March 11th, 2017

Think you could do it better?

Did you ever have to try to reform or redesign a real-world program?

When I was in law school, I took a course that focused on the welfare system. We were assigned to read reams of papers detailing all the things that were wrong with welfare, and as you can imagine there were plenty of them.

And then we were given the assignment to design a better system. That was both a humbling and an edifying experience, one I wish everyone could have.

That was only an academic exercise, but many years later I was part of a panel that made recommendations for divorce law reform. We did something similar in terms of process—studied the laws in many states in order to figure out what model might be best for our state. The result was the same: the complexity of the matters involved and the law of unintended consequences kept rearing their ugly little heads. We ended up with something that no one really liked, but it was the best we could do.

And believe me, we were really really trying our best.

It’s easy to sit at home at a keyboard and figure out what we might do if we were in power. No, actually, even that isn’t so easy; for example, I’ve never come up with what I consider a good plan for health care reform, one that I think would actually work well in the real world.

And even if I could, to implement it I’d have to get all those other politicians to agree on it. Good luck with that.

29 Responses to “Think you could do it better?”

  1. Geoffrey Britain Says:

    You’ve described ‘Gordian Knot’ problems. Alexander demonstrated the only way to solve them. You cut through them, letting the chips fall where they may and start over with a fresh start. Knowingly accepting that innocents will be unjustly hurt whatever the reform and because the alternative of doing nothing is ultimately, far worse.
    Gordian Knot situations consist of circumstances where all the choices are bad and no matter what is done, innocents will suffer. Tragedy is part of life and there but for the grace of God, go you and I. And sometimes, through no fault of our own, it turns out to be our turn and it sucks to be us.

    While also understanding that you’re not defeated until you refuse to try to get back up on your feet.

  2. Griffin Says:

    And once you come up with that perfect plan try and get it passed by others that may not agree that you have designed the perfect plan.

    Then try and get reelected by some of the people that came up on the short end of your perfect plan.

    What a horrible job.

  3. Ben David Says:

    There is no need to design a replacement system.
    Repeal both Obamacare and the WWII-era laws that linked health insurance to employment.

    Then sit back and let the free market find a range of solutions at various price points.

    The only federal legislation required is a bill guaranteeing competition across state lines.

  4. Irv Says:

    The problem comes from from mixing healthcare with welfare. These must be treated separately. A fair and efficient healthcare system has the most free choice with the least government interference.
    The states can help the people on welfare buy their own or put them into high risk pools supported by the state. The state could even tax people to cover the cost of a high deductible catastrophic policy for everyone. No one law or system can do both.

  5. neo-neocon Says:

    Ben David:

    I think you are dreaming.

    Americans will not tolerate it if that many people cannot afford health care, which is what would occur. And what of all the laws that say hospitals must treat?

    It’s not 1950, when health care was relatively simple and most people didn’t need insurance. People no longer accept that the poor will suffer and/or die from diseases that are quite treatable.

  6. Ymarsakar Says:

    It is better to use somebody else’s existing system than trying to reform a corrupt Deep State owned system. Flat taxes, for example, exist in some organizations. They do not, however, exist in the US layers of government for a reason.

  7. CW Says:

    >>”Think you could do it better?”

    Better as defined by whom? Yes, I think I could do it better in the sense that it would be righter (i.e. more in keeping with the Constitutional intent of limited federal government), but it would not be better in the sense of pleasing everyone. If you want to do it right, which I would define as getting the federal gov’t out of the business of ensuring that people have healthcare, you have to go in with the understanding that a lot of people are going to be unhappy, at least initially. Notice how the Democrats have less of a problem pushing their agenda through? That’s because they don’t worry over the prospect of making Republicans unhappy. They figure we’ll get over it once we adjust to the new normal. Republicans could borrow a page from that book right now. The sooner we rip this Band-Aid off the better, so that we speed up the process of people realizing that personal responsibility and the free market and the normalcy this restores aren’t such bad things after all.

  8. Geoffrey Britain Says:

    Despite favoring Ben David’s approach, I too think that he’s dreaming. As I agree that it is a politically impracticable solution with today’s electorate. The simple truth is that no solution is acceptable to a consensus of opinion. So we will continue to stumble toward socialized medicine and far more will suffer ever poorer health care, evidenced by the debacle that is the UK.’s healthcare and at some point, the aged will be subject to secret death panels. But we will have our “equal sharing of misery”. While civilizational progress will wither as the tentacles of quota derived equality spread ever deeper.

    In a democracy, an ignorant electorate will always self-destruct.

    Some will respond that we have a republic, ignoring the consequence of having the erasure of the American republic now being the core agenda of the democrat party and that, “Socialized medicine is the capstone of the Communist State” Vladimir Lenin

  9. neo-neocon Says:


    Better in terms of meeting the goal of covering as many people as possible with decent coverage for as little expense as possible, and also in terms of actually coming up with something that has a prayer of passing, as well as protecting liberty.

