Yuval Levin’s Pragmatic Conservative Approach to Healthcare Reform

2020.04.13 Yuval_Levin_AEI_1-Oct-2015

Respected conservative thinker and policy expert Yuval Levin adds a healthy dose of pragmatism to what has all too often been a bitterly ideological debate over healthcare reform. This post will look at Levin’s ideology and his pragmatism.

First, let’s find the several broad areas in his analyses that line up with this Fixing U.S. Healthcare blog. Starting out from points of agreement in this way itself lines up with this blog’s attempt at healthcare fixes that downplay partisanship and ideology, that bridge the divide among factions, and that appeal to American practicality, ingenuity, and a spirit of shared destiny  Indeed Levin, himself, rejects tired old ways of framing policy debates between recalcitrantly polarized rivals.

Liberals and conservatives both frequently insist not only that the path to the America of their (somewhat different) dreams is easy to see, but also that our country was once on that very path and has been thrown off course by the foolishness or wickedness of those on the other side…  (FR pp. 1-2) Democrats talk about public policy as though it were always 1965 and the model of the Great Society welfare state will answer our every concern. And Republicans talk as though it were always 1981 and a repetition of the Reagan Revolution is the cure for what ails us… (FR, p. 15) But … the prescriptions of these [two camps] are nonetheless fundamentally backward looking, because their standard is a particular point in time.  It is a time from which today’s America has much to learn… But it was not the paradise that some now suggest, and it was made possible by a set of circumstances … that constituted an inevitably fleeting transition: a highly consolidated society in the process of liberalizing. No combination of public policies could re-create them… Instead, we should consider how they came to be, how and why America has changed, and what this might mean for what America is becoming. And we should apply the lessons we learn to the essential work of economic, social, and political reform. (FR, p. 30)

Levin brings to his writings – not only on healthcare but also domestic policy issues, more generally — his perspective as a fellow at the conservative American Enterprise Institute, as editor of National Affairs, and as a former White House policy staffer under President George W. Bush. This blog will draw from several of Levin’s books and articles, listed under References, below.

The Problem:  Cost

Here are the claims made by this blog, and Levin’s mirror statements:

  1. Healthcare costs are growing uncontrollably.

[W]e need to grasp the underlying economic problem that explains both facets of the issue: the exploding costs of health coverage and care. The cost of health care has been growing far faster than the general inflation rate for decades. (NA)

  1. Healthcare spending is in competition with other vital and worthy spending.

Put this way, it is clear that the health care debate forces us to weigh health against other national priorities. (NA)

  1. Failing to act is imprudent (Levin goes even further).

If we don’t keep those costs from growing that quickly, they will overwhelm everything else our government needs to do and they will crush our future prosperity. (NA)

Key Values and Principles

Levin is an unabashed conservative, both regards economic policy (reliance on free markets) and social values (emphasis on the traditional family and on civic and religious mores).  Here are several of his values and salient principles:

  1. Quality health care is an essential element of a well-functioning society and economy, which provide opportunity and prosperity and which allow all to thrive.

It means, rather, that we should emphasize increasing opportunity and mobility for Americans at the bottom (and to some extent in the middle as well).  We must revitalize the institutions that will enable vulnerable Americans to thrive…  Any such agenda must begin with growth, which is necessary, if not sufficient condition for economic mobility.  The preconditions for growth – such as an efficient tax code and regulatory environment, a health-care system geared to enabling real competition and cost containment, restrained public spending and deficits, monetary stability and predictability and more – are preconditions for prosperity, and so for mobility. (FR, p. 126-127)

  1. Levin identifies pernicious corporate power embedded in the healthcare system as the root cause of its problems, especially as evident in Medicare. He also implies that monopolistic price gouging drives up prices [NR]

By politicizing payment rates, [Medicare] favors the most politically powerful providers of care and has encouraged the consolidation of such providers into local monopolies able to impose their will on insurers and patients. (NR)

