“the irony is this: ‘exchanges’ and ‘mandates’ as originally designed were *conservative* programs intended to foster individual self-reliance and personal responsibility”
That’s too common to be ironic. Where do you think Cap n Trade came from, or the earned income tax credit, or income tax withholding, etc. From the minds of people like Newt Gingrich, whom I’ve heard described as a “frugal socialist.” He takes the Welfare State and massive government intrusion into the economy for granted, which is only reasonable. Then he looks for ways to shift responsibilities back to individuals, which seems prudent. But the resulting programs expand government further, which shouldn’t be the object. Ah, you say, socialists would expand it even further than that. It’s a chess game, and we’re sacrificing for position.
Only they never stop there, and it is painfully obvious the mandate, the exchange, etc. will be a stepping stone toward an inevitable single payer system and the complete nationalization of healthcare. Why do we play along? Because we’re still the stupid party.
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.