  10. groundhog Says:

    Geoffrey Britain Says:
    March 11th, 2017 at 4:01 pm
    You’ve described ‘Gordian Knot’ problems. Alexander demonstrated the only way to solve them. You cut through them, letting the chips fall where they may and start over with a fresh start. Knowingly accepting that innocents will be unjustly hurt whatever the reform and because the alternative of doing nothing is ultimately, far worse.

    Imagine dropping the entire tax cod?

    Repeal and replace.

  11. groundhog Says:


  12. CW Says:


    >>“… as many people as possible…”

    Does that include people who should be capable of doing what’s necessary to obtain coverage on their own but who choose to use their time and resources on other things knowing that the gov’t will assume the responsibility of taking care of their needs?

  13. Fred Says:

    plan for health care reform
    Two days ago I was invited to Alumni, one of the recipients was a doctor who awarded for his work with kids health especially in poor area/families, partnering with the schools.

    He put it in a very simple way how things work with the new technology.
    At school, there are few medical sensors/ tools to exam the sick kid/s, these tools send data to a medical centre from there that data shared worldwide. as he continue his example in two mints the local data center pick this matter and posted, further two mint some one respond to the problem and send his medication, later one spencer the medication cost and sent the medicine to a pharmacy 500m near the school!

    So this showed how fast and effectiveness of this system and tool which took under 10min to achieve the result.

  14. parker Says:

    IMO health care is not a right, along with things like equal results for unequal talents and efforts. However, few wish to see the poor go without basic health care, including me. Let the laboratories of the States experiment. Sooner or later what works best in a particular State in terms of best access and affordability will either happen or it will not. Failure is opportunity to to try, try again.

    Nothing government creates is ever perfect, often it is in the exact opposite. Get the feds out of the process and chances for something imperfectly more beneficial increases dramatically.

  15. Cornflour Says:

    In a comment to another recent post, by Neo, on the GOP healthcare insurance bill, I said that I’m a defeatist on healthcare reform. Sadly, in the last week or so, nothing’s happened to change my mind; but I’ve long hoped for a complete repeal followed by a new decentralized program that emphasized high risk pools, catastrophic coverage, and health savings accounts.

    Given that, I was happy to read Irv’s comment (March 11th, 2017 at 4:18 pm). Just wish there were a few hundred million more who felt the same way.

  16. Big Maq Says:

    “It’s easy to sit at home at a keyboard and figure out what we might do if we were in power.” – Neo


    Why I laugh at and simultaneously am annoyed by simpleton phrases like “We just need to ‘Enforce the Law'”.

    We could wish for a world so black and white, but it ain’t so.

    If it were, we’d probably be living on the fictional planet Vulcan.

    WRT MEDICAL INSURANCE (hate calling it “healthcare” or “health insurance”, etc.) there are so many aspects that are regulated by our various governments, that any “solution” will have significant downsides with their political ramifications.

    That said, it was always a problem that the GOP blustered about obamacare without having settled on what they’d do.

    Like Cornflour, rather disappointed. It doesn’t help that trump gave some major statements during his campaign that made it difficult for the GOP to unify in this direction.

  17. Ben David Says:

    responding to criticisms above:

    1. What were all the needy

  18. Ben David Says:

    responding to criticisms above:

    1. What did all the needy people who will be stranded by Obamacare do a few short years ago? People were not dying in the streets.

    They can move (back) temporarily to Medicare and Medicaid until the market provides solutions.

    2. One other way the government can facilitate a baseline of care without creating a behemoth is by specifying a basic basket of services – including hospitalization coverage – and requiring this level of coverage. Kind of like the required component of car insurance. There is no reason hospitals should be required to treat people who have no intention of paying.

    3. Whether you’re rich or poor – things always go more smoothly with money. There is no way to eliminate the gradient in treatment – and nobody has a “right” to health services, which often require lots of expertise and resources.

    4. One major cause of the current problem is employers and government inserting itself between buyer and seller – masking the true cost of things. It’s a version of the “tragedy of the commons”.

    5. The rhetoric of entitlement does not tell the whole story, and has been successfully countered in countries (like Israel) that rescued failing socialist health systems by introducing free market reforms. “Who decides if you *deserve* that hip transplant” etc. Horrific examples from Western European utopias abound.

  19. Sarah Rolph Says:

    Yes, I had a similar experience in college. We were given the assignment of redesigning the cafeteria in any way we wished. We all came up with lots of superficially good ideas with bad unintended consequences. In the debrief it became clear that nobody had done any real thinking about whether change was actually needed. It wasn’t. The best answer would have been to leave things the same — people who knew what they were doing had already thought about the important things, the stuff we ignored. It was a good lesson.

