The Hill’s Jason Millman is reporting that Joel Ario, who oversees the exchanges for the Department of Health and Human Services, is trying to calm fears that employers would seek to dump their workers into the exchanges once they become operational in 2014. Many conservatives and some employer groups are arguing that the government may be underestimating the shift, but Ario is taking the tact of arguing that if the exchanges provide more efficient coverage, so be it:

“They’ll continue to provide it, and we may wind up with an employer-based system for a long time because exchanges may not develop,” Ario said.

However, if the exchanges prove to be a source for better and cheaper coverage, then employers will be incentivized to scrap their health plans.

“If it plays out the exchanges work pretty well, then the employer can say ‘This is a great thing. I can now dump my people into the exchange and it would be good for them, good for me,’ ” Ario continued.

This sounds right, but it’s worth noting that some economists are predicting that the actual shift will be quite mild, since “firms would need to compensate the workers from whom they remove a current benefit.” In fact, a survey of 2,800 businesses conducted by Mercer in 2010 found that employers are “not likely” to stop providing health insurance coverage out of a reluctance of losing control over a key employee benefit. Massachusetts — which has a much more robust employer requirement than the ACA — actually experienced an increase in employer coverage after reform.

After the first 10 years, the Congressional Budget Office estimates that “the number of people obtaining coverage through their employer would be about 3 million lower in 2019 under the legislation.” Actuaries at CMS estimated that just 1.4 million would move out of employer coverage.

Brett Coughlin of Politico Pro is reporting that House Republicans are reportedly divided about the political wisdom of including Rep. Paul Ryan’s (R-WI) proposal to transform Medicare into a voucher program for future retirees in next week’s GOP budget, fearing that voting to significantly alter the program (and potentially alienate senior voters) makes no political sense if the proposal will go nowhere in the Senate:

Rep. Paul Ryan of Wisconsin, the Budget Committee chairman, and House Majority Leader Eric Cantor are on the deficit-cutting side of the debate. Ways and Means Committee Chairman Dave Camp of Michigan and House Speaker John Boehner are on the other side of the debate, weighing if voting to carve up the Medicare program — only to see it die in the Senate — is worth the political hit, a senior Senate Republican aide and House Republican chief of staff tell POLITICO. [...]

“I see and appreciate where Chairman Ryan — and Majority Leader Cantor — are coming from on this. I also recall the ugly politics in 1995 and 1996,” the Senate Republican aide said. “The challenge is a group of conservative freshmen in the House who are really concerned about the deficit, but who have never had to face a negative reelection campaign.”…Privately, however, Camp is saying — according to the GOP staffers — that he doesn’t see the wisdom in voting on a plan to dismantle Medicare in the House, only to see it die in the Senate.

Coughlin notes that the internal divisions could jeopardize the GOP’s ability to present a unified budget and alienate seniors who have come to depend on the Medicare program. And for good reason. Under Ryan’s plan, new Medicare enrollees would receive an annual voucher they could use to purchase health insurance beginning in 2021. The voucher — which does not keep up with health care costs — would initially be worth an average of $5,900 (in 2010 dollars) and increase to an average of $11,000 in 2010 dollars once all age-groups are phased in.

Seniors, in other words, would pay more. According to this report from CAP, under current law, people with Medicare coverage can expect to pay $2,730 per year ($228 a month) in 2021 for total Part B and Part D premiums. Under Rep. Ryan’s proposal, conversely, new “Medicare enrollees will pay an average of $3,579 for equivalent coverage—a 31 percent increase in their premium for this year.” (See the chart here). As the Congressional Budget has pointed out, “Voucher recipients would probably have to purchase less extensive coverage or pay higher premiums than they would under current law…the federal government would pay [less] for enrollees on a per capita basis, relative to the projections under current law” and “future beneficiaries would probably face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”

Republicans have long tried to distance themselves from Ryan’s proposal. Last February, then House Minority Leader John Boehner (R-OH) described the plan as “his,” saying “I know the Democrats are trying to say that it’s the Republican leadership. But they know that’s not the case.” Ryan has even admitted that the proposal has not attracted substantial Republican support. “While I am proud to have 13 House Republicans co-sponsor the legislation, and have been overwhelmed by the support outside the Beltway,” he claimed, “my plan is not the Republican Party’s platform and was never intended to be.”

Jonathan Cohn offers some insight into Gov. Mitch Daniel’s (R-IN) much touted Medicaid reform program (The Healthy Indiana Plan), which Republicans are presenting as the anti-Obamacare success. Cohn explains that the plan — while built on the conservative philosophy that people would use less care if they had more skin in the came — pairs a high deductible health care plan with a health savings account (standard conservative fare) but also includes some rather progressive elements that are also part of the Affordable Care Act:

In some respects, though, the program is not as conservative as its reputation suggests. For one thing, Healthy Indiana applies cost-sharing with discretion. The monthly contributions into the Power Accounts [ vary between 2 percent and 5 percent of income, with the poorer recipients paying a smaller share than the richer ones. And that’s only for people who have incomes. About one-third of the program’s beneficiaries pay nothing at all. The state also regulates the insurers that participate in Healthy Indiana, requiring that they cover preventative care free of charge. These are the sorts of features favored by liberals, most of whom agree there should be some “skin in the game” but worry about placing excessive burdens on the poor and chronically ill.

Still, Healthy Indiana would not meet most liberals’ expectations — because it doesn’t really qualify as adequate insurance. The program doesn’t require coverage of vision, dental or even maternity care. It also has lifetime caps on benefits, the kind that the very sickest patients inevitably reach. “The track record of Healthy Indiana to date does not show that it is a truly affordable, accessible program for all uninsured adults in Indiana,” says Roos, noting that even token financial contributions can be a real hardship.

That last part about adequate coverage is really key because Medicaid spends most of its money on low-income disabled and elderly population who need chronic care and can’t afford to pay for it. Daniels’ approach — like the general conservative principle about high deductible coverage — won’t work for this population and Republicans in the state seem to be exploring ways to bolster the coverage provisions.

So it’s certainly not perfect, but it’s some kind of a start that offers us an important glimpse of how the GOP’s “skin in the game” health care theories operate in practice.