Reihan Salam writing on why some Republican politicians have switched sides on a federal health insurance purchase mandate:
As with SOPA, the fact that a large number of Republican lawmakers in 1993 backed an individual mandate doesn’t necessarily mean (alas) that they had thought deeply about the issue. Rather, they had outsourced thinking on that question to credible policy elites. But when they had good ideological and political reasons to think otherwise, they flipped. That is, when new elite voices became engaged in the conversation and contested the claims made by the narrower elite, the issue moved from the realm of the uncontroversial to the controversial — and the side that won was the side that was more in tune with the larger ideological community.
Salam further writes that “Essentially, Republicans assigned moderates the responsibility for thinking through policy domains like health, education, and welfare, which were considered, during the Cold War years at least, less important that foreign and defense policy” But as the Cold War ended “Domestic policy gained in relative prestige, particularly as southern conservatives who were particularly exercised by the failures of the welfare system gained in power and prominence relative to the declining moderate wing. Moderate Republicans, meanwhile, started going in different directions. Those who shared the Democratic faith in activist government, tempered by a desire for decentralization and fiscal rigor, often left the party to become Democrats. Those who shared conservative skepticism of big government, tempered by a recognition that Social Security and Medicare were here to stay, found themselves gravitating to the right.”
I think Salam gets the story largely right, but I’d add that discussion of health care policy (in the sense of having large policy proposals apart from tort reform) was (in my experience) much less prominent among rank-and-file voting and media consuming conservatives as compared to say tax cuts. Speaking for myself, I tended to read National Review and the Weekly Standard (though not every issue.) I listened to conservative talk radio when I was in the car and Limbaugh or somebody was on, and I watched more C-SPAN than was healthy. I remember watching a speech by (I think) Chris DeMuth who said that the key political economy arguments of the future were going to be over health care. He wasn’t simply talking about stopping “socialized medicine” or enacting tort reform. He was arguing that the status quo was unstable and that the coalition that won the argument over the size and scope of government would be the one who enacted it’s policies to reform the health care market. The speech caught me short. If I’d ever heard such a message before, I certainly hadn’t heard it very often (compared to say the argument for how tax rate cuts could increase revenue.)
My sense is that rank-and file conservatives haven’t moved very far to the right on health care policy. I actually think that is something of a bad thing. So here is something I wrote over at the old No Left Turns site:
This is an interesting chart (though a bit blurry) from National Review in 1993. It lists the health care ”parties” from left to right with single-payer health care on the extreme left and consumer-oriented reforms on the extreme right. What jumps out is that a combination of mandates, guaranteed issue and subsidy (the building blocks of Obamacare after the public option was taken out) is positioned as the moderate conservative position. One way to read the chart into the present is to argue that conservatives have gone far to the right on health care since what was moderate conservative in 1993 is now socialized medicine.
I don’t think such a reading would be correct, because the chart left out an important category. For one thing, most conservatives could rightly argue that they never supported mandate/guaranteed issue/subsidize and never considered such a policy either moderate or conservative. In 1993, I sure didn’t. Mandate/guaranteed issue/subsidize might have had a following among some conservative policy analysts and Republican politicians, but I don’t remember that such a policy (and especially not mandates) was popular among the mass of conservatives. My sense from listening to and watching, (and later reading through the right-blogosphere) conservative media and my conversations with conservatives over the last seventeen years is that neither mandate/guaranteed issue/subsidy nor consumer-oriented health care was the dominant position among most self-identified rank-and-file conservatives. The dominant position seemed to boil down to several propositions:
1. America had the best health care in the world and the health care system was basically functional.
2. Socialized medicine was a menace that must be defeated.
3. Premiums were rising too fast, but tort reform and making it easier for small companies to pool to buy health insurance would reduce frivolous lawsuits and defensive medicine, increase the supply of doctors, and make it easier for employers to offer affordable health insurance.
The first two propositions were the most important. This position was oriented more toward protecting the then-existing system from radical change (understood, almost by definition, as coming from the left) than in its suggested reforms. This helps explain the fairly low priority that health care politics took among conservatives between the defeat of Clintoncare and the credible threat of Obamacare. Tort reform would have been nice, but conservatives had basically won in preventing socialized medicine and there were always other, more pressing issues.