  20. Rich F Says:

    The late great Walt Kelly came up with the following :

    Looking at a dragon, one character says : “you know that story about a camel is a horse created by committee ?”


    “Well, that thing is a CAMEL created by committee !!”

  21. Mark30339 Says:

    My good friend was lecturing me about how great it was that with Obama, his family finally had health insurance. He was shocked to learn that those of us who don’t get subsidized have seen chaos as our choice. If my family loses employer coverage, Obamacare gives us the privilege of paying $12,000 a year to have another $12,000 in deductibles before even starting to have coverage. Robbing from the not rich to give to the poor is not working and people expect a quick, simple fix. Good luck restoring the competitive, reasonable marketplace with pre-existing condition barriers. And good luck with the HOWLING if you kick the poor and the chronically ill back to the curb. I have no idea how to fix it, but at least give middle class people more options to get around the bitter few choices out there.

  22. neo-neocon Says:

    Ben David:

    No, they can’t “move back temporarily to Medicaid and Medicare.” Many of those who can’t afford insurance do not qualify for either. Medicare is only for the elderly, except for a few very specific exceptions such as those with end-stage kidney disease. People who qualify for Medicare qualified for it before Obamacare, during Obamacare, and after Obamacare. It’s irrelevant to the current discussion.

    The Medicaid expansion under Obamacare gave Medicaid to some people who hadn’t had it before, but by no means to all people who can’t afford to pay for their health insurance under the old system. It is also expensive, and federal subsidies to the states are due to end in 2020, and then the proverbial excrement will be hitting the fan. In addition, a lot of people have been given Medicaid in name only, because there are not enough providers who will accept the low payments it involves, so it’s hard to find a doctor who will take them. And you’re suggesting expanding the program? This would take some sort of magic wand.

    In addition, you can say medical care is not a right, but that’s not what most people believe anymore. There is also a law requiring hospitals to treat regardless of ability to pay. Good luck repealing that one.

  23. fiona Says:

    I’ve posted this here before. My county in Florida has two hospital systems North and South supported by property taxes. We pay $.50 per mil, amount set by a board appointed by the Governor for “indigent Care”. With Medicaid, I am not sure who that is, maybe illegals. This ensures that emergency rooms are available county wide. Having worked for the legislature for a time, I know that the hospitals are frequently complaining that people who come in on an emergency basis who are eligible for Medicare under state guidelines don’t have it and have no interest in filling out the paperwork so that the hospital can be reimbursed. After all, what’s in it for them?

  24. n.n Says:

    The goal is to optimize a fitness function with three variables: moral, natural, and personal imperatives, while limiting progressive corruption leading to a dysfunctional convergence (e.g. war, mass abortion, dodo dynasty, involuntary exploitation including slavery).

    Presumably, an adaptive function with conservative changes will discover the optimal outcome, albeit while following a suboptimal but stable path. The limitation is of course chaos. The observation that accuracy is inversely proportional to time and space offsets, established by the limits of natural and enhanced human perception and causality.

    So, we have liberalism which is divergent, progressivism which is monotonic, and conservatism which is [slowly] adaptive.

  25. Tim Turner Says:

    Ideally, the final system would embody these points:

    1. No one should be forced to join an insurance program against their will.
    2. Patients should get a reasonably accurate price estimate, prior to receiving care.
    3. Insurance should share the cost of disaster across the community, not force the community to pay for every minor bruise and scrape of those who are unwilling to provide for themselves.
    4. The patient should always pay a graduated percentage of the cost.
    5. Medical malpractice should provide restitution to the injured, but should not cause doctors to opperate under fear of punishment.
    6. All medical insurance should have the same tax breaks, regardless of whether it is employer-provided.
    7. The government should not artificially restrict competition which will lower prices and improve services.

    The points above would make the system more affordable, but no system will give us all healthcare for free. Funding care for those who can’t afford it should be separated, so it’s role is clear and observable. It shouldn’t be hidden and twisted up the insurance system. It would be preferable to just write a check.

  26. Frog Says:

    Neo worked on designing a welfare system and revising/optimizing divorce law. The problem is likely in the starting-point assumptions.
    Should there be welfare? Run by the government?
    Should divorce be on-demand, no-fault?
    What are the unintended consequences? The foreseeable ones, that is.
    We know the answers now. The first is a fiscal cancer into which trillions have been poured to little beneficial effect from the societal standpoint. The second is progressively leading us into hedonistic moral relativity and societal decay, and I say this as one who has been through two divorces, one I sought and one I didn’t.
    We have shot ourselves in the foot with both, and there is no going back. So much for hubris, a key feature of Progressivism.

