Okay, so I fully agree with the point that licensing cartels are most of the reason that physicians are the single highest paid occupation in the US and it isn't even close. Virtually every highly paid supposed free-market-loving, anti-union private sector champion…from doctors to lawyers to CEOs to start-up entrepreneurs…are full of crap bc ALL of them use the law to protect themselves from competition, just via non-competes, monopoly, licensing cartels, and regulation (despite the public widely believing their BS about regulations hurting business, since most regs are written BY business interests and are protectionist). So yes, a lot of the cost disease in medicine is bc of doctors, not insurance.

But the admin burden of private insurance has to be a significant part of this equation, because otherwise it simply makes no sense that plastic surgeons make so much money. We have the perfect example of what medicine looks like in a world without insurance, because cosmetic surgery is all paid by the patient, cash upfront. And it works just like everyone expects: patients actually shop around, since there's no “in network/out of network” to worry about, and they get an actual itemized quote for the actual price, which will tell them precisely how much it costs, and cosmetic surgeons compete on price. The result is that the costs of plastic surgery have increased less than the rate of inflation over time. In other words, if you take inflation into account, it is actually cheaper now to get a tummy tuck or boob job than it was 20 years ago.CPI over 20 years been about 66%, while the cost of cosmetic surgeries have only increased 31%…that's less than half! And the cost of medical services in hospitals has increased 230% over that same period!! So cosmetic surgery has worked exactly like free markets are supposed to, by increasing efficiency and lowering prices over time, while prices neverendingly skyrocket for every other type of insurance-paid medical care.

But here's what I don't get: how is it that plastic surgery can be so relatively cheap compared to all other medical care, and yet plastic surgeons are one of the highest paid types of doctors??? They make something like $700k/yr on average. How is that?? A 5 hour surgery under general anaesthesia that requires a surgical suite, physician, 2-3 nurses, and an anaesthesiologist will cost half or a third as much if it's a cash-pay facelift done by a plastic surgeon, as compared to what a 5 hr surgery like that would cost in a hospital where insurance pays. So how is it that plastic surgeons aren't making way less money??

In a perfectly free market with full competition, the trend is for profit margin to get competed away. So I understand that the licensing cartel is doing a lot of the work here, and maybe the answer is just that there’s a severe shortage of plastic surgeons relative to demand. But the huge price discrepancy and the fact that plastic surgeons are not just well paid but usually one of the top 3 highest paid specialties in a given year, is a mystery. They have overhead just like everyone else. If anything, they spend a lot MORE on marketing and have fancier offices. So how the hell does this make sense UNLESS a giant portion of medical expense is simply all the admin of dealing with insurance companies? It doesn't scratch out otherwise. This isn't a small difference here…hospital costs have increased at more than triple the rate of cosmetic surgery in two decades, and non-hospital insurance-paid medical services have increased by about double. Yet plastic surgeons AREN’T making less money. To me that points to a giant cost of overhead just dealing with multiple insurers, which cosmetic surgeons don't have to do…they just charge cash up front. Can someone explain how else this could be, unless there's a huge admin cost that exists for no reason but dealing with labrythine billing requirements and prior auths for a bunch of different third-party payors?

People seem to want to be either-or on this one, but to me cosmetic surgery shows it is clearly both: the AMA protectionist racket and the admin waste of dealing with multiple for-profit insurance payors.