David Brooks in the NYT today promotes Stuart Butler's plan for reforming the health insurance system. Skepticism is advised, on political grounds. The principle political obstacle holding back an efficient and fair benefit system is public fragmentation. Some of us get most benefits from the government- some of us get them from the private sector (with help from the government that often goes unrecognized). And most people don't want to lose what they have, even if it might be for a better deal later on. This system is both unequal and inefficient. It creates smaller risk pools and prevents effective management of a dysfunctional health market. It distributes bigger benefits to higher paid workers, and fewer to low-paid workers. An increasing number of people are being left out of the system entirely. But what Butler and Brooks have in mind is a further fragmentation of the public. They envision a system of many small "insurance exchanges" managed by different private social groups. While the proposal might have merits, it would serve to divide up the benefit system even further, and hinder reform later on. One can easily imagine that some exchanges will offer better benefits than others- that some people will like the system, and some won't- but that the people who like the system will defend it and keep anything better from taking shape, just like what we have today. It might be refreshing to see conservatives recognize and meet the need for an expanded benefit system, and one where the public is playing a larger role than handing out tax breaks. But in the long-term, proposals like theirs will only make the benefit system more unequal and inefficient (a cynic might say that was the plan all along). What's really needed is a plan to move us away, in incremental steps, from a decentralized system and fragmented public. (For more on this dynamic, check out the book The Divided Welfare State)