http://blogs.forbes.com/aroy). Forbes.com is one of the more widely-read websites in the world, with more than 23 million unique visitors a month. One of the things I’ve found most rewarding about The Apothecary is that it has attracted a politically diverse audience, and I’m optimistic that joining Forbes will help further that trend. Avikroy.org will continue to host my prior work, along with that of Austin Bramwell, and I’m sure I’ll be referring to old blog posts from here for quite some time.
Forbes has invested considerable resources into online media, exemplified by their recent acquisition of Lewis DVorkin’s True/Slant. Lewis now heads up new media development for Forbes, where he is implementing his vision of “entrepreneurial journalism.” To me, this concept makes perfect sense. I’m grateful to Bob Langreth and Matt Herper at Forbes for giving me the opportunity to participate.
I’m also grateful to Rich Lowry and Reihan Salam at National Review, for whom I will continue to write, and also Yuval Levin at National Affairs, who gave me my start as a writer on health policy. I’ve learned much from all three, and I would be nowhere without their sponsorship of my work.
Most of all, I want to thank you, my readers, without whom this exercise would be pointless, and especially those of you who’ve taken the time to post your comments. (This is as fitting a time as any to recognize my all-time commenting champion, Steve.)
When I created The Apothecary in March of 2009, sitting around in my pajamas, I was concerned about what I saw around me. While health care reform was the central ambition of President Obama and the progressive political movement, I saw skeptical indifference among conservatives. Conservatives had successfully defeated HillaryCare by arguing, as Bob Dole did on the floor of the Senate in 1993, that we have “the best health care system the world has ever known.” While our health care system could be improved by incremental, common-sense reforms, most conservatives believed, there was nothing urgently wrong with our system, nothing that required conservatives’ intellectual and political energy. As Patrick Ruffini put it after Obamacare passed the House,
On health care, I have no idea what our basic guiding principle is. Seriously, I don’t…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.This conservative skeptical indifference to health care policy has deep historical roots. The modern American conservative movement was founded in the 1950s by men such as William F. Buckley, Jr., Friedrich Hayek, and Russell Kirk, for whom the New Deal, World War II, and the Soviet Union were formative. The grand ambition of American conservatives in the second half of the twentieth century was defeating communism abroad, and expanding free markets at home. In those days, the government played a relatively small role in health care policy, and so these men had bigger fish to fry.
For the generation of conservatives who were reared by the Buckleys and the Kirks, 1964 was a seminal year. It was the year of Barry Goldwater’s campaign for the Presidency: the first true free-market conservative to gain the Republican nomination since Calvin Coolidge. Goldwater’s uncompromising defense of individual liberty inspired millions of Americans. Ronald Reagan’s speech at the 1964 Republican National Convention—a speech that anyone who thinks of Reagan as an “amiable dunce” must watch—launched the Californian to national prominence. When Reagan was elected President in 1980, and in 1989 when the Berlin Wall fell, it appeared that conservatives had gained the epochal victories that they had worked for half a century to achieve. To those conservatives who had worked in the Reagan White House and had built the institutions that supplied that White House with intellectual energy, 1964 was a year of triumph, a year in which true-blue conservatives took control of a major political party.
There was only one problem. Goldwater got annihilated in the election of 1964. Lyndon Johnson was swept into office with one of the largest ideological majorities since the Civil War. Johnson embarked on a “war on poverty,” and signed the Medicare and Medicaid programs into law. Though conservatives fought against these programs, many saw conservatives’ opposition, as Lionel Trilling had put it, as an “irritable mental gesture.” After all, the government projected that Medicare would cost approximately $12 billion by 1990, inclusive of inflation. Wasn’t it worth it to guarantee health care for the elderly for that price?
But, when 1990 finally came around, we weren’t spending $12 billion on Medicare, but $107 billion. In 2010, we spent $520 billion on Medicare, and a similar amount on Medicaid. Today, according to long-term projections of the Congressional Budget Office, every dollar of growth in federal spending as a percentage of gross domestic product is a result of increased spending on federal health care entitlements.
In the mid-1960s, a group of New York progressives became disillusioned with Johnson’s war on poverty, finding that the real-life consequences of Johnson’s war were to extend and ossify poverty, rather than to relieve it. In 1965, two of them—Daniel Bell and Irving Kristol—founded a journal called The Public Interest. Its first issue published essays not only from Bell and Kristol, but also a future Hall-of-Fame cast including Robert Solow, Jacques Barzun, Robert Nisbet, and Daniel Patrick Moynihan.
Kristol et al. did not oppose statism on philosophical grounds—indeed, most of Kristol’s crew had supported Johnson in 1964. But they were liberals who had, in Kristol’s immortal words, been mugged by reality: a reality that Johnson’s “war on poverty” had made worse.
When landmark welfare reform legislation was signed into law in 1996, it was because Kristol and his intellectual descendants had succeeded where Goldwater had not: by persuading even moderate Democrats that the old model of welfare dependency was harming the poor. Those moderates were swayed not by philosophical appeals to Jefferson or Locke, but by the overwhelming evidence that they could best help the poor by incentivizing them to gain private employment.
Despite hyperbole from many on the Left that welfare reform would cause poor children to starve, the Personal Responsibility and Work Opportunity Act of 1996 was a dramatic success, leading even The New Republic to opine in 2006 that “a broad consensus now holds welfare reform was certainly not a disaster—and that it may, in fact, have worked much as its designers had hoped.”
The great health reform debate of 2009 and 2010 called attention to the fact that conservatives had not put as much energy into health care reform as they had into welfare reform. Medicare drug benefit aside, Republicans controlled the White House and Congress for most of 2001 to 2006 without being particularly concerned about the fact that health care entitlements were spinning out of control. Members of both parties expanded Medicaid without putting any thought into how the program was deeply harming those it was intended to help.
Those days of blissful ignorance must end. It may not yet look this way to the average voter, but our health care system is on the verge of collapse: increasingly inaccessible to individuals and unaffordable to the Treasury. Liberals who claim to represent the interests of the poor need to reflect honestly on how well the poor are served by our present government-run system. Conservatives who speak abstractly of lower spending have a lot of work to do before they can earn the electorate’s trust to enact reforms of their own.
Obamacare, in my mind, is disastrously misguided. But it has served one useful purpose. Since the fall of the Berlin Wall, conservatives have strained to identify a central, unifying domestic policy goal. With the passage of PPACA, they have found it. As the editors of National Review put it in a recent editorial,
This will be a long struggle. The proponents of government-run health care are dug in, and will do anything to stop repeal [of PPACA]. Republicans must bring an equal amount of determination and persistence to the fight—because the stakes could not be higher. In terms of spending, deficits, debt, and size of government, health care is the central battlefield. If Obamacare is allowed to stand, no matter what else happens, the country will move steadily toward ever higher levels of spending and taxation, slower growth and less opportunity, and lower-quality health care. That cannot be allowed to happen. And today’s vote gives us hope that it won’t.I would emphasize that last part: lower-quality health care. Because, at the end of the day, that’s what it’s all about: will Americans gain better health care with a government-run system, or with a free-market one, or some combination thereof? If there is ever to be a bipartisan solution to our health care conundrum, it will be because moderates on both sides come to agreement as to how government policy can best serve the interests of patients and their families.
I’ve spent my whole life in the health care world: as the son of a molecular biologist, as a student of science and medicine, and as an analyst of, and investor in, health care institutions. We’re having a critically important debate about the future of our health care system, because the future of our health care system is inextricably tied to the future of our country. I hope I can play a small part in that debate. I hope you will too.