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What conservatives should learn from No Child Left Behind and Medicare Part D

Bush bolted testing and competition onto big federal programs. The programs lasted and the reforms faded, a lesson for the next conservative reformer.

4Republican Staff · Published July 21, 2026

Let me tell you about the oldest trick in Washington, and it is a trick that has been played on conservatives for generations. You walk into the room with a good idea. Say it is accountability for schools, or competition among insurers. The people across the table say, "Wonderful, we love it, and by the way, we would like to build a brand-new federal program to carry it." You think, well, a program is a small price to pay for a reform. So you sign. Five years later, the program is still there, bigger than before, and the reform has been sanded down to a nub. The program was the real deal all along. The reform was the wrapping paper.

George W. Bush made two big domestic bets of exactly this kind, both in his first term, and both are worth studying from the right with a cold eye and a fair mind. One touched your children's classroom. The other touched your parents' medicine cabinet. Here is my thesis, and I will argue it in order: when conservatives attach their ideas to a new federal program, the program tends to outlive the ideas, and the right should therefore either build the safeguards into the structure or think very hard before agreeing to the program at all.

Bet number one: No Child Left Behind

On January 8, 2002, Bush signed the No Child Left Behind Act. It was a rewrite of the Elementary and Secondary Education Act, the 1965 law that started the big federal money for schools, and it passed with big bipartisan votes. Senator Ted Kennedy was one of its leading Democratic supporters, which should tell you something right away about what kind of conservative victory it was.

The idea at its center was a good one, and I will defend it. If the public is paying for schools, the public should be able to find out whether children are learning to read and do math. So the law required states to test students every year in reading and math in grades three through eight, and once in high school. It required the results to be broken out by groups of students, so that a school with a high average could not hide a struggling group behind it. It required states to set standards and to measure whether schools were making "adequate yearly progress" toward the goal that every student would be proficient. Schools that kept missing the targets faced consequences that grew over time, including options for parents to move their children to other public schools and to get tutoring.

That is the conservative part: measure, publish, give parents an exit. It rested on a belief that I share, which is that the soft bigotry of low expectations is real and that you cannot fix what you refuse to measure. The country got data it never had before. Parents in districts that had coasted for years suddenly saw numbers that showed whole groups of children falling behind, and that was uncomfortable for everybody who had preferred not to know.

What happened to the reform

Now the trouble. Here is the part the program's architects did not like to talk about.

One. The law set an all-students-proficient target for 2014. Every educator knew that a target of one hundred percent was a goalpost on wheels. As the deadline got closer, more and more schools were labeled failing, and the label lost its meaning.

Two. The enforcement mechanisms were mostly sticks aimed at schools, not choices handed to families. The choice provisions that were supposed to let parents leave a low-performing school were thin in practice, because there often wasn't another seat available. Choice that does not exist is not choice.

Three. States responded the way any rational actor responds to a high-stakes federal test. Some lowered their definition of proficiency so that more students would count. Others narrowed what was taught in class to what would appear on the exam. You may call that gaming; I call it predictable.

Four. The federal government had reached into a field that the Constitution does not assign to it, and the reaction was a backlash from the right and the left alike. If you want the larger constitutional point, read The Constitution Never Mentions Schools and That Is the Whole Point.

In 2011 and 2012, the Education Department began granting waivers to states that wanted out of parts of the law, in exchange for adopting other federal conditions. Congress finally replaced the law in December 2015 with the Every Student Succeeds Act, signed by President Obama after bipartisan work led by Senator Lamar Alexander, a Republican, and Senator Patty Murray, a Democrat. The new law kept annual testing, and that is the key fact. The testing requirement, the part conservatives thought they were buying, survived. What it gave back was the decisions about what to do with the results, handing more authority to states. You can follow the whole arc in From Title I to ESSA, Fifty Years of Washington Meddling in Your Schools.

So what was the outcome? The program, a federal role in testing, stayed. The accountability teeth were pulled. And the parental exit, the thing that would actually have changed the incentives, never became real in most places. Remember that when someone tells you a new federal program will carry your reform safely.

Bet number two: Medicare Part D

The second bet came in December 2003. The Medicare Prescription Drug, Improvement, and Modernization Act, signed on December 8, 2003, added a prescription drug benefit to Medicare for the first time. Medicare, created in 1965, had been built around hospital stays and doctor visits. By 2003 the way medicine was practiced had shifted toward pills, and seniors who were paying for their own drugs were pressing for coverage.

Here is the conservative design inside it. Rather than have the government run the drug benefit as one giant insurance plan, the law created Part D, in which seniors choose among competing private plans. The plans bid, the government pays a subsidy, and beneficiaries pay a premium that varies with the plan they pick. It was the nearest thing to a market that Medicare had ever tried. The same law also created health savings accounts, a long-time conservative goal, giving families a tax-advantaged way to set aside money for medical costs and to own the decision. If you want a plain-English walk through all four parts of Medicare, the explainer at Medicare part by part, what A, B, C and D cover and who pays will help.

The benefit began on January 1, 2006. And here is where I give credit. Many conservatives and many independent analysts have argued that the competing-plans design held down the cost of the benefit compared with early projections, and the structure has proven popular with seniors. I would urge you to check the actual numbers rather than rely on me or anyone else: the Medicare Trustees report and the Congressional Budget Office publish them, and the figures change every year.

The objection from the right

But there was a loud conservative objection, and it was not foolish. The fiscal hawks in the House argued that Congress was creating a huge new entitlement, an unfunded commitment on top of a Medicare system that already faced long-term financing trouble. Why would a party that said it wanted smaller government add the biggest expansion of Medicare since its creation?

The House vote in November 2003 made the point. It was one of the closest and longest roll calls anyone could remember, and it was held open for hours, in the middle of the night, while party leaders worked on members who had come in as no votes. It passed by a handful of votes. Estimates of the cost became a fight of their own, with a dispute about when administration officials had known a higher price estimate and whether that information had been shared with Congress. You can believe either side of that dispute and still see the larger point: the vote was won on a knife edge, by a party that had to bend its own principles to win it.

Let me lay out the fiscal hawk's argument at its strongest.

A new entitlement is, in practice, permanent. Once seniors have a benefit, no politician will take it away.
The benefit was added without a dedicated way to pay for it. It went on the national credit card.
Prices are not fixed by bargaining. The law barred the government from negotiating drug prices directly with manufacturers, which most conservatives thought was right, but which meant the market competition was between plans, not between drug companies and the buyer. In 2022 the Democrats in Congress changed that with the Inflation Reduction Act, which allowed some negotiation, and many conservatives opposed that law. The argument over how much market and how much government in drug pricing is not over.
It was a political payoff. The Republican Party wanted to close a gap with seniors before an election and bought the votes with a new benefit.

I have to concede the first two points. The permanence is a fact, and the lack of a financing plan is a fact. It is hard to look at the national debt and say Part D was a model of fiscal restraint.

The answer to the objection

Now the other side of the ledger. One, the status quo was not a free option. Seniors were already getting drug coverage through a patchwork of Medicaid, employer plans and gaps, and the political pressure for a federal benefit was going to produce a program anyway. The only question was what kind. Two, a program designed with private competition and a limited government role is, from a conservative perspective, better than a government-run one that would have come with price controls. Three, the new benefit came with a structure that gave seniors a visible choice and a visible price, which is the opposite of the faceless bureaucracy conservatives fear.

I think the honest verdict is this: Part D was a better-designed entitlement than the one the other side would have written, and it was still an entitlement, added without paying for it. Both of those sentences are true. A conservative can say yes to the first and shake his head at the second.