- https://www.smithsonianmag.com/smart-news/1000-mile-long-sto...
-https://mallhistory.org/items/show/274
100 years and more information than ever, yet we have’t figured out this out-of-sight, out-of-mind problem.
The center of this country (outside of a few major urban/sub-urban areas) is hollow.
Between the loss of agriculture as a family job, loss of industrial jobs, and opioid use after decades of methamphetamine use, it's bleak.
And no one really cares. As a general rule, we're told, "just move to Chicago (St. Louis, Kansas City, wherever)". That's not a solution, or a possibility for a lot of folks.
Then we need to work to make it a solution and a possibility, because I don't know what the alternative is. I'm from Appalachia, though my former oil-town retains a meager amount of relevance via the nearby industrial dairy farm. The owner of the only grocery store retired and nobody was interested in taking over, so the storefront laid empty until the government gave tax breaks to a hardware chain to set up shop and stock a little corner in the back with groceries so that it wouldn't become a food desert. But the situation isn't sustainable; there's not enough jobs. The population is declining. Most everybody drives to neighboring towns to work. I got out and moved to a big city, and wild horses couldn't drag me back.
I love the idea of small towns; not everyone needs to live in a big city (and almost nobody should be living in a remote cabin in the woods either; what an isolating experience). But if they're not economically viable, I'm not going to pay people to live there just so that small towns can continue to exist as a concept. What I will pay people to do is move to a city where they can find opportunity, and fight for more housing so that it's more affordable to do so.
these things are not written in stone, or the laws of physics. Layers of policy and taxation choices have led to this. Nothing says that the current system is stable, either.
When my wife and I drove to Kentucky--from NYC--for a road trip in the late 2000s, it was disappointing just how much more of the same we saw. Back then, it was strip malls. Walmarts.
A lot of the day-to-day Americana and culture we were hoping to see was simply fantasy or diluted, as most of the money--and therefore the culture--comes from large companies and interests.
The problem is this is completely untrue. One party had been talking about coal-mining industry ending and promoting job retraining for over a decade if not longer. Federal funds were administered to pre-empt this exact problem that was foreseen. That same party had frequently about the need for social programs to support this transition so people can still be productive. The problem is, this party never wins in Appalachia - all of their policies are ignored. Nobody takes the job training. Everyone locally votes against it and opposes those social support systems.
The problem isn't costal elites ignoring the issue, it's that no matter what one party does to help resolve the problem the other party says don't trust them do it on your own. Which isn't possible when entire industries aren't viable any more.
It's pretty similar to people desperately needing health care in the same regions and yet refusing to get it because it's been slandered by the party they vote for.
Fundamentally the issue is that one party has not supported policies to help this region for ages, but still gets voted for due to a few key touch button issues.
What are you talking about? Appalachia was a core part of the FDR coalition. From 1932 until 2000, West Virginia voted Republican just three times: Reagan, Nixon, and Eisenhower (each just once, in landslide re-elections for those candidates).
West Virginia and similar places were the base that provided the majorities for Democrats’ social welfare programs of the 20th century. Who is more qualified to conclude that whatever crumbs they get from social welfare don’t compensate for the downsides of economic change from globalism and social change from immigration?
I would imagine the American development pattern makes the economics even less favorable. Cars are very expensive and most (all?) small towns are designed exclusively for car-dependency. Infrastructure cost scales with sprawl too, so city costs to maintain infra are presumably high per-capita.
I'm not sure what the solution is. We could subsidize rural areas more (we already do quite significantly, but clearly the handouts aren't sufficient). But I think in the end we have to accept that times change, and certain lifestyles just aren't sustainable.
My wife and I presently had twins, and we spent 7 days living in the hospital with a lot of help from nurses and so on, and it cost us $130. Which was me paying for 3 days of living there because the 3 days was the max you had to pay. Sure I pay 39% in taxes on the first $120k of my yearly income and then around 55% on anything above this (well except for a bunch of sort of loop holes to invest before taxes), but it’s basically still pretty nice to have that sort of healthcare system.
I’m bipolar type 2 and I have ADHS. Now in case you don’t know, this involved a lot of trial and error with a psychiatrist to find the best medication for me. During this I learned that many prescription medications which are “normal” in the US are illegal or at least only used in extremely severe cases here in Denmark, because of how dangerous the side effects are. This is due to heavy government regulation, because we don’t elect politicians the way you do. We don’t have a winners takes all system which tends to lead to conservative governments which are heavily influenced by the private sector. Hell, you can even see it in our own local “opioid crisis” which was caused by deregulation by right leaning government (though to be fair, Danish conservatives would probably be considered communists by US standards).
