If the Obamacare exchanges are a mess and the individual market is facing cost spirals, then conservatives are going to face some understandable skepticism (more even than usual!) from voters if they talk up the virtues of free market health care and the individual marketplace in 2016 and beyond. But in principle, the distinction between Obamacare’s approach to health policy and the conservative version of means-testing, block-granting, and competitive marketplaces is clear enough. That’s because while Obamacare may be using neoliberal rather than New Deal-style means, it’s still chasing essentially left-of-center ends: It seeks a level of universality and comprehensiveness that conservatives don’t think is necessarily worth pursuing. And it’s that quest, those goals, that require the complicated mandate-regulate-subsidize combination that could undo the individual marketplace if the enrollment isn’t where it needs to be and the subsidies and fines and regulations aren’t successfully fine-tuned.
In other words, pace Konczal, the potential problems with Obamacare aren’t necessarily “driven by means-testing, state-level decisions and privatization of social insurance.” They’re driven by the law’s attempt to employ these (notionally) decentralized means while still seeking essentially centralized ends.