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First of all, it’s important to understand that there’s no such thing as “Obamacare” as a form of insurance. The name “Obamacare” was given to the Affordable Care Act by Republican opponents of the law. It misrepresents what the law actually is, however. You cannot have “Obamacare” as your insurance.The Affordable Care Act is mostly a series of regulations that private insurance companies have to follow. For example, they can no longer reject a customer because of a pre-existing medical condition, or impose annual or lifetime limits on the amount of care they are willing to pay for. But it also was intended to provide easier access to health insurance for people who do not receive insurance from their employer.See, if you’re unemployed or live below the poverty line, you have Medicaid, which is a government insurance program. If you’re over 65 you have Medicare. If you’re employed and your job provides you with health insurance, then you have private insurance paid for by a mix of contributions from your employer and money deducted from your paycheck. But if you live above the poverty line but have a job that does not offer insurance, then you have to buy it on your own or go without it entirely. About 15–20% of the population fell into this category before the ACA was passed. But buying insurance for yourself was both very expensive and difficult to do; it was hard to know what options were out there for coverage, and so most people who actually bought insurance this way either paid more than they should have because there were few plans available and insurance companies took advantage of how hard it was to even just explore what coverage options were offered by different companies, or they purchased plans that provided very minimal coverage. And because of the expense, many people just went without insurance altogether. When those people had medical emergencies and ended up in a hospital, they couldn’t pay the resulting bills. When hospitals did not get paid by a significant minority of patients, they responded by raising the cost of care on everyone else to cover the losses they incurred from caring for patients that could not pay for those services. So everyone else paid higher prices for their medical care, which was passed on to consumers in the form of higher premiums charged by their insurance companies.What the ACA did was establish health insurance “exchanges” on which private companies would offer plans for people who did not receive insurance from their employers. The idea was that these companies would offer a variety of plans with different coverage options and different costs, all available to consumers in one place, and that by being forced to offer these plans side-by-side, insurers would have to offer more competitive pricing, and the various types of plans would be much easier for consumers to find. To aid low-income people in affording these plans, the federal government offered subsidies to cover a part of the cost of the monthly premium (in the same way that, for example, if you have insurance through your employer, the employer pays part of the monthly premium before deducting the rest from your paycheck.)But when you buy insurance on one of the exchanges, you are not enrolling in a government insurance program called “Obamacare”. You are buying insurance from a company like Aetna, or Fidelis, or United Healthcare. These are private companies that are in the business of making a profit. Their profit depends on taking in more money in premiums from healthy people than they are paying out in services to sick people.So when you hear “Obamacare premiums are rising,” what that means is that those private companies are now charging more for each plan they offer on the exchanges because they need to take more money in than they are paying out.So as far as why “Obama can’t make Obamacare free,” it’s because “Obamacare” doesn’t really exist, and he cannot directly influence what the private companies charge on the exchanges, and certainly cannot require them to charge nothing. Alternatively, covering the full cost of everyone on the exchanges through 100% subsidies would be extremely expensive; it would be more cost-efficient to simply create a government-run plan like Medicare that applied to everyone (Medicare only covers people over 65). But there’s not enough political support for a publicly funded government insurance plan like that, or at least there has not been up to now.So President Obama cannot directly affect what people pay for insurance on the ACA exchanges, and certainly cannot make those insurance plans free. But it’s important to note that most people do NOT buy insurance on these exchanges; somewhere between 80–85% of Americans get their insurance either through their employer or through Medicare or Medicaid. So increases in ACA premiums don’t affect most people, but the regulations established by the ACA, like the end to lifetime or annual coverage caps or the requirement that insurance companies must give young people up to age 26 the option to be covered on their parents’ plans, do apply to everyone, regardless of how you get your insurance.

