What the middle class needs most is not lower income taxes but a slowdown in the soaring inflation of health-care costs. If health-insurance costs had risen 50 percent rather than 100 percent over the Bush years, middle-income voters would have enjoyed a pay raise instead of enduring wage stagnation. John McCain’s health plan, which emphasizes tax changes to encourage employees to buy their own insurance rather than rely on employers, is a start  but only the very beginning of a start. Some Republicans have brought great energy to this problem. In the Senate, Robert Bennett of Utah has written a bill with the Oregon Democrat Ron Wyden that would require employers to “cash out” employer-provided health care  and then midwife a national insurance marketplace in which employees would join plans that offered more price control and price transparency. Mitt Romney in Massachusetts put an end to the tax disadvantage that hammers consumers who buy health care directly rather than through their employers. Rudy Giuliani proposed a federal law to enable low-cost insurers in states like Kentucky to sell their products across state lines in high-cost states like New Jersey. But it remains unfortunately true that the Republican Party as a whole regards health care as “not our issue”  and certainly less exciting than another round of tax reductions.

Unlike liberals, conservatives are not bothered by the accumulation of wealth as such. We should be more troubled that the poor remain so poor. With all due respect to the needs of employers, Republicans need to recognize that the large-scale import of unskilled labor is part of the problem.

Meanwhile, the argument over same-sex marriage has become worse than a distraction from the challenge of developing policies to ensure that as many children as possible grow up with both a father and a mother in the home. Over the past 30 years, governments have effectively worked to change attitudes about smoking, seat-belt use and teenage pregnancy. Changing attitudes about unmarried childbirth may prove more difficult. Yet it is a fact that the only way to escape poverty is to work consistently  and that even after welfare reform, low-skilled single parents work less consistently than the main breadwinner in a low-skilled dual-parent household.

At the same time, conservatives need to ask ourselves some hard questions about the trend toward the Democrats among America’s affluent and well educated. Leaving aside the District of Columbia, 7 of America’s 10 best-educated states are strongly “blue” in national politics, and the others (Colorado, New Hampshire and Virginia) have been trending blue. Of the 10 least-educated, only one (Nevada) is not reliably Republican. And so we arrive at a weird situation in which the party that identifies itself with markets, with business and with technology cannot win the votes of those who have prospered most from markets, from business and from technology. Republicans have been badly hurt in upper America by the collapse of their onetime reputation for integrity and competence. Upper Americans live in a world in which things work. The packages arrive overnight. The car doors clink seamlessly shut. The prevailing Republican view  “of course government always fails, what do you expect it to do?”  is not what this slice of America expects to hear from the people asking to be entrusted with the government.

It is probable that the trend to inequality will grow even stronger in the years ahead, if new genetic techniques offer those with sufficient resources the possibility of enhancing the intelligence, health, beauty and strength of children in the womb. How should conservatives respond to such new technologies? The anti-abortion instincts of many conservatives naturally incline them to look at such techniques with suspicion  and indeed it is certainly easy to imagine how they might be abused. Yet in an important address delivered as long ago as 1983, Pope John Paul II argued that genetic enhancement was permissible  indeed, laudable  even from a Catholic point of view, as long as it met certain basic moral rules. Among those rules: that these therapies be available to all. Ensuring equality of care may become inseparable from ensuring equality of opportunity.

Equality in itself never can be or should be a conservative goal. But inequality taken to extremes can overwhelm conservative ideals of self-reliance, limited government and national unity. It can delegitimize commerce and business and invite destructive protectionism and overregulation. Inequality, in short, is a conservative issue too. We must develop a positive agenda that integrates the right kind of egalitarianism with our conservative principles of liberty. If we neglect this task and this opportunity, we won’t lose just the northern Virginia suburbs. We will lose America.