Which Country Has the World’s Best Health Care? by Ezekiel J Emanuel

Today, the US healthcare system occupies a place very like US beer did in the 1990s.

See back then, US beer was a joke to liberals, or anyone that took beer seriously, and a point of patriotic pride to conservatives.

These days, after decades of shifting regulations that allowed the market for craft beer to first find a foothold, then blossom, US craft beer is world-renowned. Numerous pubs in other countries proclaim they serve “American-style craft beer.” People across the political spectrum can take pride in their local brewers, no snobbery or jingoism required.

Our healthcare system has not experienced anything close to that kind of renaissance. Conservatives refuse to countenance any critique of the system, while liberals use it as a tired punching bag. We’re warned of the dangers of “socialist medicine,” all the while my mother-in-law is constantly harassed about a $4,000 bill she doesn’t owe (the hospital filed it wrong with her insurance), doctors and nurses are overworked, and millions go without any sort of insurance.

And, frankly, Medicare for All sounds great, but it scares the bejeezus out of anyone to the right of Bernie Sanders. Not to mention it’s sort of vague on details, and seems to require a rather large leap to get from here to there.

So I was primed for a retread of the old arguments in Which Country Has the World’s Best Healthcare?. US healthcare is terrible, Canada’s is great, etc etc.

Thankfully, that’s not what I got at all. Instead, I found the missing manual, a way to evaluate different healthcare systems around the globe. Along with a proper sense of the history and workings of eleven of them.

Emanuel describes a set of axes along which to measure a healthcare system. Things like patient wait times, or costs at the point of service, or choice of doctors. Then he proceeds to examine each country’s system in turn, looking at the things it does well, the challenges it faces, and — most importantly — how and why it does those things well or badly.

True, the US performs terribly on basically every axis. That’s not news. What is news is that multiple countries manage to provide better coverage, better care, and cheaper care, without giving up private practices, or even — in some cases — letting go of private insurance!

Reading this, I felt both relieved and angry.

Relieved, because with so many different systems out there, no one’s got a monopoly on the “right” way to do things.

Angry, because for so long the debate in the US has been framed as single payer or status quo. When the truth is that we can do a lot to improve our system without letting go of the basic free market nature of it.

How much further would we liberals have gotten, if we’d argued for a regulation of drug prices, instead of single-payer? Or insisted that insurance coverage for children be provided for free, as part of any policy, like it is in other countries with well-regulated markets?

We don’t have to have the government take over as the single payer for everyone. We don’t need to radically overhaul the system. We need to properly regulate it, to get the outcomes we want: patients being able to choose their doctor, use their insurance to help pay for their care, and not go broke obtaining the prescriptions they need.

Framed as the proper regulation of a free market, what could the conservative response have been? I suppose they could argue that Greed is Good, and everyone that has to choose between paying the rent and buying their blood pressure meds deserves it, so the CEO of some corp can enjoy a multi-million dollar bonus.

But that doesn’t have quite the same ring as “death panels,” does it?

So ultimately, I’m grateful that Emanuel and his team chose to write this book, and publish it now. It’s high time we brought a more nuanced, useful debate, to the argument over healthcare.

Keeping Score: August 7, 2020

I need to get back to working on the novel.

I’ve let it sit these past few weeks, untouched, while I finished getting one short story into shape and started plotting a new one.

But if I’m going to meet my personal deadline of having the novel ready to submit to agents by December 1st, I’m going to need to edit this second draft.

To be honest, I’m intimidated. I’ve never edited anything this long before.

How do I even do it? Read it all through, and then go back and edit passages? That sounds…like it’ll take forever.

Or do I work chapter by chapter, editing each one until it’s done, and then moving on? That sounds like an easy way to lose sight of inconsistencies (or to having to go back and edit previous chapters anyway, as inconsistencies show up).

