Obamacare: The End of the Beginning
For the foreseeable future, health care must be the dominant focus of conservative domestic policy.


Avik Roy

Sixty-eight years ago, after a long-sought victory in Egypt that marked a turning point in World War II, Winston Churchill said, “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

In what will be a long and arduous struggle to bring fiscal stability and true reform to our tottering health-care system, partial Republican control of Congress was a necessary first step. But, now, the hard work begins.

The Republican health-care platform, such as it is, is pretty simple: Repeal Obamacare and replace it with incremental, common-sense, politically popular reforms. The GOP’s “Pledge to America” may therefore have been an appropriate platform for a midterm election. However, the document barely begins to address the profound and difficult issues that any serious government must. Indeed, if the early signals are any indication, the troubling reality is that the Republican health-care agenda for 2011 and 2012 may actually make it harder to repeal Obamacare in 2013, and thereby harder to achieve conservatives’ long-term goal of a humane, efficient, and fiscally sustainable health-care system.

The best way to grasp the enormous difficulties ahead is to work backwards.

Runaway growth in government spending is America’s biggest fiscal problem today. Growth in Medicare and Medicaid spending, in turn, accounts for nearly all the projected future growth in government outlays relative to GDP. If the principal domestic-policy goal of conservatives is to restore the country to a truly limited government that can live within its means, we can achieve that goal only through serious and thoughtful reform of health-care entitlements.

That is to say: For the foreseeable future, health care must become the single dominant focus of conservative domestic policy.

Hence, our first and most important problem is intellectual. Conservatives speak often of repealing and replacing Obamacare. But how many can articulate a conservative vision of what our health-care system should look like? Leading Republican politicians have plenty of detailed opinions on a broad range of subjects. But does anyone know what John Boehner’s vision is for the future of American health care? How about the main contenders for the 2012 Republican presidential nomination? To ask the question is to answer it.

It should be said that, within the diminutive circle of conservative health-policy wonks, there is a fair amount of agreement as to where we should go. But translating that wonkery into plain English isn’t easy.

Among less specialized conservatives, a common refrain is, “I’m not clear on the details, but that Paul Ryan sounds like he knows what he’s talking about.” And Rep. Paul Ryan’s plan is indeed a solid start. But unless other Republican leaders fully immerse themselves in health-care policy, they will be able neither to articulate the core principles of free-market health care, nor to address new issues as they arise, nor to persuade American voters that they should be trusted to enact far-reaching reforms.

The core health-care principles that Republicans should embrace can be summarized in three words: freedom, security, and innovation.

First, the conservative vision must, out of both principle and pragmatism, hold that the best health-care system is one that trusts individuals to make the choices that are best for them and their families. The liberal view of health care is the opposite: that individuals are neither knowledgeable enough nor wise enough to make health-care decisions for themselves; instead, these decisions are best left to unelected government experts.