When I first took a look at the list of projects in Chicago’s 49th Ward’s Participatory Budgeting experiment, I was a little disappointed. Participatory Budgeting sounds so lofty: We the People choosing directly. And yes, some of the items folks get to vote for are pretty cool, like art projects or community gardens. But most of the voting choices are for mundane items like potholes and speed humps.

But then I thought about the nasty pothole I try to avoid while getting on the freeway ramp to work (unfortunately, public transit to my latest job is dismal). Almost every freakin’ day it gets on my nerves. So do the drivers who, in an effort to spare their axles, make incredibly stupid, last-minute maneuvers. If I had the chance to rid myself of that jarring irritation at the start of every day, I’d vote that sucker off the asphalt island in a second.

And knowing that I and my neighbors had the power to make that call? I’m ashamed to admit, it would mean more to me than getting to vote for my city council rep. Except when my Councilperson does something really awful, I don’t pay that much attention. I know, bad, bad me. But I’ve only got so many minutes and brain cells to spend every day, and DC’s city government feels like the weather — there’s not much you can do about it but complain. It feels too far away, too removed from my daily life. And the amount of work it would take to have a real impact feels overwhelming.

But voting on that pothole? It feels real — a victory in the daily battle against life’s small irritations.

Similarly, I’m sure my city council rep has voted to create a community garden or two in our district. But if I were the one doing the voting — and therefore meeting my neighbors who were pitching it — I’d feel a real sense of ownership. If my neighbors’ and my votes gave the green light to that community garden, I’d check it out once in a while to see the results of our small exercise of power. Even if I never put seeds into the earth, I could look at it and say, I did that.

In turn, that small exercise the power might change the way I think about DC’s government. The $1.3 million budget I’d vote for is a drop in the city’s bucket. But if I had a real say over it, I might start paying more attention to where the rest of my city tax dollars were going. And now that my neighbors and I had taken smaller actions together, taking action together on a slightly bigger stage might not feel so overwhelming.

What does this have to do with healthcare reform? Polls have consistently shown that one of the biggest long-term obstacles to reform is that most folks don’t trust the federal government. They may vote for their senator and for Obama or McCain, but they don’t believe they’ll have a real say or that their needs will get met. We can probably get out of this mess by delivering more victories like the half-asked-but-way-better-than-status-quo healthcare bill. But taking small steps that hand back direct power, even if it’s just over potholes, could also make a real difference.

For example, one of the most important players in the fight for high quality health care for all that doesn’t bankrupt us is Medicare. Medicare solicits lots of “community input” through public hearings, etc. Right now, Big Pharma and other big players still win hands down because the rest of us are checked out. But if more folks had a real say over their community’s potholes, progresses might convince them it’s worth fighting to give everybody a real say over their community’s medical procedures. Even in small doses, hope can do amazing things to the body politic.

Maybe potholes and speed comps aren’t so mundane after all.

If you’re a moderate or conservative, what do you get if you stop pretending that the massive government intervention into healthcare you’re promoting is a “free market” solution? You can build a pro-private sector health insurance system that actually works. Here’s how they do it in the Netherlands:

Health care in the Netherlands is financed by a dual system. Long-term treatments, especially those which involve (semi-)permanent hospitalization, and also disability costs such as wheelchairs, are covered by a a state-run mandatory insurance. This is laid down in the Algemene Wet Bijzondere Ziektekosten (AWBZ, see article in the Dutch Wikipedia), “general law on exceptional healthcare costs” which first came into effect in 1968.

For all regular (short-term) medical treatment, there is a system of obligatory health insurance, with private health insurance companies. These insurance companies are obliged to provide a package with a defined set of insured treatments. For those who would otherwise have insufficient income, an extra government allowance is paid to make sure everyone can pay for their health care insurance….

Funding for all short term health care is 50% from employers, and 45 percent from the insured person and 5% by the government. Children until age 18 are covered for free. Those on low incomes receive compensation to help them pay their insurance. Premiums paid by the insured are about 100 € per month with variation of about 5% between the various competing insurers.

The key to the system is that they take away insurance companies’ incentives to avoid insuring sick people.

Risk variances between funds due to the different risks presented by individual policy holders are compensated through risk equalization and a common risk pool which makes it more attractive for insurers to attract risky clients.

Here’s how risk equalization works:

arranging for a third party to organize a regulatory system of risk-adjusted premium subsidies. The financial transfers are then channeled via a so-called Subsidy Fund. In European countries such as The Netherlands, Belgium, Germany and Switzerland the Subsidy Fund is run by a government agency which assesses risks for individual policy holders.

Personally, I’d still prefer a single-payer system — it seems like a much simpler, straightforward way of providing affordable, high-quality healthcare insurance. But if you want a major role for the private sector, this approach seems like a very smart way to go.

documents obtained by the House Committee on Energy and Commerce… show, for instance, that one Blue Cross employee earned a perfect score of “5″ for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

WellPoint’s Blue Cross of California subsidiary and two other insurers saved more than $300 million in medical claims by canceling more than 20,000 sick policyholders over a five-year period, the House committee said.