“Drain commissioner! What the heck is a drain commissioner? And why do the drains need a commissioner?”
I had recently moved to a rural county in the United States to work as a physical therapist, and as I read through the advertisements in the local paper for electoral offices, this one particularly intrigued me.
As a young boy growing up in India, I remember electoral politics being an ever-present topic of discussion at home. So, I was interested in what was going on during the election season in my newly adopted country.
Elections, in India, focus on electing a Member of Parliament (MP) for the National Parliament and a Member of Legislative Assembly (MLA) for the State Legislature. The MPs and MLAs, from the majority party, then appoint a national and a state cabinet, respectively. The cabinet is made up of ministers responsible for specific tasks like irrigation, health and roads. These ministers then oversee various bureaucrats in their departments. It is these unelected bureaucrats that make a majority of the decisions affecting the day-to-day running of the government.
In comparison, democracy in the United States is more direct. Even a very basic government function like maintaining and developing surface drains is carried out by an elected official and not by a civil service appointee from Lansing or Washington.
When I moved to America, one of the questions that burned at the back of my mind was why the United States had been such a success at being a democracy and India had not. People expect their roads to be drivable, their police and fire to respond to 911 calls, their judges to decide, their schools to teach, and soon. The common denominator? The basic services that are needed to work do work the majority of the time.
As I grew older, observed and read more, I noticed a glaring exception—the US health care system.
One might say that it works for those who are fortunate enough to have resources to pay for it, but that would not be entirely true. Yes, if you have good health insurance you are more likely to receive interventions of some kind, but that does not mean that those are the interventions that you will benefit from or that you even need. There is plenty of solid published evidence speaking against the overutilization of health system resources. Some of us have even observed it as patients.
As for myself, I had dental surgery for removal of my wisdom teeth just last week. Fun, I tell you! The oral surgeon insisted on putting me under sedation although I did not want it. What’s wrong with that, you ask. For one thing, it almost doubles his reimbursement, so he has to work only half the time. Unfortunately, all too often health care choices made for us by providers are guided by financial motives, which means that people with good insurance and the ability to pay get unnecessary services, whereas people without money lack even the most basic care. There is most definitely a problem with our health care delivery in the United States.
This brings me back to this drain commissioner business. As I researched the differences between the parliamentary system of government inherited from the British by India and the system of government here in the United States, one little difference stood out. Here in the United States, elected officials are responsible for specific public functions, while a Member of Parliament (MP) in India, and probably in England, is responsible for everything!
Since MPs are responsible for everything they are, in effect, responsible for nothing. You write to your MP, or his or her state equivalent — your Member of Legislative Assembly — if your public hospital is not working right, your cops are corrupt, your roads are bad, or if you are afraid that the neighboring country is about to attack you. It’s not that there is not an official responsible for roads, or police, or hospitals, because there is. However, they are unelected and, thus, in many ways unaccountable. I found this difference very refreshing about the United States. If your roads aren’t working, you could vote out the road commissioner. Too many murders and thefts? Lets throw out the sheriff. Too much flooding in the fields? Drain commissioner, out you go.
And this brings me back health care in this country. There is still talk of a system like the British National Health Service (NHS) being implemented in this country. Currently the political winds are against anything like it, but if Affordable Care Act (ACA) fails to contain growing costs, you and I might end up spending a majority of our professional lives under something similar to the NHS.
What’s wrong with that, you say. After all, it is health care for all, evidence-based medicine, lower cost and less unnecessary care. I completely agree with you on those points, but I think we can do better. A country like the United States, with its vast size and rich diversity, might not be the optimum environment for a top-down system like the NHS.
The other big gorilla on the table in the United States is accountability. Are you going to hold your member of Congress accountable on the running of this health care system, or for the vote they cast in getting involved in an overseas war? Where is the local accountability? Even if the system as a whole runs decently well, are the hospitals and clinics in your county or city a dump?
I pose a reasonable solution for all the above problems. In a country like the United States where the judges, university regents, public prosecutors, sheriffs and other public officials are elected to carry out a specific task, maybe, just maybe, we could have an elected county, city or state physician.
Better yet, we could have a board with an allotted number of physician and public members. This board would run the health care system in the county or the city, under regulations drafted by the state and the federal governments. Its financing could come from a combination of federal and state funds and maybe even local taxes. Its mandate would be to provide equitable, evidence-based care to all the residents of the locality.
If it doesn’t do its job, the beauty of the United States governmental system may be carried out: just as the drain commissioner gets voted out, out with the board!