> - The United States is 85 times larger than Switzerland. The entire country of Switzerland is the size of a small US state. Covering the US with broadband is much harder than Switzerland.
I see this argument come up a lot with regards to all kinds of infrastructure, and the thing is it simply _isn't true_.
What matters is population density, GDP per capita, geography, and will. A countries size doesn't matter since twice the area will, all things being equal, also give you twice the workforce to make it happen. In fact the only change a larger area typically makes is better ability to make use of economies of scale, which makes things _easier_.
The only correlation between larger countries and trouble with infrastructure is that a large country is more likely to have large areas with nearly nobody in them, but these areas also typically account for a vanishingly small percentage of the population so they don't really count when people are talking about bad infrastructure.
Density is not the correct measure here because empty land decreases density but doesn't need to be covered. What matters is how much the population is clustered.
But that makes it even worse because a lot of Switzerland is entirely unoccupied mountains whereas millions of people live in places like Kansas and Nebraska and expect to have internet access.
25 Gbps is a silly (but illustrative / clickbaity) take in this context. The more relevant measures as others have pointed out is how well-covered clusters of population are, but also what their broadband quality is. I live in Sweden, where we have extremely well-built out broadband networks, especially in cities. (My professional take is that quality is often very poor, but that is comparing to the rest of the country). We are a small country too, but we have still chosen symmetric active ethernet over the assymmetric PON, we have largely discontinued DSL, our cable/coax offerings have largely been replaced with fibre, and where DSL was not profitable, 4G is generally built out well enough to cover most people. Swedes in rural areas buy Starlink not for their reach, but for redundancy or even price.
I would say most of those things are not true in the US market. The united states IS a much, much bigger country, but my guess is that the median reach, stability, and speed is way lower than the Swedish and Swiss examples, compared to what it could be. The US has way higher military costs, still relatively high taxes, and most of all a stronger buying power. I pay $35/month for 300/300 Mbps Active Ethernet FTTH, and consider that overprized. When I last looked, the median American could generally afford more than that, but had access to less. Sorry, I don't have the numbers at hand.
My 8mbps DSL line is $43USD/month after everything, and the cheapest internet I have access to.
The next tier up is Starlink or 250mbps Fiber, which have the same cost. I do not wish to support Starlink. But I also can't afford to almost double my internet bill.
I live on a major national highway in a crossroads town.
Which of the things you said don't also apply to the people in Zurich?
Also, if you say people in Kansas don't need fiber then you have to expect that to get averaged in. The population density in California is less than half what it is in Switzerland. Only 10% of US states have a higher population density than Switzerland and those states represent less than 10% of the US population (because of those 5 states the one with the largest land area is Maryland).
If the least populated 3% of Switzerland's geographic area didn't have internet access at all, no one would care because it's just a single frozen mountain.
If the least populated 3% of the USA's geographic area didn't have internet access at all, people would care because it's the entire state of Wyoming. Okay, most people wouldn't care, but some people in Wyoming would.
That seems like another way to lie with silly stats though. If 3% of the least populated areas of all the subdivisions of the US the size of Switzerland were not connected, then that would indeed be just as irrelevant.
Wrong, there are scaling problems. Have you ever worked at both a very large and very small company? Were things that were easy at small companies much harder at large ones?
It's a false equivalence to compare working in a company to have the same scaling problems as implementing policies to set up broadband infrastructure.
Taking politics out of it. If you wanted to start a 25gbps project today, who do you think could get it done quicker. A small local municipality with a few network engineers. Or getting a Federal agency to do it?
I agree that a smaller municipality would be more successful, but not because they are smaller.
The municipality is a more concentrated interest, and more motivated to deliver on a solution that works for their constituents.
Compare that to the federal government needing to execute a national “Interstate Highway for broadband” mega-project. The federal government can and has executed these kinds of projects, but it needs to consider different things than the municipalities.
Extending the highway metaphor, a smaller municipality can pave local roads just as quickly as the federal government can build highways.
Efficiency is not a perfect function of government size.
