The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care - T.R. Reid
I decided last month that I'd like to have a better understanding of the American healthcare system, so I wanted to devote a good chunk of this month's nonfiction reading to healthcare. I googled some books, found some interesting looking ones, and started with The Healing of America.
The Healing of America is journalist T.R. Reid's global quest to understand different health care systems around the world, both to fix his bum shoulder injured in the army and to learn ways to improve and fix America's broken healthcare system from other countries. When I started the book I knew almost nothing about healthcare anywhere except it's cheap in Taiwan and expensive in America, so I was mostly hoping for just a basic level of understanding and actually ended up learning a lot.
I love how he organized the book, opening the discussion with three chapters on terminology and basics, moving into detailed analyses of how various countries approach healthcare, and then concluding with a reflection on America's current system and potential improvements. Each section is clearly detailed and divided, so it's always very easy to follow and grok the main points. He also writes in a very simple and digestible way, and I almost never felt confused by what he was trying to say. As I was reading the chapters on , I did have some trouble keeping track of the differences between the different countries in my head, but he always repeated and reiterated his points, really hammering in the key points and takeaways. In addition to analyses of different countries, the book includes his personal experiences with the healthcare systems he encounters, giving a personal angle to the logistics that helped me understand and remember how each system works. I also really like how he addresses the pros and cons of every approach in detail. While every healthcare system falls under 4 basic models, because of cultural, political, economic, and historical differences, every country's healthcare has their strengths and their downsides, their variances and their differences , and he provides a nuanced analysis for each.
Here are some of my takeaways:
- It was nice to learn the vocabulary, terms like individual mandate, guaranteed issue, etc. that I've heard before but never really understood.
- Healthcare is certainly partially an economic question, but countries who have successful models of healthcare were driven to build theirs primarily because they saw universal healthcare as a moral decision.
- "Those Americans who die or go broke because they happened to get sick represent a fundamental moral decision our country has made."
- There are four basic models of healthcare, and America's healthcare system is a medley of all four:
- The Bismarck model (private providers and payers) financed mostly jointly by employers and employees and supported/regulated by the government. Examples include Germany & Japan.
- The Beveridge model (public providers and payers) financed and provided by the government through tax payments. Examples include Britain and Cuba.
- The NHS model (public payers and private providers), typically single-payer (or something similar) and private hospitals/doctors. Examples include Canada and Taiwan.
- The out-of-pocket model, which is the model most developing countries have. Examples include China and India.
- Healthcare in America sucks- we pay more for lower quality care, a large percentage of claims are denied by insurers, America is the only developed country that allows insurance companies to be for profit and to refuse coverage to people who most need it, the system is staggeringly complex with different payments systems and prices and rules, the list of woes goes on and on
- There are many common healthcare myths, all of which I've heard before, (e.g. "It's all socialized medicine out there" or "they are wasteful systems run by bloated bureaucracies") that he discusses and debunks at the end of the book (too long to repeat here)
The book is great, with lots of info (I highlighted half of the book on my Kindle), it's pretty short, healthcare is important, go read it!!
Between the World and Me - Ta-Nehisi Coates
Between the World and Me is Ta-Nehisi Coates' letter to his son, recounting some of his personal history and background. Directly addressed to his son, the book is a deeply thoughtful and insightful meditation on blackness in America reflecting on his past and his background, through which he poignantly frames the frustration and fear that black people feel in America.
His writing reads almost like poetry, like a long extended thought that you dive deeply into and come out many pages later, feeling a little out of breath and disoriented. The book shares a perspective that I can't fully understand, growing up where and how I did, but I still felt it deeply, and it completely changed how I understood the experience of being black in America. It is a very important book to read to begin to understand and engage with some of the fucked up societal and cultural shit deeply entrenched in America today, a system where abuse, disenfranchisement, and violence are not exceptions to the system but the system itself.
Some of my favorite quotes:
- On autonomy and self possession:
"As for now, it must be said that the process of washing the disparate tribes white, the elevation of the belief in being white, was not achieved through wine tastings and ice cream socials, but rather through the pillaging of life, liberty, labor, and land; through the flaying of backs; the chaining of limbs; the strangling of dissidents; the destruction of families; the rape of mothers; the sale of children; and various other acts meant, first and foremost, to deny you and me the right to secure and govern our own bodies."
- On the violence of America:
"You must always remember that the sociology, the history, the economics, the graphs, the charts, the regressions all land, with great violence, upon the body."
- On the American dream:
"And for so long I have wanted to escape into the Dream, to fold my country over my head like a blanket. But this has never been an option because the Dream rests on our backs, the bedding made from our bodies."
- On the historic exploitation of black people in America:
"You cannot forget how much they took from us and how they transfigured our very bodies into sugar, tobacco, cotton, and gold."
