From The Economist:
The chaos was all the more shocking to Chileans because they like to think of their country as the best-organised in Latin America. Officials admit that planners and politicians made big mistakes. These included President Bachelet’s decision to launch the system when almost none of the bus lanes and the technology was ready. Other cities, such as Bogotá, Colombia’s capital, have adopted similar rapid-transit systems based on bus lanes, but have done so piecemeal, allowing glitches to be fixed quickly. And in Santiago, the planners imposed arbitrary routes that took little account of passengers’ habits.
Let’s think about (groan) the healthcare debate. Ezra Klein made a strong case that a piecemeal approach to healthcare will never deliver universal healthcare, and I’m sure he’s right. But I’m pretty sure a comprehensive, carefully planned approach to universal healthcare will also fail to deliver universal healthcare. It will allow us to declare victory, to be sure, but my hope is that our goals go further than that, to deliver a better quality of life for as many people as we can.
It’s true that a piecemeal, state-by-state approach will fail under the status quo. We need to follow John Kitzhaber’s lead. Kitzhaber
calls for giving Oregon control of all the public dollars spent on health care in the state. That includes federal Medicare and Medicaid money, state funding for the Oregon Health Plan, and taxes the state currently forgoes because employers are allowed to deduct what they spend on employee health insurance.
This would allow Oregon to
set up a system that provides at least a basic range of coverage for all residents, such as prenatal care, treatment for high blood pressure, and care for other common but often costly ailments.
I’d go much further. After chatting with one of our leading lights, I thought, “That makes sense — why not let Hawaii establish a genuine single-payer system?” Let them try it. Yes, that might mean banning Hawaiians from purchasing private health insurance. I’d oppose this measure tooth and nail. If I were a doctor, I’d move to the mainland. But we need to give states an extremely wide berth to embrace a wide array of solutions to the problem. That will be uncomfortable for conservatives, but that’s tough. We need to address healthcare piecemeal, so we can fix glitches quickly.
So conservative plans to overhaul “the healthcare system” (don’t you mean systems? don’t you mean a dense network of providers, insurers, etc., that often work at cross-purposes and in unpredictable ways) along, say, consumer-directed lines are as misconceived as efforts to impose a one-size-fits-all Medicare expansion.
The other side — the partisans on the right and left of a one-size-fits-all solution — has moral urgency, and fear, on their side. Our side has one powerful argument: decentralized decision-making, subsidiarity, and local knowledge tend to deliver better outcomes. Tend! And it’s entirely possible that the Hawaiian experiment I have in mind will be a smashing success. So why rush headlong?