Conservatism And Healthcare

I find myself again in agreement with David Frum. It was one thing to oppose greater government involvement in healthcare in 1993. It is another to do so in 2009. There are several reasons for this and it is hard to improve on David's summary of them. The status quo means:

(1) flat-lining wages, (2) exploding Medicaid and Medicare costs and thus immense pressure for future tax increases, (3) small businesses and self-employed individuals priced out of the insurance market, and (4) a lot of uninsured or underinsured people imposing costs on hospitals and local governments. We’ll have entrenched and perpetuated some of the most irrational features of a hugely costly and under-performing system, at the expense of entrepreneurs and risk-takers, exactly the people the Republican party exists to champion.

I'd add the crippling health costs for the private sector - costs that are slowly killing their global competitiveness. But the deepest reason for reform is fiscal. No serious plan to reduce deficits without hugely increasing taxes excludes healthcare savings. There's no way to get from spiraling debt to stable public finances without tackling the exponentially rising costs of healthcare. So this is a fiscally conservative issue.

Instead of pulling a Palin, conservatives should propose real reforms: ending the tax exemption for businesses; medical malpractice reform; an independent body to provide some kind of data on the relative effectiveness of treatments; incentives to reward doctors less for any and all services provided than for health outcomes within clear budgets. This, actually, is not far from the Romney model, as the NYT notes today. Real conservatives should point out that the current proposals are not tough enough on costs - and criticize Obama for that, not for fantasies like a communist takeover or euthanasia program for special needs kids.

The Romney-Obama model will require fiscal boundaries to healthcare provision and this will mean a trade-off that will be hard to postpone much longer. We'll get less innovation, and probably some rationing at some point. But that is already happening - the rationing is done by insurance companies.

One final thing: most Americans do not want people dying in the streets.


If you have guaranteed emergency room care for the uninsured at public expense, you have already effectively socialized medicine. It makes no sense not to bring these people into the insurance system, and to offer less expensive, long-term preventive healthcare. To insist that ideology stand in the way of this piece of compassionate common sense is irresponsible.

I've come to accept that the fiscal and economic costs of the current system, however wonderful it has been for a few decades, simply cannot be sustained much longer. I say that not because I have become a socialist, but because the US is on the brink of the kind of bankruptcy it will be very hard to recover from if we do not tackle its source now. Taking measures to avoid fiscal collapse even greater than today's is a conservative impulse. Letting one sector of the economy destroy the rest of it - and public finances too - is sheer recklessness.

What do you want, GOP? A permanent populist culture-war? Or actual solutions to pressing problems? Let us know when you've matured enough to answer that question.

2006-2011 archives for The Daily Dish, featuring Andrew Sullivan

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