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 s omething 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.

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