This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
Posted this in the comments last week, but was curious to get some more thoughts on a potential path forward on the healthcare front that isn't just single-payer across the board:
I do occasionally wonder if you could get to a decent place via:
That's going to create some winners and losers, hospitals will be upset that more high cost people are on Medicare, but shifting people from Medicaid to commercial reimbursement rates should help out with that. The amount of bureaucratic nonsense saved by getting rid of Medicaid should be huge.
All a bit of pie in the sky dreaming anyways...
It's not about the system, it's about the people.
Low income, high obesity, non-White or non-east-Asian will topple any system.
What evidence is there of this for income or race?
What kind of evidence are you looking for? That the largest brown population groups in America make less money than the Whites and East Asians? That low income people pay less, despite requiring the same treatment? That obesity is a cause for many medical issues? That doctors can spend up to 30 hours in a week servicing people who don't pay anything at all, ever?
Conceptually it's a simple proposition. The system is based on pooling resources together, and then that pool is used for those in need. People who pay more than they take out can maintain the system. People who pay less make it harder. Both ends of this equation matter.
The problem America has is that it wants to maintain a 'high' European or East Asian standard, but it's lacking the population to maintain it on both ends. Which leads to odd systemic 'errors'. The complexity of the system muddies the water as to why it is so expensive. But it makes sense when you operationalize the population differences.
If your logic is based solely on income, including race is very confusing.
It's not based solely on income. I said that it's based on people and the differences between them.
We can tease out some obvious differences using various proxies, such as the examples I gave before: Income, obesity, or 'race'. But the overarching point is that we have big natural experiments when comparing various different health care systems. Those experiments collapse a lot of the complexities, but they also help verify the proxies we used before and the limited but relevant insights they give into the health care systems.
What natural experiments show this for race, controlling for income? That's why this is confusing.
I want to say any majority black country, but I'm not sure we are on the same wavelength with regards to income.
To highlight what I'm getting at the most obvious example I can think of is the fact that the black population In the US can not functionally maintain the white/east asian standard. I.e. you have a population block that does not contribute to the pool of potential quality medical staff in a similar way that the white/east asian group does.
This disparity might not be pronounced in any relevant way so long as there are proportionally enough candidates for quality medical staff, but change the proportions enough and you will run into the aforementioned 'system errors'. This has similar cascading effects when looking at other professions that require high quality people.
To that extent income isn't as relevant a factor as one might think. There are a lot of wealthy people whose wealth is only made relevant by the existence of the quality people that enable that wealth to begin with. You might argue that to be the case with regards to any society in general, and I'd agree, but what I am getting it here is that the wealth generating avenues are not at all equal or equally predicting with regards to social outcomes. Which is exemplified by the fact that even when controlling for income, blacks commit more crime than poor whites.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
What, other than benefit cliffs, is bad for Medicaid recipients? Hospitals would rather the reimbursement rates were higher, but what hospitals are saying that it's "such a disgusting mess for all involved parties that it's better to just kill it with fire?"
Disclaimer: I am not a Medicaid expert Medicaid reimbursement is generally a lot lower than commercial - though maybe there is enough direct and supplemental payment shenanigans that it is worth it? I just know every time I have touched it it seems like a mess of different categories and paperwork
More options
Context Copy link
More options
Context Copy link
Why avoid this when every single proposed solution seems like replacing the current inefficient massive headache with yet another inefficient massive headache?
Single payer also has tons of issues, but when your healthcare system also involves a massive extra layer of insurance bureaucracy (and knock-on bureaucracy requirements for hospitals, etc. to interact with the insurance bureaucracy) and value capture (every dollar of insurance profit is a dollar not spent on making humans healthier) it seems like you're doomed to fail.
I'm open to examples of healthcare systems that do a great job of juggling this (Germany and Switzerland?) but it seems to me that you fundamentally must make trade-offs in a healthcare system. It is also too important and chaotic to leave to market mechanisms, for reasons like: no one who needs an ER is going to shop around for the best/cheapest/highest utility to them ER, people who can't pay for healthcare get treated anyway and then hospitals can't collect and have to charge everyone else more, etc.
