The Conservative Reformation: Washington’s Roles
Yesterday, we paused on the doorstep of defining Washington’s key roles in the process of fostering DNS or dispersed, networked solutions. Once again, those key roles include: standard setter, catalyst, and backstop.
As standard setter, Washington would establish the basic rules of the road; the fundamental requirements, assumptions, or framework under which the other dispersed nodes of the network (the states and their sub-governments) would operate, as they consider, trial, and implement solutions.
In doing so, Washington would not attempt to prescribe the details of every solution or build mammoth, one-size fits all programs. We don’t need more inside-the-Beltway departments, agencies, and offices that require hundreds of staffers and billions of dollars to implement heavy-handed programs and enforce volumes of meticulous rules. Philip Howard has ably demonstrated the limits of such centralized approaches, which consistently fall short of their aspirations for a number of reasons: they stifle “common sense”; they are a step or two removed from the “real world”; they gloss over (fail to recognize) legitimate exceptions to the rules they establish. Instead, we need outlines, which would generally indicate where the states can go and where they can’t, leaving most of the rest of the process to them.
For instance: On the subject of universal health care, several possible, broad standards come to mind:
* All citizens should be offered a commonly defined “base-level” of coverage.
* This “base-level” of coverage should be offered at rates commensurate with the insured’s ability to pay.
* It should also (importantly) be portable (or replicable) if individuals move from one state/jurisdiction to the next.
* No one should be barred from coverage for pre-existing conditions.
* Those who require treatments that exceed the defined base-level should be offered additional coverage, again commensurate with ability to pay and considerate of options that help “finance” (pay over time) the premiums for the necessary coverage.
* Barring a finite list of uncontrollable circumstances, state insurance solutions should be sustainable, with cost-control and abuse-prevention mechanisms.
I realize some readers will label these sample standards as “unrealistic” or “overly idealistic.” Others will demand refinements to them — e.g., to prevent mission creep, which is no stranger to ambitious programs, here or elsewhere. I accept those criticisms, recognizing that I’m not a policy expert, nor am I trying to play one on TV. Instead, I’m only attempting to illustrate the type of broad, brush-stroke guidelines that might be issued by a federal government that acted as standard setter rather than bureaucracy creator.
Next, within this sample framework of standards, the states would be free to trial-and-error different programs, including mixes of free-market, not-for-profit, and state-sponsored solutions. And that’s where Washington’s second primary role — as catalyst — would come into play.
As states experiment with different approaches, measure/report results, and iterate their way to improvements, Washington could catalyze the process through a mix of incentives (for vetted experiments) and rewards (for programs that prove efficient, effective, and sustainable). Federal funds may not be the only form of said incentives and rewards, but they would probably be the most logical and powerful form, as we’ve seen before; e.g., Reagan’s use of highway-funding threats and promises to establish a nationally consistent drinking age. (Granted, that may not be the perfect illustration — it borders on the type of minutiae the Feds may want to avoid — but, for now, I can’t think of a better example to illustrate the point.)
The ultimate extension of the catalyst role would be for the Feds to gradually move away from their position as a collector and (re-)distributor of funds. Sticking with our health-care hypothetical, a state that proves its universal-coverage capabilities might be allowed to raise its tax rates in proportion to a lowering of the federal tax rates for its citizens. This move would help correct the gross imbalance we see today. Using my state, Missouri, as an example: The Feds (on average) collect and spend nearly four times more per U.S. citizen than Missouri does per Missouri citizen. [These calculations are based on (i) the most recent federal budget for which figures were available online, divided by the estimated population of the U.S.; and (ii) the most recent Missouri budget for which figures were available online, divided by its estimated population.]
One of the more powerful points Barry Goldwater made in Conscience of a Conservative was perhaps his most intuitive point. Toward the end of the book’s third chapter, he wrote: “The people of my own State … have long since seen through the spurious suggestion that federal aid comes ‘free.’ They know that the money comes out of their own pockets, and that it is returned to them minus a broker’s fee taken by the federal bureaucracy.” Translation: If we reduced the administrative charges required by centralized solutions, there would be more money available to help those in need through the governments that operate closest to their needs.
