Roberta Costa and Andrew Stiles have written an interesting and mostly heartening article about the House Republican retreat.  The House Republicans seem to be asking a lot of the right questions. One section pulled me up a little short:

Minority outreach is a priority. Greg Walden, who is also chairman of the National Republican Congressional Committee, acknowledged the obvious at his press conference: Republicans have done a poor job of reaching out to Hispanics and other minority groups. But he predicted that House Republicans would make improvements in the run-up to the 2014 election. “We just have bad communications in many cases,” Walden said. On Friday, the topic will be explored at length in a morning session featuring Ana Navarro, a Hispanic political strategist.

Communication is big part of the problem, but it can’t be separated from the policy and intracoalitional tensions within the Republican party. Take the health care issue. A wide majority of Hispanics approved of Obamacare. So did a plurality of young voters. This even though Obamacare actually shifts health care costs upon the young.

Rhetoric explains some of what went wrong in the above polls. Most Republican presidential candidates couldn’t make a case against Obamacare Romneycare to Republican primary voters never mind to nonwhites and ideologically uncommitted younger whites. But the problem isn’t just how Republicans criticized Obamacare.  It is also how Republicans have approached health care policy generally.

Older right-leaning voters have been socialized into a particular view of the politics of health care. This view has the following key propositions:

1. America has the best health care system in the world.

2. America’s health care system must be protected from socialized medicine.

This is an overwhelmingly defensive political agenda. There are some affirmative policy views that are associated with all this. Prominent popular conservative spokesmen (Rush Limbaugh comes to mind, but others too) would talk about the importance of tort reform. If pressed, they would argue that most problems in health care were caused by government interference and the real solution was to get government out of health care.

The affirmative policy prescriptions were not the driving force. Tort reform was never a policy priority on the order of say, tax cuts. It was more of a conversation stopper. Oh, the Senate Democrats are filibustering tort reform? That just shows that they aren’t serious about containing health care costs. Time to move on to another issue. Conservative spokesmen weren’t really agitating to end Medicare. Too many people in the audience were on Medicare, would soon be on Medicare, or had parents on Medicare. The point was to show that government involvement had driven prices up. And they had a limited but very important point.

But while the affirmative conservative policies were either low priority or rhetorical, the fears of socialized medicine were real. Older conservatives really were happy with their existing health insurance arrangements (though not always the rising health care premiums), happy with the quality of care, and worried about liberals finding a way unwind the health insurance system and replace it with centralized government rationing. When you put all this together, you had a strong status quo bias and it left the initiative to the left.

Nonwhites and younger whites who were not socialized into the conservative narrative don’t have the same hostile reaction to phrases like “socialized medicine.” It is a rhetorical short cut that doesn’t get you anywhere. You need to slow down and explain how particular policies will produce benefits and costs in their lives. And it isn’t just how people respond to particular words and phrases. Nonwhites and younger people are more likely to be outside the system of employer-provided care or know more people who are outside that system. The system doesn’t look as good when you have to wait a long time for an appointment with one of the comparatively fewer doctors who accept Medicaid or wait in a clinic hoping to see a doctor who is volunteering their time. Absent preexisting political commitments, these experiences push people in the direction of favoring policies that promise increased insurance coverage if that coverage can somehow be tied to access to health care – even if there is a risk that the policy might actually make things worse in the end. It is a chance worth taking. All other things being equal, attacking attempts to increase coverage (even if they are well presented), will sound like carping in the absence of a positive alternative.  And all other things aren’t even equal. Only a minority of disproportionately older whites consume much right-leaning media. Most nonwhite and many (maybe most) younger whites consume media that would lead consumers to think better of Democrats. The resulting rhetorical, policy, and media problems amplify each other.

There are  reasons (other than the relative lack of interest of much of the party electorate) why Republicans (especially presidential candidates) are unwilling to focus much of their campaign energy on positive health reforms even when they propose some pretty major health care policy changes in their platforms. The left’s long-term strategy is to ration care through government denial and delay of care, but to leave incumbent health care providers in place to divide up the more-slowly-growing pie. You can see a center-right agenda that seeks to move the working-aged into a system of catastrophic health insurance and the elderly into a premium support system along with supply side reforms. Such a set of policies would push providers to offer care at the lowest price, and for consumers to make more cost conscious decisions about expensive procedures with low likelihood of success. These policies might well lead to a more efficient health care system that increases the take home pay of most people while maintaining their health care security. The losers would be many incumbent medical providers who are influential at both the institutional and individual level – and who probably include a fair amount of registered Republicans. So the Republicans face risk aversion everywhere they look.

Taking the risk is probably worth it. Republicans are talking to a minority that is in relative demographic decline. They need to champion policies that accord with the principles of their base and that offer a better life to people outside that base. If Republicans can’t do that, they face the more likely risk (and nearly the certainty) of becoming as marginal as the California Republican party.