5 ms·

It's a truism that America's system was never designed -- it's a patchwork of different pieces that each pay for some people in some situations. But I've been

It's a truism that America's system was never designed -- it's a patchwork of different pieces that each pay for some people in some situations. But I've been reading about our system, since I fell down a rabbit hole a couple years ago. Things are bad, yes, but there are actually interesting ideas out there, and real efforts at reform that are being tried. For example, did you know Maryland has a different way of funding hospitals than most other states? [0] And that other states are interested in copying it? [0] https://www.vox.com/policy-and-politics/2020/1/22/21055118/maryland-health-care-global-hospital-budget https://www.vox.com/policy-and-politics/2020/1/22/21055118/m...

bombcar 10mo ago
A system built as a mish-mash patchwork is likely to be solved by a similar "ground-up" framework. Each state should be free to experiment (as Maryland has done here) and the federal levels should be restricted to providing funding and basic guidelines that have to be met. Part of the problem is that as you begin to delve in and see where the outflows are, you start to realize that fixing the fundamental problem involves making the people healthier in general, which will rumble the very foundations of Wall Street.
- jpalawaga 10mo ago
  One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever. Many countries around the world enjoy the benefits of coordinated public health departments. Part of the United States' poor response to COVID was because there was no central public health department that could work closely with state agencies to e.g. provide data about what's going on, share best clinical practices, etc. Each state is an island. So no, I don't agree that the only goal of the federal government should be piggy bank. States should have a lot of latitude with their policies, but generally standardizing things across the nation would be a net positive.
  - bombcar 10mo ago
    Many countries around the world are the size of US States. The UK and Germany are only twice the size of California, for example. The problem in the US isn't that we can't do things, it's that nobody can agree on what to do. And to solve that problem, let states do their own thing as much as we can, and it'll become obvious where the good systems are. Or in other words, an argument needs to be made why the EU "works" with individual "states" doing their own thing, but the US cannot "work" unless it's considered as one large country.
    - rwj 10mo ago
      This analogy is quite misleading, because, in addition to California, there is also Wyoming, with a population of less than <600k.
      - emchammer 10mo ago
        Scalia was right in saying that the checks and balances slowing things down is a feature, not a bug. The Framers were right about protections against faction. I’m not sure they understood how badly malicious schemers could deliberately manipulate the system. Things just aren’t getting done, and it is killing people.
        psunavy03 10mo ago
        Half of the problem with American politics these days is people from blue and red states trying to force the entire country to become one giant blue state or one giant red state. It's too big for one-size-fits-all answers. Every state should be able to largely do its own thing as long as it isn't violating the Bill of Rights.
        matthewdgreen 10mo ago
        If you look at some of the more controversial bills being passed in the states, they're also being more or less lifted out of national political action committees and think tanks. Extreme in-state gerrymandering (supported by national party organizations) has effectively nationalized big parts of state politics in those states.
- nneonneo 10mo ago
  Canada’s public healthcare system was started in Saskatchewan, one of the provinces, and rapidly copied to other provinces (and later to a federal level): https://www.cma.ca/healthcare-for-real/who-started-canadas-universal-health-care-system https://www.cma.ca/healthcare-for-real/who-started-canadas-u... If one state can manage to make it actually work, it might be enough.
doctorpangloss 10mo ago
There are already numerous and simple policy levers that actually affect costs and cannot be gamed. Such as the age you become eligible for Medicare. You don't have to reach for anything innovative like global hospital budgets. I'm skeptical of your category of reforms - you really mean, "benign-looking administrative decisions," because if you're not making any hard choices, you're not making reforms. I would hardly call it "real efforts."

bombcar 10mo ago

A system built as a mish-mash patchwork is likely to be solved by a similar "ground-up" framework. Each state should be free to experiment (as Maryland has done here) and the federal levels should be restricted to providing funding and basic guidelines that have to be met. Part of the problem is that as you begin to delve in and see where the outflows are, you start to realize that fixing the fundamental problem involves making the people healthier in general, which will rumble the very foundations of Wall Street.

jpalawaga 10mo ago
One of the great powers of federalism is not having to duplicate efforts for every state. It also reduces cost by allowing 'one-size-fits-all' and economies of scale, rather than each state having its own bespoke whatever. Many countries around the world enjoy the benefits of coordinated public health departments. Part of the United States' poor response to COVID was because there was no central public health department that could work closely with state agencies to e.g. provide data about what's going on, share best clinical practices, etc. Each state is an island. So no, I don't agree that the only goal of the federal government should be piggy bank. States should have a lot of latitude with their policies, but generally standardizing things across the nation would be a net positive.
- bombcar 10mo ago
  Many countries around the world are the size of US States. The UK and Germany are only twice the size of California, for example. The problem in the US isn't that we can't do things, it's that nobody can agree on what to do. And to solve that problem, let states do their own thing as much as we can, and it'll become obvious where the good systems are. Or in other words, an argument needs to be made why the EU "works" with individual "states" doing their own thing, but the US cannot "work" unless it's considered as one large country.
  - rwj 10mo ago
    This analogy is quite misleading, because, in addition to California, there is also Wyoming, with a population of less than <600k.
    - emchammer 10mo ago
      Scalia was right in saying that the checks and balances slowing things down is a feature, not a bug. The Framers were right about protections against faction. I’m not sure they understood how badly malicious schemers could deliberately manipulate the system. Things just aren’t getting done, and it is killing people.
      - psunavy03 10mo ago
        Half of the problem with American politics these days is people from blue and red states trying to force the entire country to become one giant blue state or one giant red state. It's too big for one-size-fits-all answers. Every state should be able to largely do its own thing as long as it isn't violating the Bill of Rights.
        matthewdgreen 10mo ago
        If you look at some of the more controversial bills being passed in the states, they're also being more or less lifted out of national political action committees and think tanks. Extreme in-state gerrymandering (supported by national party organizations) has effectively nationalized big parts of state politics in those states.
nneonneo 10mo ago
Canada’s public healthcare system was started in Saskatchewan, one of the provinces, and rapidly copied to other provinces (and later to a federal level): https://www.cma.ca/healthcare-for-real/who-started-canadas-universal-health-care-system https://www.cma.ca/healthcare-for-real/who-started-canadas-u... If one state can manage to make it actually work, it might be enough.

doctorpangloss 10mo ago

There are already numerous and simple policy levers that actually affect costs and cannot be gamed. Such as the age you become eligible for Medicare. You don't have to reach for anything innovative like global hospital budgets. I'm skeptical of your category of reforms - you really mean, "benign-looking administrative decisions," because if you're not making any hard choices, you're not making reforms. I would hardly call it "real efforts."