Granted, our citizenry is remarkably mobile, moving from one state to the next, and some states are poorer than others; hence, the worthwhile goal of “equal opportunity” may continue to require some re-distribution of funds, as will the scale of monies required for national infrastructure and defense projects. Net: We may never get to a 1:1 ratio — where the Feds collect and spend a dollar per U.S. citizen for every dollar collected and spent by the individual states on their respective citizens — but I do think today’s 4:1 ratio (or worse) is inefficient and can be improved or re-balanced.
Another reason why the state:fed balance may never be 1:1 is the need for Washington’s third role in a dispersed, networked paradigm; namely, its role as a backstop.
One the more common arguments I hear against a states-driven approach to universal health care is the barrier presented by cycles of economic malaise. In those times, state budgets naturally contract and safety-net projects are often the first to be curtailed.
Thus, as backstop, Washington might act in these situations like it does after natural disasters strike, providing incremental funding and other resources to help state and local governments bridge the gaps and restore their situation to BAU (business-as-usual) status.
Such backstop or bridge funding would not be distributed without conditions. Priority funding might be reserved for the states that present the most realistic plans for budget re-alignment, for managing their way through the budget crisis, including estimates on the level of bridge-funding required and (perhaps) a post-downturn re-payment plan.
Several logical questions arise from this outline of dispersed, networked solutions and Washington’s roles in fostering those solutions; questions like:
* Doesn’t Washington already (largely) act in this manner today?
* Wouldn’t the DNS approach be too slow and haphazard to be accepted by an impatient American electorate?
* Don’t certain issues require a centralized rather than dispersed approach?
We’ll consider these and related questions tomorrow, in the final chapter of this series.
30 Responses to “The Conservative Reformation: Washington’s Roles”
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Pete,
As always, I will take the governmental minimalist/free market approach.
I agree that the government should set standards, but only in the broadest of terms. If we were discussing restaurants, I believe the government should set a standard of safety/cleanliness/proper labeling. If the mindset of the healthcare debate was applied, they would be mandating the menu and portions for each meal.
Let the market decide.
As with restaurants, some people believe they need steak and lobster, while others choose hot dogs. No one denies the hot dog eaters access to higher priced food, it remains their choice. Alternately, the lobster eaters often go to the hot dog stand, just because they are frugal. Healthcare needs to follow this model.
It’s their life, let them do what they want.
Hillary struggled with trying to make healthcare fair. She advocated severely limiting specialties, using “gatekeepers” and outlawing individuals paying for services. Of course, this was doomed to failure from the concept stage.
By staying to the most basic standards, the government will insure that healthcare can be delivered with dignity. Any attempt to mandate (and thus institute controls) eliminates the ultimate decision making of the individual and thus eliminates human dignity from the process.
There is an answer, but the steps are to define the problem, outline the best result (actually taking the time to think about how you would like your healthcare experience to work) and then devising a plan that achieves that result.
Once a plan is made, we can move to how the government acts as a catalyst for implementation.
jwest, you make a good point, but your hotdog and steak analogy doesn't quite work. Sometimes the people who need steak & lobster healthcare can't afford it. How does the market address that?
Very good Amanda. How does this nation afford steak and lobster health care with a 10 trilion dollar debt and a 600 billion dollar budget deficit next year
The federal government should be _minimalist_ (that is true for all of our governments, but especially for the federal government) and should set _minimal_ standards, without any aim at engineering something more than minimal in the name of desireability, or with the intent of future incrementalism or “ratcheting” (we know which direction the ratchet normally moves).
The scope of federal interventionism should, again, be _minimal_. Air pollution is a legitimate object of federal interventionism, for example (because pollution does not honor state boundaries). Air traffic control, yes. But for something that is a local or state issue, even involving corporations (producers) that are multi-state and multi-national (auto makers, appliance makers), there shouldn't be federal interventionism. The federal government should have no involvement whatsoever in my going to a nearby barber shop for a hair cut, for example — though it currently is involved (such as with federal minimum wage laws). More insidious and sinister is the practice of effective income (tax revenue) redistribution (something Amanda begins to scratch above), minus a substantial “reprocessing and central bureaucratic inefficiency fee” collected by Washington for the privilege, of revenues to states to meet “needs” or to achieve better equity. All too often, unnecessary and harmful requirements go along with the money. “If you take their money, they'll tell you how wide to make your doors.” Worse, the states get dependent on this money (some even wrongly come to expect or demand it) and are rendered susceptible to federal intrusion as a result.
