William Voegeli offers an astute and fair-minded reading of one of theimportant divisions within the Republican Party and the conservativemovement today ("The Wilderness Years Begin," Spring 2009). Happily, the division that Voegeli analyzes—the division between Traditionalists and Reformers—is also the one most easily resolved. Over the next political cycle, the Traditionalistswill have the upper hand and will get to do things mostly their way.If that works—if the GOP wins the White House or at least recoverslarge numbers of seats in Congress—then the Reformers have beenwasting everybody's time, including our own. If it does not work, thenthe Reformers get their innings in 2013.
As Voegeli notes, Reformers disagree amongst themselves. He veryaccurately puts his finger on the source of the division: whether totry to expand Republican political reach laterally or vertically. Thisis a very difficult problem, and one that Reformers themselves tend tounder-appreciate.
Let's put it this way: the core constituency of today's Republican Party is whites who arenot poor but who did not graduate from college. Even in a terribleyear like 2008, the GOP wins a super-majority of these voters.
Ross Douthat and Reihan Salam, and Ramesh Ponnuru, too, envision a future Republican Party that scores even more highly among this group than it did in the 2000s. To that end, they urge a renewed emphasis on social conservatism along with various economic measures aimed at lower-middle-class families.
But the fact is that even in a bad year like 2008, the GOP alreadygets north of 60% of the white working class vote. How much can thatsupermajority realistically be enlarged? And can it be enlarged fastenough to compensate for the relative shrinkage of that group? Americais not only becoming less white, it is also becoming more highlyeducated. As recently as 1990, only about 20% of whites held a collegedegree. Today, almost one-third do. The constituency fora message that is socially conservative and economically populist (butnot economically liberal!) is shrinking before our eyes. The populistReformers have to hope that they can somehow also reach sociallyconservative Hispanics and blacks. Call it the Proposition 8coalition. It's not impossible to imagine such a coalition takingform. But it will require a degree of ideological transformation muchmore radical than anything the populist Reformers have yet contemplated.
Of course, the same might be said to those like me who see the futureof the GOP in reclaiming a larger share of the college-educated vote.The college graduates of the 2010s are very different people from thecollege graduates who responded to Ronald Reagan in the 1980s: muchmore numerous both absolutely and relatively, more female, lesseconomically secure. The kinds of measures I have been talking about—a new emphasis on the environment, a concern for a next generation ofpublic health problems like obesity, a more moderate tone and style, agreater emphasis on technical competence—are probably also only anopening bid in the changes necessary to reach this group. So we are all in the wilderness together, groping our way forward.
A final thought. There is another dividing line in conservatism evenmore immediately relevant than that between Reformers andTraditionalists or that subdividing Reformers and Traditionalistswithin themselves. It is the line between politics and show business. The tone for conservatism in 2009 is not being set by any of thepeople discussed by Voegeli. It is being set by talk radio and FoxNews, and they are guided by very different imperatives andincentives. While politics proceeds by addition and benefits from somemeasure of creative ambiguity, modern media profit from division andintensification. Conservative entertainment excites and mobilizes millions of Americans while alienating even larger numbers. There will be no conservative comeback until politically-mindedconservatives of all descriptions find some escape from this dead end.
American Enterprise Institute
I never read William Voegeli without learning something, and in the last CRB I learned a few things about myself. It turns out that I believe that advocating the public-policy changes I desire is a sure route to political success, and that I am a redistributionist. I had not known these things previously because they are not true.
Voegeli takes my statement that a pro-family tax reform would create winners and losers to mean that it is redistributive. Not so. Few people—well, few conservatives, anyway—would call a flat tax redistributive, although it would create winners and losers too. Some people would give up tax breaks without being fully compensated in the form of lower tax rates. Any tax reform that is designed to be revenue-neutral on static assumptions would create winners and losers; not all such reforms would be redistributive. The centerpiece of the tax reform I have advocated is, as Voegeli notes, a large tax credit for children that parents could apply against their income and payroll taxes. In arguing for it, I have continuously stressed that the effect of that credit would be to make the federal government less redistributive rather than more. The tax code, combined with entitlements, currently redistributes money from households with children to those without.
