I don't want a public option. I want three or four of them. I've suffered under the byzantine bureaucracy of a dozen or more private insurance companies. But I'm a realist, and know there's no guarantee that a single public plan will always be well managed. So why not create three or four of them, and let us switch at will? That way if one atrophies into mismanagement, customers are free to flee—and it will have to reform itself or be reconstituted from scratch.
Forgive this tangent when we're all supposed to be focused on just getting ANY public option passed. But this is worth some thought, because what will we do if a single public option gets off to a poor start? Plus, this is a model for general economic progress. Our for-profit economic system has reached its limits. The health insurance industry is just one of the best examples of that: it has produced enormous profits, but has failed to produce the promised socially desirable byproducts of affordable and hassle-free coverage. If we can solve the health care problem with a better way of organizing labor and capital, then we can try rolling the innovation out to other dysfunctional industries—for example, energy. How will we know if our new system works better than the old? Our public plans will have to compete right alongside the private ones. May the best plan(s) win.
|Insurance companies are sending emails to their customers warning against "government run health care plans." (I got one the other day.) I don't want a "government run" plan either. It's not that "government run" can't also mean well run—it can. Medicare is a good system. The V.A. system is great, actually. But those systems were set up in a different era. Today—and again, forgive me for being realistic—the U.S. government's management culture is so demoralized that a new agency run out of one of those big square buildings in DC is likely to be as dysfunctional as, say, Homeland Security. But I'll take an independent organization that's overseen by managers appointed by our elected officials. In other words, I'd love a health plan that's as well run as the U.S. Post Office or the Marine Corps.
But why put all our eggs in one basket? Economy of scale isn't a good reason, because even if we have four public plans, each will still be larger than the health systems of most European countries.
We'll have fun with this. It will be like sports. Maybe we can throw a subsidy to ESPN to follow the hot competition between the plans. Every year we'll throw a big awards ceremony. C-SPAN will televise it, and millions of odd people like me will watch it. Managers and workers will deliver acceptance speeches for awards such as Best Customer Service, Most Aggressive Negotiating with Providers, Best Mental Health Care Coverage, Easiest to Understand Plans, etc.... CEOs, managers and workers will be rewarded monetarily, but the honor of winning and the fun of the competition will do more to motivate, as countless psychological studies have shown.
I suspect that part of the reason this option hasn't even been mentioned, is that economic dogmas on both sides of the debate are strong. The private side holds the dogma that private companies will always outperform public companies. We don't need to give this dogma much thought, because its advocates don't even believe it themselves. They're simply making a lot of money in the current "private" system and don't want anyone to mess with their racket.
Meanwhile, on the public side, our thinking takes place in a pretty murky economic worldview. Progressives are equally attracted and repulsed by the economic categories of markets, competition, and profit. On the one hand, there is the faint echo of 20th century textbook socialism that mistakenly identified those categories as the source of all our problems. On the other hand, most progressives have been quietly converted—without even noticing it themselves—to believing that the profit system is the only mechanism we can trust to power our economy, and that the only problem is not policing and regulating markets well enough.
But the truth is that markets, competition and profit (in the sense of monetary rewards for desirable results), are not the problem at all. But neither are they the solution. They are just mechanisms that can be used toward any set of goals. The problem in our current system is that those mechanisms are set up in service of the blind goal of "more profits!" But these kinds of profits are not rewards for desirable results—in fact, they are just as often rewards for socially undesirable results. They are just a brute expansion of capital—whether it's good for anyone or not. This kind of profit, in the case of our health insurance system, has almost no relationship whatsoever to delivering quality care to customers—in fact there are many incentives to deliver the worst care possible. It's a dumb system.
But allowing our public plans to compete in a consumer market for customers would be a great thing. We just don't want them competing for arbitrary profits. We want them to compete with each other to achieve desirable goals, including not only customer satisfaction but also cost control. Their success will be rewarded in our fun award ceremony—and in the pay checks of managers and workers.
Just keep this idea in the back of your minds. We might need it someday soon.