I think what I’m going to do is a series of editing passes. Pick one thing to look for — like the consistency of a single character’s dialog — and edit all instances of that. Then pick something else — the descriptions of a ship, say — and edit all of those.

I’m hoping this will give me a structure in which to do multiple reads over the book, without getting lost in the weeds of any individual chapter. And it should broaden my perspective so I can stitch the book together, so to speak, with these edits. Make it more coherent, more whole.

But what do I do with the short story I’ve been outlining? I don’t want to lose momentum on that. And I worry that the novel, once I start editing it, will take up all the room in my brain for narrative.

I want to work on both. Use the story as a break from the novel, and use the novel as a break from the story. They’re different enough — one’s near-future sci-fi, the other is early modern period fantasy — that I should be able to keep them separate in my head. And editing is different enough from drafting that I’ll be exercising different writing muscles with each.

What about you? What do you do, when you’ve got a longer piece to edit and a shorter one to draft? Do you alternate working days? Finish the shorter piece before editing the longer? How do you handle two stories that both need your attention?

Are Job Degree Requirements Racist?

Since reading Ibram X Kendi’s How to be an Antiracist, I’m starting to re-examine certain policies I’ve taken for granted. What I’ve previously thought of as meritocratic or race-neutral might be neither; it might instead be part of the problem.

In that book, he gives a clear criteria for whether a policy or idea is a racist one: Does it establish or reinforce racial inequality?

With that in mind, I thought I’d look at my own house — the tech industry — and at our very real tendency to run companies composed mostly of white males.

There are many reasons why this happens, but I’d like to drill into just one: The university degree requirement.

Most “good jobs” these days require some sort of university degree. Tech goes one step further, and asks for a degree specifically in computer science or another STEM field.

The degree isn’t enough to get the job, of course. Most interview processes still test skill level at some point. But the field of candidates is narrowed, deliberately, via this requirement.

The question is: Does requiring this technical degree bias the selection process towards White people?

Criteria

Before diving into the statistics, let’s back up and talk about the criteria here. How can we tell if the degree requirement biases selection?

In order to do that, we need to know what an unbiased selection process would look like.

And here is where it’s important to note the composition of the general US population (and why the Census being accurate is so very very important). If all things are equal between racial groups, then the composition of Congress, company boards, and job candidates will reflect their percentages in the population.

Anything else is inequality between the races, and can only be explained in one of two ways: either you believe there are fundamental differences between people in different racial groups (which, I will point out, is a racist idea), or there are policies in place which are creating the different outcomes.

With that criteria established, we can examine the possible racial bias of requiring university degrees by looking at two numbers:

  • How many people of each racial group obtain STEM degrees in the United States?
  • How does that compare to their level in the general population?

Who Has a Degree, Anyway?

According to 2018 data from the US Census, approximately 52 million people (out of a total US population of 350 million) have a bachelor’s degree in the US.

Of those 51 million, 40.8 million are White.

Only 4.7 million are Black.

That means White people hold 79% of all the bachelor degrees, while Black people hold only 9%.

Their shares of the general population? 76.3% White, 13.4% Black.

So Whites are overrepresented in the group of people with bachelor degrees, and Blacks are underrepresented.

So by requiring any university degree, at all, we’ve already tilted the scales against Black candidates.

Who is Getting Degrees?

But what about new graduates? Maybe the above numbers are skewed by previous racial biases in university admissions (which definitely happened), and if we look at new grads — those entering the workforce — the percentages are better?

I’m sorry, but nope. If anything, it’s worse.

Let’s drill down to just those getting STEM degrees (since those are the degrees that would qualify you for most tech jobs). In 2015, according to the NSF, 60.5% of STEM degrees were awarded to White people, and only 8.7% of them went to Black people.

The same report notes that the percentage of degrees awarded to Black people (~9%) has been constant for the last twenty years.

So universities, far from leveling the racial playing field, actually reinforce inequality.

