One of the main problems with monopoly-based systems of governance around the world is that they’re set up around a zero-sum fight for political power, either fighting for some plurality of votes or fighting for the place of absolute ruler, with the resulting decisions made affecting everyone who lives within the government’s territory. In New Hampshire, like much of the U.S., there is effectively a two-party system controlling state politics (despite people without a formal party affiliation outnumbering either major party in the state). Even if there were proportional representation with more than two parties, the problem remains: whatever decisions the representatives make at the end of the day, everyone who resides in the state has to live with them.
Some government services are necessarily place-based, such as maintaining roads and utilities, or caring for parks and wildlife, and thus not only prone to monopoly but are perhaps best provided as a democratically governed monopoly. For these services it’s reasonable to expect the people living in these places and using these resources to take responsibility for them and live with the decisions of the local governance system. Other government services however, such as certain regulations, education, and social services aren’t dependent on where you live. These services could be offered on an a la carte, opt-in basis no matter where you live, provided by a market of different service providers. Instead of having to move to a new school district, for example, parents who want better quality education for their kids could opt-in to a different school or education system. Instead of having to move to a new jurisdiction with a different set of regulations, businesses and customers who prefer stricter or more lenient rules could opt-in to different regulatory systems.
This already happens today, to some degree. For example the rules that riders and drivers in on-demand ride services opt-in to are different depending on the app they are using. Similarly, buyers and sellers participating in different online marketplaces are following different rules depending on the marketplace they are using. These private jurisdictions and dispute resolution systems are usually designed to be legally binding within the government court system while still providing new, custom rules for participants to follow. A similar market for private governmental services could form around currently-monopolized government services that are not necessarily dependent on the location of the users. People would be able to prioritize and choose the services they want to fund rather than having these decisions made for them by representatives through the political system.
A service that reaches a critical mass of demand will inevitably be provided by entrepreneurs — and not necessarily for-profit — possibly even before the service would be popular enough to tip the political scales in its favor under the current monopoly government system. Services that fall out of favor or become outdated will naturally wind down due to financial or social realities, with no need to convince a room full of politicians when is the right time to end a program. Popular, well-run services will receive the necessary funding and could grow to service other markets where there is demand. There is no reason for a successful team that has built and scaled a popular, well-run service to be confined to a particular geographic area when they could replicate their successes in multiple places like any other business or nonprofit.
So if you get a healthcare provider that you feel really understands your needs and takes care of you well, you can recommend them to family and friends in another part of the provider’s coverage area and they can sign up too. On the flip side, if you feel like your healthcare provider is incompetent or doesn’t truly care about you then you can cancel the service and sign up for a different one. Rather than having one monopoly system that everyone is forced to pay for via taxation — whether or not that system works well for the people it is supposed to serve — multiple systems could work alongside each other to give people maximum choice and the best quality available. In this kind of “system of systems”, known as panarchy or polycentric governance, almost everyone can get almost everything they want.