You seem to have overlooked the example I provided of the UK’s National Health Service, which in fact is highly decentralized. Yes, it’s a big world, with a lot of people in it. My own state alone, California, has 40 million people, so its government is sizable, but we also devolve a great deal of political power to the counties, and they to cities. Since you seemed to refer approvingly to our federal system, I’m guessing you agree that this is the best way we’ve figured out so far to keep government responsible and as efficient as we can.
But of course governments, like all organizations, can become bloated and inefficient, and of course we should resist that. Conversely, governments, just like companies, can be hobbled by over-zealous cost-cutting that leaves them understaffed and inefficient.
Debating just how to solve any particular problem efficiently is worthwhile and necessary, but I don’t think that such debate is well served by making dogmatic pronouncements like “there is one thing for certain, government is not efficient at running ANYTHING.”
For the many millions of Americans who purchase their health insurance from Health Maintenance Organizations, those days are already here. If you’re insured by an HMO, you can be assured that an administrator who has no medical training whatsoever will be making critical decisions about your medical care, e.g. what tests, treatments, and procedures you’re entitled to receive. What’s more, that administrator might work two or three thousand miles away.
So given the choice, whom would you rather have making those critical health decisions: a bureaucrat who is ultimately responsible to your elected government, or an administrator who is ultimately responsible only to his company’s shareholders?
Elected governments, who are ultimately responsible to their electors, take care of their bureaucracies.
They don’t always do a terribly good job of it. Sometimes they allow the bureaucracy to balloon; sometimes they kneecap it so that it can’t do its job efficiently (perhaps leading people like you conclude that “government is not efficient at running ANYTHING.”)
But at least
you have a chance to influence your bureaucracy through the exercise of your democratic political power. Unless you hold shares in your HMO, you have
no chance to influence their decisions except through government regulation.
Even if you do own shares in your HMO, in the US every publicly-traded company has a fiduciary responsibility
under law to maximize the return on its shareholders’ investment. Ultimately, every critical decision your HMO administrator makes boils down to just one question: which standard of patient care will make the most money for the health insurance company?
In the US, at least in theory, the federal government was constituted expressly
…to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity…
In contrast, for-profit companies are constituted for the express purpose of making money for their shareholders. If a for-profit company is providing your health care (and almost all health care in the US is now for profit), your welfare is ultimately of interest to them only insofar as it serves their profit.
That is the very heart and soul of our capitalist system, and for some things it works great! (I can’t imagine that a government department would have done a better job of developing personal computer hardware and software than did Apple, for example.) But I do think there are some things that could be done more efficiently by cutting out the profit motive, and health care is one of them.
(And efficiency aside, I also think there are some things that are worth doing even if their
cost-effectiveness can’t easily be measured, such as education—which I agree is a mess in this country, patronage of the arts, scientific research, space exploration, and yes, even just taking care of our neighbors, because that’s what decent people do for each other. Who can best do those things? That’s a discussion well worth having, but for-profit companies aren’t always the answer.)
Yes, and I said “more efficiently” precisely because I was taking exception to your dogmatic pronouncement that “government is not efficient at running ANYTHING.” I thought it was understood that the goal of the space race was to beat the Soviets to the moon, and that it didn’t need to be explicitly stated. Apparently I was mistaken, so l’ll withdraw my question and rephrase it:
Do you really think that any private company, or even consortium of companies, would have gotten us to the moon
before the Soviets more efficiently than the NASA of the 1960s?
That’s as may be, but it might be worth mentioning that the Manhattan Project was not the most expensive of the Second World War. The project to develop and produce the
B-29 bomber was even more expensive, costing ~50% more of the public’s money than the Manhattan Project, and it was run by Boeing, a for-profit, privately owned company.