To my amateur observations, it seems like you can:
You can have a collective/single payer healthcare system that tries to take care of everyone, and is constrained by resource availability/requires you to pay taxes that mean people you don't like get healthcare.
or
You can have a privatized healthcare system that siphons a ton of value/resources into insurance profits/bureaucracy and thus deprives the actual humans who need medical care of the medical care they need. It also functionally requires you to pay taxes that mean people you don't like get healthcare in the form of insurance premiums and meme-tier prices because hospitals have to eat the cost of people with no money still getting healthcare (yet another way that healthcare breaks market mechanisms, because hospitals don't like when people die, they treat people first and ask for payment after).
I would be a lot more sympathetic to the USA's current healthcare system if it managed to be either cheaper than it's peers, or more effective, but it is somehow both more expensive and worse.
I think the USA's current healthcare system actually looks pretty good when you adjust for our terrible demographic/cultural headwinds (we are fat, love shooting each other, going fast in cars, drinking, and combining all 4 activities). People come to the US for top tier care (Mayo Clinic, Cleveland Clinic). We drive huge amounts of pharmacy innovation.
We absolutely spend a ton of money on it, but some of that is just we have a bunch of money to spend.
This is predicted on having a lot of money to spend, which many Americans do, and also many Americans do not
More options
Context Copy link
More options
Context Copy link
It's not that hospitals "don't like it", it's that they are legally forbidden from doing so. If it was legal to turn people out to die, you would absolutely have some cheaper hospitals that made sure you could pay out of pocket or had insurance before they treated you, and if you didn't they would just escort you off the property.
It sure seems like all the liberal examples of 'women dying because of abortion bans!!!' were, well, obviously not that, but the thing they actually were seems to be mostly EMTALA violations. Hospitals obviously violate EMTALA if they think they can get away with it.
IIRC there was a pilot program in parts of Texas to guarantee EMTALA care gets paid for, but it was canceled because illegals were benefiting from it.
More options
Context Copy link
Yeah exactly. Healthcare systems fundamentally cannot play nice with market mechanics because people get unhappy when the market mechanics cause people to die.
So privatized healthcare seems to end up being an awful chimera hybrid of the worst of both worlds.
But you can say that about anything? "People don't like it when the market causes people to starve/end up homeless, so we need socialized grocery stores/housing". We don't; we just need to make it cheap enough that the possibility of starving/ending up homeless/dying for lack of healthcare becomes remote for any reasonably functional person. We are pretty much there with food; for housing and healthcare, we literally just need to stop stopping people from building housing/providing healthcare.
I'm with you on that.
I think the floor (no pun intended) cost for housing is much lower than healthcare, I am somewhat doubtful that healthcare can ever be a non-risk pooled consumer good but I'd love to be wrong.
Down with doctor training cartels, I mean the AMA*
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
The whole situation is a mess, I like to think of healthcare economics like communism - yes you can absolutely up end the system and make it way better than what we have now, but when has that ever happened successfully?
The thing that probably gets the most complaints over in doctor land is that changes to the current medicaid structure is likely going to result in a further decline in safety net and rural hospitals. This trend has been ongoing for some time but loss of medicaid dollars will probably accelerate it greatly and people are expecting to see that with the current wave of budget cuts.
Two specific things off the top of my head that you'd have to watch for:
-It is very easy for the hospital to help you by signing you up for medicaid. Private insurance would likely find ways to block this. Hospitals rely heavily on this.
-Medicare and Medicaid are much lower overhead on the clinical side of things and less paperwork. Private insurance is a lot more work (although Medicare is trying to change that! Yay). Don't expect a reduction in medicaid to reduce bureaucratic costs and middleman costs.
Basically every other western nation manages to spend equivalent or less amounts of healthcare than the USA, and has equivalent or better outcomes. So yes, basically everyone else's system is better than the USA status quo.