First and foremost comes the need for minimalism — the classic libertarian principle that is our English-American heritage remains in effect. The burden of proof always lies upon advocates of government interventionsm to justify it. The record of interventionism is a poor one and all too often it's tempting for “the central node” in Pete's network to become a master node with all others mere slaves. And the federal government's standards should be _minimum_, not any kind of “driver” for “progress” as “progressives” or idealists would like to see have happen. (They also like federal interentionism because it means the majority cannot vote with their feet to reject what would otherwise be sought, say, in Vermont or Massachusetts. As Bork wrote so ludidly, “enlarge the scope of jurisdiction to make escape impractical.” This is petty when not truly sinister.)
* * *
” a catalyst”
This concept is fully correct, and is so powerful its danger should be obvious.
“Let the market decide. [...] It’s their life, let them do what they want.”
That remains the American as well as the truly liberal (free) way. Burden of proof always lies on those who want interventionism. Universality of government health care may be appealing for a number of reasons (though Cadillac “insurance” will be astronomically expensive; some states have made this mistake rather than have true insurance only, i.e., catastrophic care); our destruction of time and distance and our mobility (including, yes, Evil Automobility, so libertarian in nature itself compared to reliance on collective transport) and the logic of single standards or a common currency are appealing. But we must not draw the illogical and harmful conclusion that if some is good, much more is much better.
“ludidly”
No, Bork is not a Luddite, though in his later years he's become a curmudgeon.
I meant “lucidly.” Sorry.
* * *
“How does this nation afford steak and lobster health care with a 10 trilion dollar debt and a 600 billion dollar budget deficit next year”
You find some of the money by redirecting it from military spending, you find some of the money by levying new taxes (stock and bond transactions and new progressive income taxes in Conyers-Kucinich, for example); you spread the cost among everyone in the restaurant by making everyone pay a per capita share (or if you're dishonest and want progressive taxes, “their fair share”) of the steak and lobster. The caviar can be added as an additional “human right” in the future.
In the real world, you make everyone in the restaurant (especially those who are less likely normally to vote for you) pay while you begin with smaller, less expensive portions of the steak and lobster or even provide a substitute that isn't quite up to that standard but which beats mere hot dogs.
In fact, this merits mentioning, at risk of being somewhat digressive or oblique or tangential (so I'll keep it short) but Medicare is not a miracle; even very liberal NPR has broadcast at least one story about one of its shortcomings (something known long before “HillaryCare”). And we don't have “Medigap” insurance for nothing. I have said that one thing Obama can do rather than extend Medicare coverage to more people (the classic age-related “pincer” being adding children in addition to the elderly), is first to consider reforms to Medicare itself and get it into better or best shape before extending coverage to others.
(The mainline strategy is to extend it to others such as children or the poor, i.e., taking over Medicaid, likely welcomed by the states; the objective is to build support for universality among others than just the egalitarian activists by making them pay for more and more beneficiaries until they demand that they, who are paying for the program, and who deserve to be beneficiaries most of all, be also included.)
Goldwater said:
“If we reduced the administrative charges required by centralized solutions, there would be more money available to help those in need through the governments that operate closest to their needs.”
This is a sound argument in theory, but it assumes something that is often just not so in practice: that all states would, indeed, use the funds to address need.
Through the very regressive tax systems (and other local laws) some states have, it is the relatively poor who fill the cofffers of the state, and the benefits go to those absolutely not in need.
Acceptance of inequity and injustice is most likely at the local level, and to address inequity and injustice has to be handled at the federal level. Wasn't that demonstrated clearly enough by how segregation was finally ended?
Treating the federal government as the enemy makes no more sense than treating it as the dispenser of all solutions. After all, we are all citizens of the US before we are citizens of a state. If not, the whole concept of being one nation crumbles and may as well be dissolved. If we are still one nation, then at a basic level, the citizens of Indiana must be concerned about the citizens of Alabama and vice-versa, and that requires a broker, the feds, along with broker fees (the dreaded and maligned taxes)
On the other hand, I do see a very clear, beneficial role for states as laboratories, where situation specific solutions can be tried out. National guidelines and requirements must be informed by the evidence of applied practices .
