But in fact, the most important public questions—including all of those listed above—combine elements of the philosophical and the practical. All of public policy is about setting priorities, which must always be done with an eye to both principle and practice, and every moral choice in politics must somehow be implemented in practical terms.

Nowhere is this inevitable intertwining of the moral and the practical more evident than in the health-care debate that has been raging in America for the better part of two decades, and that has been especially prominent in the past two years. Simply put, the health-care debate presents us with a moral imperative to solve an economic problem. The moral character of the imperative does not negate the economic character of the problem (and therefore the need for an economically viable solution), while the economic character of the problem can never blind us to the moral weight of the matter. This combination of the moral and the economic is what makes the health-care dilemma so challenging, but awareness of the combination helps us to distinguish among the solutions offered by the left and the right.

The moral imperative we confront in the health-care debate presents itself in two distinct facets. First, there are the 50 million Americans who lack health insurance today, and are therefore potentially without access to routine and chronic care. To be sure, some of them have chosen not to buy insurance, though they could afford it. Some are in the United States illegally, and so do not qualify for programs that otherwise assist the poor. But several tens of millions are simply unable to afford coverage. They are not poor—the poor are insured by the Medicaid program. They are not elderly—the old are insured through Medicare. They are, for the most part, lower middle-class people who do not receive insurance through an employer (as most American families do) and cannot afford to buy it on their own. And their numbers have grown in recent years because the cost of insurance has been growing far faster than wages.

Meanwhile, the second moral facet of the problem is the immense burden that our health-care entitlement programs present for the nation’s future. The numbers are depressing and staggering. A decade from now, our national debt will be as large as our entire economy—a level of debt we have not seen since the immediate aftermath of the Second World War—and (unlike the late 1940s) it will be on a trajectory of persistent ballooning growth. By 2035, according to the Congressional Budget Office, the debt will be twice the size of the economy and still expanding quickly. The resulting much-diminished economic growth will cast a great shadow over the prospects of the next generation, which will be unable to experience anything like the prosperity that Americans have taken for granted over the past 60 years. This is a moral problem at least as much as an economic problem—it is a failure of the present generation to meet its charge to the future.

Our health-care entitlement programs are by far the foremost cause of this coming explosion of debt. In its latest long-term projections, published in June, the Congressional Budget Office reported that, between now and 2050, federal spending on health-care entitlements (especially Medicare and Medicaid) will nearly triple as a percentage of the economy, while all other federal spending (including defense, discretionary spending, even Social Security—everything but interest on the debt) will actually decline as a share of the economy. Health-care entitlements are, in short, entirely responsible for our long-term debt problem.

These two moral facets of the health-care debate at first seem to contradict one another. More and more Americans are uninsured, even as the cost of paying for our existing health insurance programs is growing so large that it risks crushing the economy. So does the government need to do more or less to provide health insurance? Democrats in the health-care debate tend to emphasize the first of these problems, and so argue that more public spending on coverage is needed, while Republicans usually focus on the second, and so devise ways to cut health-entitlement spending. But wouldn’t focusing on one problem make the other worse? Is there a way to address both at once?

To answer that question, we need to grasp the underlying economic problem that explains both moral 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. Last year, health-care costs grew by more than 7%, while inflation was below 2%. That means that the cost of insurance premiums is rising far faster than people’s wages, leaving more and more people unable to pay for coverage. And, combined with demographic trends that mean a greater share of the population is over 65 than ever before, it means that the costs of our health-care entitlements are growing far faster than tax revenues, leaving the government more and more in debt.

The health-care debate is therefore properly understood as an argument about how to restrain the growth of health-care costs. The moral dilemmas that compel us to act force upon us an economic question: what can we do to keep costs from growing so quickly without undermining the quality of care and people’s access to it?

The debate now being fought in the political arena does in fact arrange itself along two different sets of answers to that question—answers grounded in economic premises, but which send us back toward the realm of moral analysis and judgment. The two answers derive from two different views of what makes for economic efficiency. Clearly, the problem with our health-care system is that it is grossly inefficient. But why?

Liberals tend to believe that our system is inefficient because it is chaotic and unfocused—there are too many players doing too many things in too many different ways, and none is moved by a concern for the public interest, so the system is a costly mess. It would be much more efficient if it were made more orderly—a system directed to the public good, governed by a single set of rules, managed by knowledgeable experts who understand what kinds of care are cost-effective, with just a few large providers of insurance (if not one huge provider) using their weight in the market to compel lower prices and more efficient delivery of services.