Observably, this statement is (still arguably, but commonly presented as) true if you replace "healthcare" with "education". But the typical solutions presented by the left are in the opposite direction there: few are suggesting we adopt European (or more extreme, Korean or Japanese) norms in education and cut funding. Is education different, or is this just a case of "conveniently, this evidence supports the action I already wanted taken"?
Liberals do not want healthcare costs cut, whatever gave you the impression that they did?
More options
Context Copy link
Education strikes me as fairly similar. It's kind of a monopoly good (oligopoly good?), demand is fairly inelastic, as a service it is incredibly hard to quantify cost vs benefits ahead of time and suss out who's the best at providing the service.
I'm generally pretty ideologically unbound, whatever system is shown to work the best is the system I want implemented. So yeah, implement European educational institutions, I think that western school board bureaucracy is an uninhibited nightmare so I'm all for getting rid of as many of them as possible. Korean/Japanese/Chinese ones seem fucking awful though, they make smart kids but I'm not sure if it's worth the hit to human wellbeing.
My uninformed opinion is that a ton of the USA's education woes are the fault of American parents, which is downstream of American inequality/poverty. But I have nothing to back that up aside from vibes.
I’d expect a significant portion of even Mottetizens to scream bloody murder if European style education system was implemented as that would also mean getting rid of their precious liberal arts education system in universities.
Back in college some engineering students thought that would be better. Shave a year off of college and skip the mandatory liberal arts classes. I'm not sure how enriched I really was taking intro courses in anthropology and gender studies. I might have been better off taking more technical classes or graduating sooner. But that's admitting college is a training program for professional tech workers. Some people really don't like that thought.
More options
Context Copy link
That's a spicy take because I would have assumed this place would shit all over liberal arts degrees in favor of STEM + finance + coding
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
Their are two problems with this line of thinking:
The U.S. is fundamentally a different place than Western Europe - we spend a lot of money on illegal immigrants, have a maximal amount of cost disease, we are more unhealthy (and importantly as other countries catch up they look more like us), we subsidize the rest of the world's medical research (maybe not fair, but we are the wealthiest country and nobody else will pick up the slack if we go away), we are more independently minded (people don't want to be forced onto insurance or into making certain decisions), medical malpractice is a huge drain, we don't have death panels and rationing, you can get care fast if you can afford it, etc. etc.
Fundamentally our healthcare system doesn't resemble anyone else's in both bad and good ways (don't believe the reddit left - the best care is in the USA).
Even putting aside those things good luck changing our system to resemble other's once reality comes into play (for instance forcing people onto plans).
They are better than the USA, which is the key benchmark. Canada is much more similar than Western Europe and also has historically out-performed the USA, although our healthcare system is getting fucked on pretty hard right now so idk how the stats match up post-COVID.
Unlikely currently, although given the USA is finally starting to (slowly) go pretty YIMBY on building a state-by-state basis, the USA does have a pretty blessed capacity to drive change in a way other countries do not.
This is one of the factors tanking Canada's healthcare system, although they're not illegal, just extremely net negative on "tax contributions - cost to society"
Strike me as a good argument to cut out the middlemen, as they need more expensive salaries
This is hard, no easy solutions here (Ozempic as a condition of Medicaid if you're obese?)
I'm torn on this, if the USA also captures most of the world's pharma profits than this is a net gain no? No idea how the math works out there though.
This is true but hilarious. Americans are violently against "taxes to pay for healthcare" but are completely fine with "employer subsidized insurance premiums that mean they get less cash in hand in exchange for access to healthcare" which is functionally just taxes but with more middlemen??!!?! And poor people I guess get less services versus single-payer, but then everyone subsidizes them anyway via higher medical bills to offset all the non-payments from the aforementioned poor people.
This is by far the easiest problem here to solve. Just legislate limits in damages or applicable suits. Although you will say "but will anyone actually do that" and the answer is "probably not" given it hasn't happened.