(I'm neither a Trump supporter nor Republican. I wrote much of the answer below in 2013, in response to a question about what aspects of the ACA people find most worrisome going forward. Four years on, I'll let you decide how true it remains.)—-Opposition to the Affordable Care Act (ACA) often breaks down into one or more of the following concerns:The way it was soldThe way it was passedThe way it was rolled outThe creation of another entitlement that we may not be able to afford unless dramatically restructuredThe questionable, constant modification of it by the Executive Branch (i.e., giving the executive branch, and neither the free market nor the legislative branch, enough influence over 1/7th of the economy), and resultant lack of durability, stability and consistency to new administrationsThe budget-busting increased out-of-pocket expense for many individuals compelled to participateThe decreasing choices for manyLet's take them each in turn.The way it was sold.Virtually every important promise we were told during the "selling" of what became the Affordable Care Act is now, and without even a hint of partisanship, provably, factually untrue."If you like your healthcare plan, you will keep your healthcare plan, period." False. "If you like your doctor, you can keep your doctor, period." False. "It is not a tax." False. "It will lower the average cost of health insurance for the typical family of 4 by $2500 per household." False. "We can do all this without adding one dime to the deficit." False. “It will lead to greater choice in the marketplace.” False.The level of misrepresentation and mendacity, not just before but after the details were known is truly historic for social legislation of such expense and import. Given the way that these facts were consistently, repeatedly misrepresented, it's entirely reasonable in my view for those that cast deciding votes based even in part on these representations to feel cheated.It is reasonable to ask -- What if we knew the truth then? What if the president and many in his party didn't so blatantly misrepresent the facts of the proposed, and later passed, law?"If you misrepresent what's in this plan, we will call you out." -- President Obama, address to Congress, 2009 http://www.youtube.com/watch?v=U...What if the media truly did its job and actually fact-checked the claim "If you like your plan, you can keep your plan" when it actually mattered most?"The media, for the most part, fell down on the job when it came to dissecting the promises made by supporters (for example, that people could keep their insurance and their doctors); who would pay for the subsidies; why essential benefits were important; and why there had to be an individual mandate with penalties for not buying insurance." - Dropped Coverage - Trudy LiebermanIf we had a more accurate picture of the proposed new reality when it was still a bill, would we still have this law? Would it have passed? Did we opt into this actually knowing the most important tradeoffs we were making?I could stop here -- and this would be enough to explain reasonable opposition.But there’s more. Let's continue.The way it was passed.Then Speaker of the House Nancy Pelosi (CA) famously said "We have to pass the bill so that you can find out what’s in it..."Let's remember that for the initial vote in the Senate, many legislators were coaxed along with state-by-state payoffs, including the infamous "cornhusker kickback" which got it just barely over the line. (via Politico: Payoffs for states get Harry Reid to 60 votes - Chris Frates.)"You’ll find a number of states that are treated differently than other states. That’s what legislating is all about." - Senate Majority Leader Harry Reid, 2009, in reference to billions handed out to various states to help move their Senator to a "Yes" vote on the ACA.Let's also remember that it was passed, with zero Republican votes, through a committee reconciliation process in the middle of the night, deliberately to avoid a sure-to-lose final vote in the Senate.And, more just to provide context than to argue that this should be prescriptive, it was also passed against majority popular polled opinion at the time. That one fact -- polling and popular opinion -- certainly shouldn't be determinative -- but it's a piece of legislation that has very broad impact on all of us and in some ways you could say that congress went against, or very much up to an even line, of "the will of the people" to make it happen. There certainly was no mandate that it be done; even those polls that suggested many people favored it now have to be severely discounted, given the frequent and blatant misrepresentations of the downsides of the plan.The facts are that it was not brought to final vote in the Senate the way laws of this size, expense, impact and import have always been passed, but rather rammed through procedurally in reconciliation after voters went to the polls in Massachusetts and elected Scott Brown to the Senate in a major upset -- this after hearing his primary message: "I will be the deciding vote on healthcare."Stepping back, historically -- there has never been such a substantial piece of social legislation passed through reconciliation -- not Social Security, not Civil Rights legislation, not Medicare, not Medicaid... nothing.The Republicans offered many amendments that were rejected -- from letting insurance companies sell insurance plans across state lines to use of Medical Savings Accounts to stricter rules for insurance companies to keep selling plans rather than cancelling them. Some of them actually might have helped the rollout. All were universally rejected, often with considerable scorn.Through all this, we are now seeing the effects of this entirely partisan legislation -- any modifications are vetoed by the other party, and last-minute workaround "fixes" are proposed that stretch the very constitutional boundaries of executive power. This is not, in my view, entirely Republicans fault -- it's in the way that it was rammed through, which dramatically hampers its ability to improve over time.The way it was rolled out.Do I even need to elaborate here? A website as easy to use as Amazon? A president, who, having been president 5 years, laments that IT procurement at the Federal level is just too darn hard? A president that tiptoes around an apology for mendacity and claims that he just didn't know that the website at the heart of his signature piece of legislation wasn't going to work until too late, and says that most of those plans that were canceled were “junk plans anyway”? An administration that initially claimed that the problems were due to overwhelming demand? A president that later realizes to his surprise that health insurance is a complex thing