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Dec 15, 2021

24. In some cases, this fuzzy thing creates serious real-world consequences. I think that Canadians are unwilling to address the shortcomings in their healthcare system in part because "we have 'free' healthcare and Americans don't" is such an integral part of national identity.

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78. The Canadian healthcare system provides, on average, similar-to-modestly better outcomes than the American one, at ~2/3 the cost as a fraction of GDP. This is decent, but hardly a point of national pride.

79. For Americans: the Canadian healthcare system functions sort of like a mediocre HMO. A government bureaucrat decides what care is/isn't worth it, and then that's the care that gets provided. Everything that the bureaucrat decides to cover is ~free at the point-of-care.

80. This analogy tells you basically all the pros and cons: Pros: - Predictable pricing - Good quality median care - Egalitarian: your healthcare quality won't depend on your ability to "work the system" - Good cost control with "utilitarian" aesthetic

(Re: that last point: American hospitals can be bizarrely fancy. I once accompanied a friend to Huntington Hospital in Pasadena. The emergency room had crown molding. The surgical recovery room had *plush carpeting*. I was stunned; this is not what Canadian hospitals look like.)

81. On the other hand, the cons are pretty significant, at least for me. First, wait times. Like the US, Canada has a significant shortage of doctors. I have not dug into this in detail, but I think it has roughly the same source: not enough medical school/residency slots.

Wait times, especially for "important but not urgent" healthcare like "elective" surgeries are ridiculous. Canadians mostly think that this is an inevitable consequence of "universal healthcare", when it's really a sign of a mismanaged labour supply.

As a child, I waited more than 6 months for a tonsillectomy while being ~continuously on antibiotics (!). A relative of mine waited more than a year for a hip replacement, during which time they basically couldn't walk (!!). Wealthy Canadians travel to the US to avoid this.

I was once in an American ENT specialist's office on a Thursday afternoon. They recommended that I get an MRI and warned me that it could be "a bit of a wait". I asked them how many months it would be; they stared back at me and clarified that I'd have to wait until Monday. 🙃

82. The second disadvantage is subtler: I broadly refer to it as the low agency or gatekeeper model of healthcare. Broadly, in Canada, if you have a health problem, the doctor decides what to do about it. In the US, if you have a health problem, *you* decide what to do about it.

10:04 PM · Dec 31, 2021Twitter Web App

83. In the US, the main gatekeeper of healthcare is your insurance company. If you have the resources, though, you can just ignore what they say and get ~whatever healthcare you want. You can easily shop around for a different doctor if you aren't getting the treatment you want.

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84. In Canada (or at least Ontario), the system is much more centralized. If the government hasn't authorized a treatment,there's little you can do to work around it (except go to another country). Put another way, Canadians mostly look at all health as public health.

85. All of this means that if you're trying to solve a health problem that's a huge deal *to you*, but not legibly a big deal to a government bureaucrat, the Canadian healthcare system will fail you.

For example: I'm not qualified to talk about this in detail, but trans friends tell me that the Canadian healthcare bureaucracy took a long time to catch up to international best practices for gender-affirming care. The costs of that delay are... enormous. :-(

87. Let's talk a little bit about higher education. The best universities in Canada are all large, public universities, roughly equivalent to strong flagship state universities. There's no equivalent of the "Ivy League" or "HYPSM" or equivalently elite American schools.

88. This has profound effects on the right tail of Canadian education. The most talented Canadian students don't spend their undergraduate years embedded in an ultra-elite crowd. Overall, this is probably good for society but worse for the most talented individuals.

IMO, the main advantage of a small, elite university is the *density of potential*: you get to know a lot of people who will go on to become famous scientists, CEOs, politicians.... This provides a ton of social capital to those who attend them. Dunno if this is net good or bad.

89. Canadian higher ed tends to be much more structured than American higher ed. At most Canadian universities, students are admitted to a program rather than the school as a whole, and programs tend to be pretty specific and structured.

For example, the University of Waterloo offers separate programs in CS, CS/Math, CS/Business and software engineering. Most of those also come in co-op/non-co-op versions, and you pick the one to attend *when you apply*.