Trim away the initial 'governement is bad' starting point, and there is much in Pete's plan to admire. I recognize, also, that the starting point does not define the plan and is greatly adjusted, augmented and fine-tuned to address my concerns.
This brings me back to my initial quibble. Too many of our debates start out at one or the other extreme and then work towards a central, accomodating position. I would jump with relief and joy, if ever I read a position paper that recognizes both extremes equally and then works toward balance, accomodation and pragmatic solutions.
We seem to be jumping to the plan before even defining the problem.
Once we know where we are going, we can devise a plan to get there and in doing so define the role of government in catalyzing and backstopping it.
If healthcare is the topic, here is where the dollars go:
http://bp0.blogger.com/_yxY2_QzkVJU/SGFgKO15GRI…
This shows overall expenditures, not the breakdown of administrative, waste, abuse and the like.
“This is a sound argument in theory, but it assumes something that is often just not so in practice: that all states would, indeed, use the funds to address need.”
So often it's simply a want, not a “need.” At least we don't have a federal Department of Human Needs yet. [gag]
“Treating the federal government as the enemy makes no more sense than treating it as the dispenser of all solutions.”
It's not “the enemy,” but it obviously has wrongly over-enlarged in the past and should be minimalist, and avoided as a resort, particuarly being the first rather than last resort to solve a problem, which in fact is perverse.
“I would jump with relief and joy, if ever I read a position paper that recognizes both extremes equally:
The extreme we do see on the interventionist side is not matched or created to any similar extent on the other side by minimalists. Where the two extremes are not equal, as is obviously true here, there is no need for equality of treatment. (Besides, minimalism is round-earth versus flat-earth for interventionists and the Fully Engineered and Enlightened Society and they don't deserve equal respect!)
“After all, we are all citizens of the US before we are citizens of a state.”
Not “before,” in any way establishing the opposite of history or in claiming federal supremacy, but rather we are US citizens as well as, in addition to being, state citizens.* The real contemporary issue today (actually since at least the 1930s and in practice, before then) is that state citizenship really isn't seen by anyone to mean anything. Driver's licenses and license plates is about all people think of.
“On the other hand, I do see a very clear, beneficial role for states as laboratories, where situation specific solutions can be tried out. National guidelines and requirements must be informed by the evidence of applied practices .”
Fine, but what's better is to refrain from rushing to national (federal) guidelines or “requirements” (?) at all, because the states, which are their own coherent communities (at least, if they're for real; that reintroduces the question of what role the states should play in contemporary times in this country), should be able to live as they choose to live. Uniformity and homogeneity may be desireable among many who want federal interventionism and true top-down command and control (while they hypocritically gush about multiculturalism!), but to what extent is this desireable, or effective, or [gasp] _proper_?
* There is no inherent power of the federal government to do whatever it wishes, no broad, unconstrained power given by the “general welfare” clause, which is instead a qualification on the power of Congress to levy taxes. The powers the federal government has are explicitly defined and listed. It was intended this way, else there would be no need to list those powers. However, with the introduction of federal citizenship to secure civil and legal equality for blacks in this country, it does introduce a new concept and a variety of implied (“necessary and proper law” forming) powers that by which Washington can do much on behalf of its citizens and gives at least quasi-legal support to 1930s-onward modern-welfare-state programs run out of Washington. (Not necessarily limited to enforcing laws against discrimination, the most strict construction of the 14th Amendment)
“We seem to be jumping to the plan before even defining the problem.”
It seems to me, J. West, that most want federally provided health care, either because they have long wanted this, they want government health care and have become conditioned (woof, woof) to looking to Washington promptly as the source, they hate the insurance companies, or they're just slowly concluding that none of the other alternatives are better. Typically they look to Medicare extension to others as the logical thing to do (which it is along with having Medicare take over VA and Indian Health in addition to Medicaid).
jwest's market magic potion fails on two levels:
1) a system based on choice leaves out the many (most) whose choices are either limited or nonexistent. As the system continues over time, it is increasingly determined by the choices of the few and represses the needs of the many(most).
