There are reports out of Texas that as many as a dozen states are thinking of opting out of Medicaid. They have their reasons. The program is expensive for the states and seems to do a lousy job of delivering care.
But I don't think the answer is for states to opt out of Medicaid. I think the answer is for Republican governors (and the newly elected Republican state legislators) to offer policy fixes for Medicaid in their own states, apply for waivers from the federal government and let the Obama administration say no if they dare. There is obviously a policy component to this. The governors would have to put together Medicaid reform plans that would either save money or plausibly offer better care to Medicaid recipients or both. There are several models to choose from including Mitch Daniels's Healthy Indiana Plan, and Bobby Jindal's plan to introduce insurance competition into Medicaid. Let a dozen reform plans bloom. Then the governors (hopefully a lot of them) could put public pressure on the Obama administration (and make intense use of media) to allow the states to experiment with plans that would save the their states money and offer better care to their states' residents. This could also be a good way to open a two front war against Obamacare as it would let congressional Republicans introduce bills to give the states flexibility. All of this would tend to increase public awareness of more free market approaches to health care reform and we might actually get some good policy out of it to boot.
Obamacare includes a huge expansion of the already problematic Medicaid program. It is also contains an opportunity for conservative politicians to gain ground on the health care issue and restructure Medicaid in a direction that nudges the country toward a more consumer-driven health care system.
h/t to Peter Suderman.
I've been thinking about what public spirited Republican governors and Republican members of Congress outside the senior Republican leadership should talk about in the next year if they are at a public forum (thanks to our commenters in the thread below.) I've also been thinking about the political implications of Henry Olsen's insights.
I think that the important thing for folks like Mitch Daniels, Chris Christie and Marco Rubio to focus on are ways to talk about significant policy change in the least scary way possible. The budget fight looks like it will mostly be on domestic discretionary spending, and while that is important, I'm not sure it is the best use of Daniels' or Rubio's time with the public to spend a lot of time talking about how this or that smallish program will be cut. We won't be saved by such changes (though we should pursue them of course) and there will be so many other folks talking about them that the comments of a Daniels or Rubio are not likely to add much value. I think the same is true of Obamacare. There will be frontal assaults ( a vote to repeal) that won't be enacted and the flanking actions most likely to pass (getting rid of the 1099 reporting requirements and undoing the cuts to Medicare), would add to the deficit, and more deeply entrench Obamacare politically, while leaving Obamcare's core structure untouched.
Folks like Daniels and Rubio should focus on strategy rather than tactics and always try to use examples drawn from the real life experience. They should build their criticisms of Obamacare around the basic problems of how Obamacare's combination of individual purchase mandates, coverage mandates, guaranteed issue and community rating have involved large premium increases in Massachusetts and increased the cost to taxpayers too. They should also note that Obamacare is an inferior system to Romneycare and that the consequences of Obamacare promise to be worse. They need to explain how the crony capitalism of Obamacare's system of health insurance waivers allows bureaucrats to cancel your health care policy and force you to pay higher premiums while others in more politically connected companies are allowed to keep the same kind of insurance.
They should keep in mind Henry Olsen's observation that many working-class (and I would add not only working-class) voters are not enthusiastic about sudden change. Conservatives should never seem like they are getting high off their own radicalism. Conservative reforms should, whenever possible, be presented not as radical change but as the moderate alternatives to the radical and disruptive changes (in the forms of higher taxes, higher insurance premiums, denial of care and fewer jobs) that would come from leaving liberal policies in place.
This has implications both for which policies should be emphasized and how policies should be sold. A Ryan Roadmap-style health care reform that would destroy the employer-provided health insurance system in one step is probably not going to fly. Incremental policies that demonstrate benefits to people who choose consumer-driven health insurance policies have a much better chance of winning public support. Whenever possible, conservative policy proposals should be paired with examples of how similar policies achieved perceptible benefits. Mitch Daniels' system of HSAs saved the government money and increased the take home pay of workers. It should be talked about at every opportunity. Where examples of well functioning alternatives are not available (like with reinsurance pools), there is no alternative to doing your homework, knowing the details and driving home the basic points that the reinsurance approach would save the taxpayer's money, cover people with preexisting conditions, and avoid sticking the rest of us with purchase and coverage mandates that will cost us more in premiums and put us at the mercy of government bureaucrats.