Conclusion

Simply by asking for a university degree, then, we’re narrowing our field of candidates, and skewing the talent pool we draw from so that White people are overrepresented.

Thus, we’re more likely to select a White candidate, simply because more White people are able to apply.

That reinforces racial inequality, and makes requiring a university degree for a job — any job — a racist policy.

What can we do instead? To be honest, if your current interview process can’t tell candidates who have the right skills from candidates who don’t, then requiring a college degree won’t fix it.

If your interview process leans heavily on discovering a candidate’s background, instead of their skills, re-balance it. Come up with ways to measure the skills of a candidate that do not require disclosure of their background.

In programming, we have all sorts of possible skill-measuring techniques: Asking for code samples, having candidates think through a problem solution during the interview, inviting essay answers to questions that are open-ended but can only be completed by someone with engineering chops.

By asking for a demonstration of skill, rather than personal history, we’d both make our interviews better — because we’d be filtering for candidates who have shown they can do the job — and less biased.

And if we’re serious about increasing diversity in our workplaces, we’ll drop the degree requirement.

Keeping Score: July 31, 2020

I feel like I’m telling this story to myself, over and over again, with each outline. New details get filled in, new connections appear, with each telling.

And each day I get up and tell it to myself another time, adding more pieces.

I so much want to just write, just set the words down on the page and let them fall where they may.

But then I’ll be plotting out the second third of the story, and I’ll have an idea that ripples all the way back to the beginning. And it makes me glad I haven’t started writing anything more than snippets of dialog just yet. Because all of those snippets will likely need to change.

This story…It’s more complicated than other short stories I’ve written. Less straightforward.

It’s a five-part structure. One part setup, followed by three parts flashbacks (taking place over years and across continents), followed by a climax. And it all needs to hang together like a coherent whole, present flowing to flashbacks and then returning to the present.

I’m not sure I can pull it off, to be honest. I’ll have to do a good bit of research for each flashback, just to ground them in reality. Then there’s the problem of each flashback needing to be its own story, complete with character arc, while feeding into the larger narrative.

It’s like writing four stories at once, really, with them nested inside each other.

Will it all make sense, in the end? Will the flashbacks prove to be too long, and need culling? Will my framing device be so transparent that it’s boring? Will the conclusion be a big enough payoff?

Who knows?

All I can do is tell myself the story, piece by piece, over and over again, until I can see it all clearly.

Keeping Score: July 24, 2020

I’ve never written a short-story this way before.

I’m coming at it more like a novel. I’m outlining, then researching things like character names and historical towns to model the setting off of, then revising the outline, rinse, repeat.

So I’ve written very little of it, so far. And what I have written — snippets of dialog and description — might get thrown out later, as the outline changes.

I’m not sure it’s better, this way. I feel frustrated at times, like I want to just write the thing and get it over with.

But I know — well, I feel — that that will result in a story that’s not as good as it could have been. Like eating grapes before they’ve ripened on the vine.

And I do keep coming up with more connections between the various pieces of the story, more ways to tie it all together. Each one is an improvement. Each one makes the story stronger.

Perhaps that’s how I’ll know when to stop outlining, and start writing? When I literally can’t think of any way to make the story itself better?

How about you? How do you know when it’s time to write a story, and when it needs to sit in your mind a little while longer?

Keeping Score: July 17, 2020

Started drafting a new short story this week.

I’m taking a different approach, this time. For short stories, I usually just sit down and write it out, all in one go. At least for the first draft.

For this story, I’m doing a mix of outlining and writing. I jot down lines of dialog as they come to me, or — in one case — the whole opening scene came in flash, so I typed it up.

But the majority of the story is still vague to me, so I’m trying to fill it in via brainstorming and daydreaming. Sketching a map of where it’s taking place, thinking through why the town it’s set in exists, what it’s known for. Drafting histories for the main characters.

It’s fun, so it’s also hard to convince myself that it’s work. Necessary work, at that.

