Can post-Obamacare reform be exchange-based?

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Is it possible to co-opt Obamacare’s endorsement of exchanges to achieve free market reforms? Philip Klein is skeptical of Avik Roy’s approach:

Assessing Roy’s plan from a free market perspective requires first deciding what it should be compared against. The plan concedes a lot of ground to the left when it comes to emphasizing universal health insurance and maintaining key regulations, and it would spend more on subsidizing health insurance in the individual market than the system that existed prior to Obamacare. On the other hand, it would loosen the government’s grip on private health insurance relative to Obamacare, and it would inject market elements into Medicare and Medicaid, which are fully government-run systems.

So, whether or not free market advocates can get behind Roy’s approach will depend largely on how they view the status of the fight against the Obamacare. Those who view the battle as largely lost, can see in Roy’s proposal a way to make Obamacare less bad, while achieving long-term entitlement reforms that have eluded limited government supporters for decades.

Roy has shared an update to his plan based on reader feedback here:

Philip Klein of the Washington Examiner reviewed the plan for his blog, and later expressed his concern on Twitter that the reformed exchanges could be co-opted by the left. “I just think if you have more and more [people] moving to universal [exchanges, you] risk future Dems adding [a] public option” to the exchanges, thereby bringing us closer to a true single-payer system.

I think the likelihood of Philip’s scenario playing out is low. First of all, the Democrats tried to include a government-run “public option” insurer on the exchanges in 2009, and failed to do so, even with 60 Democratic senators. Secondly, the Universal Exchange Plan gradually moves nearly 100 million Americans off of single-payer health care–Medicaid, Medicare, and the VA–and so a concern that these individuals might return to single-payer health care, at a later date, seems a bit circular.

But a bigger challenge could be how the politically toxic nature of Obamacare could eliminate the ability to utilize steps like exchanges to solve the problem. This latest polling from The Morning Consult indicates as much:

A majority of people are worried about employers moving them on to insurance exchanges, with Republicans reporting the highest level of concern at 72 percent. But once they actually get insurance on the exchange, most Democrats and Independents, 43 percent and 39 percent respectively, think the shift would have “no impact” on their coverage. In contrast, most Republicans, 41 percent, think it would have a “very negative” impact. The majority of Republicans and Independents say they would consider looking for another job if they were shifted onto an exchange, at 62 percent and 52 percent respectively. Democrats reported that they would look for another job at a rate ten percentage points below Independents, at 42 percent.

This is another reminder that even talking about health care reform post-Obamacare is going to be difficult, given the level of political fractiousness surrounding the law. It remains to be seen whether political leaders are capable of navigating that new reality.