To some extent there are, but in many cases it's because the law prohibits that. It imposes build out requirements so that if you want to offer service in the higher density area you also have to provide service over a wide area that includes a bunch of farmland or similar.
In theory this is supposed to be to make sure someone is serving rural areas but in practice it's because the incumbents don't want new challengers showing up to provide better service in the areas where it's profitable to build a competing network and so lobby the government to saddle them with a huge barrier to entry.
Indeed. But also some things that were harder at the small company were easier at the large one. You have processes in place, were things in the small company are all done ‘by hand’.
So I think it is hard to compare small and big. For one company things are easy that are hard for the other and vice-versa.
> Were things that were easy at small companies much harder at large ones?
I don't know about anyone else, but I have *never* found this to be the case.
Dealing with a larger company you've got a far greater selection of people you can get to say "uh, yeah, I guess, why not? It's not really my department..." which you can take as a yes.
In a smaller company no matter what you're doing you've got to get it past Old Bob, who's been there since before most of the current management team were born and will argue over everything simply because he can.
The difference is that the US companies are using it as a means to an end, they need to make just enough profit that the investors don't all get cold feet before they get to AGI. The Chinese companies on the other hand are trying to be profitable immediately, which means that they're going slower to save development costs.
Just because the users were already sick when they started using ChatGPT doesn't mean that ChatGPT isn't exacerbating the issue. Sickness isn't a boolean condition.
A big problem with LLMs in general when it comes to people like this is that they are too sycophantic, they don't push back when you start acting strange and they're too gentle about trying to validate you.
I think this is a great analogy, but it’s not exactly an optimistic one. We haven’t really done a great job managing hyper palatable food up until this point tbh. The best solution we’ve found involves paying hundreds of dollars a month for a pharmaceutical that helps the people most at risk to the harms of hyper palatable food manage their cravings for it. I hope we find a better alternative for the people that get addicted to hyper palatable socializing, but maybe individual cognitive tinkering is the best tool we have.
boy, if we treat it like junk food, things are only going to get worse for some places in the world. The food over here in the states is pretty awful if you aren't paying attention. Sugar in everything, high calorie/low nutrition etc.
In my experience AI can write _something_ from scratch, but often edge cases won't be handled until I go through and read the results or test it. Usually when I'm writing by hand I will naturally find the majority of edge cases as I go.
By the time I've read through the results and fixed said edge cases, I usually would have been faster just doing it myself.
My experience is the opposite: AI takes too many edge cases into account and guard against even the most unlikely thing. The upside is that it often handles edge cases that I either didn't think about or was too lazy to implement.
I can with full confidence say that the code AI writes is more robust and safe than if I would have done it myself. The code definitely becomes more bloated though.
My experience has been that it wraps all the obvious things, and even some obscure things, in error handling. In this sense it is safer.
It also fails to write abstractions unless they're carbon copies of a well established pattern, and when abstractions already exist, it needs babysitting to ensure it will use them appropriately. It won't introspect about its current direction unless forced to by the user or by an error, and when forced it will happily "fix" non-issues just because you pointed them out, since it's a happy little yes-man.
Because of this, code written by a good engineer is more likely to start out broken but converges towards correctness as more abstractions get built, while code written by AI duplicates abstraction layers, leaks between them, and never converges towards anything.
I've definitely had a lot of these same experiences (in fact I've been fighting it on one particular issue the past couple of days and I'm pretty much just giving up and going back to solving it manually now).
But it still seems to get it right (or at least close enough to right that I keep using it) more often than it gets into these traps.
This has been my experience thus far. Yes, a complete prototype can be made, but.. you don't really know until you read the code and test it. Just yesterday, small things came up in terms of Qt screen focus that wouldn't have come up otherwise save for initial testing.
I think, and I recognize it is mostly against the 'agentic' push, I will stick with slow iteration.
Agile cannot go over budget or scope because those are failures of planning. Agile is the methodology that was developed specifically to counteract those problems with planning. Projects that use Agile can go over budget and scope but they never do that because they are using Agile, rather they use Agile because they might do that.
