The Affordable Care Act (ACA), aka Obamacare, is law.  And its implementation is moving along slowly, but steadily.

You have to give credit to the folks who believed in it, whether grass-roots supporters or highly placed politicians.  They rammed it down the American gullet like a lead ball down the muzzle of a Hawken rifle.  The problem is, once it goes off, the whole thing is going to explode.

The reasons are many, but from my perspective in emergency medicine, there are some very important issues that the crafters and supporters of the law either failed to notice or (more likely) intentionally ignored.  While I’m not a medical economist, or a politician for that matter, I am a physician. And as a physician, I pretty darn good observer of humanity.

As the cost of insurance rises, people with limited incomes are simply going to pay the fine and go without insurance.  Rather than pay $900/month for their families, they’ll pay the $695 yearly fine … unless of course the qualify for various exemptions.  For some young people, this will be fine.  But many will still be ill and will still show up in emergency rooms, as they have for decades, in the full knowledge that they’ll receive good care and simply be billed later.  But not to worry!  They can still apply for insurance as soon as they need it and not be denied.  Problem is, the concept of insurance then fails. They won’t have put any money into the system, which could have been making money for the company until they became ill or injured.

Of course, many won’t bother with the fine either.  And it’s the height of lunacy to believe that the government (which simply can’t imagine imposing voter ID) will actually track down and prosecute those who don’t pay.  If it did, they would just call a reporter and talk about how they have no money for insurance and the fine would be dropped.

I take care of a lot of folks in this demographic.  Some genuinely have financial struggles and try their best. I love them.  But a not-insignificant group of patients will continue to find ways to move from ER to ER, from narcotic prescription to narcotic prescription, state Medicaid to state Medicaid.  They will still find money for a smartphone, cigarettes and methamphetamine.  They will continue to drive large, late model trucks and fish whenever possible.  They will not give accurate addresses, either to the government or to the hospitals who treat them.  And they will not abide by the rules of the Affordable Care Act.  That is, they’ll find a way to have money. But they aren’t foolish enough to use it for insurance.

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