As I understand it, you Americans have the ability to both influence national and stateside policies. So that if your national government fails you, then you can still regulate your local laws. Which probably should have meant voting for politicians who would regulate your healthcare system in your states and ban medicine that is clearly a threat to public health. That you chose to not do this, and then blame your costal elites is just baffling to me.
But maybe I just don’t understand your country well enough?
The other big issue, is like a lot of things in the US, if someone has money healthcare is great. It's probably the best in the world. Those who get elected have money and don't personally feel the healthcare issue. Heck, politicians at the federal level have their own healthcare system making them even further removed.
One of the biggest voting blocks is seniors, and they have already have access to what many say could be a step towards universal healthcare if opened to everyone. So they are also not inclined to think about it too much.
All in all, it's complicated.
Fun fact... many people know that Coca-Cola originally included cocaine as an ingredient, but fewer are aware that 7-Up was originally made with lithium.
"The product, originally named "Bib-Label Lithiated Lemon-Lime Soda", was launched two weeks before the Wall Street Crash of 1929. It contained lithium citrate, a mood-stabilizing drug, until 1948... Its name was later shortened to "7 Up Lithiated Lemon Soda" before being further shortened to just "7 Up" by 1936."
I have been misdiagnosed a number of times and was finally treated in the US for a major condition the doctors missed here in Denmark.
We get a number of privileges for our very high tax: childcare is cheap, education is free, and births cost us virtually nothing but let's not try and overstate the value of our system to theirs. Ours too is broken, it's just a matter of degrees and where.
Our middle-class, in return, gets taxed to high heaven while our income disparity between rich and poor continues to widen.
I think healthcare in the US is beyond messed up. In my area which is a large city in the North East US it is very difficult to be able to get into ER because rooms are filled with people who are trying to get non-urgent care. These people have no money, no insurance and their only way to get care is to go to ER. System is rotten to the core.
I also did not get your last paragraph are you talking about the US or Denmark? I would be shocked to hear income inequality problem is worse in Denmark.
The less said about our mental healthcare the better.
> I also did not get your last paragraph are you talking about the US or Denmark? I would be shocked to hear income inequality problem is worse in Denmark.
I was shocked too when I first heard it but live here long enough and it's very obvious. Income inequality has increased over the last thirty years with a Gini coefficient of 30 [1] in 2022.
[1] https://www.dst.dk/en/Statistik/emner/arbejde-og-indkomst/in...
While all systems have their issues, it cannot be undersold how absolutely captive American health is to the profit motive of private companies. If it does not leave room for profit in the US, we are told to die.
I would love a Medicare for all, because that's the most cost-effective system we can possibly get short of having no system at all. It'd also increase job mobility--nobody tied to their jobs for "benefits"--and put a sane check the price of basic-level care.
However not all countries with public healthcare are drug-free--Portugal just manages, not solves, its problem despite 50 years of public health--and that's because the incentives to both sell and use these powerful painkillers don't merely go away with a public system. Medical doctors were also complicit; or the more responsible ones, yanked-away the prescription out of caution but unintentionally drove their patients to the black market.
I'll concede that a streamlined system would have helped alert the powers that be sooner, but I'm not convinced that the powers-that-be would have done anything concrete until it became a crisis.
I'll keep my reasonable tax rates and absolutely top notch health care I receive through my employer, thank you very much.
You really don't. You live in a country that is either 11 million or 6 million people with fully enforceable border controls and immigration controls. You can control who comes into you country. You can control the goods that come into your country. Your population rivals one of the larger metropolitan areas of the USA.
Problems don't scale linearly. At 6 million people you can afford to fund pensions through nothing but an oil extracting operation out of your country. 7.7% Unemployment at 11 million people is, believe it or not, much less debilitating than 4% unemployment at 332 million people. There are more unemployed persons than the entire population of Sweden. And these populations cluster, and they depress local economies, and they drain their local workforce and social services. Then crime happens, and populations move, and housing prices fluctuate, and then this spreads. But here's the trick: You only need so much space to live. So much money to eat. So much space to grow food. You only have so many hours in the day you can work. Any doctor can see 20 patients a day, spending 30 minutes on each consultation. You don't need that many doctors to meet that demand at 6 million people. You need a lot more doctors to meet that demand at 332 million. Costs and living standards are relatively fixed beyond a tolerable level of comfort. Scandinavian countries achieved this comfort. But this comfort doesn't scale. Because problems don't scale linearly.