[Our same twenty-first century objection] is true of corporatism, or cronyism, in our politics.  It too has plainly declined in prevalence and power since the middle of the twentieth century, but the significant amount that remains has grown far less tolerable in our diffuse society, distrustful as it is of big institutions and elite collusion. This is mostly to the good, in both cases.  We should combat cronyism, which corrupts our politics, and we should generally welcome a populist spirit in our democracy. But we much also be careful to avoid allowing both causes to become mere channels for corrosive cynicism. (FR, p. 190)

  1. Levin is mistrustful of a narrow profit motive when applying market mechanisms to healthcare.

Looking to market mechanisms doesn’t have to mean prioritizing profits, or putting money at the center of the policy arena. Markets are systems for solving problems by a distributed process of experimentation, evaluation, and evolution… (FR, p. 133)

Levin’s Goals

Likewise, Levin’s goals overlap extensively with Fixing U.S. Healthcare blog.

  1. Protect the sick and other vulnerable citizens.

[T]he funding involved could be modulated to find some balance between the need to protect the most vulnerable beneficiaries and the need to contain costs. (NR)

  1. Contain costs.

The health care debate is therefore properly understood as an argument about how to restrain the growth of health care costs. (NA)

  1. Allocate costs according to need.

[A recent American Enterprise Institute proposal] would better target financial support to beneficiaries who need the most assistance while bringing greater market discipline to the provision of medical services, especially for those who are not most in need. (NR)

Levin’s Methods – and Pragmatic Approach

Levin unabashedly adheres to conservative political formulas for reforming healthcare.

  1. Markets and competition

There is of course an economic case for a more market-friendly health sector. The problem we confront is after all a problem of exploding costs caused by the immense inefficiency of our system of paying for health care. (NA)

  1. Undo Obamacare, which Levin considers a political cheat, a legal abomination, and a policy travesty.

…[T]he Affordable Care Act… has made the federal government the primary regulator of health insurance in American and created a system of lumbering, ill-designed benefits and mandates to increase access to subsidized insurance coverage. The law was enacted with a bare majority through appalling legistative chicanery, has remained exceptionally unpopular, and its implementation has required numerous administrative contortions of highly dubious legality. (FR, p. 233)

  1. He endorses bottom-up (or rather middle-out) rather than top-down solutions.

Those customs and institutions that have stood the test of time (which is really a recurring trial-and-error process, generation after generation) are likely to be best adapted to help us address timeless human challenges and meet enduring human needs, and therefore to enable genuine progress. They are likely to possess more knowledge than we can readily perceive, and more than any collection of technical experts, however capable, is ever likely to have. And, of course, such institutions – families, communities, civic and religious groups, markets, and more – make up the mediating layers of a free society. An appreciation of those middle layers is therefore one of the things that most often sets conservatives apart from progressives. (FR, p. 208)

For the individual market, conservative health experts have been developing proposals to use some of the resources now directed to Obamacare’s subsidies to enable states to tailor programs to the particular needs of their residents. Let different states develop different policies while allowing individuals the option of taking the money that would be spent on them and using it to buy private insurance of their choice: Such an approach could encourage the provision of higher-value options while protecting the sick. Conservative ideas for Medicaid reform, meanwhile, have long coalesced around a number of potential block-granting approaches. (NR)

But at the same time, he appeals to national unity, the mutual social contract, and pragmatism.