This vision is roughly what the health-care law enacted last year aims to make a reality: to restrain the growth of health-care costs by putting the health-care sector under tighter supervision and making the government a larger buyer and provider of coverage. It involves a vast expansion of Medicaid, more price controls in Medicare, and a system of highly regulated state insurance exchanges that will gradually transform the private insurance sector into a system of public utilities.

Conservatives tend to believe that our system is inefficient because it is too opaque and over-managed—that the fee-for-service structure of Medicare (which pays doctors by how much they do rather than how efficiently they work), the design of Medicaid (which allows state officials to increase spending at the federal government’s expense), and the powerful tax incentive for employer-provided insurance (which prevents consumers from making purchasing decisions and so prevents the emergence of a real market) all make for a badly broken health sector incapable of finding paths to efficiency in the ways that a market economy normally does. What is needed, they say, is a real market in which insurers compete for consumers and therefore have a reason to offer an attractive product at a low price, which would cause them to work with health-care providers to find more efficient, innovative ways of organizing their work.

That is roughly what most conservative health-care proposals aim to do: to restrain the growth of health-care costs by giving consumers real choices and making the health sector more competitive and therefore more innovative. This change involves turning today’s health-care entitlements (including the tax preference for employer-based coverage) into a system of premium-support subsidies to be used in a highly competitive private insurance market in which insurers and health-care providers have broad latitude to experiment with different avenues to efficiency and quality.

In other words, the left argues that experts know how to produce efficiency and that centralized control is the best way to empower experts, while the right argues that markets best discover paths to efficiency and that consumer choice and competition offer the best operating strategies for markets. That difference is the essence of the health-care debate.

But that does not mean that the moral significance of the health-care debate is only apparent or relevant in defining the problem, and not in assessing solutions. The two kinds of solutions offered differ not only in their economic assumptions but also in their moral consequences.

Centralized management of the health-care sector inevitably invites an explicitly utilitarian approach to comparing the worth of different people’s lives as a matter of public policy. Deciding what treatments to cover for which patients involves the government’s determining whose lives are worth living and whose are not. Princeton’s Peter Singer, an unabashed advocate of such public rationing, explained in the New York Times a few years ago that such an approach would, for one thing, require the government to value the lives of the disabled less than those of everyone else—a quadriplegic, for instance, should be valued at roughly half the worth of a healthy active person. “Some will object that this discriminates against people with disabilities,” he wrote, but that’s only because we begin from the premise that all human beings are equally valuable. That can’t be true, Singer argued, since the very fact that we seek cures for illnesses and disabilities proves that we believe such conditions make life less worth living. He concluded: “Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.”

This kind of embarrassing sophistry is precisely where public control of the health-care system, and the resulting public rationing of treatment, must lead—to a rejection of human equality as a principle guiding government policy. Centralized bureaucratic administration of coverage decisions leaves no room for moral diversity (so, for instance, Obamacare compels everyone to fund abortion, despite some cheap tricks employed to make it seem as though money is not fungible). It leaves no room for individual decisions, and fewer ways for families to weigh their priorities and make unavoidable but difficult judgments humanely and compassionately.

Of course, any system of health insurance has to involve decisions about what to cover and pay for—and, in that sense, what to ration. But an underappreciated virtue of the market is that it puts such decisions far closer to the ground, and so to the people involved. Allowing for a wide variety of insurance options means giving people more choices and more power, and therefore also allowing families far greater freedom to choose among treatment options with their doctors. Hard choices will still need to be made, but having more of them made by families and physicians with some power to choose is vastly better than having all of them made by distant bureaucrats with the power to impose.

Believing in equality does not mean pursuing one-size-fits-all public policies. On the contrary, central planning and command-and-control administration too often require a betrayal of equality. Public rationing is not private rationing writ large; it requires an explicit rejection of our most fundamental national premise. Enabling a private market—backed with subsidies to allow those with lesser means to choose among options for themselves—would not only avoid the economic inefficiencies of central planning; it would also reduce the moral enormities of public rationing.