Are death panels real anywhere? I also feel like prices/medical bankruptcy (66% of all USA bankruptcy filings) are kind of analogous? If you can't afford chemo you sell everything you have until you run out of money to pay for it and die. Also you absolutely do have rationing, it's just in the form of prices versus bureaucratic limits. It can be debated which type of rationing is better, but the human demand for healthcare is infinite, supply never will be.
Profoundly true
Unfortunately profoundly true, I'm pretty black-pilled on western nations being able to pro-actively change anything until it explodes in their faces and they are forced too, at great cost.
In some ways I guess the USA's system is more survivable in that way. I can't really see it ever imploding, it'll just get shittier and shittier to get care from as all the costs/frictions drag on it. Unfortunately, I can see Canada's healthcare system imploding if it continues to be as mis-managed as it seems to be.
I believe the system as-designed has you sell everything until you qualify for Medicaid, at which point the state/feds should pay for almost all of the treatment. Now, Medicaid-accepting providers have a bit of a reputation for being, well, worse than other doctors (true also for Medicare, but less so because it pays out a bit more, IIRC), so the quality of care might drop. But it isn't supposed to be a death sentence there (in practice, I'm sure it happens).
While that's technically better than just dying, this is so fucking awful it's kind of funny to present this as an alternative.
"Hey man you're not dead, you're just destitute, sick, and are receiving the bare minimum amount of care we can get away with giving you. Have fun rebuilding from 0 once you're better, hope you aren't close to retirement!"
After typing that out, if you're north of ~50, might actually be more merciful to just not treat them and limit the suffering
More options
Context Copy link
More options
Context Copy link
Don't fall for the propaganda here, the U.S. has worse outcomes on many metrics but a population that is more unhealthy and those worse metrics are driven by a social goal (you have the freedom to accept lifestyle diseases). When you get sick you are better off here than everywhere else in every way except the pay check. You'll get faster care if it's outpatient, and better across the board. You might have worse outcomes because you eat too many Big Macs but that is a public health and cultural problem instead of a medical care one. The expense is higher is really the only problem.
(And note well: those lifestyle disease worsen outcomes on everything, example diabetes fucks with wound healing and metabolic process of all kinds, obesity makes surgery impossible, etc.)
I don't know either but good thinking.
This manifests in all kinds of ways. Don't want to take vaccines and want to accept the bad outcomes? American individualism. Clearly dying grandma with 95% 30 day mortality rate? Spend EVERYTHING. Etc.
The usual way this shows up in real life is in other countries under spending on end of life care (which is super expensive and with where I am in my life now.....yes I'd want that for me) and delay of care. Canada is notorious for this. I need major hip or knee surgery in the US and I can get it within the week, but Canada though? Months. People also die from cancer and other diseases or have worse morbidity because it takes awhile to be seen and treated.
U.S. has a lot of profit motive and well payed people so they get to both care about patients and actually hustle when it's necessary and the system allows it because $$$.
Also, since I don't really get to talk about my favorite medical topic here but now is a perfect time - Trauma!
No better place in the world to get fucking shot (at least in a civilian context)!
Super fair point.
This is kind of a large "but" given how much of a nightmare healthcare costs are to those who can't afford/have shitty insurance, but I do happily agree that the upper bound of USA healthcare quality is incredible, it's just a matter of having extended access to it...
Brother tell me about it. So far all my experiences (I do a lot of dangerous sports, so I've been to the ER far more than I would like) have been speedy and great, but I live in downtown Toronto and have a great family doctor, so I am pretty lucky in that way. My friends/their parents all have overall good experiences/timelines as well, but again, we're all educated white collar workers who live nearby to the largest agglomeration of healthcare resources in the nation.
The news stories and stats I see though.... Jesus Christ it's grim.
As my parents (and me! yikes!) get older I do find myself wondering if I should familiarize myself with USA v Canada "healthcare arbitrage". If I can get one of my parents an MRI in 1 week for $5,000 vs in 9 months for free when time is directly proportional to better outcomes, that's $5,000 I'd spend in a heartbeat.