It always felt like Agile is the lazy attempt of people unwilling to learn what it takes to build software, to make it more predictable. Unfortunately project planning methods that work for buildings are not really great for software. It's just corpo stuff project managers do to feel meaningful.
Yes, there's a reason it was abandoned as a KPI almost as soon as it was introduced. Just because AI is writing the code instead now doesn't magically make it a good metric.
For performance-sensitive scenarios where case types include value types, libraries can also implement the non-boxing access pattern by adding a HasValue property and TryGetValue methods. This lets the compiler implement pattern matching without boxing.
Not necessarily, C#'s incremental source generators mean you could simply slap an attribute onto a class you want to use the non-boxing pattern with, and it'll just generate the pattern for you.
You hope it offers a way to revert or accept your computer no longer works. I bumped into someone at the local bar, I think Windows is just corrupted, but she had no interest in fixing it.
> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion
How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.
As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK.
Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the slightest out of their parameters, tough luck. And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you. I could bore you with countless stories of doctors who have used tricks not to provide service and make it look like it was the patient's fault.
The problem with private healthcare is that profits corrupts it. The problem with public healthcare is that politics corrupts it. There is no good solution.
I think this is mostly a problem with state funded healthcare budgets being cut (relative to population demographics) in these countries. If the UK or Spain spent anywhere even close to what the US spends on healthcare (per capita), I have no doubt that it's healthcare provision would be just as good. In the UK, healthcare provision was notably dramatically better 20-30 years ago under the same system (except for less private finance).
I don't think so. With state funded healthcare you get rigid rulebooks and policies. In the capitalist-ish US model, if you are a successful advocate then you can get better than average care because there's enough flexibility in the system (in many cases, physicians can individually decide to over-extend for one patient if they choose to) to allow for this. Having a private payer market absolutely helps here.
Having care depend on "being a successful advocate" does not sound like a good thing to me! Albeit it's probably impossible to avoid entirely. We want good care for everyone.
I'm mostly familiar with the UK system, but medical professionals make pretty much all the decisions here, with a large degree of discretion according to their professional judgement (and they never have to adjust or delay their care based on whether you can pay). Except for some particularly expensive treatments (think CAR-T for cancer) which are not available at all in the state funded system. But you can still pay for those privately if you want to.
The data supports this. The AMA's 2024 Prior Authorization survey found 93% of physicians report PA requirements delay medically necessary care. Twenty-nine percent reported a PA delay causing a serious adverse event for a patient. Seven percent reported PA contributed to a patient death.
The requirement that patients fight for care isn't just a frustration. It's a documented cost driver: Health Affairs (2025) puts the total system-wide cost of prior authorization at $93.3B/year, including $35.8B borne directly by patients navigating the process. The persistence required to appeal a denial is unevenly distributed across income, education, and time availability. That is a structural equity problem as well as a cost problem. Issue #5 of this series covers the full mechanism.
> With state funded healthcare you get rigid rulebooks and policies.
We could just not do that. If you change the flow of control certain problems solve themselves. Think about a landscape where government funding multiplies the patient dollar, for example.
Personal anecdote...
My uncle is an auto mechanic in Scotland (Scottish NHS) and my brother-in-law is an auto mechanic in WV, USA.
Both have similar health care outcomes - they have ready access to quality care, specialists, etc. ER/A&E is available. The biggest difference is the perceived cost and stress incurred by that cost. My uncle doesn't give much thought to health care - he can work, retire, whatever and be assured a reasonable level of care. My BIL will work to 65 or beyond, fighting red-tape the entire time, then retire and still have to deal with supplemental programs.
Looking at another uncle, who was a small business owner in Scotland vs my father (also small business owner), it's similar to above, just with more money at stake. Uncle also purchased additional insurance on top of NHS for faster access to selective care, still cost less than insurance in the US, even after accounting for tax differences.
American's kid themselves when they say the Western Europe has higher taxes. Once you account for medical care, college funding, and other similar things, it's pretty close.
