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The question of state capacity is so crucial to most of the big ticket reform proposals in American health policy.
Reading about the mess that is the Medicare fee schedule, I have a hard time imagining how you'd manage to operate a federal single-payer system in the US without vast improvements in federal administrative capabilities.
That's not to say that government can't do health insurance well - it certainly can. We just frequently...don't. And it's not a trivial problem to fix.
Similarly, SSA's failure to effectively manage the SSDI and SSI programs in a manner compatible with work has real implications for implementing any UBI proposal if it has even very modest means testing.
The obvious solution to these problems is to improve state capacity. And we should! But it really needs to occupy a more central place in progressive policymaking relative to big ticket proposals.
Competent administration is so supremely underrated as a policy objective.
Hard to imagine CMS pulling anything like this off:
This cuts both ways, incidentally - lack of state capacity doesn't just make it harder to implement big ticket progressive programs, it also severely impairs fiddly private sector solutions.
We see this very clearly in Medicaid managed care, which usually only works as well as the capacity of the state Medicaid agency to monitor outcomes and health plan behavior.
It can work well! But it requires actual expertise and careful attention that are often very much not in evidence.