to buy? An administration that outsources a multi-million-dollar, privacy-and-security-laden project to a Canadian company after railing about private companies outsourcing US jobs on the campaign trail? An administration that once said it wanted to be the "most transparent in history" deliberately withholding vital information -- such as the realtime enrollee numbers (known hour by hour, day by day), or the actual makeup of the actual "enrollee" pool? A redefinition of words like "enrolled" to mean putting something in a shopping cart, not actually what most people might assume -- like paying? Insurance executives saying they've been repeatedly warned not to critique or share their concerns about the ACA?No. I don't.The creation of another entitlement that we may not be able to afford.We are now at $20 trillion in debt, roughly 100% of our GDP. Millions like me in the individual insurance markets have seen their insurance cancelled. The increase in prices for a worse plan for us is around 40%.Yet 80%+ of all "enrollees" have so far, registered not to pay in a thin dime -- but rather have signed up for Medicaid - which is 100% funded by taxpayers.Do I think Medicaid should help our neediest? Absolutely.But it's worrisome to me that we're accelerating the fiscal implosion of the Medicaid program. Simpson-Bowles (haven't read it? you really should: http://www.fiscalcommission.gov/...) is very clear on this: Entitlements -- particularly Medicaid, Medicare and Social Security -- are breaking our fiscal back. And our economic security as a nation depends upon getting control of our long-term-debt."Commission members, and virtually all budget experts, agree that the rapid growth of federal health care spending is the primary driver of long-term deficits." - Bowles and Simpson commenting on their report, "Moment of Truth", 2010As well-intentioned as many of the sentiments are around the ACA, the solution is not, in my view, to layer on yet another major entitlement without thinking it through, via a law that far too few legislators actually read before voting.Medicaid rolls will swell. Many, many people that were OK bearing the full cost of private insurance will now get a subsidy. It's cost us $600 million so far to get a non-functional website. Billions more will be spent; millions of once-insured folks, relatively happy to continue to pay for 100% their own individual insurance, are now being subsidized by taxpayers, borrowing, and ultimately our grandchildren's prosperity.Is there good that comes out of the ACA? Sure! But there are substantial negative tradeoffs too, and these were severely misrepresented or never even discussed.The questionable, constant modification of it by the Executive BranchArticle I, Section I of the Constitution vests all legislative powers in the Congress: "All legislative Powers herein granted shall be vested in a Congress of the United States, which shall consist of a Senate and House of Representatives."Article II, Section III defines presidential powers, declaring with respect to laws that "he shall take Care that the Laws be faithfully executed." Nowhere in the Constitution does it provide for the president to modify settled law, and the separation of powers are there for deliberate reason!Yet well after the legislation was passed, the president came out with major new adjustments, exemptions for congressional staff, selective delays and additional mandates for insurers. He and his staff were effectively adding to, modifying and removing things in the law that were not permitted by legislators. And that is very worrisome indeed.Yes, the Supreme Court declared that the individual mandate, if considered a tax, is Constitutional.But my point here is that I do not think that the president has the power to make such broad changes to settled law. For instance, he is choosing to selectively implement pieces to align -- lo and behold! -- with electoral calendars, and -- surprise! -- choosing favored groups (e.g., unions) to dole out special exemptions. This should be troubling to the left and the right and those of us in between -- this is not what the founders specified in the Constitution.If, say, a sitting president said that for 2014, blue cars can go 70 mph on the highway and red cars only 55 mph -- that certain speeders violating the law wouldn't be "enforced", I think we'd have some trouble with that. So too with any settled law. "He shall take Care that the Laws be faithfully executed.""I wonder if he has the legal authority to do this." - Howard Dean, former governor, presidential candidate and chair of the DNC.Further, this constant ex-post-facto tinkering with mandates and what the insurance companies are allowed/required to offer must be making insurance executives' heads explode. (Tying some of these elements together, that he feels he cannot send it back to Congress for proper, legal modification is due in no small part to the way it was passed.)"On Thursday, [the president] passed a new law at a press conference. King George III never did that. But, having ordered America’s insurance companies to comply with the ACA, the president announced that he is now ordering them not to comply with the ACA. The legislative branch (as it’s still quaintly known) passed a law purporting to grandfather your existing health plan. The regulatory bureaucracy then interpreted the law so as to un-grandfather your health plan. So His Most Excellent Majesty has commanded that your health plan be de-un-grandfathered. That seems likely to work. The insurance industry had three years to prepare for the introduction of the ACA. Now the King has given them six weeks to de-introduce the ACA." - Mark Steyn - Thus Spake Obama"Obamacare is introducing a new form of government​—​improvisational government, characterized by continuous ad hoc revisions of statutory law by executive decree. This is a reversion to a primitive form that long antedates our Constitution and rule-of-law traditions. Transported