Additionally, popular choice is not necessarily good choice and the tawdry, wasteful and downright harmful has as much, if not more, chance of defining 'success' as the valuable, economical and beneficial.
2) that markets don't work well if left totally unchecked has been demonstrated in numerous areas, the destruction of the credibility of media being one glaring example and the dissolution of a viable health care system being another.
That worshippers at the 'markets' altar never look back at the consequesnces of their tenecious beliefs reveals a 'let them eat cake' attitude that cost Antoinette her head, and can cost democracies their future.
Let's just get back to the real world and the BREAD and butter issues important to the commoners comprising the majority.
Markets( a tool) should work for us; we shouldn't work to sustain markets as a specific tool when that tool doesn't work.
“there is much in Pete's plan to admire”
In addition to (physical) disaster relief, what about (I doubt modern politicians in Washington could be trusted with it, though): a general-purpose “rainy day” fund, i.e., a contingency reserve, funded by a fiscally prudent government running a small but significant surplus?
“that markets don't work well if left totally unchecked has been demonstrated in numerous areas, the destruction of the credibility of media being one glaring example and the dissolution of a viable health care system being another”
Actually, that's not true because markets are not usually left unchecked, and whatever you may believe about the effects of commercialism and poor quality programming is separate from the fact that they're responding to what too many people prefer and that may be bad in this example, but it is in no way truly wrong.
And with insurance, actually it leads to…
“a system based on choice leaves out the many (most) whose choices are either limited or nonexistent”
Yes. “If there's great demand, let the price rise in response to the demand, and then those who value it more highly will pay more to get what they want” is itself an ivory tower approach and could be accused of being a variant of “Let them eat cake;” an elegant alternative the British economist Vickrey used is succinct: “Willingness to pay implies ability to pay.”
Just wait until the human genome is studied to the point that all kinds of disease is shown to be genetically affected. Insurance companies will want rigorous, thorough genetic screening and will refuse coverage for any diseases related to whatever genetic information about you they obtain. At that point government interventionism is all but assured.
Well thats a bunch of hot air that talked around in circles and still did not offer one even remotely simple answer to a simple question.
Ya remind me of a guy I had in Kuwait when we was putting out oil well fires. He would analyze the situation, discuss it, call his buddies overseas and while he was doing all that crew number two was just putting out fires.
I perfer answers to talk. Weve been talking for 200 years and we still havent answered the question.
If we want health care. How do we do it?
My vision of healthcare combines individual healthcare accounts with a national catastrophic Medicare program. I go this way because I can’t stand the idea of a government bureaucrat or an insurance company making decisions about my healthcare.
Using individual accounts puts the decision making process into the hands of the user. It allows total freedom as to how this money is spent on healthcare. A debit card would access the owner’s account for immediate payment for services, which would greatly reduce the estimated 28% of healthcare dollars now going to administration. The less fortunate in our society could receive funds for their account through a system similar to the earned income tax credit.
Standard fees for service would be available on the internet. Each time a debit card was used, it would automatically update a website that tracks medical charges by zip code. Displayed for any area would be a list of providers (sorted by cost) with the average of what they charged for the last 10 similar procedures.
Specialization would explode. A doctor who specializes in lancing ass boils would be able to develop cost and time effective methods that would bring the cost down substantially. Just as you wouldn’t want to pay a skilled surgeon to do a simple procedure, you don’t want the director of “Boils Are Us” performing heart surgery on you.
To accommodate specialization, advance degree nurses would fill the initial contact role. Less expensive and more convenient, these diagnostic nurses would be able to devote more time and compassion to people, knowing not only your personal history but that of your family. By delivering the initial stage diagnostics in the home, environmental factors, diet, etc. could be taken into account in the early stages. Using portable equipment, vital signs, fluids, etc. could be collected and if not analyzed on the spot, be sent expeditiously to a lab. Once all the data and impressions are correlated, the nurse can communicate with the right doctor quickly and effectively.
Of course, there is much more. I just thought you could use a break.
DLS writes so much, but contributes so little.