Back to borders and immigration: You control your borders. You can say that drugs don't enter your country. And they won't (at scale, at least). In the USA that's not enforceable because the country is so large. Illinois can say that they ban guns. But that doesn't stop them from going to Indiana and getting them. Or Kentucky. Or Missouri. Your local change can only accomplish so much when you are against the tide of your neighbors. You can say that you want to control your borders. But your neighbors disagree. So they go around you controls and infiltrate your economy anyway. And you don't know how bad it really is. Because statistics are an approximation of a segment of a population that doesn't want to be tracked. But these people still get sick. And some costs are fixed. So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient. Because people can pay for themselves to get a blood test. You relieve your burden on the system, for the moment. But now companies charge more because they also know that certain costs are fixed and people are willing to tolerate more costs for a relatively inexpensive service. And of course, they optimize. Because there's nothing stopping them. Since you can't tell them not to do something when you can't solve the problem yourself. And here we are.
The GDP difference seems more than enough to counter it, maybe, but socially, geographically, and historically, the US is a relatively libertarian project where "high taxes and free healthcare" are anathema.
Isn't that just the last 4 decades though? Before that, US had very high taxes and was not against spending on social programs. That all changed with Reagan and after, but it's not some set of core American values, but rather just the current, and relatively recent, dogma.
> Back to borders and immigration: You control your borders. You can say that drugs don't enter your country. And they won't (at scale, at least). In the USA that's not enforceable because the country is so large. Illinois can say that they ban guns. But that doesn't stop them from going to Indiana and getting them. Or Kentucky. Or Missouri.
Short of draconian measures like in China (also a very large country), which nobody wants.
> Your local change can only accomplish so much when you are against the tide of your neighbors. You can say that you want to control your borders. But your neighbors disagree. So they go around you controls and infiltrate your economy anyway. And you don't know how bad it really is. Because statistics are an approximation of a segment of a population that doesn't want to be tracked. But these people still get sick. And some costs are fixed. So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient. Because people can pay for themselves to get a blood test. You relieve your burden on the system, for the moment. But now companies charge more because they also know that certain costs are fixed and people are willing to tolerate more costs for a relatively inexpensive service. And of course, they optimize. Because there's nothing stopping them. Since you can't tell them not to do something when you can't solve the problem yourself. And here we are.
This is what I want to dig into. The heart of this argument is that publicly funded hospitals are forced to cover for those who neither contributing to the system nor are paying out-of-pocket for it.
> So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient.
Are you certain the EMTALA is really the cause of the problems we see today? I agree that it made it worse, but the cost of medical care was ballooning before the 1980s. I'm not sure what it was so I'd love to hear input from you or others.
Still, you do bring up a good point: Given that you have individuals that can't contribute to the system even if they would otherwise and given that it will also balloon costs, how do we solve this?
Perhaps its a taxation issue.
I doubt this will ever get traction but I'd love to see a compromise where we replace the blanket constitutional right where "you're a citizen if you're born here" with something different but equivalent at the amendment level.
Chasing down and returning migrants--this just funds the very problematic human traffickers--is a bandaid solution; it's inefficient; and it doesn't solve the needs of both Americans as well as our neighbors.
Instead, why not just ID them on the spot--state level with RealID, to make it palatable--make them pay a fine that is effectively the cost of a tax to fund the public infrastructure; and make such an ID either the requirement of using the triage service.
Or if they're undocumented, just treat them once and give them a choice after triage: Deportation or ID.
Carelessly thought out, I think that this sets up a two-tier residency system ripe for abuse: If said "temp" residents had children, what's the status of their children, for example.
But that's an incredibly unpopular solution. Every politician goes around orally fellating the small business ethos because it feeds into the meritocratic delirium. So essentially, Americans will backhandedly wail about illegal immigration while eating cheap fast food and hiring them to paint their walls.