They must do so by starting with that system as they find it; there is no other choice. Championing changes in modern government must not be confused with a willingness to abide the presumptions that have distorted that government for many decades. (FR, p. 212)

Ultimately, and perhaps most important, such an agenda will also need to draw us together again in an age of division and fracture. In its conservative and its liberal forms, it will need to help us as Americans begin to rediscover what unites us, and why a restoration of the mediating layers of our society would also be a restoration of a robust idea of citizenship. (FR, p.213)

And only such a citizenry [capable of tolerating a multiplicity of outlooks and ways of life while recognizing one another as equal in freedom], too, will be able to resist the excesses of our age of fracture, and to see the need for balance, and for limits… The institutions of our society offer those – compelling us to confront the limits of choice, the extent of our deepest more-than-chosen commitments, the necessity of reciprocity, the humanity of our neighbors, and the depths of our dependence and therefore of our obligations. (FR, p. 216)

There will be no simple, wholesale solution to our problems but rather a diverse and variegated mix, expressing in different settings and circumstances different sets of priorities, different diagnoses, and different assessments of value.  Subsidiarity means no one gets to have their way exclusively. (FR, p. 217)

What Levin Gets Right and What He Gets Wrong

  1. Healthcare is more than insurance, and healthcare reform must be more than financing reform. The system itself needs to be restored to a focus on health, not just revenue.
  1. Markets do some things well, but fail in other regards. In particular, markets fail to assign proper value to public goods like workforce health and wellbeing, as well as to social capital such as citizen solidarity and self-sacrifice for the common good. (Note: Markets do not capitalize public health or strategic preparedness.)
  1. Levin ignores that Medicare — which he criticizes as over-centralized, bureaucratically rigid, and unimaginative (see NR) — is in actuality a good example of a public-private hybrid – the very model Levin advocates – and has proven remarkably nimble and creative.
  1. Subsidiarity means allowing decisions to be made closest to where they have their effect, as Levin claims. He emphasizes allowing states, regions and local healthcare systems to control financing and delivery. At the same time, Levin correctly acknowledges that subsidiarity also means allowing decisions to be made at a high level if required, for example to combat power distortions, market distortions, or administrative fragmentation. Hospitals should not be allowed unfettered monopolistic behavior. Markets should not be allowed to sell low-quality health insurance policies that are not worth the premium nor to deny insurance access altogether to poor citizens. Software companies should not be allowed to purvey non-interoperable information systems, and insurers should not be allowed infinitely byzantine billing standards and procedures.

There are limits, and there are times when national action is the only way to achieve a national purpose. Subsidiarity means entrusting power to the lowest level that can effectively use it to the good, not simply to the lowest level. But it also means that national action should therefore be an exception, not the norm. (FR, p. 217)

What Levin assuredly does get right is the need for compromise. He gets right the need for all Americans to ask, no matter our place in the healthcare system (or in society more generally), Given my role here, how should I act? (See ATB, p.42) And Levin is right about America’s need to rebalance all of our priorities realistically, drawing on our collective wisdom and Yankee ingenuity.  His healthy dose of pragmatism can temper the message of this blog that only the full faith and clout of the national government can overcome the powerful forces that divert the healthcare system from its purpose and drive up costs.

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(NA) “Putting Health in Perspective,” The New Atlantis, Number 36, Summer 2012, pp. 23-36 – https://www.thenewatlantis.com/publications/putting-health-in-perspective – Summer 2012  (Accessed April 13, 2020)

(NR) “Chronic Condition – Stasis in the health-care debate,” with Ramesh Ponnuru, National Review 70(23), November 17, 2018 –  https://www.nationalreview.com/magazine/2018/11/17/chronic-condition/  (Accessed April 13, 2020)

(FR) The Fractured Republic – Renewing America’s social contract in the Age of Individualism, New York: Basic Books, 2016

(ATB) A Time to Build – From family and community to Congress and the campus, how recommitting to our institutions can revive the American dream, New York: Basic Books, 2020

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Image Credit

Title:  Yuval Levin, editor of National Affairs and Hertog Fellow at the Ethics and Public Policy Center, discusses Edmund Burke at the American Enterprise Institute event, Economic Liberty and Human Flourishing,

By: Taylordw (Donald Taylor)

URL:  https://commons.wikimedia.org/wiki/File:Yuval_Levin_AEI_1-Oct-2015.jpg

License: This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

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