Moving on to more general points: Voegeli suggests that conservative "Reformers" are prone to what we might call, borrowing from Judge Robert Bork's usage in a different context, the heart's desire school of political strategy. I think the distinction between "Traditionalists" and "Reformers" is overdone. If we accept this division, though, I think it is the Traditionalists who are more prone to this error. Their explanation of recent Republican political setbacks tends to center on the party's departures from their program, particularly on federal spending. Their prescription for political renewal is to embrace that program. I would like to see much lower federal spending, but this analysis seems to me to be based more on wishful thinking than evidence.
Voegeli is surely right to say that political analysts are too quick to assume that what they want is also what the public wants. I attempt to guard against this temptation. I may not always have succeeded. But there are all sorts of public-policy changes that I favor which I am willing to concede would be disastrous for a political party to make the basis of a campaign: the abolition of the Department of Education, for example, or a prohibition on abortion that applied in cases of severe fetal abnormality, or privatizing the licensure of doctors, or...well, you get my point. It is true that I believe that it is possible for some of the most pressing policy changes I favor to be combined and presented in a way that could attract majority support. All that means is that I am not yet ready to succumb to political despair. Voegeli concludes that a conservative—one might say anyone with principles—must be prepared to do his duty and die on the losing side. I agree, as I usually do when Voegeli writes. I hope he agrees that it is at least possible that our circumstances are not yet so dire.
William Voegeli replies:
I appreciate the careful attention given to my "Wilderness" essay by David Frum and Ramesh Ponnuru. Both their letters raise the question of whether, or to what extent, conservatives need to retool their arguments and agenda in the pursuit of an electoral majority.
For Frum, the most pressing need is for conservatives to present themselves in ways that appeal to voters outside their core constituency. He laments that the rhetorical style of conservative talk radio and Fox News does a better job of expelling heretics than winning converts, thus making the conservative movement more cohesive, but also smaller and weaker.
Frum's argument resembles one put forward by Peter Beinart in the New Republic just after the 2004 election, when liberals were in despair at the re-election of George W. Bush and the presence of 55 Republicans in the U.S. Senate. Liberalism, Beinart warned, would never become electorally viable again until liberals shunned their own dividers and extremists, such as MoveOn.org and Michael Moore, just as liberals in the Americans for Democratic Action had excommunicated Henry Wallace in 1947.
Beinart's article was not prophetic. Despite refusing to conduct the purges he recommended, liberals wield more political power today than they have since 1965. Rather than repudiating their entertainers, for example, they elected one to the U.S. Senate from Minnesota. It would be nearly as difficult to argue that the stridency of people like Keith Olbermann of MSNBC, or Markos Moulitsas of DailyKos.com, has been bad for their careers as to show it has been harmful to the broader liberal political project.
Apparently, then, the show-business proclivity for division and intensification is not inherently lethal to the political addition needed to build the biggest possible coalition. The fact that Beinart was wrong does not prove that Frum cannot be right, however. There might be two mitigating differences between liberals' situation after 2004 and the one confronting conservatives after 2008. First, if the liberal tide began coming in after 2004, and the conservative one is now going out, then liberals would have enjoyed more latitude to give free rein to their entertainers than conservatives do today. Second, the playing field is never level—liberals dominate academia and journalism, so they can get away with rhetoric conservatives can't. The situation is unfair, but conservatives have to play the hand they're dealt, not the one they deserve.
The best sort of dispute to avoid having with someone who writes as much and as well as Ramesh Ponnuru is a semantic one. Before capitulating, then, I'll note quickly that a tax-reform plan whose explicit goals include leaving one big group of citizens significantly better off, and another big group worse off, sounds like it contains elements of what Stephen Colbert might call "redistributiviness." I take Ponnuru's point to be that the crucial question is the choice of baselines: tax and spending policies that increase the disparity between the pre-tax and after-tax income distribution are the only ones rightly called redistributive. Policies that would change the after-tax distribution of income from what it is at the moment, but move it closer to the pre-tax distribution, which is what Ponnuru's plan sets out to do, should be called something else. "Re-redistribution"? "Un-redistribution"? The terminological muddle does not undo the basic point that Ponnuru's tax proposal is not helpfully described as redistributive.
The more important question is whether it's a good idea. Does Ponnuru's plan advance the related but distinct goals of more conservative governance and a more conservative electorate? I think it does, but it's a close and interesting call.
