Here is a longish but well worth reading summary of Obamacare's likely impact. It goes well with Avik Roy's explanation of how the mandates and rules making process created by Obamacare gives the government the authority to quietly strangle the private insurance market. One thing that strikes me is that health care policy is a long-term battle of position within a constantly changing environment. Liberals have managed to shape the environment in such a way that if conservatives are not winning policy victories, they are losing - if only slowly.
The NCPA report makes it clear that Obamacare will speed up the unraveling of our system of employer-provided health insurance, increase the number of people on government-provided insurance, mandate participation in a destructive and irrational system of comprehensive health care prepayment, and make the middle-class dependent on government health care subsidies within an environment of sharply rising premiums. Obamacare is, in and of itself, a big step toward government-run health care, and in the years to come, it will slowly shift the political battlefield ever more in favor of ever more government control.
Republicans holding office won't stop these changes. If Republicans win control of Congress in 2010 and Obama vetoes Republican attempts at repeal (assuming the Republicans can even beat a Democrat filibuster in the Senate), nothing changes and we stay on our path to government-run health care. As Obamacare changes our health care market and health care politics, a policy of simple repeal will (by itself) become less and less the basis of a winning politics.
The old Republican policy of "tort reform plus not much" won't get it done. There is nothing wrong with tort reform, but is doesn't address enough problems to become the basis for a winning politics of health care. Tort reform has mostly functioned as a kind of conversation stopper for conservatives who didn't really want to talk or think much about health care. Oh, the Senate Democrats are filibustering tort reform? That just means they aren't serious. Let's talk about cutting taxes.
A "get government (or even just the federal government) out of health care" rhetoric is of course a kind of self-marginalizing literary politics. There will be significant government involvement in the provision of health care (if only in the form of tax subsidies and provision for the destitute) under any realistic scenario. I hear this line of argument on talk radio every once in a while and it is just another conversation stopper. It is even worse than that. It doesn't so much stop the health care conversation so much as it leaves the conversation to be dominated by liberals.
A Ryan Roadmap-type tax change that produces a leap into individually-owned insurance is probably too big a step to win majority support. It would seem to leave people and their families naked in the health care market with only a (insufficient seeming) tax credit for help. This problem becomes worse as premiums rise and people feel even more vulnerable and afraid of being on their own.
A winning conservative politics of health care will mean assembling and relentlessly pushing a set of incremental policies that do two things. First, they would have to be able to win not only majority support among the public, they will have to be consequential enough that voters will consider voting for those policies a high salience issue. This means a set of policies that neither do too little to motivate enough voters (tort reform plus nothing), nor do so much that those voters freak out (the Ryan Roadmap.) Second, the policies, once enacted, must shape the political environment in a way that future market-driven health care reforms become both easier and more popular.
Those are some very narrow needles to thread. There are some obviously wrong answers, but the right answers are much less clear. I don't think there is any one right answer, but there are pieces of a potential right answer lying around waiting to be assembled (and somewhat changed) into a winning platform by a center-right party that is serious about winning the long and grinding health care battle.