Because my guilty writer conscience wants to see words on the page. No matter that I’m not ready, the ideas only half-formed. For it, it’s sentences or nothing.

So I’m pushing back by reading a book specifically about short story techniques, using the authority of another writer to argue (with my guilt) that it’s okay to pause and think. That progress can mean no words save a character bio. That every story needs a good foundation, and that’s what I’m trying to build.

It’s working, so far. My guilt does listen, just not always to me.

What about you? How do you balance the need to feel productive with the background work that every story requires?

How to Fix: Fate of the Furious

I love the Fast & Furious movies. Yes, even 2 Fast 2 Furious (Roman cracks me up).

I’m not even a car guy. I just love the stunts, the emphasis on practical effects, and the way they juggle so many charismatic characters on screen.

And the way the series embraces heart, with the emphasis on family, and (especially) the tribute to Paul Walker they built into the ending of the seventh movie.

That ending was so powerful (confession: I cry every time) I never saw the eighth movie. Until last week, after binge-watching the others to put me in the right mindset.

And I gotta tell you: Fate of the Furious is the worst Fast & Furious movie I’ve ever seen.

(Warning: Spoilers Ahead)

What Went Wrong

Beyond the bad dialog (of which there’s plenty), and the numerous close-ups of characters staring into computer screens (which is exactly as boring as it sounds), Fate of the Furious has deep, fundamental problems with the story it’s trying to tell.

Cipher’s motivation (pause for eyeroll at the character’s name) is so vague you get the feeling the script just has EVIL VILLAIN PLOT written out for the scenes where she’s supposed to explain what she wants.

If she wants nukes, then as a hacker, wouldn’t it be easier to steal the Russian missile codes, then seize control of a land-based missile? You know, one that can’t be sunk or stuck in the ice? And if you can hack the security on hundreds of cars at once, why do you need an EMP to get into one abandoned base?

And what are the nukes for, anyway? She’s going to play world cop? The anarchist hacker is going to take on the job of hall monitor for world governments? Really?

Since her motivation is silly and her plan is vague, there’s no tension in any of the set pieces. We know she’s going to lose, because she’s the EVIL VILLAIN. With MAGIC HACKING POWERS. Yawn.

And what does she need Dom for, anyway? His role in the great nuclear football caper is to — wait for it — cut a hole in the side of a car using a tool anyone could use.

That’s it. That’s his vital job.

Oh, wait, he also has to drive the EMP into a base and set it under a sub. So hard.

It’s not like they could have, I dunno, suborned a shipping company, then had someone unload the EMP box under the sub, could they?

Since Cipher as a character doesn’t make sense, and her need for Dom isn’t obvious, then there’s no reason for us to get invested in any of what happens.

Yes, I know there’s a baby involved. The timeline on that kid doesn’t make sense, either, so my suspension of disbelief is blown there, too.

Finally, a special shout-out to Scott Eastwood, who is a terrible actor performing a useless role. Really, who needs him around, when we’ve got Kurt Russell?

How to Fix It

To fix it, we’ve got to reach deep into the engine of the plot, and completely rebuild it.

Let’s start with Cipher’s motivation, and work backwards from there.

Instead of wanting to steal nukes and play cop, she wants to steal a submarine as a broadcast platform. The plane she’s been using has to land periodically for supplies and to refuel. Not to mention it’s got to constantly calculate radar coverage for every country’s military in order to keep from being discovered.

Much easier to use a sub, and stay underwater for as long as you need. Surface only when you want to broadcast. There’s plenty of ocean that’s international waters, where she’d be legally free to be. And the nukes in the submarine would ensure world governments kept their distance.

So now we can keep the end set piece, where they go to get the sub. But now the sub is a specific means to an concrete end, not some remote-controlled toy.