There have been attempts to implement an ID system, especially when it comes to voting locally. But it was deemed racist. Because it meant only citizens who had the ID could vote. And some citizens didn't have IDs. And a portion of those people were poor minorities. And they didn't want to get them because it infringed on some rights. Or something. So America has this contrived system of registering to vote where people get tricked into also registering their political affiliation which is often used by politicians to sling mud at other politicians and political statisticians to pull slightly more accurate numbers out of their asses.
In some locales you straight up have to register with your affiliation to be able to vote. There's a significant segment of illegal immigrants who may or may not vote to support local political constituents that have their interests at heart, and a political party that appeals to those illegal voters. This political party uses this voter demographic for their benefit, because these local political constituents that are voted in have a voice in who the party as a whole can nominate for higher political parties. Since part of the political establishment is based on elections are based on representatives who then choose other representatives. And so the cycle continues.
Also, nobody wants to fucking pay taxes
It's the opposite, actually. Denmark is a part of Shengen zone, which means it has no border controls at all. When you enter neighboring country, you'll only know this because a sign on the road will tell you so. Similarly, migrants are free to roam entire Shengen zone and get in and out of Denmark as they please (unless emergency measures are introduced to stop them).
I’m not sure where you got the idea that we have right border control, we basically have no border control. Sometimes we have temporary border controls, but typically your only checked if you’re “suspicious” (which means non-Scandinavian looking, in a weird car or transporting goods”, or very unlucky. It’s been like this since the EU opened its internal borders. I’m usually not even checked in border control when I fly within Europe.
As far as keeping illegal drugs out, well, I imagine we’re like every country considering we can’t even keep drugs out of our prisons.
Do you imagine for example that the non-broken healthcare systems of the world are what is preventing opiate addiction there from becoming as severe as it is in the US?
Most young adults have no pressing need for healthcare except possibly birth-control pills for the young women (since those require a prescription in the US) and if the millions of young adults in the US who have become addicts during this crisis had unmet health-care needs at a significantly higher rate than their counterparts who did not become addicts, addiction researchers would almost certainly have noticed by now, and I probably would've heard about it from journalists who cover the issue.
Oh, yeah, I’m not saying that healthcare is the only factor or even the most important factor, just that it is relevant (and it does seem to be where the US opioid crisis _started_; oxycodone and similar were made available in ludicrous quantities as a substitute for actual medical care).
Granted, it is probably much harder to put the genie back in the bottle now it’s out there.
Anecdotally: cardiologist, inpatient rehab, dental work, maintenance medication, labs/blood work, mental health meds/counseling, ER visits and ambulance rides, and more.
These are things that non-addict young people do not usually need unless they’re big athletes or suffer from serious trauma.
Having access to these things also improves the likelihood of a full recovery from addiction (IMO).
Politically, it's nearly the opposite, where conservatives use the outcome of the epidemic as evidence that cities are dangerous hellholes, and actively fight solutions to minimize harm (monitored usage sites, needle exchanges, etc).
In terms of generally ignoring solutions to the problem, politicians as a whole seem to be the problem, rather than it being a city vs rural thing. Most likely liberals don't care about rural areas because they aren't winning those voters, and conservatives need the epidemic to harm cities so they can use it as fodder, so they won't help the rural areas, especially since they're going to win those areas anyway.
Also, it's kind of wild to blame the dust bowl on politicians and the coastal elite when it was primarily farming practices to blame. Why are coastal cities to blame for ignoring a problem that doesn't directly affect them when the affected areas are actively causing the problem, and not solving their problem locally? In the end it was the politicians who solved that problem.
Every problem has a different solution, but our inability to mobilize and solve the problem before it becomes a crisis seems to share a common theme.
Namely that our representatives and government officials have chosen to ignore the problem; I feel journalists have played a large part in exposing the problem and even then it's been an uphill battle.
> Or do people just not know how to solve it? What would you propose as a solution?
The political will to treat our fentanyl and opioid addicts is sort of there but the funding is not. Right now governments have been battling the Sacklers in court and it seems our collective state and federal government isn't really winning.
I'll go back to the Dust Bowl: My fantasy is to bus all of the addicts to the people who need to see this non-stop. No violence.
Bring them to the state/Federal officials where they work of course, but I'd love to see them bused to near the Sacklers' home; and to their retreats of choice. Non-stop. Until there's nowhere for them to run except out of the country.
And the opioid-wealthy become pariah until they clean-up their own mess.
As an immigrant who never learned how to be politically active and am a bit old and crusty now, I wouldn't even know where to start; but it's a fun fantasy at least.