I see two big advantages to Ponnuru's plan, and one significant concern. The first good thing Ponnuru's plan would do is weave together into a stronger coalition conservatives preoccupied with limiting government and those whose highest priority is strengthening the family. As William Bennett used to say, the nuclear family is the original department of health, education, and welfare. A proposal that addresses children's needs by giving tax relief to their parents does more to help the needy than a round of budget increases for an endless list of welfare state programs, while also vindicating the principle of leaving people alone rather than entrusting the government with the responsibility for improving their lives.
The second good thing about Ponnuru's plan is that ending the federal deductibility of taxes paid to states and localities would simultaneously strengthen federalism and limited government. As matters now stand, residents of high-tax states have the purchase price of Big Government at the state and local level marked down. Their discount corresponds to a federal tax premium paid by the residents of low-tax states, who have smaller deductions on their federal returns. Both fairness and the cause of limiting government would be promoted by letting the residents of every state and locality pay full price for the amount of government they purchase.
The worrisome thing about Ponnuru's plan concerns this same idea—that the growth of government will be constrained if people are confronted with its costs directly. The Ponnuru proposal clearly serves this goal at the local and state level, but its impact at the federal level is murkier. According to the most recent data available from the Congressional Budget Office, the poorest quintile of the American income distribution paid 0.8% of federal taxes in 2006. That's 80 cents out of every $100 of all federal taxes—income, payroll, corporate, and excise. The next-highest quintile paid 4.1% of the total, and the middle quintile paid 9.1%.
Under these circumstances, a solid majority of the American people has good reason to think of the growth of government and the resulting growth of taxes as somebody else's problem—somebody richer's problem. The 86% of the federal tax burden not paid by the poorest 60% of the population in 2006 was divided, after rounding, between the fourth quintile, which paid 16.5% of all federal taxes, and the highest quintile, which paid 69.3%. The 1% of the population with the highest income paid 28.3% by itself, and the next highest 4% paid another 16.4%.
This gets us back to the question of winners and losers under Ponnuru's proposal. Because of the Earned Income Tax Credit, effective federal income tax rates for the first and second income quintiles are already negative. Thus, payroll taxes are the only significant federal tax liability faced by most poor and lower-middle class families. A $5,000 credit for each dependent child, applicable to both income and payroll taxes, would give millions of American families a sabbatical from federal taxation that concluded only when their youngest child was no longer a dependent. Any conservative argument against new federal spending would have to sway these voters purely on the strength of its abstractions, because they would be exempt from any resulting tax increases prior to the empty-nest phase of their lives.
Of course, there would be losers under Ponnuru's proposal, too, those people who currently pay little or no federal taxes but wind up paying quite a lot. They include the childless and residents of high-tax states and cities. The proposal is revenue-neutral, which means the number of dollars coming into the U.S. Treasury remains unchanged. It is not necessarily taxpayer-neutral, however. The number of taxpayers who end up paying negligible federal taxes could grow, shrink, or stay the same.
I'm not sure which. The question may be economically unanswerable and politically irrelevant. It would be unanswerable if even the best statisticians were unable to take Ponnuru's plan out for a test-drive that was revealing enough to settle the question of its impact on the size of the untaxed cohort. It would be irrelevant if the size of that cohort is so large now that increasing it wouldn't make much difference. That is, the distribution of the burdens of federal taxation may be so top-heavy already that the correlation of forces between those who want to shrink and those who want to expand the federal government is as favorable to the latter as it can possibly get.
Conservatism is in a ditch, and the least promising approaches for getting out are those that emphasize risk-avoidance. Frum's advice on rhetoric and Ponnuru's tax reforms are both gambles, but shrewdly considered rather than reckless ones. Both proposals are exercises in the statesmanship of ideas, ones that seek to marry good governance to good politics. They deserve careful consideration.
* * *
Too Few Doctors?
Among the recommendations Mark Helprin makes for the American health care system is that the United States take immediate steps to double the number of physicians trained each year, in order to reduce physicians' prices ("First, Do No Harm," Spring 2009). Mr. Helprin further asserts that other industrialized countries have on average 150% more physicians per capita than the U.S., and that worsening shortages loom.
