Josh Barro takes me to task for suggesting that Republican critics of PPACA, including Republican governors who oppose the law’s Medicaid expansion, aren’t necessarily opposed to coverage expansion as such.
Where to begin?
First of all, governors can’t repeal the Patient Protection and Affordable Care Act. Their option is to take federal funds that will pay for 90-plus percent of a Medicaid expansion to cover the working poor, or not. Republican governors who decline these funds will be attacked for blocking coverage expansion to help the poor and the sick that is nearly free to state taxpayers because that is exactly what they will be doing.
Second, any governors who believe that undermining Obamacare is part of a long game to get a better health reform are mistaken. If there is Republican enthusiasm for “a health system reform that seeks to contain cost growth through progressive cost-sharing, deregulation designed to facilitate business-model innovation, and other market-oriented measures,” then where was that reform (or even serious legislative action toward such a reform) when Republicans ran the federal government between 2001 and 2007?
The alternative to PPACA is nothing. Mitch McConnell’s comments last weekend were instructive — Republicans in Congress have no meaningful plan to replace Obamacare and think that 30 million uninsured Americans is “not the issue.”
The post is interesting throughout, and I recommend reading it. He makes another important point later on:
Conservative health wonks will object to my characterization. They will say they have many plans to use markets to drive down costs so that affordability is less of an issue. They may even advance plans that spend money to subsidize some sort of coverage for some expanded group of Americans. But Republicans have not taken them up on those plans when they have had the chance. That’s partly because expanding coverage costs money, and Republicans aren’t willing to spend money on it. And it’s partly because achieving significant cost control, even though market mechanisms, goes against the interests of groups that support Republicans, such as doctors and seniors. [Emphasis added]
My basic disagreement with Josh, I suspect, is over our mental models of how politicians think and how political coalitions evolve. My working thesis is that politicians, like all of us, have conflicting impulses, and that they operate in a larger institutional and ideological context that binds and constrains them in a variety of ways. This is implicit in Josh’s characterization, e.g., Republicans aren’t willing to spend money, presumably for ideological reasons, and Republicans are wedded to certain constituencies, like doctors and seniors.
But contexts change. For example, Josh could have written a very similar post in 2010 arguing that congressional Republicans would be strongly disinclined to endorse something like the Wyden-Ryan plan, as Republicans are wedded to seniors. Indeed, many conservative commentators argued that the GOP embrace of premium support was politically suicidal. For a variety of reasons, congressional Republicans moved away from strategic ambiguity on entitlement reform towards a broad architecture that was vulnerable to political attack.
So the interesting question is how contexts and constraints change. Part of the story is that larger economic shifts change the circumstances facing constituents, and this in turn creates a demand for new policy responses that politicians and political entrepreneurs then try to meet. The universe of potential policy responses, however, is constrained by ideology and identity. Many thinkers on the right believe that tolerating some modest increase in inflation is a good idea, as it might help mitigate the burden of household debt, it might increase employment levels, and it might make investors less risk-averse while the monetary status quo has led to sharp increases in social expenditures and and it has encouraged risk-averse investors to aggressively seek government guarantees. Yet politicians on the right resist this view because it clashes with their identity as inflation-fighters, and also because it is a high-salience issue for a minority of their supporters who are exposed, or who believe themselves to be exposed, to significant inflation risk.
One view, advanced by the political scientist Hans Noel, is that ideologues play an important role in defining the playing field — in determining which ideas are and not “kosher” for allied politicians to embrace:
To say that ideology is about justice means that ideologues are political moralists. But they are not pure moralists. The political intellectuals develop beliefs that are consistent with a set of interests or predispositions. Their efforts at persuasion lead them to develop links with others who have compatible interests, predispositions and ideas. This generates a coalition of people who originally cared about a narrow set of issues, but will come to agree on the entire ideology. However, ideologues have no particular concern with short-term minimal winning coalitions, and so will not modify their beliefs to include or exclude particular groups. Thus ideologies create coalitions among similar thinkers, but these coalitions are not perfectly tuned for electoral competition. The coalitions spread as the ideologies behind them are spread, especially to the most highly informed and politically active citizens.
Persuasion is central. Policy entrepreneurs develop ideas “with an eye toward some notion of justice,” and then they seek to influence and persuade people, including politicians, with “compatible interests, predispositions, and ideas.” If we assume that a Republicans governor has clashing views and interests, the role of a policy entrepreneur might be to persuade her to move in one direction by persuading her that it is kosher, i.e., ideologically acceptable, to do so. Recently, for example, grassroots conservatives managed to persuade large numbers of Republican officeholders that certain kinds of heavy-handed anti-piracy interventions are ideologically unkosher. This was an entirely new development, and though some of us have been making the case for this ideological shift for some time, it was not obvious that it would come to pass. Part of why it did come to pass is that politicians are interested in survival, and so they adapted to the fact that what looked like a high-salience issue for Hollywood and a low-salience issue for everyone else turned out to be a high-salience issue for Hollywood and for the technology industry and for a medium-sized and growing constituency of vocal, educated, and affluent voters.
During the mid-2000s, I often had conversations with Hill staffers about health reform, an agenda that had been pursued by members of the George W. Bush’s administration yet that never became a high priority. I was often told that the political barriers to a serious coverage expansion effort were very high, as the tax treatment of employer-provided health insurance was arguably the central problem with the U.S. health system yet it was very difficult to reform without unraveling the health insurance enjoyed by large numbers of Americans. Now, however, PPACA has created a moment of disruption: the creation of a near-universal four-tranche health system will significantly alter the health insurance arrangements for large numbers of Americans, which means that the prospects for other reform architectures may have improved by virtue of seeming less comparatively radical. That is, the playing field has significantly changed.
When I survey the affluent market democracies, I see a good deal of ideological ferment. Just as stagflation challenged the orthodoxies of the late 1970s and created an opportunity for new policy ideas and new ideological formations, we’re seeing a churn of ideas in the post-crisis era, usually but not always on issues that had historically been low-salience and marginal yet that have grown in prominence. Naturally, politicians will have an interest in masking this churn, and in claiming that some new set of ideas is fully in tune with the time-tested truths of social democracy or conservatism, etc. The plausibility of these intellectual efforts is important, and it is established socially, through the creation of a new consensus. If people who identify as being on the left agree that the left has always been for and must always be for collective bargaining for public sector employees, the fact that FDR opposed it or that the current president has imposed unilateral wage freezes seems like a trivial and irrelevant curiosity.
To return to the Republican governors, I actually do think that many if not all of those who oppose PPACA want coverage expansion of some kind (they certainly want the expansion of unsubsidized private coverage enabled by increased levels of employment and productivity — I don’t think anyone disputes that) and that they think PPACA is the wrong model. But I also think that the Republican governors are responsive to ideological cues from a variety of sources, which is part of why conservative policy entrepreneurs are making the case for alternative approaches to reforming the U.S. health system.
It is possible that the conservative policy consensus is fixed, that the post-crisis environment has had and will have no impact on how Republicans approach safety net issues, etc. But I think the evidence is strongly in favor of the punctuated equilibrium model of policy change as introduced by Baumgartner and Jones in Agendas and Instability in American Politics.
I should stress, however, that Josh could very well be right. We’re dealing with live disagreements here and we don’t really know how they will play out. Those of us who are in the persuasion business — i.e., the business of persuading our ideological allies that various ideas are kosher — necessarily have a different from view from those who are exclusively in the prediction or the analysis business.