Ignoring this conservative position on health care (which I suspect is still the dominant one among conservatives as a whole) would continue to distort how we look at the politics of health care. While the opposition to mandate/guaranteed issue/subsidize is much more intense now than in 2008, the change among conservatives is probably smaller than it appears. Most conservatives are where they have always been, they are just more active and the priority of the health care issue has increased. I also suspect that there is less change among most conservatives than might appear regarding consumer-driven health care reform. Conservative policy analysts, conservative journalists, and more and more Republican politicians have come out in favor of various versions of consumer driven health care reform, but I wonder what the majority of conservatives who showed up at the town hall meetings and Tea Parties think? My best guess is that they would be quite happy with a total repeal of Obamacare, plus tort reform, plus allowing employers to buy health insurance policies across state lines, and getting that, would be quite happy to move on to other issues. I also doubt that they would be very enthusiastic about consumer-driven health care policies that would destroy the private, employer-provided coverage that gives them access the world’s best health care system. Which is to say that I suspect that supporters of consumer-driven health care (of which I am one) should take some, but not too much solace from the movement of policy analysts, conservative journalists and Republican politicians to their side, and that they have a huge job to do selling their ideas to their fellow conservatives – to say nothing of persuadable nonconservatives
Update: I got the chart from this Stephen Spruiell post over at NRO’s Corner.”
Okay, I’m back. The one caveat I would add is that rank-and-file conservatives seem more open to phased in premium support Medicare, but we haven’t seen Obama and his media allies launch their general election campaign about how Romney-Ryan Medicare vouchers are going to force old people to bankrupt themselves and then die untreated. Maybe otherwise conservative elderly and near-elderly will be dissuaded from voting out of fear of what changing Medicare will do (even if the proposals would not apply to them) and maybe some younger people will too.
June 22nd, 2012 | 2:08 pm
I like this explanation a lot, much more satisfying that the attempted “conservatives flipped purely for the expediency of opposing Obama” narrative, which has always rung hollow to me because I don’t think the sheer effectiveness and strength of conservative opposition to Obamacare can be explained solely by partisan opportunity. There had to be something of substance to motivate conservative opposition.
Something Pete touched on in passing that I’ve suspected for a while, is the fact that conservatives were essentially caught flat-footed by healthcare as a major public policy issue, because conservatives by their nature won’t take too much interest in the subject apart from preventing governmental intrusion. If you have a limited government mindset, then you’re not going to go out of your way to think of policy proposals in an area that you don’t think the government should be involved in to begin with. This would also help explain the early fumbling attempts at developing a conservative health care policy that included mandates. When you’re not familiar with a subject, it takes a while to work out a practical policy agenda in line with your political philosophy. Several years of intense debate on the issue has probably done wonders to educate both conservative elites, and the rank and file.
On the flip side, I think the left has a similar blind spot when it comes to foreign policy and military affairs in particular. Though this is anecdotal, my liberal acquaintances (many in grad schools) can’t talk realistically about, say, Iran, because they don’t know the first thing about how a military engagement with Iran might actually play out.
June 22nd, 2012 | 8:10 pm
Having worked for small companies the last few years, after having worked for big companies for a while before that, it is screamingly obvious to me that employer-provided insurance should go the way of the dodo. I know it won’t, because it’s “conservative” to keep this familiar system intact, no matter how stupid it is, but it really would be so much better to be completely eliminated.
Also, having had several expensive medical issues in my family the last few years, I have had far, far worse experience dealing with medical billing coming from the doctors and hospitals than I have had dealing with my various insurers. I’ve actually been able to convince insurers they were wrong, but billing departments?–never once. I suspect a lot of the problem with rising cost of health care is being attributed to the wrong link in the chain…
June 22nd, 2012 | 9:44 pm
My conservative confreres think I’m preaching heresy when I propose ending employer-provided health insurance. If most of these guys spent a month as an entrepreneur I know they’d be on my side. It’s just too easy to be contented with the status quo when it’s painlessly deducted from your paycheck every month (same with taxes). Those of us on the front lines of small business understand how inequitable the current state is.
June 23rd, 2012 | 9:35 am
Brian and Mrsschiavolin, astute observations, and Fabius, you’re quite right about the comparative right/left blind spots, although I’d like to think that everyone gets as bored stiff and as confused as I do on the health-care stuff.
On that note, Pete, perhaps you could take us through the ABCs of consumer-driven health-care. What it sounds like to Troglodyte me is the paperwork equivalent of having to do my taxes, but every month instead of once a year, and never, ever with that feeling of “it’s done!”
