Piecemeal Healthcare
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.
This reminds me of a terrific post on Bogota’s Transmilenio BRT system. And it also reminds me of an idea Jim Manzi has powerfully been imparting to us — experimentation beats planning.
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?
Hahaha, I just read this article while riding Paris’s woefully centrally planned tramway and had the same thoughts. Not about the US healthcare system(s), but about the shortcomings of central planning.
I definitely agree with you. This is definitely true about education. But then again, some centrally planned schemes do work (take the example of Bolsa Familia, from the same issue).
While the peacemeal approach is the best overall, public scrutiny and intelligence can sometimes provide a good national plans.
— PEG · Feb 11, 12:42 PM · #
Reihan,
Have you ever read the Ishmael books by Dan Quinn? They’re a wonderful read, and even though they’re at least 50% hogwash, they’re 100% thought-provoking.
I believe in the third one, ‘My Ishamel’, the psychic gorilla (trust me, it somehow makes sense in the context of the books) suggests something just like this as a solution. Paraphrasing: “what if, somewhere in New Mexico, a bunch of doctors decide to set up a new hospital, something entirely outside the paradigm of more money for more procedures. And what if it’s a smashing success, but, somewhere in Cincinnati, a bunch of other doctors say ‘hey, we can do even better than that?’ You pride yourselves on being such an inventive species. So invent.”
The only thing I would add to this discussion is that you have to have some sort of national accounting and standards to make sure that the solutions being delivered actually, you know, work. For explanations as to why (and why I disagree with PEG about just how obvious it is that this works in education), see Matt Miller’s “First, Kill All the School Boards” in last month’s Atlantic, at
http://www.theatlantic.com/doc/200801/miller-education
— David Samuels · Feb 11, 04:45 PM · #
The reason state experimentation fails when it comes to health-care is that generous state programs cause a lot of sick people to come to that state, exploding the costs of that program, and causing it to eventually be rolled back. That happened in Tennessee with TennCare a couple years ago.
— Jamie Carroll · Feb 11, 05:39 PM · #
David,
Re: bottom-up innovation in education: what if, somewhere in New Mexico, a bunch of parents decide to set up a new school, something entirely outside the paradigm of what’s been done. And what if it’s a smashing success, but, somewhere in Cincinnati, a bunch of other parents say “Hey, we can do even better than that?”
My parents sent me to a small, reactionary preschool with books and standards from the 19th century, and I’m extremely grateful for the instruction I got there. One of my friends went to a small Montessori school run by hippies, and she’s extremely grateful for the instruction she got there. Which one of us got the better deal? I don’t know, but I’m glad each of us got that particular opportunity.
— PEG · Feb 11, 06:00 PM · #
Excellent point.
It does have to be a little more complicated than turning the money back to the states and telling them to go for it, as Jamie Carroll pointed out.
One thing that would help this approach fly would be to allow states (and maybe even other entities) to contract with the VA and other federal medical programs.
— Peter · Feb 12, 09:00 PM · #