Pointing our how everyone else is wrong does not constitute a plan for what is right. Neither does a list of personal preferences, if they're just blanket assertions without due attention to the ocnsequences.
For starters what does 'minimalist' look like when it stands in front of you in real life? The whole argument is an attempt to determine the minimal amount of government involvement necessary to deliver a fair and just system of governance. Everyone is a minimalist. as no one wants the government to intercede where it's not necessary , so we have to determine where it is necessary.
Everyone is against taxes, as no one wants to pay taxes that are unnecessary, and so we have to determine when they are necessary.
Catch word arguments (taxes, minimlist, nanny state, markets) just distract from the effort to define what and when something is needed and how it works.
“For starters what does 'minimalist' look like when it stands in front of you in real life?”
???
What does anything standing in front of you in real life look like? Is it as distorted as anything on here must be in order to explain your frequent illogical and untrue statements?
jwest,
You make a very good start with your take on a health care system. I agree with some parts, disagree with others.
I don't think we'll arrive at a national solution on this thread.
I do have one observation, however, and it's about private health care accounts.
To have a broken leg set costs the same minimum amount whether you are rich or poor. To put aside the money for potential broken limbs, however, is much more difficult, and sometimes impossible, for families whose income barely covers the price of the roofs over their heads and the grocereis in their kitchens.
What happens, then, is that the broken leg will be set in an emergency room, and everyone pays anyway. and pays a higher total price.
Let that be a model for a general observation about health care. Any plan that doesn't examine how it actually works for different sectors of society has an inherent fatal flaw, which will bring us back to the arguing table faster than you can say health care. The reason; what may look like savings at face value can result in much higher costs in the long run.
Another reason to not elect McCain… He'll cut spending here only to keep spending in the Middle East at the same level if not higher. At least Obama's spending will benefit Americans.
Here's an interesting take on the ever increasing deficit.
http://www.greenfaucet.com/hanlons-pub/obama-mc…
“Using individual accounts”
Why not just make the expenses tax-deductible? (No income-percentage threshold or other gimmicks.) Or do you forsee using the accounts and their potential as savings or investment vehicles (which can grow in value beyond what is put into them) as a form of “leverage” increasing the ability of people to pay for health care as well as make their own choices about it?
“national catastrophic Medicare program”
This would be true insurance. Note that rather than cover anything that happens inside hospitals (using hospitalization as a criterion for coverage) there might be less use of hospitals in the future and more out-patient services to reduce costs.
Runasim,
The beauty of the program I’m advocating is that it brings the same purchasing power (along with the resulting dignity of being treated as a welcomed, paying customer) to all, regardless of their income.
Funding the individual accounts for the poor/low income would be done on approximately the same scale as the earned income tax credit. The money would be available only to licensed healthcare providers and outlets. If the individual exceeds the federally mandated minimum in one year, the catastrophic Medicare benefits would kick in. If the individual didn’t use anything out of their account in a year, the person would be able to transfer 10% of the account balance for their own use.
On the broken leg scenario, the savings would be substantial along with the service being far better than any low income person would be accustomed to. With this system, the person would look (quickly) on the internet or in advertisements in the yellow pages for immediate care clinics. The clinic would have every incentive to treat the person quickly, professionally and at a good price using the same basic theories as any business – they want to have happy satisfied customers who will come back.
The clinic owner would have minimal overhead because he would be paid immediately after the service is performed. No arguing with insurance companies, no months of screwing with the government. Fraud would be easy to catch, due to the software monitoring of procedures per location/doctor etc. If a typical Medicaid fraud perpetrator was on this system, he would receive a visit from the authorities the day after he claim to have performed 8 hip replacements in one day. Also, the person who was charged for the hip replacement would have received a call, just like credit card companies spot check unusual charges.
DLS,
You seem to zero in on some of the benefits before they are even brought up.
The growth aspect of the accounts is a part of the plan and is also tied to a variation of tax reform. But I was trying to present this in baby steps.
Additional thoughts.
Using the broken arm scenario above, think of the benefits of having a system where everyone has the purchasing power of an individual account.
Aside from having the dignity of being a paying customer, access to quality healthcare would be vastly improved. Investors would immediately pour money into building rapid care clinics in high-density underserved areas knowing that money would flow immediately as service is provided. Doctors would be more likely to practice in areas they previously avoided if the accompanying hassles of collection were eliminated.
