With the Iowa caucuses 48 hours away, poor Ted Cruz just can’t catch a break. His debate performance was lame, his campaign got caught playing Big Brother with voters, and now he - rather than any of his competitors - had to field the killer question on Obamacare.

An Iowa voter confronted him at a town hall and told  the story of the voter’s wife’s brother,  a hard-working self-employed barber who couldn’t afford health insurance until the ACA came along. Then he felt sick, went in for a check-up, and was diagnosed with inoperable late-stage cancer. The voter’s question was straightforward: if you repeal Obamacare, what replaces it for people like my wife’s brother? (Left unspoken: if ACA had passed earlier, the brother-in-law might have lived.)

Cruz expressed ritual sympathy and immediately pivoted to his health-care talking points. The voter pressed for a real answer, but Cruz didn’t have one for him, just as none of his competitors would have had one. No Republican has proposed any actual substitute for the ACA formula of affordable health insurance for everyone who wants it.

Now, there’s an honest conservative/libertarian answer to that voter’s question; I’ve heard it from friends on that side of  the aisle. It goes more or less like this:

I’m really, really sorry to hear your sad story. It’s awful when people die, especially when they could have been saved. But health care isn’t the only important thing in the world, and we have to make sure it doesn’t keep consuming a growing share of economic output.

As a moral matter, your brother-in-law had a right to whatever health care or health insurance he could afford, or that someone else was willing  to give him. But he had no right to the uncompensated (or price-controlled) services of health care providers, any more than he had the right to drive a car he didn’t want to pay for. And he had no right to have other people forced to contribute to his health care through the tax system or a mandatory insurance system with redistributive cross-subsidies built in.

The more important quality health care is, the more damaging it is to do anything to interfere with market processes that lead to technological gains and cost reductions. As a practical matter, any attempt to prevent price-gouging by pharmaceutical companies or other health-care vendors would tend to impede innovation and damage quality.

A government big enough to give you everything you want is big enough to take from you everything you have. So while it’s too bad your brother-in-law died, I oppose any law that would try to prevent such losses by interfering with the operations of the free market.

Of course, this is the sort of thing that can get said in private, or at seminars, or in libertarian think-tanks, or even in right-leaning punditry. No politician who wants to get elected and re-elected would say it out loud. In a way, that’s too bad, because some of it is true: there is value in controlling health-car costs, and there are trade-offs among cost control, access, and incentives for innovation.

Being an unreconstructed liberal, I’d argue for spending tax money to encourage innovation, for example by offering prizes rather than patents for the development of new drugs and by having an arm of HHS buy the rights to promising drugs from innovators, spend the money needed to get them through the
FDA process, and then license production to generic drug manufacturers. I’d also argue for utilization controls as a substitute for price-rationing for expensive drugs and procedures, and some narrowing of the residency pipelines that keep pumping out specialists in expensive invasive procedures, and the application of federal muscle to force the adoption of cost-saving innovations such as a universally portable electronic medical record and ACA-style disincentives for expensive medical mistakes.

On top of all of this, I would liberalize the import of medical services and resources: immigration by health-care professionals, “medical tourism” for procedures expensive enough to cover the air-fare to overseas medical centers, and pharmaceuticals from abroad.

I think the result could be an increased rate of innovation, reduced financial insecurity among health-care consumers, and fewer people dying for lack of treatment that could have saved them, at some cost in higher taxes on people above twice the median family income (which includes many families earning below $250K/yr.) and some denial of coverage for high-cost, low-value interventions, though I think the overall rate of growth in health-care expenditure would be lower under my plan than under either the conservative plan or the existing kludge.

Of course, I’d say all that because I don’t have to run for office, either, and therefore don’t have to worry about PAC money from Big Pharma or the hospital chains or the AMA, or about being accused of advocating “socialism” or favoring “death panels.” In an honest debate between the real liberal position on health care and the real conservative position, I’m not sure which side would get a majority of the votes. What I’m sure of is that neither side is willing to say out loud what it’s really for, leaving the voters mostly in the dark.