The RAND Round 5.1 study (2023) puts US commercial insurer payments at 254% of Medicare rates for identical procedures. That's the mechanism behind the international gaps — it's not complexity or quality, it's that commercial insurers negotiate against chargemaster list prices rather than against cost. The HCRIS cost-to-charge analysis (3,193 hospitals, FY2023) puts median markup at 2.6x actual costs.
I think this difference mostly disappears if you group Americans by wealth. So wealthy Americans have similar life expectancies to those in other countries. It's really the poor that are most affected by our dystopian healthcare system, which is probably a big part of why it never gets fixed.
The obesity adjustment is worth quantifying. US adult obesity: 42% (CDC). UK: 28%, Australia: 31%, Germany: 22%. Those gaps are real, but they don't explain a 2.5x per-capita spending differential. The Commonwealth Fund's 2021 analysis controlled for age, income, and chronic condition burden; the US still spent roughly $5,000 more per capita than the next-highest spender (Switzerland).
Obesity also matters less than assumed in hospital pricing: a hip replacement costs $29,000 commercially in the US regardless of patient BMI, vs. $15,000 in Germany and $9,000 in Spain (iFHP 2024). The cost structure is in the pricing system. Johns Hopkins researchers estimated eliminating US obesity would reduce healthcare spending by about 12%, real but not 2.5x. Repo with methodology: https://github.com/rexrodeo/american-healthcare-conundrum
Hvae you considered that America is a much larger and much more diverse country that these other countries and and it is very different social norms? Obesity is a major problem in America and it is not the fault of the doctors. I wonder if this has anything to do with it?
Yet, living in Germany, the problems I hear about our healthcare system from friends or in the media are an absolute far cry from the insanity that I hear about the US system. Maybe some of it is sensationalism, but I very much doubt that would account for the whole story.
What's usually missing from anecdotes is class cohorts - so, US working class with Medicaid or a crappy marketplace plan vs working professional with an amazing plan vs retiree with Medicare vs...
Nothing's perfect, but the plan differences seem stark. For example, my wife had a crappy marketplace plan and I had a plan through my employer. For her, an MRI was denied, denied, then finally approved with many calls. For me, it was approved immediately. For her, pre-auth to a specialist was denied until her doctor went and tried a different referral strategy. For me...well, I haven't been denied yet. It goes on - same city, same hospital, some of the same referrals, etc.
I've come to think the price discrimination really does mean we have class-based care which seems to allow for the sensationalism. Combine a dire scenario with a working or indigent class American, and they don't have to exaggerate much at all.
Having lived in both Germany and the US, my experience with the German system is that there are a lot more, smaller hospitals and private practices, the care is good, and all I ever paid for out of pocket was prescription medications. I didn't have to wait long for an MRI (two weeks) versus months in the US. I had a number of things that would have been hundreds or thousands of dollars in the US that I never paid a penny for in Germany. I'll also say that hospitals are absolutely crazy about sending bill collectors after you. I had a handful of small charges--like $10 or $20 things--that I hadn't realized were even there and two months later they freaking inundated me with bill collector notices.
It does make a big difference exactly where you are in the US, however. Some places have a glut of healthcare providers and other places don't.
> I didn't have to wait long for an MRI (two weeks) versus months in the US.
Where in the US did you have to wait months? There seems to be an MRI/imaging location in every other shopping center in the US right now. I've never had a problem getting a same day MRI when needed. Perhaps you were waiting for the 'free' one your insurance would accept?
Personal experience with specific interventions reflects something real: US cancer survival rates, cardiac procedure outcomes, and access to cutting-edge treatments are genuinely strong for people with good coverage. That's not disputed.
The cost-outcome tradeoff shows up at the population level. US life expectancy: 77.5 years. Spain: 83.6. UK: 81.6. Infant mortality: US 5.4 per 1,000 vs. Spain 3.4, UK 3.7 (OECD 2023). The US spends $14,570 per capita. Spain spends $3,300, UK $4,100. If the premium were buying 10 extra years of life expectancy and half the infant mortality, it might be worth the argument. The data shows the opposite at population scale.