June 23rd, 2012 | 3:29 pm
Carl, different answers for different populations but a program like Indiana’s combination of Health Savings Accounts + tiered cost sharing + catastrophic coverage seems to save the average worker money while insuring against catastrophic costs and doesn’t seem to include much more insurance company wrangling and paperwork than more comprehensive pre-payment style insurance policies. http://online.wsj.com/article/SB10001424052748704231304575091600470293066.html Now how to get from here to there…
I’d also include mandatory price publication and letting nurses and physicians assistants handle more routine care.
None of this is the answer to everything, but better is better.
June 23rd, 2012 | 7:37 pm
Carl: I don’t understand why you think individual-centered health insurance needs to be so complicated. Do you have homeowners/renters insurance? Auto insurance? Life insurance? None of these require monthly attention. There’s no reason why health insurance should either. And there’s no reason your employer should arrange health insurance and not all these other insurances, as if you were their child. Heck, why not have them pay your rent/mortgage while they’re at it. I should stop before I give the government too many ideas…
June 25th, 2012 | 8:35 am
So let me get this straight. The conservative Wise Men, even after the Reagan revolution, just weren’t interested in the health care “business” (health care has nothing to do with human dignity and flourishing, and should be profit-motivated), and never gave it a thought, being rightly preoccupied with Demon Communism and all. When they did start to think about it, under some liberal pressure, they only thought about it in a very shallow way, which led them to propound solutions the liberals later thought they might actually agree to. Then, *finally*, the Wise Men managed to really activate their Reasonable Right-Wing Faculties and saw God’s truth: that their earlier solemnly propounded systems were actually (HOLY S**T!) unconstitutional.
So how do we know they actually got it right this time, in all their Wisdom?
June 25th, 2012 | 11:27 am
HT, if that interpretation helps you get through the day (and leaves more time to find ways to remove the profit motive from anything that has to do with human flourishing), then I say go with it.
It would mean ignoring that the most elected Republicans never supported a federal insurance purchase mandate and probably never though much about the issue until it became a matter of urgent dispute. You could probably say the same thing about a lot of center-left folks and same sex marriage from 20 years ago (oh, the human flourishing of it all!! oh, the failure of the liberal wisemen to anticipate all the arguments that would come up and from every angle!!)
You are right that the center-right in general had a very strong status quo bias on health care policy and my sense is that preferred policy proposals (mostly tort reform and creating an interstate market in insurance purchases) were often deployed more as conversations stoppers that anything else (oh, so you’re not for tort reform? Then you’re not serious about reducing health care costs. Now let’s talk about cuts to the capital gains tax.)
June 25th, 2012 | 2:42 pm
Pete, I just report what I hear from you folks, in my own words. :-)
It is an interesting narrative you propose, if one gets off on the minutiae of politics (the center-right vs. the hard right vs. the libertarian right vs. the hawkish right vs. the isolationist right vs. the neofascist right vs. the ultramontane right vs. the social right vs. the pomocon right vs. the front-porch right vs. the crunchy right vs. the think-tank right vs. the congressional right vs. the redneck right vs. the Fr.-Neuhaus-I’m-so-high-falutin-I-wanna-sound-like-Newman-or-Waugh-without-the-Victorian-queerness-right or whatever: but they all vote the same in the big elections anyway, i.e. for the plutocracy, which is largely true of the Dems also), which I don’t. Unfortunately all these fascinating little political games have consequences for little people like me (no consequences for Pelosi or Romney or the Kochs beyond some small dent one way or the other in their Midas-hoards).
June 25th, 2012 | 3:26 pm
HT, I don’t know what Paul Newman has to do with this, but people do act within political coalitions and do respond to what happens both within and outside of their coalition, and, if you want to understands how their perspectives change over time, it helps to keep that in mind. Or you can dismiss them as a the Other who are duped into working overtime for the Plutocracy – unlike yourself. I’d also add that a party that whose congressional leadership and membership supports premium support is different from one who looks at Medicare and says either let’s not talk about it or let’s get rid of it or just wants to fund the staus quo. So how these things change do matter to folks who hope to live long enough to get Medicare.
I think that Pelosi has some pretty strong policy prefernces that she seeks to advance alongside of her goal of winning and holding power (and mostly apart from how this effects her net worth.) I’m not nearly as sure Romney is in it for his policy preferences, nor could I tell you with any confidence what they are (though I also don’t for a second think he is in it for the bucks.)
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