When a strong public institution/policy cannot be dismantled or repealed through a frontal assault, opponents can find alternative means and strategies to achieve their ends.  Political scientists have identified a number of strategies by which “incremental” change can be pursued.  The one that seems relevant for our discussions of the recent Medicaid voucherization proposals is Layering (Schickler 2001; Streeck and Mahoney 2005; Thelen and Mahoney 2010).

If you can’t directly get rid of a massive entitlement program that has popularity and a large support constituency, layer a private alternative beside it, and let the private alternative eat into the support and continued viability of the public option. 

From Streeck and Thelen (2005; 23): “While the established public system may well be unassailable, faster growth of the new private system can effect profound change, among other things by draining off political support for the public sector.”

Dramatically increasing the availability of health insurance by covering those people between 100% and 138% of the poverty level is a fantastic achievement.  We must, however, be mindful that doing so in a way that fragments support for public health insurance makes the spending cuts that have been fought off in the past more likely to succeed in the future.

Streeck and Thelen continue to describe why layering can be such an effective tool in policy and institutional change: “Since layering is not seen as a direct assault on the existing program, they typically do not provoke counter mobilization by defenders of the status quo.”

Fundamental change in our entitlement programs will begin just as this Medicaid expansion did – relatively quietly and out of the direct public glare.  

Perhaps Democratic politics are changing, and the Obama administration has decided that they are willing to trade expanded coverage for a larger and fundamentally different role for private plans within our public health insurance programs.  Or perhaps the Obama administration just needs to re-read their copy of Streeck and Thelen. 

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