Funnily enough, as MRI is the only example I actually know of for "things its worth going to the USA for". The one time I got an MRI, for in retrospect was a slightly frivolous diagnostic rule-out, I was scheduled for one a week after my ENT appointment. Although I am assuming that is Toronto-privilege, I bet if I was in Halifax that would not have been as fast.
MRIs are only a few hundred in Mexico (City, Guadalajara etc.) They even accept walk ins. Random reddit link for random info.
But, you do realize you can go private in Canada, too and pay about 1k cad, right? Plenty of Americans go to Canada for private healthcare. Ilumina's in Toronto. In Buffalo, you're looking at about 500.
Good to know! Medical arbitrage is a fun game. Turkey is another one where the all in price of airfare+hotel+medical procedure can be cheaper than the north american sticker cost
I think it's a borderline scam, but some Turkish hospitals basically have all inclusive packages for plastic surgery/"""comprehensive""" medical scans/etc
More options
Context Copy link
More options
Context Copy link
Yeah you can absolutely get some things done faster by heading over to the U.S. but keep in mind that the times where it's really useful (ex: cancer workup, need a new knee) it will become cost prohibitive and unreliable very quickly.
I assume the reality of the situation is Canada is not as bad as some of the stories would make it seem but those stories are still quite alarming.
It's also worth noting that while US care is expensive EMTALA and others things ensure you will get care for most types of maladies even if you become bankrupt afterwards. Many countries don't ensure this this outside the affluent west.
Mexico has western-standards dental work and elective surgeries for cheap. Cash only.
More options
Context Copy link
It's a last resort to hedge against
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
My preferred solution is that Medicare or Medicaid covers everybody for catastrophic illnesses and injuries. Everything else you buy on the ACA exchanges. The large pool of 330 or so Americans paying into this via taxes should help keep costs reasonable, and the lack of those coverages on other plans for those same illnesses would probably lower costs of those plans as well. It also allows people to decide how much risk they’re willing to bear in their health insurance. If you’re 21, you probably don’t need much besides the catastrophic health care package. You are not likely to get sick, and thus you can skip the rest. If you’re 45 you might want more coverage for drugs or doctor visits or whatever else you think you need.
But now you've concentrated the risk pool for the >45 year olds. If the 21 year olds can't bring the average risk of the insurance premiums down, the premiums for coverage that isn't "you got hit by a car" are going to be insane.
Almost every collective welfare system in a government is predicated on extracting value from the young(er) and working to the old(er) [and very young] non-working.
More options
Context Copy link
IIRC we already have a system where people get seem immediately for emergencies, but have trouble scheduling appointments for non-emergency issues.
It works terribly. Someone notices a strange lump on their body, calls the doctor, and makes an appointment months out. They start feeling weak, call the doctor again, but still have to wait until that appointment. Things get worse and worse until suddenly they collapse and are rushed to the ER. It turns out they had cancer all along, which is now stage 4 and requires expensive surgery and medications. If they got a checkup when they first noticed the lump, they would've had better outcomes and their insurance/government would've paid less.
Also, "how much risk they're willing to bear" means that unlucky people who were low-risk get stuck with unfairly high payments. A 21-year old may not just get injured from a car accident, they may suffer from an autoimmune disease or genetic condition that only appears later in life.
More options
Context Copy link
The reasons this is unworkable are political- the ‘thé government should cover ozempic/IVF/whatever’ platform is always going to be more popular than the ‘keep universal healthcare only for catastrophic’ platform.
My preferred solution- all children on Medicare, hospitals get guaranteed reimbursement for EMTALA care, low-coverage plans and low-risk pools are legal again.
Given how much obesity costs the US healthcare system/economy, this might be a positive EV move.
Sure, willing to believe that. But the point is the government is going to start adding non-catastrophic care they cover, often through rational cost-benefit analysis(vaccines etc) and then expanding the list will become a political issue with a ratchet that only goes one way.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link