Of course, a more market-based approach would only reduce, not eliminate, such problems. In a competitive health sector, some rationing decisions would be made by insurance companies, not by families, especially in cases where the family’s means are limited. Having insurers make such decisions is marginally better than assigning them to a panel of distant public officials—since the insurers are more directly answerable to their consumers and more directly in touch with the particular physician on the spot—but only marginally so. Well-conceived public policy could significantly constrain the problem and expand the range of options available to families and individuals, but it could never eliminate it.

No one could argue that the market is a perfect solution to the economic inefficiencies of the health sector or to the moral travails of medical decision-making. But in both cases, it is easy to see how a regulated but highly competitive market backed by subsidies is a far better solution than central planning.

It is not by coincidence that the fiscal and moral concerns that define the health-care debate are both best (if always imperfectly) addressed by market-based solutions. For all the tension between market capitalism and traditional morality, both begin from a belief in the essential equality of all and the profound freedom and dignity of the human individual. Social and fiscal conservatives hang together—and jointly oppose the technocratic collectivism of the left—for far more than pragmatic reasons.

Seeing that deeper case for conservatism requires not only reflection on first principles but also careful examination of the complicated questions that underlie our most divisive and prominent public-policy debates. Those debates always combine moral with practical elements, and so always require the engagement of citizens—and the guidance of leaders—armed with principle and prudence alike. That combination is just what we should put to use as we consider who our next president should be.

Yuval Levin is editor of National Affairs and a fellow at the Ethics and Public Policy Center. This essay is part of the 2012 Election Symposium. Read all of the entries here:

• Ryan T. Anderson, “Liberty, Justice, and the Common Good:
  Political Principles for 2012 and Beyond”
   
• O. Carter Snead, “Protect the Weak and Vulnerable:
  The Primacy of the Life Issue”
• Maggie Gallagher, “Defend Marriage: Moms and Dads Matter”
• Samuel Gregg, “Fix America’s Economy:
  Two Principles for Reform”
• Ed Whelan, “Defend Our Laws: Justice Matters”
• Helen Alvaré, “Uphold Conscience Protection:
  Religious Freedom’s Contribution to the American
  Experience and Threats to its Survival”
   
• Jennifer Bryson, “Promote Democracy:
  Start at Home but Don’t Stay at Home”
• Yuval Levin, “Heal the Sick and Reduce the Debt:
  The Moral Economy of the Healthcare Debate”
• Jane Robbins, “Empower Parents:
  Return Educational Policy to the States”
• Patrick Trueman, “End Child Pornography:
  Enforce Adult Pornography Laws”
• Laura Lederer, “End Human Trafficking:
  A Contemporary Slavery”
   
• Robert P. George, “Reflections of a Questioner:
  The Palmetto Freedom Forum Revisited”

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Copyright 2011 the Witherspoon Institute. All rights reserved.

“There was a bill that was put forward before the Illinois Senate that said you have to provide lifesaving treatment and that would have helped to undermine Roe v. Wade. The fact is that there was already a law on the books in Illinois that required providing lifesaving treatment, which is why not only myself but pro-choice Republicans and Democrats voted against it.”

But the facts of the born-alive debate tell a different story.

A few years ago, after it became clear that some infants who were born alive in the course of an attempted induced abortion at Christ Hospital in Chicago and elsewhere were being left to die without even comfort care, Republicans and Democrats around the country united in an effort to make the practice illegal and declare that any child outside the womb, even if she was an abortion survivor whose prospects for long-term survival might be in doubt, was entitled to basic medical care. Even the most ardent advocates of the pro-choice position agreed that a child born alive, even after an attempted abortion, deserves humane treatment.

The tragic stories of infants being left to die moved legislators to act at both the state and federal levels. In Washington, D.C., consensus can be a rare commodity, and never more so than on the issue of abortion. But the Born-Alive Infant Protection Act of 2002 was just such a rarity. The bill passed both houses of Congress without a single dissenting vote-it was 98-0 in the Senate-and numerous states then proceeded to enact similar measures. In Illinois, however, a series of efforts to pass “Born-Alive” legislation from 2001 to 2003 met with stiff resistance from legislators concerned the measure would constrain the right to abortion in the state. Prominent among these opponents, and the only one to actually speak in opposition to the bill when it was debated in 2002, was state Senator Barack Obama.