The Saga of Darren Shan - Darren Shan
I last read this series in middle school, was reminded of it by a reddit comment, and decided to reread the entire series. I liked these books a lot in middle school, and I was really happy to find that I still like them now! The story is good, but as expected of titles like Tunnels of Blood or Sons of Destiny, the storyline is not very deep. To its credit though, the story is still engaging, and the books have interesting, varied characters and pretty solid world building. Exciting stuff happens in every book, and when you read the series in one go (as I did in the reread), the story actually moves along pretty seamlessly from book to book. I liked almost all of the characters in the book, even the villains, which in my opinion is how you can really judge an author's character exposition. Characters I liked include R.V., Steve, Arra. Mr. Crepsley, Vancha March, and Harkat Mulds (the list goes on; his characters are good!).
The writing is again geared towards audience, so there isn't a lot of sophistication there, but his style is consistent and compelling, and he writes with a lot of energy that drives the action well. One of the things I didn't like is that he uses a lot of foreshadowing, to the point of being overdone. A lot of chapters end in short sentences punctuated by exclamation marks, random cliffhangers meant to shock you into reading on. I find that style of writing lazy, and when used too much starts to lose its effect. Some of the weak parts of the plot are also explained away by destiny (Mr. Desmond Tiny, in the book). I think it works and it makes sense, which is more than can be said for a lot of stories, but again, it seems a little lazy to me to tie up loose ends by referring to destiny.
These were a fast, enjoyable read that I mostly finished on the plane, and if nothing else they were better than the Delta movie offerings.
Do Androids Dream of Electric Sheep - Philip K. Dick
Do Androids Dream of Electric Sheep is a sci-fi novel exploring the idea of sentient A.I. and the distinction between artificial intelligence and human intelligence as technology advances. It is apparently the inspiration / source material for Blade Runner, a fact whose significance is lost on me because I've never actually seen the film.
I tend to not be a big sci-fi fan (although Dune and Stranger in a Strange Land are amongst my favorite books), but I liked the story a lot here, and thought the philosophical discussion was good, if not somewhat predictable. The book is centered around bounty hunter Rick Deckard, who is hired to track down and "retire" 6 rogue robots. Their world has advanced far enough that most people have left Earth, leaving it a dusty, dirty bowl, and with the extinction of most animals, having an animal has become a status symbol of sorts. The book's primary philosophical theme is the blurred lines between A.I. and humanity, questioning exactly what it is that make us uniquely human, besides our flesh and blood. This doesn't seem to me a particularly innovative idea to write about, but to be fair, it was written in the late 60s and predates a lot of sci-fi books that I've read, so perhaps it was ahead of its time and only pales in comparison because now that we have discussions of killer robots every week pitting Elon Musk against Mark Zuckerberg.
The book is well written, although I got a little bit confused while reading the last few chapters, especially the chapter describing his religious experience and climbing the mountain. Nevertheless I enjoyed the story as a whole, especially the ending with the toad, and I might even watch Blade Runner sometime.
America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System - Steven Brill
America's Bitter Pill is my second book on healthcare, and I think together with The Healing of America gave me a pretty good base to understand healthcare in America. The Healing of America focuses on different healthcare systems around the world, taking lessons that we can apply in America, but America's Bitter Pill focuses more on Obamacare, and "the money, politics, backroom deals, and fights" that went into the controversial healthcare reform.
Brill goes into exhaustive detail on the intense and endless conflicts centered around Obamacare- the vicious and brutal struggle politically and internally between the House and the Senate, between the Republicans and the Democrats, between the various stakeholders and financial players in healthcare, and even within the Democrats supporting reform. It is a thorough retrospective of the challenges, successes, failures, and history of Obama and his administration in directing the most comprehensive and revolutionary health care reform since the establishment of Medicare and Medicaid during LBJ's presidency, providing an insightful look into how we got to where we are. Boy, it really isn't pretty. As with any detailed story of healthcare in America, America's Bitter Pill shows the brokenness of our political process and the painful inadequacy of our current healthcare system.
As our current president recently learned, healthcare is really complicated. Brill's account of Obamacare includes a painful, Game of Thrones level number of names, titles, political affiliations, and aspirations, but he does the best possible to break the story down to more digestible, understandable parts. The book is long (almost 500 pages) but it is organized fantastically, and with the more important names he often includes small reminders of who the person is. I still found myself flipping back and forth a lot to remember names, but the story overall is distilled to maintain simplicity without losing breadth or depth in a very complicated story.
My favorite part of the book by far is the very last chapter, where Brill discusses his idea for a new system of healthcare, integrating healthcare payer and provider into a single hospital. I was explained this idea earlier in the month, but had some trouble understanding how it works until I read about it in the book. Essentially, the primary question of healthcare becomes who bears the risk, and Brill argues that it makes the most sense to have healthcare providers also be healthcare insurers, encouraging competition, but cutting costs by removing the middle man and aligning incentives. This has the added benefit of being a much more plausible transition to a better healthcare system than single payer overnight, because similar systems are already happening in many places with massive hospital mergers.
The most impressive part of the book by far is how cogent the narrative is, backed by a tremendous amount of research, interviews, and work distilled into a fascinating and gripping tale of Obamacare's triumph and failure. I am really happy about the two books I chose to read about healthcare, because now I feel like I have an opinion backed by facts & analysis and can participate better in discourse on healthcare.
