In his latest New York Times column, Paul Krugman makes an argument near and dear to my heart and familiar to regular readers here: the two parties’ approach to the Medicaid program ought to be a really, really big deal in this election:

There’s a lot we don’t know about what Mitt Romney would do if he won. He refuses to say which tax loopholes he would close to make up for $5 trillion in tax cuts; his economic “plan” is an empty shell.

But one thing is clear: If he wins, Medicaid — which now covers more than 50 million Americans, and which President Obama would expand further as part of his health reform — will face savage cuts. Estimates suggest that a Romney victory would deny health insurance to about 45 million people who would have coverage if he lost, with two-thirds of that difference due to the assault on Medicaid.

Krugman goes on to patiently explain the Medicaid program: its central role in providing health insurance and not just to needy families with children (particularly the working poor) but also to “medically needy” seniors, including the 6 million for whom Medicaid pays nursing home bills; and its sterling cost-control record as compared not only to Medicare but to private health insurance. And he’s right: this is one of the relatively few areas of domestic policy where both Romney and Ryan have been very clear about their intentions (if not at all honest about their consequences, since they treat block grants as some sort of magic that enables already fiscally stressed states to cover more people with vastly less money).

I’d add to Krugman’s argument a simple political one: despite the CW holding that people who vote care intensely about Medicare but not at all about Medicaid, messing with Medicaid is unpopular. A Kaiser Family Foundation poll back in May showed that the sales job for Paul Ryan’s Medicaid block grant proposal wasn’t going over terribly well (per Emily Swanson at HuffPost):

The Kaiser poll finds that 60 percent of respondents would prefer to keeping the government health insurance program for low-income and disabled Americans as it is now, “with the federal government guaranteeing coverage and setting minimum standards for benefits and eligibility.”

Only 35 percent would support changing the program “so that the federal government gives states a fixed amount of money and each state decides who to cover and what services to pay for.” That suggestion is part of Wisconsin Republican Paul Ryan’s proposed 2012 budget, which passed in the House with overwhelming support from GOP Reps.

And that’s with very little attention having been paid to this topic by Ryan’s critics, consumed as they were with Medicare. As Kaiser found, a little more pushback to the block grant proposal moved even more voters:

[A]n even larger percentage of those who initially said they would favor the changes said they would be swayed to keep Medicaid in its present form by a potential Democratic argument. When told that “[o]pponents of this change say it will increase the number of uninsured, increase financial pressure on states and health care providers, and cause more low-income people to go without health care and long-term care services, particularly during tough economic times,” 26 percent of those initially in favor of the change said they would now be opposed, for a total of 25 percent in favor of block grants to states and 69 percent opposed.

If Romney wins, particularly if it’s by convincing swing voters that he’s this moderate technocrat who will just smooth off the edges of Obama’s policy agenda and apply his management acumen without radical changes in the role of government, the failure of Democrats to make a big deal out of his and his party’s health care agenda beyond Medicare should haunt progressives for a long time. The Medicaid block grant is the biggest example of a card not played, but a more intensive focus on the positive aspects of Obamacare, and also exposure of such reactionary GOP “ideas” as interstate health insurance sales (which would destroy existing state protections of people with pre-existing conditions and older and sicker Americans generally) also largely failed to make the cut in Democratic arguments about the “big choices” this election entails. And if these proposals are actually implemented, no one can say they were not warned.

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Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.