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Describing the health care vouchers plan from Ezekiel Emanuel and Victor Fuchs, Ezra Klein describes a part of the system that's relevant to a lot of other reform proposals:
The con of this proposal is that if you describe it as "decisions made not by elected officials, but by largely unaccountable political appointees" it doesn't sound so good. But if you describe it as "decisions made by appointees insulated from political pressure like the Federal Reserve system" it does sound good. Which is another way of saying that the Federal Reserve system works well, even though it doesn't sound (to me, at least) like something that would work very well.
Unfortunately, I'm not really sure that we as a society have a great grasp on why the Fed does work well. In principle, it's an appealing model that could be applied to various other questions where it seems better to keep congress in more of a supervisory role rather than a direct policymaking one (issues that have a technical dimension or where the geographic nature of congressional constituencies is inappropriate, etc.) but it also holds the potential for disaster. You wouldn't want the Bush FEMA team making these kind of decisions, and you also wouldn't want it to become the locus for constant congressional battles. What you want is something like, well, the Federal Reserve appointments where even Bush has felt obligated to pick people like Ben Bernanke who are genuinely well-qualified and well-respected. What you fear, though, is that this would become a "revolving door" scenario where industry lobbyists go to work as regulators, do favors for industry, and then cash in with cushy jobs once they leave government.
Big decisions within the system are made not by Congress or by insurers, but buy a Federal Reserve-style National Health Board that has, in turn, twelve Regional Health Boards. These commissions, staffed by a variety of experts who're appointed by the president and confirmed by the Senate, will define benefits, carry out research on effectiveness, figure out risk adjustment, and so on (in this, the plan has shades of Tom Daschle's plan).
The con of this proposal is that if you describe it as "decisions made not by elected officials, but by largely unaccountable political appointees" it doesn't sound so good. But if you describe it as "decisions made by appointees insulated from political pressure like the Federal Reserve system" it does sound good. Which is another way of saying that the Federal Reserve system works well, even though it doesn't sound (to me, at least) like something that would work very well.
Unfortunately, I'm not really sure that we as a society have a great grasp on why the Fed does work well. In principle, it's an appealing model that could be applied to various other questions where it seems better to keep congress in more of a supervisory role rather than a direct policymaking one (issues that have a technical dimension or where the geographic nature of congressional constituencies is inappropriate, etc.) but it also holds the potential for disaster. You wouldn't want the Bush FEMA team making these kind of decisions, and you also wouldn't want it to become the locus for constant congressional battles. What you want is something like, well, the Federal Reserve appointments where even Bush has felt obligated to pick people like Ben Bernanke who are genuinely well-qualified and well-respected. What you fear, though, is that this would become a "revolving door" scenario where industry lobbyists go to work as regulators, do favors for industry, and then cash in with cushy jobs once they leave government.
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