Obama’s case against the bill did not revolve around existing state law, as he seemed to suggest last night. The law Obama referred to in the debate was the Illinois abortion statute enacted in 1975. But at the time of the debate about the Born Alive Act, the Illinois Attorney General had publicly stated that he could not prosecute incidents such as those reported by nurses at Christ Hospital in Chicago and elsewhere (including a baby left to die in a soiled linen closet) because the 1975 law was inadequate. It only protected “viable” infants-and left the determination of viability up to the “medical judgment” of the abortionist who had just failed to kill the baby in the womb. This provision of the law weakened the hand of prosecutors to the vanishing point. That is why the Born Alive Act was necessary-and everybody knew it. Moreover, the Born Alive Act would have had the effect of at least ensuring comfort care to babies whose prospects for long-term survival were dim and who might therefore have been regarded as “nonviable.” As Obama and the other legislators knew, without the Born Alive Act these babies could continue to be treated as hospital refuse. That’s how the dying baby that Nurse Jill Stanek found in the soiled linen closet got there.

Obama, who in 2003 became the chairman of the state senate’s Health and Human Services Committee, argued not that existing law did everything the newly proposed measure would do, but that the born-alive bill would put too much of a burden on the practice of abortion.

“As I understand it,” Obama said during the floor debate, “this puts the burden on the attending physician who has determined, since they were performing this procedure, that, in fact, this is a nonviable fetus; that if that fetus, or childhowever way you want to describe it—is now outside the mother’s womb and the doctor continues to think that it’s nonviable but there’s, let’s say, movement or some indication that, in fact, they’re not just coming out limp and dead, that, in fact, they would then have to call a second physician to monitor and check off and make sure that this is not a live child that could be saved.” This, he argued, was too much to ask of a doctor performing abortions, and it could also, as he put it, “burden the original decision of the woman and the physician to induce labor and perform an abortion.”

To address the concern of Obama and others who believed in a sweeping right to abortion, Illinois legislators in 2003 amended the bill in Obama’s committee, inserting language clarifying that the bill would in no way affect the legal status of a human being before birth. It applied only to a child born alive. Identical “neutrality” language in the federal version of the bill had persuaded every single pro-choice legislator in Congress to support the measure. But Obama opposed the bill anyway, and his fellow Democrats followed their chairman’s lead, killing the legislation in committee.

When Obama was challenged to explain himself, earlier in this campaign, he at first insisted that he opposed the Born-Alive Act in Illinois because it didn’t have a neutrality clause. When critics contended that this claim was false, Obama accused them of “lying.” But then the critics produced indisputable documentary evidence that in fact Obama had voted against a bill that did include the neutrality clause. Obama had plainly misrepresented his record. Now he really had some explaining to do.

But Obama still did not tell the truth last night. As his original 2002 statements make clear, he sought to defeat the Born-Alive Act because he recognized that it bears at least implicitly on the larger question of abortion in America. He seemed to realize that the logical implication of protecting the child born alive after an attempted abortion is that abortion involves taking the life of a child in the womb, and that acknowledging that, even at the extreme margins of the practice of abortion, could put the legitimacy of abortion itself in question. Therefore, Obama chose to defend the widest possible scope for legal abortion by building a fence around it, even if that meant permitting a child who survives an abortion to be left to die without even being afforded basic comfort care.

Some of Senator Obama’s supporters are now making one last, rather desperate-sounding attempt to defend his votes against protecting infants born alive after unsuccessful abortions. Their argument goes this way: Permitting children who survive attempted abortions to be abandoned is so heinous, so barbaric, that for someone to accuse Senator Obama, a decent man who is himself the father of two daughters, of supporting what amounts to legalized infanticide is too outrageous to merit an answer. There is a problem, though. In light of the documentary evidence that is now before the public, it is clear that the accusation against Senator Obama, however shocking, has the very considerable merit of being true.

Robert P. George is McCormick Professor of Jurisprudence and Director of the James Madison Program in American Ideals and Institutions at Princeton University. He is a member of the President’s Council on Bioethics and previously served on the United States Commission on Civil Rights. He sits on the editorial board of Public Discourse.

Yuval Levin is a Fellow and Director of the Program on Bioethics and American Democracy of the Ethics and Public Policy Center and senior editor of The New Atlantis.

Copyright 2008 The Witherspoon Institute. All rights reserved.