialized training to work as a plumber in Germany. dw.com/en/refugee-plumbers-to-plug-german-skills-gap/… I'm not sure if it's due to state regulations/licensing or employers just won't hire plumbers without those degrees/papers.

As for the private sector offering higher pay in Germany, that doesn't seem to really the be the case for most jobs reddit.com/r/germany/comments/17s4v8o/…

@MakeStackExchangeGREAT4ever In Germany most professions take a 3 year apprenticeship. Craftsmen professions often have a bachelor/master program where the bachelor takes ~3 years (individually longer or shorter), after which you can work as a hired plumber. And if you want to work as a self-employed plumber or hire apprentices plumbers, you'd need another 1-2 years to obtain a master degree (professional degree not academy or whatnot). That's why German professionals usually have a high quality because calling yourself a job title usually requires at least 3 years of training on the job.

@haxor789 for doctors I would focus on creating more residency spots and removing unnecessary parts of doctors training that can now be substituted with computers and AI. Is every part of the medical curriculum actually necessary to do a good job or is it done because “we’ve always done it this way”? You could also work on reducing the burden of documentation, doctors waste lots of time on paperwork.

@haxor789 for plumbers and electricians you could replace the need for training with the requirement to carry liability insurance. Let the free market decide what level of training is appropriate. If a major insurance company is willing to sell me insurance for plumbing work, then I should be good to go.

@MakeStackExchangeGREAT4ever what does an engineer at the German Tesla factory make compared to an engineer at DB?

@Peter-ReinstateMonica the public vs private salary gap is increasing every year for the top performers who are now sought after by every corporation in the world. In the 70s you could convince a top-1% performer to stay in their small home town because moving was much harder and information spread more slowly. Nowadays a top 1% person can go on LinkedIn and find themselves a 3x paying job in a different corner of the world within a couple of months.

+1 Some good nuggets of info here, not least wrt to aging population. And, yes, the NIMBYs role in screwing up housing fully warrants calling out. However, it's also not surprising that it gets downvotes with such little jewels like I live in the US and have no issue accessing doctors because medicine here is privatized. I wonder if you would be making the same statement if you were less well off or had more extensive chronic health problems making said privatized care difficult to afford for yourself. Some regulation is good, too little or too much is bad seems would be my own take.

@ItalianPhilosophers4Monica the breakdown of insurance for New York is as follows: 50% have employer-provided insurance or buy their own plan, 18% are on Medicare (retiree insurance). Both groups have the exact same doctors access as I do. 27% are on Medicaid which is more tricky, with wait times of about a week for primary care - this would be considered perfectly acceptable in the EU. Finally 5% don't have any insurance at all. So 95% of New Yorkers have better or equivalent care standards to German residents.

@ItalianPhilosophers4Monica another anecdote: I've had a persistent issue that was bugging me for years. In Czechia I've visited several specialists and they've all sent me away without scheduling a proper (invasive) test, giving me nonsensical advice which never worked. And the wait time for a specialist was around 6-8 weeks I moved to the US, went to a specialist (wait time was ~2 weeks), he immediately schedules the invasive test for me. Lo and behold, they find the problem, gave me the right medicine and I'm cured now.

@ItalianPhilosophers4Monica Oh and the medicine I got in the US was fully covered by the employer insurance but in Czechia it would not have been covered because its under patent and very expensive, despite clinical trials showing much better outcomes than the previous generation medicines. So even if I managed to convince a doctor to diagnose me properly, I would not have gotten the best available medication.

@JonathanReez With all due respect, but you do realize that Germans are culturally notorious for complaining about everything? It's literally not a joke that "There's nothing to complain about." is a compliment in Germany. So when Germans complain that there are no plumbers or no doctors, it doesn't mean sewage is running through the streets, right next to where the bodies pile up. It's rather that they take longer to see a specialist for a non-urgent problem, which apparently is mandated to still be below 4 weeks if their GP argues it's that urgent.

@ItalianPhilosophers4Monica last anecdote: for years I've been having teeth issues, went to the best dentist clinic in Prague, been doing cleanings, flossing regularly, etc. But the dentists could never quite get things right and I constantly had cavities and other issues. I move to the US, go to a great dentist here, they scratch their head in shock about all the shoddy work done in Prague, and I spend a few months of repeat visits while they fix up the mess. End result: zero cavities and zero tooth pain for 5 years now. After insurance I believe it was $5k total but so, so worth it!

@haxor789 I'm a Czech citizen and worked in Germany for some time (though never went to see a German doctor). I know both the EU and the American system extremely well.

@JonathanReez I don't know what the core curriculum for medicine entails, not a medical doctor. And with regards to AI... That's a wide field and some applications make sense while others are just to capitalize on the hype. So some data analysis has long been assisted by AI without calling it as such while making decisions about my health based on parameters that no one understands or can explain... cautious. Also not a fan of compromising on quality especially when it comes to healthcare, so rather make algorithms automize the documentation than to get rid of it...

@JonathanReez And with plumbers and electricians the problems isn't that there are none and that people would compromise on the quality. The problem is that there aren't as many people wanting to get into those jobs. They require long training are often physically taxing and the payment isn't great. If you reduced the training you'd make the quality drop but that doesn't make the job more attractive so that doesn't solve the problem but would create a whole lot of new problems. Also professional plumbers already need liability insurances....

Let us continue this discussion in chat.

These anecdotes could be seen as shed light on Czechia medical practices, but I don't really see how they change that - compared to non-ex Warsaw Pact Western countries - the US spends nearly twice as much per capita on health, yet has slightly lower life expectancy.

@ItalianPhilosophers4Monica the US has lower life expectancy because Americans have a higher BMI. See this chart. Germany is at a median of 23 (healthy), the US is at a median of 28.8 (overweight). But things will rapidly turn around this decade thanks to Ozempic.