James Capretta and Yuval Levin write that Republicans need to make major right-leaning health care reform the centerpiece of their campaign in 2012. They estimate the stakes correctly when they write:
For Republicans committed to maintaining a vibrant and free society, there is no choice but to make genuine health care reform the centerpiece of their domestic agenda. If the health care debate is lost, then the fight for limited government is lost as well.
But the obstacles to Republicans enacting, or even running on a right-leaning health care reform agenda are enormous. Part of the problem is with the right. Aside from tort reform and vague calls to get the government out of health care, no particular set of right-leaning health care reform policies are a component of conservative identity. Lower capital gains tax rates, expansion of oil drilling and opposition to socialized medicine are issues that have, for many conservatives, established narratives about growth, opportunity, freedom and justice. Voucherizing Medicaid and giving a flat tax credit towards the purchase of catastrophic health insurance don't. These kinds of connections can be made, but it takes time, effort, and repetition to create familiarity with the benefits of those policies, and the connections of those policies to principles of freedom, markets, and individual empowerment. It could happen. Most conservatives were in favor of greater oil exploration, but it took a combination of circumstances and political activism to make "drill baby drill" a big election issue (until the financial collapse.) For a tangle of commercial and cultural reasons, it is not safe to expect the main outlets of the populist right-leaning media to take the lead in emphasizing particular right-leaning health care reform policies. If those policies seem to be catching on, the populist right-leaning media will follow.
One could hope for evangelical-minded conservative politicians and candidates to expand public understanding of right-leaning health care reform, but it would take a candidate of unusual character to make right-leaning health care reform the "the centerpiece of their domestic agenda." That doesn't mean most conservative politicians won't have a good health care plan on their website (McCain did.) That doesn't mean they won't have a one line or one paragraph nod to health care reform in their stump speech (McCain did.) It means that focusing on right-leaning health care reform at current levels of public understanding and salience will endanger their campaigns. In the Republican presidential primaries, it would make more purely political sense to talk about cuts to the corporate income tax, complain about this week's provocation from liberal-leaning figures, or find some new way (or yell some old way) to express contempt for Obama.
Paul Ryan in one figure who takes right-leaning health care reform seriously. He will get attention for his policy suggestions in the coming months (and not just on health care), but there are many segments of the population that a congressional committee chairman is not going to reach. The politicians who can reach those other segments are Presidents and presidential candidates. Ryan isn't running for President. Newt Gingrich is (probably) running for President. I heard him on the radio talking mostly about tax cuts and oil exploration and making fantasy promises about low unemployment rates and low gas prices. Pawlenty is running for President. His most recent CPAC speech included a vague little paragraph about giving people control of their own health care spending, but saved his energy for a phony and hyperbolic scream about how Obama should stop apologizing for the USA. Gingrich won't be Republican nominee and Pawlenty might, but their behavior closely tracks the political incentives and we probably can't expect better from most other politicians (that is a probabilistic rather than a normative statement.)
It doesn't get better when you get out of the Republican presidential primaries. The issues involved in right-leaning health care reform are complicated. Right-leaning health care reform policies would mean many people switching out of their employer-provided policies. What about the currently uninsured and uninsurable? There are answers (subsidized high risk pools or direct subsidies for those currently without insurance but with a cutoff date for new entrants), but they are complicated. All the time the Democrats will be attacking you saying that you are going to kill grandma and throw people on the street if their kids get sick. Public comprehension of right-leaning health care reform is low on the right, but virtually nonexistent among the potentially persuadable. Health care security is an extremely personal and high salience issue. John McCain was, in one sense, being quite rational in trying to get people outraged by pretending to believe that Obama called Palin a pig. It sure beat having to explain his heath care plan.
But Capretta and Levin are right. Public understanding and support for a patient-centered and market-oriented health care reform will have to be built somehow. It could be a candidate of public relations genius, or a book that catches the imagination of the right-leaning populist media. I hate waiting for one person to do something. What if they get run over by a bus? Also, 2012 might not be the year for Republicans to win (maybe it will, but conservatives should be ready for both eventualities.) Republicans will have the opportunity to govern again, but will they be ready with the right reform program? Even more important, will they have enough public understanding of, and support for their program so that Republicans politicians will be able to enact and sustain their policies in the face of Democratic counterattacks?
I'll try to have some thoughts a little later in the week.