If Senate Dems decide to include Carper's version of a public plan as a compromise, there are some positives to it as well as negatives.
First of all, supplying start-up funds and then requiring the public plan to compete, while artificially limiting its pool of customers and not allowing it to peg its rates to Medicare, is a complete nonstarter. An approach like that is doomed to fail.
However, if the pool isn't limited and it's allowed to use Medicare rates, it does offer some interesting possibilities.
For one thing, such a plan may actually pass, and it may even include some of that GOP support the Obama administration seems to so desperately crave. The fact that it plays to states' rights and includes the opportunity for states to opt out takes away some of conservatives' main excuses for opposing a public plan.
Second, what state is going to opt out and leave its people without nonprofit coverage when their neighbors across state lines have access to it? Seeing what someone else has is a powerful motivator.
Third, conservative state legislators who continue to refuse such an option to their populations for no good reason, when others in nearby states have it, will not continue to be state legislators for long. It's one thing to demonize the health care plans of those heathen Canucks or the Marxist French, it's another to try to do it to those of an adjacent state, where friends, neighbors, and local media will tend to counteract the lies.
So, politically, the dynamics of an approach like this could be very interesting.
In operational terms, it's reminiscent of the origins of the Canadian system (again, assuming those artificial restrictions against opening the pool and pegging to Medicare rates aren't followed).
Early on, all kinds of experimentation occurred in the development of the Canadian system, including public subsidization of private insurance in Alberta (Canada's Texas), where Saskatchewan's public plan was derided as "socialized medicine." Other provinces tried other approaches, like limited means-tested public coverage. Health care insurance originally covered just hospital care, and evolved into comprehensive coverage over a number of years.
It took two decades to develop into a system of universal coverage with national standards supported by taxes and grants.
Could such a thing happen in the US as well?
I actually suspect not. Not in two decades. (Though maybe once the last of those with a living memory of the passing of the Civil Rights Act have all died off. Yes, I think race is at the heart of opposition to universal health care in the US.)
Each step of that progress happened because it was enticed to the next step by the offer of 50% federal funding. Not something politically likely any time soon with the federal deficits the US is facing.
One of the largest items in the Canadian federal budget is block grants to the provinces and territories to help pay the costs of their health care programs. With those block grants come a number of strings. The provinces are free to negotiate their own schedule of fees with health care providers and what services and procedures they will cover. But if they decide not to cover services that the federal government specifies they must cover, they could lose all or part of their block grant - a powerful incentive to hew to the federally set national standards as a floor for their own coverage.
The stated goal was to improve the health of the population. US legislators don't talk in those terms. Their prime concerns seem to be the cost of health care and not putting an existing insurance industry out of business.
Maybe having a parliamentary system with publicly financed elections makes politicians more careful to appear responsive to voters and their personal well-being instead of to financial interests.
Also on the positive side of the Carper plan is the allowance for states to form regional alliances, giving them economies of scale and more clout to bargain with health care providers when setting reimbursement fees.
There's something to be said for a decentralized system. It can add experimentation and customization to local needs.
But historically speaking, the state governments inspire little confidence generally that they won't be too corrupt/inept/unmotivated to deliver programs like this without the usual waste, fraud, and abuse.
What would be better would be if the Democratic leadership just promises the Blue Dogs to adjust the rates for Medicare so that there's more parity between rural and urban rates if they'll just vote for the damn public option (the robust version, Medicare plus five percent).
Or better yet, Medicare For All, not that that's on the table.
Because who wants to wait half a lifetime to get the health care system they really want and that they need now?