Much ink and many pixels are being expended on writing health care's political postmortems, but the focus should rightly be on the policy front -- in the think tanks and in the legislative priorities of recent Republican administrations and Congresses. In short, the battle was lost before the first shot was even fired because Republicans did not present a compelling alternative story of what was wrong with the health care system, or how they would fix it.
When it comes to health care policy, conservatives have been seriously outgunned. And I say this in all fairness to the friends I have who work night and day on free market solutions to health care. On economics, you always know what the conservative answer is: tax cuts and generally hands-off regulatory policies to spur economic growth. No matter how good the Democrats' promises sound, we return to these simple, pro-growth touchtones that resonate with a majority of Americans who intuitively get that you can't micromanage your way to a better future.
On health care, I have no idea what our basic guiding principle is. Seriously, I don't.
We have tried ineffectively to stretch free market rhetoric to health care without appreciating that health care is already too far removed from a free market for the analogy to make sense. Real markets are sensitive to price. Health care isn't. The insurance companies hide the cost of actual care from the consumer.
What we have lacked in this debate is a simple clarion call to address an aching need -- bringing free market principles to bear to improve tangible health outcomes.
Instead, we have allowed the left to define the problem as exclusively one of access -- of the nearly 50 million without insurance dying in the streets (of course, we don't talk about that number anymore because nearly a third of that number are illegal immigrants, an issue Obamacare studiously avoids).
And it's no surprise. The left has had a far greater number of health care analysts devising grand plans for the eventual takeover. And they have invested more political capital in this issue than any other. It should surprise no one that the conservative effort in this space has been paltry in comparison. We just haven't had as many people thinking about health care, and we didn't actively move legislation on it when we were in power.
Perhaps you might say that's beside the point of the awfulness of this plan, and that our full efforts must go towards repeal. Be that as it may, Republican inattention to health care and the failure to develop a compelling free market narrative on the issue led to the place we are now. By pounding home the notion that the uninsured were the central problem with the health care system, and pointing to the fact that their numbers were growing each and every year, liberals built a sense of urgency that conservatives didn't have and were able to demand action -- even if that action was political suicide.
At the outset of his Administration, George W. Bush set out to neutralize a key Democratic issue, education, with his No Child Left Behind Act. NCLB was a grab bag and not beloved by conservatives for its massive expansion in Federal spending in education, but it did insist on the vaguely conservative principle of accountability.
The merits of that legislation can continue to be debated, but one political outcome is clear. We don't talk much about education at the federal level these days. There is a sense that the problem was "solved" by NCLB, which is now nearly a decade old. Likewise, no one will try to move welfare reform legislation because the successful 1996 reform law substantively and politically took the wind out of the sails of that issue.
Imagine if instead of the Medicare Part D entitlement, the Bush administration had moved a smart, substantive health care bill that addressed cost as the key to unlocking access, making health plans dramatically more affordable, addressing medical liability, and moving away from employer-based plans by giving any group -- whether an employer or not -- the ability to organize their own health insurance pools?
I was there, and I can attest that the Bush Administration did make good faith efforts to move medical liability and association health plans, but it was never the central, overarching focus. It was clear they would never expend political capital like they did on the prescription drug issue that they let themselves get baited on by Al Gore in the 2000 campaign, or the war, or tax cuts.
A well-developed Republican health reform effort could have addressed the high cost of health care -- actually the most glaring issue in our system -- in a way that would have served as a kind of tax cut for the already insured. And in lowering costs, we could have covered the people who wanted health care but couldn't afford it -- the nub of the uninsured problem.
Debate the details of this all you want, but the political upshot of this would have been to render the health care issue, a major Democratic hobbyhorse, politically dead for a generation. A bill less ambitious in scope, designed to address real pain points not a quixotic campaign for 100% insurance, could have forestalled this bill even in the event of a complete Democratic takeover.
This may be oversimplified. There are certainly many very good conservative health care scholars whose work I should have been reading more closely these last few years. But politics is a battle of perceptions, and the perception -- that became reality -- was that Republicans brought a knife to a gun fight when it came a debate about the scope and reach of health care reform. We may have won the political battle over health care, in that a majority of Americans opposed Obamacare, but sometimes it is the policy battles that set the tone for the future political battleground, moving the entire spectrum on which they are fought further left.
