Ross Douthat, after ruling out the tumbrels for me, concedes the case for gradualism in free-market health-care reform. But he also thinks that I underplay the political merits of making the case for disrupting current health-care arrangements. First, he points out, any reform is going to involve some acceleration of the shift away from employer-provided coverage and therefore we should not engage in a rhetoric that denies this fact or implicitly portrays it as terrible. Second, he thinks Republican politicians need to be jolted out of their attachment to the status quo. Once they embrace the case for free-market reform it will be time to explain that it should be pursued moderately.
I agree that conservative health-care reformers (and, I suppose, other kinds of reformers) should not deny that employer-provided insurance is eroding or portray that erosion as a calamity. Where we may differ is that I would not do a lot of celebrating of that fact, either. I think the right way to think about reform, given the way people get health insurance today and their reasonable concerns about change, is that employer-provided coverage is eroding, that this development presents some problems, but that there are ways of making sure that people will be able to pay for health insurance even as it happens. Since I think that’s the right way to think about reform, that’s also the way I’d recommend talking about it. I’d make the case, that is, in terms of conservative realism rather than libertarian utopianism.
As for change-averse politicians, I think they are more likely to come on board if they see that free-market reform doesn’t have to take the form of a big bang, and if they can sell it to their constituents that way.