The newsletter's framing isn't that US clinical quality is poor. It's that the US is paying $3T more per year than Japan (same life expectancy, lowest infant mortality in OECD) for aggregate outcomes that are worse.
The cost and life expectancy differences are indisputable, but the rationale may need more nuanced: that's not necessarily a problem with the healthcare industry, but with lifestyles, safety regulations, food standards, and a long et cetera of reasons. For instance Spanish people, on average, have more balanced diets and are more active than American people. They also lead much less stressful lives. That's a big factor.
"And don't you dare ask for a second opinion, you'll get the doctor that has been assigned to you and accept whatever they tell you."
This happened to us with private healthcare. There is basically one specialty group for the procedure my family member needed so any 2nd opinion request just got routed back to the same doctor, "Oh, your Dr X's patient".
Also, we could barely afford the procedure so we missed out on some follow up testing that would have verified things worked properly and basically got blacklisted from that practice so hopefully it's resolved...
There are other public healthcare models besides Beveridge though. Some countries do the payment & financing via gov, but the actual service is a mix of public/private. Not a perfect solution, but in my opinion better than what we have now. Maybe more achievable than Beveridge too.
Norway funds health care through taxation, seems to work pretty well here. But we don't have PFI, instead there are fully private healthcare companies that act as suppliers of services such as MRI, CAT scans, etc. So if your GP orders an X-ray or MRI you will most likely get it done by a private company rather than the local hospital. The patient doesn't really see any difference most of the cost is borne by the state, the patient pays a small egenandel (like copay in the US, excess in UK insurance terms) wherever it is done.
I'm not sure how the other Nordic countries do it but I think it's probably similar.
You can also get private medical insurance in the UK. The cost is usually much lower than the US and quality is decent. NHS acts as an anchor keeping down premiums.
I guess that's because many/most countries don't have the concept of a private emergency department.
It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment.
I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years.
But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!"
After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need.
(I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)
We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required.
I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.
I've unfortunately had a number of emergency visits over the past few years. I'm a bit torn on the public vs private situation. For certain classes of issue (e.g., broken bones) my friends who work in hospitals have repeatedly said they'd go public purely because the volume of patients those surgeons have to treat daily means the teams in the public systems are typically incredibly experienced. And yet, I smashed my hand to pieces mountain biking on a holiday weekend and when I arrived at the ER the place was absolutely rammed and it was going to be a many hours wait to even get triaged. We got straight back in the car and drive to the private ER 5 minutes down the road and were seen immediately.
In the moment I was incredibly appreciative of that option. It does make me feel uncomfortable that it was only an option because I could afford to pay to jump the queue though.
Simple test: The reports saying the UHC systems are better always are using statistical games. If they were really better why would they put their thumb on the scale?
Things like making 20% of the score "fairness"--as in UHC. And hiding the fact that most of the life expectancy difference is infant mortality and most of the difference in infant mortality is a reporting issue: infant mortality + stillbirth produces a far flatter plot. Thus much of the difference is whether it's considered to have died before birth or after birth.
There are certainly locations in the US where the standard of patient care -- ignoring cost -- is world-class.
And there are certainly locatioms in the US where the standard of patient care is nowhere close to that, and would be easily beaten at any major hospital in any other first-class economy.
There are people who have lived in multiple countries, and speaking with them the only place that seems to be comparable (until you factor in private healthcare of course) is Switzerland.
Patient outcomes should provide reasonably hard data for comparisons. Life expectancy at least is not vastly better in the US, how about other metrics?
I see this argument come up a lot with regards to all kinds of infrastructure, and the thing is it simply _isn't true_.
What matters is population density, GDP per capita, geography, and will. A countries size doesn't matter since twice the area will, all things being equal, also give you twice the workforce to make it happen. In fact the only change a larger area typically makes is better ability to make use of economies of scale, which makes things _easier_.
The only correlation between larger countries and trouble with infrastructure is that a large country is more likely to have large areas with nearly nobody in them, but these areas also typically account for a vanishingly small percentage of the population so they don't really count when people are talking about bad infrastructure.