In my last week at the American Action Forum, I wanted to focus this Weekly Checkup on the state of health policy as a conservative priority. Despite a dedicated cadre of policy wonks working on big ideas, the greater conservative movement has largely avoided even discussing serious health policy reform for the better part of a decade. Let’s talk about why that is, and why it needs to change.

It’s no secret why conservatives at-large became reluctant to make major changes to the health care system: the failure to repeal and replace the Affordable Care Act (ACA). Conservatives struggled to coalesce around a plan, while messaging from the left framed conservative efforts as an attempt to take health care away from people. The late Senator John McCain’s (R-AZ) immortal “thumbs down” doomed the last of some 70 attempts to repeal the ACA. While losing a massive legislative fight was bruising enough, the real pain came a year later: Despite a strong economy, Republicans suffered a 40-seat loss in the House, the largest in the party’s history since the post-Watergate Scandal midterms in 1974, while only gaining two Senate seats with a map that was historically unfavorable to Democrats. The message seemed clear: Health care was a losing issue for the right.

Since 2018, the right has made a very gradual return to health policy, much of it centered around good government and transparency measures. Between debates over the Inflation Reduction Act, a variety of drug pricing measures, the Lower Costs, More Transparency Act that passed out of the House Committee on Energy and Commerce last year, and multiple pharmacy benefit manager (PBM) reform bills in the Senate, there’s been a noticeable uptick in the last few years from the right to re-engage with health care issues. The problem for conservatives is not that nothing is happening; it’s that the right has failed to provide a cohesive vision for systemic health care reform, let alone a vision that candidates and elected officials want to make a priority. Put bluntly, the right hasn’t come up with a response to the left’s “Medicare-for-All” proposal with a cohesive strategy or popular support.

I have written previously about the numerous dangers to our current private health care system: more generous subsidies that increase reliance on government-subsidized and substandard ACA plans, the weakening of employer-sponsored offerings through overregulation at the state and federal levels, constantly increasing premiums and deductibles, and a host of other issues. The weaker and more expensive private insurance becomes for the beneficiaries, the more those beneficiaries will turn to the federal government for subsidization and assistance. Eventually, Americans will begin to question the value of privately sponsored insurance in the first place. This is why some of us have been so insistent about protecting the Employee Retirement Income Security Act’s (ERISA) preemption clause, and why I recommended in my response to the House Committee on Education and Workforce’s request for information that third-party administrators, such as PBMs, need to be explicitly protected under ERISA to ensure the employer plans that rely on them to function don’t face costly state regulation. Rather than opting for increased government control of health care, lawmakers must strengthen what we know, by and large, already works: employer-sponsored insurance and the private market. In other words, conservatives will need to offer a better version of the best parts of our health care system.

But transparency and shoring up the private market won’t be enough. The right needs to make the argument about why, with Medicare already on the brink of insolvency, we can’t afford expanded government health insurance programs. Right now, whether it’s through continual and gradual Medicaid and subsidy expansions from the center-left, or full-on promotion of Medicare-for-All by the far left, the country is being dragged slowly but surely toward a single-payer system of care. The transition from continually expanding government safety-net programs to a de facto single-payer scheme will be subtle and, I think, not very far off in the future. The right must educate the broader public (and itself) about the false promises and catastrophic fiscal implications of a single-payer system. Notably, this education must include a conservative alternative to socialized medicine. Playing at the margins with hospital oversight rules, PBM regulations, and Medicare payment adjustments fails to recognize this pivotal moment in the U.S. health care debate.

The conservative movement must re-embrace major health care reform as a primary policy platform. My fellow conservative health wonks have more than a few ideas, but the GOP must begin taking those ideas seriously and pushing for them with greater urgency. Conservatives should no longer be scared to talk about big health care ideas, but they should be scared of the increasing likelihood of socialized medicine in the United States. It’s time for the right to care about health care again.