The US healthcare system is a monument to perverse incentives, unintended consequences and political inertia. It is astonishingly bad — indeed, it’s so astonishingly bad that even people who believe it’s bad don’t appreciate quite how bad it is. ... Reforming American healthcare will require an almighty effort. With politics gridlocked and soaking in lobbyist money, it’s not obvious that the US government is capable of running the kind of healthcare system that works elsewhere — even if Congress decides to try. But try it must, because the status quo is a tragedy. US healthcare is literally killing people, Tim Harford, Financial Times, 13 JulyIt's not just healthcare. Our political systems are comprised of, and help to sustain, institutions of all kinds that start out as well intended but, almost inevitably, become fossilised. They invest too much, emotionally and financially, in ways of doing things that might have been efficient at one point, but then become outdated as society and technology change. Eventually their overarching raison d'etre becomes that of self perpetuation. They become adept at resisting threats to their survival. In the private sector competition is supposed to keep businesses on their toes, but too often the smaller enterprises are smothered by big business which, with its pals in government, regulates them out of existence. Nevertheless, there are still parts of the private sector where competition does its work, and creative destruction goes on.
It's much worse in the public sector or, rather, in the provision of social and environmental services, where people have much less information and power than service providers (healthcare) or where competition otherwise cannot operate effectively. The vested interests are government bodies, trade unions, big companies or, more and more these days, NGOs and charities. All have entrenched hierarchies and ways of doing things, and tend to resist changes that threaten their existence. So we get monstrosities like US healthcare, or the EU's Common Agricultural Policy, both of whose corrupt lunacies have been well documented for decades but about which little of significance has been done.
Social Policy Bonds might be the answer. They would inject competition into the solution of our social and environmental problems. They would lead to the creation of new sorts of organisation, comprising protean coalitions whose every activity would be aimed at achieving society's goals with maximum efficiency. They would have incentives to ensure inefficient approaches would be terminated - not, as nowadays, bailed out with eye-watering sums of taxpayers' money in order to save the face of their instigators.
To focus on health specifically: we need to reward the achievement of successful health outcomes, which, for a country, should be a combination of variables, each of which will have to fall into a specified range before the targeted outcome can be deemed achieved. The variables would be likely to include: longevity, Quality Adjusted Life Years, infant mortality and other objective data. Consider how far removed are the incentives in current healthcare systems - not only in the US - from rewarding good health. Today's incentives are, essentially, to screen, test and intervene - whether or not the intervening does any good at all. There's more about the application of the Social Policy Bond concept to health here.
More generally, a bond regime would undermine the powerful institutions in the public- or private sector, whose existence is predicated on blocking reform. To give these bodies time to reform, and to shift their goal from self-perpetuation to serving the public, the bonds could be phased in over time, as I describe in chapter 4 of my book (all chapters downloadable free of charge here). Social Policy Bonds, at first sight, seem a radical, even zany, approach to the solution of the problems that we face. The question, though, is whether there's anything better. In health, the environment, nuclear proliferation, violence in poor countries, to take obvious examples, the challenges are huge and urgent, and it would doubtless be difficult to overcome the obstacles to progress. But, as Mr Harford would say: try we must, because the status quo is a tragedy.