这篇讲座探讨了美国K-12教育和医疗保健领域所面临的挑战，强调了财政联邦制和路径依赖所带来的复杂性。讲座首先回顾了之前关于不安全感、全民基本收入、最低工资、劳动所得税抵免和全民调整援助的讨论，将它们置于政治现实的框架下，视为受政治现实塑造的政策建议。 讲者将缺乏政治可行性的政策构想（例如皮凯蒂的全球财富税）与在缺乏健全政策情况下却具有政治效力的行动进行对比，并以次贷危机为例说明后者。他强调，有效的政策需要一个精心设计的计划和一个在政治上可行的策略。 随后，讲座深入探讨了在美国实施大规模社会政策的困难，尤其是在教育和医疗保健领域，这主要是由于联邦体系的权力分散性质。讲座提到，权力分散在联邦、州和地方政府之间，导致协调一致、产生重大影响的变革变得困难。 讲者以戴尔·鲁萨科夫（Dale Russakoff）关于新泽西州纽瓦克教育改革的书籍《奖品》（The Prize）为例，进行案例研究。这项由克里斯·克里斯蒂（Chris Christie）、科里·布克（Cory Booker）和马克·扎克伯格（Mark Zuckerberg）等人支持，向纽瓦克市陷入困境的公立学校注入2亿美元的尝试，被认为是可预见的失败。该尝试是自上而下的，缺乏社区的支持，并且未能解决该市学校系统内的系统性问题。这一失败与改善学生基本需求和家庭环境没有得到满足时改善教育成果的内在挑战有关。讲座还谈到了围绕特许学校的争议，特许学校可能会通过创造一种“救生艇”效应，使一些学生受益，而将另一些学生留在资金不足的学校中，从而加剧不平等。 讲座将务实的本地解决方案与失败的全国性努力（例如1965年的《中小学教育法》和《不让一个孩子掉队》计划）进行对比，突出了它们的缺点以及它们所遇到的政治阻力。讲者指出，美国教育体系的分散式和本地资助结构，使得全面改革缺乏动力，尤其对于那些身处拥有优质学校的富裕地区的人们来说。 在转到医疗保健领域时，讲座指出，与其他发达民主国家相比，美国制度的独特之处在于缺乏全民覆盖和以雇主为基础的保险制度。以雇主为基础的制度起源于二战期间的工资管制，并随着时间的推移而根深蒂固。讲者指出，医疗保险（Medicare）在全民医疗保险的联盟中造成了裂痕，因为老年人已经获得了医疗保障。 讲座接着讨论了奥巴马政府通过《平价医疗法案》（ACA）改革医疗保健的努力。尽管《平价医疗法案》将医疗保险覆盖范围扩大到2000万人，但它受到了政治和结构性挑战的困扰。一个关键的挑战是控制成本，但政府决定不同时与大型制药公司（药品价格）和保险业（公共选择）作斗争。约瑟夫·利伯曼（Joseph Lieberman）因康涅狄格州拥有庞大的保险业而反对公共选择，导致其从法案中移除。 对《平价医疗法案》的挑战在法庭上持续不断，最高法院维持了个人强制保险作为一项税收，但也驳回了联邦政府强制各州扩大医疗补助（Medicaid）的能力。特朗普政府随后废除了个人强制保险，进一步破坏了该体系的稳定。 最后，讲座提出了一种潜在的自下而上的医疗保险扩张方案，首先允许26至30岁的人购买医疗保险，然后随着时间的推移逐步扩大资格范围。这种方法将建立一个支持全民覆盖的政治联盟，并避免与“全民医保”等更激进的提案相关的“价格冲击”。通过采取分阶段的方法，这项政策更有可能成为一项可行且在政治上实用的政策。

This lecture addresses the challenges of K-12 education and healthcare in the US, highlighting the complexities arising from fiscal federalism and path dependence. The lecture starts with a review of previous discussions on insecurity, universal basic income, minimum wage, earned income tax credits, and universal adjustment assistance, framing them as policy proposals shaped by political realities. The lecturer contrasts policy ideas that lack political viability, such as Piketty's global wealth tax, with politically effective actions that lack sound policy, citing the subprime mortgage crisis as an example. He emphasizes that effective policy requires both a well-designed plan and a politically feasible strategy. The lecture then delves into the difficulties of implementing large-scale social policies in the US, particularly in education and healthcare, due to the decentralized nature of the federal system. It's mentioned how power is distributed among federal, state, and local governments, making coordinated, impactful change difficult. The lecturer uses Dale Russakoff's book, "The Prize," on educational reform in Newark, New Jersey, as a case study. The attempt to inject $200 million into Newark's failing public schools, backed by figures like Chris Christie, Cory Booker, and Mark Zuckerberg, is characterized as a predictable failure. The effort was top-down, lacked community buy-in, and failed to address the systemic problems within the city's school system. This failure is linked to the inherent challenges of improving educational outcomes when students' basic needs and home environments are not addressed. It also touches on the controversy surrounding charter schools, which can exacerbate inequalities by creating a "lifeboat" effect, benefiting some students while leaving others behind in underfunded schools. The lecture contrasts pragmatic local solutions with the failed national efforts, like the Elementary and Secondary Education Act of 1965 and the No Child Left Behind program, highlighting their shortcomings and the political resistance they encountered. The speaker points out that the American education system's decentralized and locally funded structure creates little incentive for comprehensive reform, particularly for those in affluent areas with good schools. Shifting to healthcare, the lecture identifies the lack of universal coverage and the employer-based insurance system as unique features of the US system compared to other advanced democracies. The employer-based system originated during World War II due to wage controls, becoming entrenched over time. The lecturer notes that Medicare created a fissure in the coalition for universal health insurance, as the elderly already had coverage. The lecture then discusses the Obama administration's efforts to reform healthcare through the Affordable Care Act (ACA). Though the ACA expanded coverage to 20 million people, it was plagued by political and structural challenges. A key challenge was controlling costs, but the administration decided against fighting both big pharma (drug prices) and the insurance industry (public option) simultaneously. Joseph Lieberman's opposition to the public option, due to Connecticut's large insurance industry, led to its removal from the bill. Challenges to the ACA continued in the courts, with the Supreme Court upholding the individual mandate as a tax but also striking down the federal government's ability to coerce states into expanding Medicaid. The Trump administration's subsequent repeal of the individual mandate further destabilized the system. Finally, the lecture proposes a potential bottom-up Medicare expansion, starting by allowing individuals aged 26 to 30 to buy into Medicare, gradually expanding eligibility over time. This approach would build a political coalition in support of universal coverage and avoid the "sticker shock" associated with more radical proposals like Medicare for All. By taking a phased approach, this policy has a better chance of becoming a viable and politically serviceable policy.