I'm not quite as pessimistic as you are: Americans are stubborn, we're going to do things her own way, and I don't think the system we have in 25 years will be "socialized"; I can't see a majority of US voters putting up with something nearly as centralized as the English healthcare system, and there are too many practical advantages to systems based on "managed competition".
Also, we really do have a substantial role for the states embedded in our political DNA, and I expect healthcare regulation and provision in the US will likely always have a substantial policy input on the regional if not the state level.
And if I had to make a guess, I would expect that the system as it evolves in the US will most likely become something that has many of the characteristics of the Dutch and German systems with some of the decentralization of the Canadian system:
"Single payer" via federal taxation, substantial policy input and control at the state or regional level, with care provided by five to seven major players, perhaps entirely privately owned, or perhaps a mix of for-profit and NFP providers.
And I'm pretty sure that the program will be both very popular and fairly efficient, and for most citizens it will probably be a more desirable arrangement than the current patch up because of continuity and portability; for example these two factors are one of the major reasons that small business is 2 to 3 times the percentage of GNP in parts of Western Europe than it is here, and why such businesses are more stable (less prone to failure, and especially to high initial attrition rates) than in the US.
Meanwhile, IMO the Republican Party's (not necessarily the same thing as "the conservative movement") decision to walk away from the table instead of fighting for plan characteristics that would likely do a better job of optimizing the system than some of the Democrat alternatives was an unwise gamble: too much downside compared to the likely upsides, and as a result it will be that much harder to rationalize the ACA.
“I can’t see a majority of US voters putting up with something as nearly centralized as the English healthcare system”
Why not? The early steps are the hardest. We got this far with 60%+ opposition. Momentum’s on the other side.
What about all the other nationalized industries? We’ve gone longer now with a central bank than we went without, and that was a damn long time compared to other civilizations. Whatever they don’t outright control now they dominate through regulation and fiscal and monetary policy, or simply haven’t gotten to. Look what they can do to student loans and energy through executive fiat. The so-called Reagan “revolution” barely slowed it down, let alone cut back.
Yeah, I’m pessimistic.
“a more desirable arrangement than the current patch up”
What really gets me is that people forget what a Frankenstein is the current system, and it gets characterized as the free market when opposed to the newer, speaker, more rational system. That always happens. Government screws it up, tgen we need nore government to fix the purported Wild West, laissez faire anarchy.
No, not Frankenstein. That implies deliberation. It is like the pile of Frankenstein pieces before they were sewn together.
“too much downside”
Easy to say now, but think what it took. Not just the summer of yelling old people, but a Republican senator in Ted Kennedy’s seat, reconciliation, deeming it to have passed, the Amazing Flopping Roberts, the taxalty argument out of nowhere, and it’s STILL not over.
Plus, the exchanges, preexisting coverage, and the mandate were at one time “conservative” ideas. Somehow we always come up with the worst ideas. Cap and Trade is ours, as a sensible “free market” alternative to, J don’t know what. Banning fossil fuels altogether? But who’d gi along with that, if we didn’t pave the ground for them.
Your feel for the US voter is accurate insofar as there’s some resistance left. But it’s a gradual thing, as I’ve said. If the president comes on tv and says that’s it, healthcare is an inalienable right. We’re taking over the hospitals. Welcome to the Tennessee Valley Healthcare System. People would revolt.
His it happens, though, is they plan for these exchanges to be set up, to solve problems spawned of each individual state’s individually wacko rubric. And they’re demagogued about the poor uninsured, who are dying in the streets as well as bankrupting us in the ER. Then there’s the tragedy of preexisting conditions, which we can’t see as the child of the idiocy of having our employers cover us. So we destroy forever the concept of insurance by forcing coverage for the cancer you already have, sorta like buying fire insurance for your inflamed house. Alone this would bankrupt the industry, but we like individual responsibility so we throw on the mandate, which forces us to be responsible on threat of paying a fine that might be cheaper than being responsible.
Good as thus sounds, it is wildly unpopular, admittedly for some because it’s not socialist enough. It passes, just barely, and we missed an opportunity standing with our consciences. It could’ve had more of these great conservative ideas, like tort reform. Which knowing us would be ordering everyone to pay lawyer retainer fees for doctors, plus welfare called “illness justice” to cover those left unavenged in malpractice suits amounting somehow to more than we’re paying for court fees and settlements now. We’d find a way.