America has tried Mr. Helprin's suggestion in the past with decidedly mixed consequences. The federal government, through a number of initiatives begun in the late 1960s, vastly increased the annual infusion of new doctors, from 7,000 graduates in 1970 to over 15,000 in 1980 and over 16,000 today. Physician manpower increased from 325,000 in 1970 to 853,000 today and will reach 952,000 by 2020, nearly triple the 1970 level. The U.S. has 255 physicians per 100,000 inhabitants, up from 137 in 1970, and will reach 258 in 2020. This compares to 334 in France, 330 in Germany, 195 in Canada, 189 in Great Britain, and 177 in Ireland. Clearly, the U.S. falls within the range of other first world countries.
The Department of Health and Human Services (HHS) projects a 1% per year increase in physician productivity over the next decade, which means we would have the output of 300 of today's physicians per 100,000 inhabitants by 2020, far greater than any English speaking industrial country and about the same as continental Europe, which has struggled with chronic physician unemployment.
What has been the effect of this great increase in the number of physicians? Mr. Helprin is right; oversupply did lead to lower prices. In real dollars the unit price for physician services has fallen about 50% since 1985. A physician 15 years out of training and owner or equity partner in his practice now earns less than a lawyer, dentist, or CPA in the same situation, and works harder.
However, Mr. Helprin's notion that lower physician prices would lower health care costs has proven wildly wrong. About 60% of heath care costs arise from tests, medications, and procedures ordered by physicians. The presence of ever greater numbers of physicians has exacerbated the cost increases caused by the availability of more advanced pharmaceuticals and technology. Other countries have avoided the bulk of these cost increases largely through rationing of access to these life-saving advances.
Physician oversupply has led not only to lower physician income, but also to lower physician morale, autonomy, and public respect. The brilliant, highly motivated people the medical profession used to attract now largely shun the field, and instead enter law, business, computer science, or finance.
A further vast increase in physician manpower would lead to increased, not decreased costs, stringent government controls, further erosion of physician quality, and, ultimately, loss of patient autonomy—outcomes none of us would wish.
Steven E. Levine, M.D.
David Geffen School of Medicine at UCLA
Los Angeles, CA
Mark Helprin replies:
First, a note on the supporting data. (Those who don't relish such interesting details might want to skip to the third paragraph.) Contrary to common assumptions, most social statistics, like election tallies, are seldom precisely replicable. Given that it is unlikely that in the last four years a fifth of British doctors simply disappeared, I suspect that this explains the difference between Dr. Levine's 189 physicians per capita in the U.K. (presumably at present) and the Organization for Economic Cooperation and Development's figure of 230 (in 2004), upon which I rely. The numbers of British and American doctors per capita are roughly equal, but, as I pointed out in my essay, it is true that "The major countries of Western Europe other than Britain [emphasis newly supplied] have on average 150% more physicians and 200% more hospital beds per capita." And it is a fact that the major countries of Western Europe spend 9.4% of GNP on health care while we spend 16%.
As Dr. Levine states, for a period the granting of American medical degrees greatly increased: cumulatively 81% between 1970 and 1990. Even when measured against the population growth of 22%, this is substantial. However, between 1990 and 2004, cumulative growth of only 2% hardly kept up with an 18% increase in population. Then we began a heavy draw of doctors from the Third World. These patterns notwithstanding, the ratios expressed in the first paragraph above accurately reflect the differences between America and the group of countries I used as exemplars. In light of these numbers, of waiting times throughout the U.S., and of the Association of American Medical Colleges prediction of a dearth of 124,400 M.D.s by 2025, I would hesitate to call what we now have an oversupply. And even if we did have an "oversupply" (for which, if you think about it, a credible definition would be hard to come by in the present circumstances), adding to it further would still lower prices.
Dr. Levine stipulates that, in fact, the increase in physician supply in the period he cites "did lead to lower prices. In real dollars the unit price for physician services has fallen about 50% since 1985." He objects that, "However, Mr. Helprin's notion that lower physician prices would lower health care costs has proven wildly wrong," because 60% of health care costs arise from everything but physician fees.
I did not propose to cut health-care costs only by lowering the prices charged by physicians—although if these costs total 40% of the total and they were cut in half, they would in fact lower overall costs by 20%. My proposal, clearly expressed, was to increase the supply of all medical goods, from cotton swabs to magnetic resonance imagers, from physicians to technicians, drugs, hospital beds, outpatient facilities—in short, whatever it is that in its scarcity elevates prices.