And how is she going to steal the sub? Well, she needs Russian nuclear codes in order to make the threat of them credible (not that she wants to use them, mind) and she needs massive drilling equipment to punch a hole through the ice so she can get the sub into the water without having to move it off the base.

She needs to steal all of this, then, and then get the drilling equipment in place, across the ice, while launching an assault on a Russian base. Easiest to steal the nuclear codes while they’re in transit with the Russian Defense Minister. Only way to get the drilling equipment into place is to convert some big rigs into monster racing cars, and train a team to drive them.

She’s going to need a expert driver, and an expert leader.

She’s going to need Dom.

But how to get him to work for her?

Her first attempt is actually part of the opening race sequence. When we see Cipher, she’s introduced as just a local hustler, under an assumed name. It’s her that Dom’s cousin owes money to. It’s her that he races for slips.

Oh, and here’s where we gotta swap out the actress. I love Theron, but she’s not going to be believable as Cuban. So we get Halle Berry. She’s the right age, she’s an amazing actress, and we can play off her Bond girl days by filming her like she’s just eye candy early on, then revealing that she’s the genius-level antagonist for the movie.

Now we can drop the “oh gosh my car won’t start, silly me” scene between Cipher and Dom. Because we establish her as a hot racing badass, easily Dom’s equal. We establish that she’s willing to cheat, in the way she has her goons try to wreck Dom during the race. But we also establish her as having some honor, as she gives Dom her respect.

And we explain why she’s kidnapped Dom’s kid. That’s an escalation, something she does reluctantly, because her gambit with his cousin failed.

When she recruits him, we drop in a few extra lines to clue the audience into what’s happening, and why Dom is going to act the way he does:

Cipher: “Do it for your family.”

Dom: “I got my family right here.”

Cipher: “Not all of them.” shows video

But we don’t show the video on-screen. So we, the audience, are going to spend the next X minutes wondering what part of Dom’s family she just threatened. Brian and Mia? One of the gang? Another cousin?

That’s building tension.

Meanwhile, we have the assembly of the gang, all the prelude to Dom betraying his team. But it’s not an EMP in Germany they’re after. Instead, Hobbs’ team is supposed to be protecting the Russian nuclear codes from being stolen in St Petersburg.

That’s why Hobbs et al would get disavowed if they’re caught: They’re operating not just on foreign soil, but on Russian soil.

So this first set-piece now has higher stakes. It’s nuclear codes, not a random EMP. And it’s on the streets of St Petersburg, not some random base in Germany. We don’t even need to know Cipher’s full plan at this point, because there’s enough here for us to take what happens seriously.

Since we’ve eliminated the EMP and moved the nuclear codes set-piece, our second one has to be different, too. This one — where Dom faces off against his team — is where Cipher’s crew (with Dom) steal the drill parts they’re going to need. They’re taking it from a North Sea oil company, so it’s in the UK, which is why Dom can arrange a meeting with Shaw’s mother. And it’s the first time we see what Dom’s been building for Cipher: the first of the racer-modded big rigs.

We still get Dom versus his team, we still get to see how they can outsmart and out-maneuver him (using the harpoons). He gets away because a) the big rig is really strong, and b) Cipher hacks Letty et al’s cars so he can get away. No zombie cars, just a very personal attack on Dom’s old crew.

This sets us up for the confrontation at the sub heist. Letty and her team have to build their own big rigs, both to maneuver on the ice and so that they can’t be hacked by Cipher. We get a quip about how they used to rob those trucks, and now they’ve got to drive ’em.

And now our final set-piece makes sense, and is more interesting. We’re going to see Dom, Letty, and the gang drive these huge trucks across the ice, which they’ve never done before. It’s a race against time, as Letty and the gang try to dismantle the drill before it can punch through the ice and Cipher escapes in the sub.

Oh, and we keep the scene where Shaw takes out a plane full of goons while carrying a baby. That’s just magical.

