Truth be told, some of the more interesting writing on the travails of the Obamacare enrollment system is coming from conservative Ross Douthat of the New York Times. On Sunday, he warned Republicans that their cackling over the enrollment mess was obscuring the realization that the Medicaid single-payer element of the Affordable Care Act was functioning better than the private insurance part of the insurance expansion:

[W]hile conservatives think the Obamacare exchanges are overregulated and oversubsidized, they are actually closer to the right-of-center vision for health care reform than the Obamacare Medicaid expansion, which is happening no matter what transpires with So if the exchanges fail and the Medicaid expansion takes effect (and, inevitably, becomes difficult to roll back), we’ll be left with an individual market that’s completely dysfunctional and a more socialized system over all.

In that scenario, the Democratic Party would probably end up pushing, not for the pipe dream of true single payer, but for a further bottom-up/top-down socialization, in which Medicare is offered to 55- to 65-year-olds and Medicaid is eventually expanded even more.

Meanwhile, the task for serious conservative reformers — already not the most politically effective bunch — might actually become harder, because they would have to explain how their plan to build an effective, exchange-based marketplace differed from the Obama White House’s exchange fiasco.

I half-expected Ross to go over the brink into speculation that the “fiasco” was planned in order to undermine the reputation of private health insurance (that was a common complaint made, you may recall, against the original ACA template with a “public option” against which private insurers might struggle to compete). But he demurred, and instead issued a wake-up call to conservatives who were “salivating over a potential Obamacare crisis” instead of thinking ahead.

Douthat comes back to the subject in his latest column, in which he asks even more troubling questions about the viability of conservative Obamacare alternatives if the ACA runs aground. The foundation for most conservative health reform models–which typically rely on health savings accounts for routine health services plus subsidized private insurance against catastrophic costs, plus enhanced risk pools for the uninsurable–is the belief that health services are overutilized; only by encouraging lower utilization rates can costs be brought under control. But aside from the inequities involved in exposing non-wealthy and non-healthy people to costs they may not be able to sustain, where’s the evidence markets have succeeded in reducing costs anyway?

[M]any liberals would dispute the premise that health insurance doesn’t have a big impact on health. (Hence the inevitable to-and-fro over what the Oregon Medicaid data actually showed.) But they could also agree, or semi-agree, with that premise and still reject the right’s policy prescriptions. Yes, these liberals would say, maybe we should spend less on health care and consume fewer medical services overall. But there’s no need to jerry-rig some kind of untested-except-kinda-in-Singapore catastrophic-plus-H.S.A.’s setup that might leave big gaps in coverage, since we already know that single-payer systems have by far the best track record in accomplishing the cost-reduction feat. Just look at the difference between what Western European countries spend on health per capita and what America spends — or, to return to my colleague’s argument, just look at the difference between what Medicaid spends and what our private insurers pay out. There’s no comparison: If you want people to spend less on health care, socialized medicine rather than catastrophic coverage is obviously the way to go.

To take this from a policy debate to pure political reality, if Americans are forced to decide whether relying on government or relying on private insurance companies to provide them adequate health coverage without breaking their own or the government’s bank, which side is likely to win? As Douthat seems to concede, it’s not much of a contest, particularly if you understand that a single-payer system (or a combination of existing single-payer programs with some flourishes to extend coverage to those who don’t qualify) doesn’t actually “socialize medicine,” but simply insurance.

If I could add a thought, from a raw political perspective conservatives might do better–and actually have done better–by abandoning their dream of changing Medicare into an Obamacare-style subsidized-and-regulated private health insurance system, and just going along with the GOP rank-and-file’s apparent affection for keeping single-payer insurance for themselves via Medicare while denying any real assistance to those people who haven’t “earned” the benefits. It’s terribly inequitable and divisive, which offends those of more tender sensibilities like Douthat’s, but it at least relieves conservatives of the burden of trying to convince people the “socialized” health insurance they like should be junked on grounds that they have too much coverage for their own and their country’s good.

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Ed Kilgore

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.