Whenever possible, try to steer the conversation away from the tactical political fight of the moment or the latest inflammatory comment. Try to be bigger than the moment and talk about the big things that get lost. Major political reform often come very, very slowly before they can come quickly. Obamacare was fifteen years in the making and is itself some distance from the intended final destination of government-run health care. We have a lot of catching up to do.
Refine & Enlarge
The Republicans' case [for representing the what "the people really want" from their government], . . . is already under assault. Along with the Democrats' open campaign to persuade the public that the election did not mean what Republicans thought, there is an allied effort underway, far more subtle, to undermine and weaken the Republican position. It comes from a group of self-proclaimed wise men who present themselves as being above the fray. These voices, acting from a putative concern for the nation and even for the Republican Party, urge Republicans to avoid the mistake of Obama and the Democrats after 2008 of displaying hubris and overinterpreting their mandate. With this criticism of the Democrats offered as a testimony of their even handedness and sincerity, they piously go on to tell Republicans that now is the time to engage in bipartisanship and follow a course of compromise. The problem with this sage advice is that it calls for Republicans to practice moderation and bipartisanship after the Democrats did not. It is therefore not a counsel of moderation, but a ploy designed to force Republicans to accept the "overreach" and the policies of the past year and half. It is another way to defend "the change." If Republicans are to remain true to the verdict of 2010, they cannot accept that the message of this election was just containment; it must mean roll back.Olsen's argument, however, is deeply rooted in his thoughtful observations of working class voters and their fears of too much change. He seems to suggest that there is something very real in the caution offered Republicans to beware of hubris. Tea Party or no Tea Party, there is no evidence of a real and consistent conservative majority in American politics--as some hopeful or lazy conservatives would have us believe. Perhaps there is something fundamental in the American character that resists progressivism . . . but it probably does not reflect much of anything conservatives have done to win them over. As Olsen puts it:
Conservatives often assume that elections like 2010 show America has a consistent conservative majority. I think it is more accurate to say that they show that America has a consistent anti-progressive majority. The task conservatives have today is to transform the anti-progressive majority into a pro-conservative one.
Say you are a Republican governor (like Bob McDonnell or Bobby Jindal) or a recently elected Republican Senator (like Marco Rubio, Pat Toomey or Kelly Ayotte.) You are able to get some bookings for the cable news networks, conservative talk radio and even the dreaded NPR. To the extent that you can steer the conversation, what issues do you talk about and what policies do you propose and emphasize in the coming year?
Refine & Enlarge
After the election, Naomi Klein commented: "What Obama refuses to get: There is no escape from furious enemies."
No less true in international affairs than in domestic politics.
Refine & Enlarge
Over at NRO, Henry Olsen of AEI has written a very interesting (and sprawling) "memo" outlining the challenges for conservatives if they hope to reclaim the public mind after this election. After last Tuesday night three points particularly stick out as worth thinking about right now.
First, if conservatives are going to build November 2 into an enduring political majority, they need to start by understanding their political opponents, the progressives. Today the Democratic Party is the home of progressives, who according to Olsen are more or less defined by their idea of freedom, which is that government must remove "material and immaterial obstacles to some individuals' ability to make the decisions they would prefer to make, even if removing those obstacles places obstacles in the paths of other Americans."
Olsen notes, however, that there is a running civil war among progressives over how to advance their goal. Liberal progressives (the "wine set") have "lofty ambitions" for transforming America right now while moderate progressives (the "beer set") want to work more modestly and slowly. (EJ Dionne has written the liberal argument in The Washington Post; Evan Bayh makes the moderate's case in The New York Times.) The two groups don't have fundamentally different goals (for example, Bayh calls universal health care a "noble aspiration"), but they do have very different attitudes. Liberals are impatient and willing to act without public support if they have the political power; moderates believe in accommodating and working on public opinion before advancing. Bill Clinton was a moderate (at least after 1994); Barack Obama is a liberal.
