[B]oth sides’ political rhetoric of principle and altruism is disingenuous. Concerns about general health and welfare or of government takeovers are window dressing for political pandering…. Tax-sensitive middle-income and upper-middle-income voters weigh more heavily in [Republicans'] minds than voters who rely heavily on means-tested programs like Medicaid or who are uninsured, and so a desire to contain the costs of Medicaid will tend to trump a desire to expand access to Medicaid…. Democrats also tend to represent public employees, which will incline them towards backing the expansion of public services more broadly….

Conservative reformers often argue that the GOP ought to devote more time and attention to coverage expansion, education reform, and efforts to increase employment and wage levels…. I’m a big believer in this agenda. It is important to acknowledge, however, that this agenda is a tough sell, as voters tend to be risk-averse and the benefits of many aspects of this agenda will likely flow to non-Republicans while the costs will be borne by Republicans. Efforts to contain medical expenditures will involve curbing the power of physicians, a constituency that is divided between the two major parties, yet which contains large numbers of Republicans. Reducing taxes on middle-income families with children in a revenue-neutral fashion will require (under one scenario) raising taxes on high-income families residing in high-tax jurisdictions, a group that is overrepresented among influential Republicans, including many GOP donors….

None of this is to suggest that reform conservatism is doomed. It is a natural fit for Republicans running for national office, or in diverse, heavily urbanized states and congressional districts….

Basically, Republican voters are faring tolerably well in a pretty dismal economy, and this is actually making it harder for Republican politicians to embrace policy approaches that are relevant to the broader economic and social problems facing the country.