Along with this system is a web-based mechanism to capture medical information so that it is immediately available to healthcare providers. Because there would no longer be traditional health insurance, the main reason to prevent medical information from being disseminated would be eliminated. Medical researchers would benefit from having all this information available (without names) in order to track areas of concern like cancer clusters.
I suggest that the USA balance the budget and then pay off our national debt. The interest alone on that debt is 400 billion dollars. That 400 billion could then be used to purchase premiums for every individual in America who makes under 30k and have a regressive premium assistance up to 100k per year.
That would keep all the insurance companies in business and would balance the budget.
Hm. So I wanted to address the “what if states don't do the right thing?” part of the comments and Pete's main suggestions regarding how the federal govt fights against that with federal funding. Runasim brings up the classic example of a state following practices that are unacceptable, namely segregation. In that sort of case, I would think the major arm of the federal government that would fight back against that sort of thing is the judiciary. They are the ones who made the Brown v Board of Education decision. No matter how centralized or networked the executive is, and that's largely what Pete's talking about, constitutional rights remain the same. However, there are likely going to be lots of other “screw-up” state programs. Withholding funds might work. Another option is a temporary federal take-over. If a state does not meet the guidlines, the feds can take over. Of course, firm limits would have to be placed on this so that the feds don't slowly take over everything.
I suppose the main innovation I'd like to add to Pete's plan is to not get locked into states versus national government as the two options. Some issues will be best handled at those levels. But perhaps others would be better handled on the county or municipal level. Or perhaps others would be better handled by a regional group. Finally, other aspects of life might be better handled through private enterprises or independently operating governmental agencies. It's hard to come up with examples for all of these, but I will give it a go. Educational curriculum is often best left to more local units; healthcare might indeed be best handled at a state level; environmental policy might be best handled at a regional level, such as all states with a vested interest in the Colorado River; …. Hopefully people get the idea. The executive wing of our government needn't necessarily be a binary state or federal decision.
Jwest,
I really do admire the scope of your thinking. Your plan sound very atractive.
The devil is in the details, however, and this is but one of several ways to arrive at universal health care through a mix of public-private funding and service mechanisms. We have the same goal,and I suppor the mix approach.
It will take a very careful cost/benefit analysis AND an analysis of how much of this plan is actually deliverable before any decision could be made.
Will doctors and clinics settle for guideline fees, for example, or will they simply opt out?
Your fraud catching idea is something I've been talking about for some time.
There is no doubt that it could be done. That it hasn't been reflects the misguided aversion to making an iinitial nvestment for the sake of reaping huge benefits down the road.
In fact, that's the hurdle to implementing any plan: the initial investment that's required.
I don't want to hijack Pete's post for one side topic. I still disagree with you on some details, and I think you are overly optimistic about results, but I appreciate your broad angle of approach.
We should go to Washington and haggle out a deal.
Runasim,
Just a quick clarification before this highjacked thread crashes.
All fees and charges would be set by the market – no government interference. Prices would be driven down by pure market forces.
I stomped the halls of congress with this plan back in ’92 when Hillary came up with her proposal. It was pitched to Jack Kemp while standing next to him at the urinals of a country club restroom. The time was just not right for a plan to make it. Maybe that time has come.
“The executive wing of our government needn't necessarily be a binary state or federal decision.”
If we were innovative we'd escape the constraints imposed by the reality of how our states are today and proceed more often with regionally oriented policies.
Pacatrue,
Education and healthcare can't be settled by Constitutional law. There has to be a federal law mandating standards in order to either uphold it or to challenge it's Constitutionality.
These are the precise areas where injustice and inequitity are liable to dominate at the local level. I disagree most fervently, then, that these are best solved without government oversight.
That creationism is taught in LA schools not only crosses the state/church line, it disadvantages the students who will have to compete on an international level.
That's a matter of national interest.
Again, I think the feds should allow states to experiment, should consider state or local results carefully and should always be sensitive to local conditions and concerns. Stay out if they're not needed.
But they should not be enslaved by local demands and shortcomings. Somebody has to be the umpire.