It is true that, just as with diamonds, gold, or oil, if supply increases relative to demand sellers will receive less, especially those who, like physicians, cannot prop up income by increasing volume. But as in the production of energy or food, should not deficits be met with the natural response of increasing supplies? This is at one and the same time the classic economic prescription across many schools, the normal response, the expected reflex, and, in the case of food or medicine, the moral imperative. The opposite course of action, to ration supply (which the need for stringent certification allows the medical profession to do at will) is what cartels attempt for their own advantage and what socialists do ostensibly for the sake of equality. The former enjoy narrowly distributed benefits arising from their promotion of unnatural restriction, and the latter enjoy stilted centralized direction arising from their toleration and imposition of precisely the same thing.
I do not conflate the lowering of health costs with physician happiness. On the other hand, I remember when ambulances carried interns, when doctors would come to the house to see a patient at four in the morning on a Sunday, when those who practiced medicine were not as rich as they are at present, and when despite this, as many sources and surveys attest, they were a lot happier than they are now. Though they did not have the science they have today, they found great satisfaction in a calling that was properly honored and respected in a less materialistic culture. They were not even vaguely overshadowed by the machines to which these days they are sometimes viewed as mere accessories, and their clients were their patients rather than arrogant, mechanical, and faceless bureaucracies.
The pressures of mortality and rapid advances in medical science have combined to elevate demand for health care to unprecedented levels. Because this demand rises from the will to escape suffering and death, it will not ebb, and it can never be called unreasonable even if it is insatiable. By its nature, it is difficult to satisfy fully, but rather than pulling back and rationing, our task should be to extend and increase supply.
Paradoxically, but according to laws of economics that have yet to be repealed, this would lower or stabilize costs while at the same time it saved and prolonged lives. Granted, insatiable demand can keep level with supply and repeal reductions in price. But even if this were so—and varying levels of patient satisfaction by era and location show that demand can level off at least until major advances in science change the nature of expectations—costs would rise less rapidly than otherwise, and everyone would benefit from the richer provision of medical care. Perhaps the average cardiologist would not, as he does now, take home $419,000 per year, though perhaps, with the debt-free education I advocate and reforms in bureaucratic practices and liability insurance, he would. Is this, however, the test?
* * *
Third World Corruption
I read Carl Schramm's "Up From Poverty" (Spring 2009) expecting at each paragraph to be reminded of the two problems that separate the developed world from the "never to be developed world," namely, nepotism and corruption. Without addressing these two problems, we can put all the money we want into "developing nations" and have no discernible effect, ever. To have even a limited effect in these countries, every dollar and decision must be watched over by an outside body. Most unsupervised aid money goes to support the worst people in each country.
C. Ferrell Varner
* * *
An Open Letter
President Barack Obama
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
In your Cairo speech [June 4, 2009] you referred to the West Bank as "occupied" by Israel. You implied that the Palestinian Arabs were being denied the sovereign rights to their homeland. But the West Bank was never a sovereign state to Palestinian Arabs. In the ancient world, Judea and Samaria belonged to what was then a sovereign Jewish state, a state from which the Jews were repeatedly driven by foreign conquerors: among them Babylonians, Romans, and Christian crusaders. However often they were driven from their ancient homeland, Jews always returned.
The millennial claims of the Jews contrast with the fact that the Palestinian people of today have no such historic claims. In fact, the Palestinians whose national identity you recognize did not exist before 1967. The West Bank was conquered in 1948 by Jordan, which subsequently annexed it and then later de-annexed it. It was de-annexed when the King of Jordan discovered he had added to his kingdom Palestinians who wanted to overthrow his monarchy. For the same reason, Israel does not want to add enemies to its body politic.
During the 19 years that Jordan controlled the West Bank, not a word was heard of a Palestinian people. After Israel's victory in 1967, Palestinian nationalism was a creation of the larger Arab world, which saw in a Palestinian state a platform from which to launch Israel's ultimate destruction. But they recognize that that victory will never come until America's support of Israel is sufficiently undermined.
To be sure, the idea of statehood for Palestinian Arabs has a history. It was proposed by the Peel Commission in 1937, in parallel with the then Jewish Homeland. It was proposed again in 1947 by the United Nations, which partitioned Palestine into two states. In both cases partition was accepted by the Jews and rejected by the Arabs. In 1948 the Arabs thought they could destroy Israel, and possess the whole of Palestine. Today they accept what they had formerly rejected, but only as a means to the same end: the destruction of Israel.
Harry V. Jaffa