Tuesday, September 18, 2012

The Way to Implement State Variation

The PPACA healthcare regs (aka, Obamacare)  generally give a lot of leeway for states to "do their own thing". I understand why this was probably necessary, politically, to get anything passed, but it sure is inefficient.

In purely clinical terms, I think the United States is so homogeneous that there is negligible justification for variation. What is going to be different--cover frostbite in Minnesota? Sunburn in Florida? Our diseases are not very particular to geographic regions. So any justification for variation is likely to be based not on local idiosyncrasies and "facts on the ground", but rather on local politics.

One oft-repeated justification for delegating power, and incurring the variation that comes with it, is that the states serve as "the laboratories of democracy".  I think I get that, and generally I support anything that leads to rational experimentation and improvement. But I can't help wondering if "the juice is worth the squeeze" here.

I have an idea for a compromise. Instead of a free-for-all, where every state has great latitude to alter the baseline, require that 5 states band together to define a common variant. One advantage is that it reduces the max number of variants from 50 to 10. But a much more important effect is that by requiring some broad consensus, this arrangement (hopefully) eliminates meaningless variation and catering to special interests.

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