The Sympathizer - Viet Thanh Nguyen
War novels are a dime a dozen, and I very rarely find a book on war that touches a subject or explores a story that hasn't already been done. That is why I am so happy and excited for books like The Sympathizer, which provide new, underrepresented perspectives on subjects like the Vietnam War. The Sympathizer tells the story of an unnamed narrator, a half Vietnamese, half French communist sleeper agent exiled to America after the Fall of Saigon, framed in the form of a forced confession written in a communist reeducation camp, recounting his life from his childhood to his years in Los Angeles to his eventual return to Vietnam.
The narrator lives with a series of dualities: he is a mixed race North Vietnamese mole who remains sympathetic and friendly with South Vietnamese military officials and a US CIA agent, he was raised in Vietnam but went to college in the US, his best friends are a South Vietnamese soldier and a North Vietnamese revolutionary, and much of the book's brilliance is how Nguyen navigates and guides the reader through the contradictions and absurdities of war and identity.
The book is full of nuggets of wisdom and piercing insight combining humor with brilliance and tragedy like:
- “She cursed me at such length and with such inventiveness I had to check both my watch and my dictionary.”
- "In this jackfruit republic that served as a franchise of the United States, Americans expected me to be like those millions who spoke no English, pidgin English, or accented English. I resented their expectation. That was why I was always eager to demonstrate, in both spoken and written word, my mastery of their language."
- “I was in close quarters with some representative specimens of the most dangerous creature in the history of the world, the white man in a suit.”
- “Now a guarantee of happiness—that's a great deal. But a guarantee to be allowed to pursue the jackpot of happiness? Merely an opportunity to buy a lottery ticket. Someone would surely win millions, but millions would surely pay for it.”
and there is also a memorable passage on the narrator masturbating with a squid that is the impetus for Nguyen to launch into an ethical comparison between murder and masturbation.
The most distinctive stylistic feature of the book is the continuous commentary of the narrator, an approach that focuses deeply on his individuality despite his anonymity and provides a complex and nuanced reflection on the contradictions in not only his own life, but the contradictions of foreign identity in America. I am very excited about these books and I think they have an important place in our understanding of these topics because they provide a perspective unheard and underrepresented, pushing back on the traditional American-centric narrative.
The Checklist Manifesto: How to Get Things Rights - Atul Gawande
The Checklist Manifesto argues that in a complicated world, checklists are really helpful in reducing complexity, allowing us to focus on what we're good at. As fields like medicine and building and engineering become more complicated, we are moving away from Master Builders and need more standardized ways to approach more and more complex problems. This is related to some ideas I learned before in SWE, formulated earlier as "removing things from your window of focus," and "letting tools do what tools are good at, and let people do what people are good at."
I have always found similar cases interesting, ever since I read the article on the importance of checklists in aviation, and how much simple checklists help hospitals and healthcare providers do a better job. I read the book hoping to think about ways to apply that to SWE. The most obvious benefits are with rote tasks, such as deploys or installs, that are mostly a set of repeated steps but often with a high degree of complexity. The task tends to not change (which is why deployment lends itself to automation), and so the programmer can follow a checklist.
But building software is not like flying or performing surgery (neither of which I've done, so correct me if I'm wrong), but creating software is the creative process of writing new stuff to address new problems, whereas in flying & medicine complications arise but the work is largely very similar, just very complicated. One possible way checklists could help is to make more specific checklists for specific types of projects. For example, for projects related to web development, perhaps there are a few important things and common bugs to pay attention to that can be put into a standardized checklist to at least promote discussion. There are interesting parallels there between his examples of finance and investing in companies, where checklists are not meant to be prescriptive, and instead are very effective in providing a list of things to remember and think about.
A quick note on style and content: I read Being Mortal by the same guy, Atul Gawande, a few months back, and the book is VERY similar in style. These books are packed with detail, and are very well organized with lots of interesting insight, but he really could be a lot more concise. He hammers the same idea over and over again, and pretty early in the book I was convinced that checklists were good and just wanted to see some application. I bought in to his thesis pretty early; I just wanted to dive deeper into specific examples.
Just kidding. I read this book in my sophomore year during my internship, and wanted to reread it since I was learning react and thought that knowing some JS would be helpful. The book is short (174 pages?) but dense, with a lot of info packed into it. I read most of it in an afternoon, with two caveats: I skimmed some sections and skipped some I thought were not going to be super helpful to me right now, like ch 8 on regex, and I didn't work through that many code examples. I was hoping for a more general understanding of the philosophy of and ways to think in JS, so for the purpose just reading the book and then actually getting experience at work would probably be more fruitful.
That being said, I read the book cover to cover the first time but got more out of this re-read because I worked with JS last summer. I think that speaks to how effective it is to work with the stuff that you're trying to learn, and to combine reading with practical application & small samples to play with it. The book is pretty well written, although I think with es5 and es6 it may be a little dated. A more experienced JS programmer will have more insight into that.