    As to “healthcare”, Obamacare and the so-called “American Health Care Act” have little to do with actual health care. The former has sneaky, nasty provisions like The Independent Payment Advisory Board, and the latter is a misnomer for a mandatory health insurance bill that tacitly accepts the Left’s notion that health care is a right to be bestowed on everyone, though it is a GOP bill.
    Let us remember that Medicare also had little to do with actual care in its early years. It was simply a financial product. But it has become a regulatory monster to which all medical advances must be reported if they are to be “approved” for Medicare-determined reimbursement. Medicare sets the “allowable” fees, and pays 80% thereof. The new CPT codebook, an AMA product licensed to Medicare and designed and produced for that client, contains 50,000 service/procedure codes, and a simple error by a clerk in choosing the correct code can through repetition lead to financial disaster by denial of reimbursement for work previously done (no retainers! Lawyers are so lucky).

  27. Big Maq Says:

    @Tim – some really good points.

    Definitely would prefer a very open marketplace, but that won’t happen politically, right now. However, there are steps in that direction that can make a big impact, to pick up on your list…

    Almost wonder if government at all levels should extract themselves entirely from managing any aspect of the medical “insurance” market.

    Might be a whole lot simpler and cheaper to eliminate all those programs and use that SAME money to issue a coupon to every citizen for a pre-defined catastrophic (basic, high deductible – i.e. no obamacare level of coverage) insurance from the provider of their choice (of course, they’d have to accept these coupons to be able to participate in the market).

    And leave it to citizen how much more, if any, insurance they want to purchase above that, and insurance companies free to formulate their offerings as they please beyond that.

    The US is third highest per capita public (government) expenditure on “healthcare” of western nations (OECD). See exhibit 2…

    That kind of money ought to buy a “fat” catastrophic insurance plan, whereas for other countries that amount is the entirety of public and private expenditure p.c., and then some.

    Instead of a “fat” policy for everyone, maybe those excess funds (above a basic catastrophic policy) get used to fund poverty support to help those make some portion of their deductibles, rather than get spread out widely across the population (some of whom “don’t need the help”).

    Agree that there are plenty of barriers to a freer market.

    Artificially restricted competition – e.g. we should be able to freely import the same drug formulations from other countries;
    lower legislative barriers to entry to practice medicine, particularly for “routine” procedures;
    ability to purchase insurance across state lines (national marketplace);
    Automatic FDA approval for drugs approved by two of eight select western nations – we don’t have a monopoly on the smarts, nor the concern for citizen safety;
    etc. (there are plenty of these types of things that could be done to simplify and open the market wider).

    Not sure how we get transparency of pricing, if other barriers to open market remain, without legislation. Seems something along a “no-surprises” commitment to cost of medical services.

    Tort reform to cap runaway juries / judiciaries, but how does one cleanly “draw the line”?

    Replace with the coupon mentioned above / phase out favorable payroll tax treatment for employers – a major distortion of the market – to allow a larger pool for private individual insurance. Employers could still offer additional coverage, as part of their compensation package, but the value is subject to FICA withholding, no different than if employers offered a car allowance.

    Obviously, these all are market interventions of one sort or another, and not all are “fully baked” (as there are many nuanced issues within each to think about and address), but they are probably more “doable” politically than what is a preferred ideal market based solution, and greatly simplifies what we had pre-obamacare, and now have post.

    (looking back – points seem a bit jumbled, but it gets the points across and gotta go)

  28. Big Maq Says:

    @Frog – great points.

    “insurance” is the misnomer, the twist in the language to sell these programs to the public.

    You are right, it is essentially a transfer, much of it being from one of our pockets into the other, with some of the juice filtered out for the benefit of those administering the programs.

    Still, the public needs to be educated and convinced. A good many of those dems who swung trump’s way are far from the free market thinking you seem to be, and I am advocating.

    So, what to do? Given trump has not made a clear case (nor have the GOP, really, other than emphasize the “Repeal!” part), and seemed to prominently indicate those folks would be “taken care of”?

  29. Ben338 Says:

    My own idea for health coverage would be something like this: (1) catastrophic care coverage for basic needs (i.e., what keeps you alive) only, say beginning somewhere like $5,000 in; (2) tax deductible health savings accounts to cover the part out of pocket that isn’t covered by the catastrophic coverage; and (3) too bad for you if you don’t have the health savings account. The catastrophic coverage would be relatively cheap, and the health savings accounts would mean a lot would be paid out of pocket by consumers which would encourage competition, shopping around, and only going to the doctor when necessary. The catastrophic coverage would be mandatory, but you could by from whichever company you wanted, and there would be something like assigned risk auto insurance for the indigent (i.e., insurance companies must take them at whatever premium they can afford to pay, in proportion to market share). Any elective procedures (defined as anything other than what’s necessary to keep the patient alive) would be cash and carry (which would bring the price down).

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.

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