And there you have it. Shift a villain’s motivation, re-arrange a few of the heists, and everything lines up. We have a Fast & Furious movie worthy of the name.

And while we’re wishing, let’s get Ryan Reynolds to play Little Nobody, ok? Set up his character for Hobbs & Shaw, and give Kurt Russell a break (because we don’t need two nobodies, do we?).

Keeping Score: July 10, 2020

Missed last week’s Keeping Score, but for a good reason: I was wrapping up the second draft of the novel!

I set down the final words in the last chapter later that weekend. It’s done!

Or rather, the current draft is done. I’ve still got some editing passes to do: for consistency, for character dialog, for general polish.

But this draft, which started out as minor edits and grew to become pretty much a rewrite, is finished. As part of that rewrite, it’s grown, from 70K to 80K.

Ditto the rewrite I was doing for the short story, which I also wrapped up last week. The story’s grown from a 3,000-word piece to something north of 8,000 words! Some of those might get cut away in editing, but it’ll still end up more than twice as long as it was before. I had no idea there was so much story left to tell with that one, until I tried to tell it.

With two project drafts done, I’ve mostly taken this week off. I need the space for the novel to cool off so I can approach the edits with an objective eye. I might leave that one untouched for a month or so, just to get some distance.

For the short story, I think I’ll start editing it this week. At least an initial pass for consistency and word choice, before sending it off to beta readers. Once I get their feedback, I’ll make further edits, to get it into shape for submission.

Meanwhile, I’ve started brainstorming a short story idea I had a while back. Everything’s still vague now, but it’s about dragons, and mentors, and loss. I’m excited to see how it shapes up!

How to be an Antiracist, by Ibram X Kendi

Powerfully written.

Kendi lays out a set of definitions for racism, racist, and antiracist, then shows how those rules apply across different areas: culture, sexuality, gender, class, etc.

Along the way, he tells stories from his own life, using his personal growth to illustrate how following the principles of antiracism leads to also being a feminist, an ally of the LGBTQIA+ community, and an anticapitalist.

Because Kendi is so willing to be vulnerable here, to admit to his previous homophobia, his sexism, his snobbery towards other Black people, his hatred of White people, he takes us along the journey with him. And he makes it okay if you’re still only part way along the journey, because he gives you a path forward.

What could easily have been a sermon, then, becomes a conversation. A directed conversation, to be sure, one with a purpose, but one where both parties admit they’ve made and will make mistakes. It made me want to be better, to think more clearly, than simply laying out his current perspective would.

And his anchoring of racism vs antiracism in power, and the way power is distributed among (invented) racial groups, is empowering. By targeting power’s self-interest, we can push for lasting changes, not just momentary victories.

We don’t wait for racism to fade away. We don’t wait for my family to become less afraid of Black people. We first remove the laws and policies keeping the races unequal, then people’s fears will go away.

It’s a serious responsibility, but it gives me hope. Because it makes the work more concrete: Not asking people to hold hands and sing together, but winding down the police state. Investing more in schools, and less in prisons. Breaking up monopolies and pushing power and money into communities that have neither.

So I recommend this book to anyone, of any race or caste. It offers clarity and hope in equal measure, because we have to see how racist power works — and how pervasive racist ideas are, in all groups — if we are to dismantle it.

Keeping Score: June 26, 2020

It’s been a struggle to write this week.

My uncle — who because of age and circumstances was more like my grandfather, so I called him Pop — died on Father’s Day. And I’ve been living and working under a shadow ever since.

Hard enough to lose him. Harder still, because I couldn’t make the trip out to Texas for his funeral, because of the pandemic.

He’s gone, but I didn’t get to say goodbye.

So I’ve been soldiering on. Writing a paragraph or two, at least, every day.

But each word is a struggle. And if I stop and think about anything for too long, my mind drifts back to losing Pop, and I come undone for a while.

Stay safe out there, folks. Wear your masks. Wash your hands.

Write what you can, when you can.