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.

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.

Choosing the President: A Modest Proposal

The Problem

The way we choose Presidents in the United States is flawed.

It’s too easy for someone with little or no experience to be elected. Requiring just an age and citizenship worked fine when the job was just the implementer of Congress’ will, but the role has expanded, and the requirements should expand with it.

It’s also too easy for a President to win office with a minority of the vote. For a position that is supposed to represent the direct choice of the voters, this is unbearable.

Proposed Solution

I think a few small tweaks to the process of choosing the President would fix these two issues:

  1. Abolish the Electoral College in favor of direct election
  2. Require experience in Congress before being eligible to run for President

The Electoral College

The first is something that’s been called for before, and needs to happen soon. The role of the President has evolved over time to one that claims to speak for the country as a whole. That claim cannot be made (though it has been) if the President is not in fact elected by a majority of the population.

To go one step further, I think we should require a President to win more than 50% of the vote in order to take office. If, after the initial ballot, no one has more than 50% of the vote, the top-two vote-getters should participate in a run-off election.

Congressional Experience

Getting to the Presidency should be a multi-stage process. In order to serve as President, you have to have first served at least one full term as a Senator. In order to serve as a Senator, you have to have served at least one full term in the House of Representatives.

Notice that experience on the state level doesn’t count. And it shouldn’t: working at the federal level of government is a completely different thing. The responsibilities are greater. The choices are tougher. And the impact of the decisions made is wider.

In a parliamentary system, the kind of experience I’m advocating happens automatically. No one gets to be Prime Minister without first getting elected to the legislature, and then spending time writing national laws and seeing their impacts.

A presidential candidate with two terms of experience has a record, one that voters can use to evaluate how well they’d do the job. Did they compromise when they could in order to make progress? Did they object to everything and do nothing? Did they fulfill their promises? Did they promise too much?

And a President that’s worked in Congress knows its rules and methods. They’ll have allies (and enemies) in the legislature, people to work with in running the government. They’ll have seen laws they wrote interpreted by the courts. They’ll be more successful, in other words, because they’ll know how to get along with the other major branches.

Objections

“If we remove the Electoral College, it’ll deprive the smaller states of some of their power in presidential elections.”

True. But when we elect governors of states, we don’t worry about disenfranchising the smaller counties. It’s because the governor has to be in charge of the executive branch for the whole state, not just a portion of it.

Similarly, the President has to serve the country as a whole, not be tied to any one state or region. Thus giving any weight to the votes of one state versus another doesn’t make sense.

“Voters should decide if someone is qualified. Anything else is undemocratic.”

This one I struggle with. Certainly I don’t want to go back to the days of deals made in smoke-filled rooms, with the will of the populace a small consideration, if any. And I don’t want to give the individual political parties more control over who runs and who doesn’t.

But I think in terms of goals. What is the goal of representative democracy? Is it to reduce our reps to mere pass-through entities, automatically doing whatever the majority says to do?

I don’t think so. I think there’s no point in having representatives, if those representatives aren’t supposed to use their judgement. Think of the rep that constantly updates their opinions based on the latest poll, and how we view them with contempt. Rightly so, in my view; if they don’t stand for anything except the exercise of power, they don’t deserve to wield it.

And I think republics aren’t born in a vaccum; we didn’t all come together (all 350 million of us) and decide to create a federal system with elected representatives. Instead, a republic is a compromise between the powerful and the people. We give our consent to their use of power, so long as that power is constrained by both law and elections.

In that sense, the most democratic thing is for us to set constraints on who among the powerful can run for office. We, the people, want the best candidates, not just the best speakers or the richest or the ones with the most fervent supporters. Leaving the field wide open puts us at the mercy of demogogues. Narrowing the scope of possible candidates puts constraints on their power, not on ours. We still have the final say, on Election Day.

Conclusion

Will these changes fix our democracy? No. There’s too much that needs fixing, from gerrymandered districts to the Imperial Presidency to the outsize influence of money in elections.

But they will give us better candidates for the Presidency. And they will ensure no one holds that office that doesn’t command the consent of a majority of voters.

Those two changes will make other changes easier. Better candidates will mean better Presidents, and better Presidents will mean better government.

And that’s something we can all, right and left alike, agree we need.

Don’t Fall For Republican Nostalgia

Paul Ryan’s only just announced his retirement from Congress, and already people in the media are writing hagiographies to how “different” his brand of Republicanism was from Trump’s.

Don’t fall for it.

These same people wrote the same hagiographies about Bush when Trump won the election. They wrote the same lies about Reagan when Bush was in office. I’m certain they’ve got similar paeons to Nixon, they just can’t get them published.

Let me be clear: the Republican Party has been a party of right-wing nationalists and bullies my entire life.

Reagan’s rise was a dramatic split with the centrist GOP of the 50s, 60s, and 70s. His faction dropped support for the Equal Rights Amendment from the national party’s platform, and embraced the pro-corporate economics (deregulation, tax cuts) that until then sat on the fringes of the party. Once in office, Reagan caused a massive recession, presided over the biggest bank scandal in our history (until W outdid him), and repeatedly lied to Congress about our military engagements. Not to mention his neglect of anything resembling the public health, like the AIDS epidemic, inner city blight, or the rise of crack cocaine. All the while, he bragged about family values and restoring our nation’s confidence.

Sound familiar?

When Bush II was elected, he followed a similar pattern: tax cuts leading to massive deficits and recession, along with misbegotten foreign wars built on lies and sustained via misinformation. And to rally the troops at home? Talk of an “axis of evil”, of the perils of Muslims, and of a restoration of morality to the White House. But nothing about the soaring cost of home ownership, or the stagnant wages of the American worker, or the struggle for single working mothers to find affordable child care.

Trump is just more of the same, but this time with the mask ripped off. Instead of talking of a clash of civilizations, he talks about “shithole countries.” Instead of dancing around a woman’s right to equal pay and equal dignity with talk of “traditional family values,” he brags about the sexual assaults he’s gotten away with. And going beyond talk of tax cuts helping the economy, he flat-out tells us that tax-dodging is “smart.”

So don’t fall for anyone who tries to contrast Trump with some golden era of Republican civility. For the last forty years, that party has been a coalition of radicals hell-bent to undo the progress made during the New Deal. Their policies have bankrupted our government and crippled our ability to respond to the domestic and foreign challenges we face today.

They are not conservatives. They’re radicals. And they’ve been that way for a long time.

No Crisis

I refuse to believe that Trump’s election is a moment of ‘crisis’ for liberalism.

We’ve always been under siege. We’ve always been fighting uphill.

We were fighting uphill when we were abolitionists. We were fighting uphill when we worked to win the right to vote for the women of this country.

We were even fighting uphill when we wanted to stand with Britain in World War II. Not many people know this, but many in this country wanted to stay out, to let the Nazis and the Soviets divide up Europe between them, and let Japan have Asia. It took liberals like FDR to stand up and say, “That’s not the world we want to live in.”

Every time, we have been in the right. It has just taken a while for the rest of the country to see it.

I am reminded of MLK’s phrase, “the arc of history is long, but it bends towards justice.” I remember the victories of the recent past, when we expanded the right to marry to same-sex couples. When we finally decriminalized a drug less harmful than alcohol. When we made health insurance affordable for 20 million more Americans.

This is not a crisis for liberalism. It isn’t the last gasp of conservatism, either, a desperate attempt by the powerful to stave off change.

They are always fighting us. And we are always winning.

This time will be no different.