Second, conservatives need to understand when and why progressives crash politically, as they did on Tuesday. Olsen shows that since the Democrats have become the party of the progressives, they have suffered big defeats four times after holding both the White House and Congress with "large supermajorities": 1965-1966; 1977-1980, 1993-1994; and 2009-2010. Each time, it was the loss of working class voters (including independents) that ruined them, as we saw in the Midwest this election. (Both Ron Brownstein and David Brooks have recently made the same argument.) Such voters deserted the Democrats in reaction against the policies and attitudes of liberal progressives (something the Blue Dogs have been warning about for a while).
This is because liberal progressivism runs contrary to a number of what Olsen calls "The Seven Habits of the Working Class": hope for the future; fear of the present; pride in their lives; anger at being disrespected; belief in public order; patriotism; and fear of rapid change. He explains these at some length (it is really worth reading), but for now it is enough to note that in some of these habits the working class is aligned with conservatives (hope for the future, pride in their lives, patriotism), in some with progressives (fear of the present), and in other habits they are aligned with conservatives or progressives depending on the policy. For example, Olsen argues, working class people like the police (conservative) and public education (progressive); and they do not like ObamaCare and privatizing Social Security for the same reason (fear of rapid change).
Third, Olsen argues that conservatives need to understand what it means when working class voters abandon the Democratic Party (as they did in this election). As many people have said, conservatives shouldn't overinterpret their mandate like the liberals did in 2008. On November 2 working class people did not so much vote pro-conservative as anti-liberal. This means that conservatives need to win these voters over to their principles if they want to begin to really make limited government conservatism the center of gravity in American politics.
Here, according to Olsen, is where conservatives run into a problem. To win working class voters, conservatives need to understand and respect their "Seven Habits" when running for office and when advancing policies. According to Olsen, Ronald Reagan was great at doing both (hence Reagan Democrats). George W. Bush also did a good job in 2000 and especially 2004.
Yet Reagan created Reagan Democrats, not new conservatives committed to limited, constitutional government. He tapped into the conservative elements in these voters, but he did not convert them. Olsen suggests that Reagan went as far as a conservative could go because working class voters simply will never wholeheartedly embrace limited government conservatism just as they have never really embraced liberal progressivism. They may not want ObamaCare but they do want the security of Medicare.
The question then is whether it is possible for conservatives to persuade such voters. The only way would be to show working class people that the principles of constitutional self-government fit with their "habits," especially if those habits can be broadened by persuasive arguments. For example, conservatives could talk about education not by calling for the immediate abolition of the Department of Education or by attacking public education altogether (which the working class respects and depends on). Rather, they could emphasize reform ideas like school choice, which is consistent with the working class "habits" of hope for the future and of taking pride in knowing what's best for your kids and being responsible for doing it. Of course, school choice is an idea rooted in the principles of limited government, but conservatives don't have to talk that way in order to begin to persuade working class voters to support conservative education reforms. Persuasion has to happen step by step. Once the idea of school choice becomes part of their "habits," for example, the working class would move further away from any alignment with progressives on the issue. The same could be possible for health care and Social Security.
In considering the problem that Olsen poses to conservatives, we shouldn't forget that enduring political change only happens in American politics with the right combination of principle and persuasion. Persuasion must be rooted in principle, but it also must respect people's habits, interests, and attitudes. You don't persuade people by shouting at them to change their habits when they don't fit with the principles of limited, constitutional government. You go to them, talk to them as equals, and try to persuade them that their concerns are met by those principles. You respect them as fellow citizens. Then they can hear what you are saying and start to embrace your principles. If conservatives could be persuasive in that way, November 2 could be the beginning of a new political alignment.