As I sit down to write this post we are within 24 hours of the start of the implementation of a law that generations of Americans have fought for or against—in one form or another—for at least a century: the nationalization of the health care industry through comprehensive national regulation and mandates. I know that what I am about to write will please none of my friends and allies, and it will be misconstrued by friends and foes alike. But sometimes somebody has to “break the ice” and begin talking about issues in different ways and with different perspectives.
Such is the problem with the Buckley Approach, which even William F. Buckley, Jr., acknowledged: it is merely a last-ditch, temporary approach to public policy that stalls a bad policy until a better idea or approach can be found. Saying “stop” as a means to control the debate over public policy, like the use of a stop sign or a stop light to control traffic, simply is not a permanent solution, and eventually becomes irrelevant—the traffic eventually moves forward and so does the public debate. Saying “stop” is only effective to change the trajectory of policy, if it slows us long enough for us to see and adopt a different course forward. This has not happened in the health care debate because conservatives have not vigorously offered a different, effective course forward. Yes, we’ve talked among ourselves about all the ideas we’ve had over the last generation, but we have made no serious effort to present a different plan to the American people while we’ve tried to stop this train from leaving the station. So, inevitably, the public has moved forward down the only track it’s been given, and Obamacare will become law—and the odds are that it will remain the law of the land for decades to come and lead us toward a European-style single-payer system.
As Obamacare rolls out over the next few months and years, what will we conservatives do? Some will argue for states to stay out of the Medicaid expansion as Texas has done (correctly in my judgment—at least for the foreseeable future), some will argue for a resurrection of greater state sovereignty, including for state nullification authority, or even some form of state autonomy or secession from the union. But, in the long-run, most of these “solutions” are not viable, let alone constitutional, answers to the problems that led to the adoption of this new law, no matter how much better making those arguments may make us feel. So, again I ask, what will we do?
As I’ve tried to say to my fellow conservatives and Republicans for several years now, it is time to regain the initiative that Reagan started, and present it to a new generation of Americans: it is time to govern using our principles, rather than simply to talk of cherishing our principles. Revering our principles as if they belong on a mantle, or endlessly engaging in analytical debates about their foundations and purposes, mean nothing to our neighbors and increasingly make us and our movement irrelevant to them. Fighting for abstract causes with ideological purity makes us look like cranks, and people stop listening to cranks. In essence, it is time to pivot from the Buckley Approach to the Beveridge Approach, just as Reagan and Kemp turned Goldwater’s rhetoric into a positive plan of action a generation ago.
So how do we shift to the Beveridge Approach now in response to Obamacare? We start by understanding two things about the current American mood and the new law. First, all of the polling shows that the public is extremely anxious and skeptical about this new law, and would be very open to changes that would insert more certainty and individual control into the new system. Second, even though the new law was clearly intended by its authors to be the first step toward eventual implementation of a European-style single-payer system, it did not create such a system. Let’s start with that second point first.
For about a century, American Progressives/Liberals of all stripes have sought to impose a national, single-payer medical system through the federal government, along with a whole structure of welfare programs that transfer money from taxpayers to government-assistance recipients, which would emulate the European systems that began in Germany under Bismarck in the late 19th Century. Consistent with our conservative rhetoric, Americans have bristled at imposition of such a European system, and a majority of voters almost always have rejected such a system. Instead, Americans have created something different in the U.S.—a social safety net at the national level, augmented by state and local single-payer systems that provide services to the poor. Under this model, only two major categories of programs at the national level have been structured on the European transfer-payment model: Social Security; and certain poverty programs, such as the food-stamp program. Otherwise, virtually all of the other American programs at the national level have funneled tax dollars back into the private-sector economy through payments to private providers, hospitals and non-profit entities. Meanwhile, public hospitals and clinics, the closest thing in America to the European system, have been maintained by state and local governments to provide essential services to the poor in local communities.
Consistent with the American model, Obamacare carefully avoided creating a national, single-payer system, but instead put virtually all of the burden of providing health care on private insurers. Obviously, the authors of this bill hope that the burden they created will prove unworkable and people eventually will demand a single-payer system. However, we should take this opportunity and run with it—we should adapt what Obamacare has created into a workable system that never morphs into a national single-payer system.
My proposal, though not perfect, would be to double-down on the American model to address the public’s anxiety and skepticism. That is, rather than allow Obamacare and the rest of the social safety net to morph over time into a European transfer-payment system, we should embrace a regulatory system (partially and ineffectively created by Obamacare) that
- encourages the private funding, investment, and management of the health care industry to provide access to private health care, and to assure the control of health care decisions, to all adults over the age of 21 and their dependents whose economic means place them above the poverty line, thereby eventually folding most future Medicare recipients into the main private insurance system; and
- transfers the total funding base and responsibility to provide medical services for the poor, including the elderly poor, to state and local governments and non-profit entities (including academic and religious institutions, and charitable trusts) through networks of public hospitals and clinics, or through their own experimental systems, which would completely replace Medicaid.
In order to get the public’s attention, we should create an experimental American-model system in one of the states that has opted out of both the exchanges and the Medicaid expansion—like Texas—to implement these approaches at the state and local level. Like Tommy Thompson’s experiments of welfare-to-work in the 1980s and 90s (which led to the federal reform), one or more of the 24 states that Republicans control should lead the way with this experiment, which then can be used by our candidates for national office as an example of a workable reform of Obamacare in the future.
Over time, this model also should be used to address the structural problems with, and the social dysfunctions exacerbated by, the transfer-payment model of Social Security and other national welfare programs. Social Security, regardless of all the terminology used to confuse it with insurance or pensions, is simply a transfer of dollars from current taxpayers to retirees (or other statutory beneficiaries). There is no lock-box, and there is no return on an investment of the dollars retirees paid into the system. The only entitlement to a payout is based on the statutory criteria passed by Congress. With the dramatic drop in the number of workers paying into the system coupled with the dramatic increase in retirees and life expectancy, this transfer payment (like many local pension plans), is not sustainable. To preserve a public retirement safety net, we need to convert the system into one that invests money in the private sector and pays out based on a return on that investment over time.
Likewise, paying people not to work creates dysfunctions at home, at school, and in the neighborhood, which are deep and that last generations. Moreover, increasing the number of people in these programs inevitably will exacerbate the long-term problems with Social Security because fewer workers will be paying into the system over a longer period of time. We must return our food stamp and other welfare programs to the welfare-to-work model that both parties embraced in the 1990s.
What I just outlined are positive, conservative ideas for addressing real problems faced by our neighbors—solutions that have been discussed among us for decades and that would preserve what is truly unique about America’s society, traditions and culture. These ideas, if promoted to the rest of neighbors and adopted into public policy, also would begin to reduce our dependence on the sale of Treasury Bonds to finance the operation of the federal government, as opposed to using them to finance large, long-term infrastructure projects. Finally, this same approach can be taken by our 30 Governors and 24 state legislatures to begin to reform our school systems and public pension systems, which would reduce their dependence on public bonds and other financing schemes to balance operational budgets, rather than pay for the modernization of our local infrastructures. Eventually, public bonds at all levels could again be used to create the needed modernized infrastructure for commerce throughout the rest of this century.
But to start promoting any ideas like these, we have to begin moving from the Buckley Approach to the Beveridge Approach to governance. The irony is that if we don’t make that transition soon, we will get the future we are trying desperately to stop.