Why We Still Need a Strong 'Welfare State'—Even as We Build Local Care Enterprises
A Respectful Response To Michael Shuman’s Powerful Vision For Community-Based Care
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In a recent post on The Main Street Journal, my friend and colleague Michael Shuman posed a compelling challenge: What if we replaced the welfare state with locally owned care enterprises? His vision draws from successful models in the UK, where small-scale “micro-providers” offer trusted, community-rooted services to older adults and others in need. It’s a hopeful, important argument—and one I believe deserves thoughtful engagement.
Michael and I share a deep belief in the power of localism. Where we diverge is on the question of whether these local solutions can—or should—replace national systems of support, what he and others sometimes call the “welfare state.” Below, I offer my reflections on why I believe a robust national safety net remains essential, even as we invest in the vibrant, decentralized models Michael rightly celebrates.
There is much to applaud in Michael’s post. We agree fully and enthusiastically that empowering local care enterprises—especially those structured as social ventures, cooperatives, or nonprofits—can revitalize communities, cut costs, improve quality, and return trust to caregiving. The UK’s micro-provider model is inspiring, and here in the U.S., I believe regulated investment crowdfunding can help fund and scale similar efforts. The opportunity for community ownership, meaningful employment, and dignified care is real and urgent.
Where we part ways is in framing these local solutions as a replacement for the welfare state. The truth is, the British system that makes micro-providers so successful is underpinned by one of the world’s most robust national healthcare systems: the National Health Service. Everyone is covered. That foundation allows local care providers to meet daily needs without the constant fear of someone slipping through the cracks.
Here in the United States, our safety net is far thinner. We lack universal healthcare. Millions remain uninsured or underinsured. Even the best-intentioned local enterprises cannot fill the gaping holes in coverage—holes that are growing wider by the day. As I write this in August 2025, President Trump and a Republican-controlled Congress are actively working to cut federal support for healthcare and social services.
While this provides an impetus for creative solutions, including local care enterprises of the sort Michael advocates for and I support, I hope we don’t support cutting more holes in our national healthcare safety net.
Let’s be honest: the services most needed in moments of crisis—emergency trauma care, cancer treatment, organ transplants, advanced surgeries—simply cannot be delivered by even the best-equipped community clinic. We need a national backstop. A real safety net. Without it, we’re setting up local care entrepreneurs for impossible tasks, and their patients for needless suffering.
In fact, if we truly want to empower local businesses—and I say this as a lifelong entrepreneur—there’s nothing more pro-business than removing the burden of healthcare administration from their plates. When Hillary Clinton proposed a single-payer system in the 1990s, I initially resisted. But I quickly realized that paying a little more in taxes would be far easier than managing insurance plans for my employees. A strong national system wouldn’t stifle entrepreneurship—it would unleash it.
So yes, let’s channel capital into communities. Let’s break Wall Street’s stranglehold on health. Let’s nurture the care economy from the ground up. But let’s not do so by tearing down the very systems that keep people alive when the worst happens. Local and national are not opposites. We need both.
I’m grateful to Michael for raising these vital questions and for continuing to lead the way in thinking about how we care for one another—economically, socially, and practically. His piece deserves thoughtful discussion, and I hope you’ll take time to read it. Then let’s keep the conversation going. What do you think the right balance is between local innovation and national support? I welcome your thoughts.
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Yes, your post makes 100% logical sense on every point.
I especially like the sentence "A strong national system wouldn’t stifle entrepreneurship—it would unleash it."
I feel that those who wish to be rid of national and state services are missing key information and/or guided by a sort of religious-like fundamentalism. Let us, including me, be wary of "holy mantras" of political or tribal beliefs.