This also means that Canadian higher education has a distinctly professional flavor. Many Canadians have undergraduate degree in fields like accounting or nursing.

In contrast, most universities in the US are almost comically flexible by comparison. There's a lot of emphasis on getting a "liberal arts education". Even the more focused tech schools (MIT, Caltech, etc.) provide a lot of flexibility.

90. The last major difference between Canadian and American higher ed is the admission process. The Canadian process is simple and permissive. The American process is *ridiculously complex*.

In Ontario, here's how you get in to most university programs: Pick your six best grades in Grade 12-level classes, including any required for the program (e.g., Calculus for engineering programs). Average those together, and compare to a cutoff.

Sometimes, you can raise your effective average with good performance on math contests, or writing a good essay about leadership or something. But the whole process is formulaic and simple. To correct for bias, the universities over-admit and weed people out in the first year.

I can't do justice to the American process here. As an applicant, you write essays, solicit letters of recommendation from teachers, tally up your extracurricular activities, and generally try to come ahead in the all-out prestige battle called "holistic admissions".

The Mad, Mad World of Niche Sports Among Ivy League–Obsessed Parents

There are entire cottage industries of fancy coaches, consultants, etc. etc. As an outsider, I honestly don't know what to make of it. This article was retracted on factual grounds, but the *vibe* is spot on. Read it as based-on-a-true-story fiction.

theatlantic.com

Where the desperation of late-stage meritocracy is so strong, you can smell it

[Final stretch! If you made it this far, you get to hear about politics.]

91. Both Canadians and Americans are mostly confused about how the Canadian government works. This is mostly fine, because Canadian politics are very boring. Occasionally, something weird happens and then it's a big problem that Canadians don't understand Canadian politics.

Everything you wanted to know about Canada but were afraid to ask.

For example, Canada nearly had a constitutional crisis in 2009, when the Governor General suspended Parliament for failing to pass a budget. Here's Rick Mercer (sort of a Canadian John Oliver) trying to explain WTF was happening to Canadians:

youtube.com

RMR: Canada Explained

92. The dominance of American media means that Canadians have a vague sense of how the US government works. It also means that Canadians tend to assume that their government works more like the American one than it actually does.

As Mercer points out above, many Canadians think that they vote directly for the prime minister, like Americans do for their president. There's no such concept in a parliamentary system, but that doesn't stop people from thinking that they are voting for "Trudeau" or "O'Toole".

93. This confusion can be personally relevant, too. Apparently, it's not uncommon for Canadians to try to "plead the fifth" even though 1) The 🇨🇦 constitution has no "fifth amendment" 2) Canadian protections against self-incrimination are considerably weaker than American ones.

94. Canadians vote much, much less than Americans, and this is probably a good thing. Canadians vote in federal elections, provincial elections, and municipal elections. Each of those happens once every few years, and each ballot has between 1 and ~5 things to vote on.

Federal ballots, for example, have precisely one thing to vote on: who do you want to have as your representative in Parliament?

In contrast, American vote all! the! time! You have a major (federal-level) election every two years, but in the meantime there are local elections and primaries and so on.

My California ballot, 2020

And at the state/municipal level, things explode. Ballot propositions! Comptroller! Judges! Recalls! Here are some people attempting to figure out how to vote on an Alameda County, CA ballot in November 2020:

reddit.com

Every election year, the Bay Area rationalists put together a slate to help each other vote. This year the coronavirus made it hard to come...

I genuinely have no idea how Americans manage to keep up with all this voting.

95. Canada has way more (relevant) political parties than the US, despite using first-past-the-post voting. In the current Parliament, there are members from five different parties (Liberals, Conservatives, NDP, Bloc Québécois, and Greens). In the US, there are two.

Because of first-past-the-post, Canadians don't actually have more choices to vote for, though. Very few ridings (districts) have more than two competitive candidates. However, more parties does make for a very different *power landscape*, with more relevant actors at any time.

For example, depending on the election, there might be two or maybe even three different inter-party power struggles, which does have the effect of making individual parties proportionally less powerful.