to the modern world, it leaves the private sector in a state of constant uncertainty and subjection." -- The Silence of the Liberals"I'm afraid this is beginning to border on a cult of personality for people on the left. I happen to agree with many of President Obama's policies, but in our system, it is often as important how you do something as what you do. And I think that many people will look back at this period in history and see nothing but confusion as to why people remained so silent when the president asserted these types of unilateral actions. You have a president who is claiming the right to write or ignore or negate Federal laws. That's a very dangerous thing." -- Johnathan Turley, law professor, author and Constitutional scholar, February 12 2014“To contend that the obligation imposed on the president to see the laws faithfully executed implies a power to forbid their execution is a novel construction of the Constitution, and is entirely inadmissible.”— U.S. Supreme Court, Kendall v. The United States, 1838The Increased Out of Pocket Costs for ManyTaking into account both increased deductibles and premium increases, the ACA is not affordable for many.The Decreasing Choices for ManyOver the last couple of years, we’ve seen:Aetna leave all ACA markets (Aetna exiting all ACA insurance marketplaces in 2018)Cigna leave all ACA markets (Cigna joins health insurance industry pullback from Obamacare)Anthem leaning toward leaving all ACA markets (Big Obamacare insurer Anthem seen as 'leaning toward exiting' many areas where it now sells plans)United Health leave all ACA markets (UnitedHealthcare to exit most Obamacare exchanges)Blue Cross Blue Shield leave much of Kansas and Missouri (Another Obamacare insurer just quit, leaving 25 Missouri counties with no options)Multiple insurance company executives declare that the ACA is in a “death spiral”22 of 23 nonprofits announce they are unprofitable, with 12/23 going bankrupt (Obamacare's Nonprofit Insurers Are Failing, Predictably)McKinsey & Co. summarize that insurers lost over $2.7 billion covering ACA plans just from 2010-2015 alone (Exchanges three years in: Market variations and factors affecting performance)If Centene leaves, Mississipi will have no insurersWhat does it look like when Obamacare explodes? This interactive graphic explains.This chart, even from ever-reliable ACA cheerleaders at Vox, tells an important story:At this writing, the United States has 3,007 counties — so that’s more than a third of counties with just one or fewer ACA insurers. The trend is not looking positive.Some specifics in the lawI understand (and generally support!) the goal of sensibly redistributing wealth and increasing the risk-pools. I take as a given that the goals of insuring the uninsured and never again allowing insurance companies to deny people for pre-existing conditions -- are laudable.But everyone has a view on what the limits of the federal government should be, and I personally disagree with the idea that, say, discretionary contraceptive care, is something that must, by law be subsidized at the federal level by everyone else in the nation, regardless of their need for it, and regardless of their ability to pay for it on their own. (And don't get me wrong, I'm just fine with with sex, thank-you-very-much! But it's optional, and come on -- you or your significant other can afford a condom, Ms. Fluke. We're not so dependent upon the largess from others that it should be a new right, that it's now society's burden to pay for it, are we?) My view doesn't come from a religious perspective, but rather a view on what constitutes something that the federal government should redistribute for us. If contraceptive pharmaceuticals, why not healthy food? Vitamins? Water? Those too are important for good health.And what of the requirement for all plans to pay for maternity care? Should we really compel the couple who cannot have children (e.g., infertility, octogenarians, elderly widowers, those who deliberately make a reasonable choice not to have kids, what have you) to pay for those that can? Do we really want to train people not to worry, that socialization will take care of every responsibility for you? (Can you think of any downsides to that approach?)On this, there are reasonable debates to be had depending upon your political perspective -- for me, I favor independence and personal responsibility where possible, and a strong safety net for those who are in need of it. But related to your question, I find it worrisome that the ACA inexorably moves "up" some assumptions about what society, and not the individual, should pay for -- because it risks a further dependency culture and loss of freedom.What's aheadAll the major vital signs of the ACA point to the fact that it’s in a fiscal death-spiral. The question is what do we do about it. Those who want to keep but strengthen the ACA have largely been silent on what specifically stops such a death spiral, and specifically how much it will add to our children's debt. We do know that insurance carriers are collectively citing billions of dollars of losses as they head for the exits, so it's hard to see how just throwing money at the problem structurally rights the ship.For me, I could actually get behind a single-payer system, if we could also still allow and regulate some completely private market options, which might evolve somewhat like public schooling (still with private options.)I could also get behind a private market Medical Savings Account system with catastrophic coverage subsidized for those that cannot pay for it.Neither of these should immediately suggest to ACA proponents that I’m against healthcare, or against providing better healthcare for our citizens. I just have a different strategy, and I see the existing data on the ACA as not really supporting the notion that the ACA is healthy and working effectively.Even if the ACA ran “smoothly” as designed, it doesn't solve a major healthcare cost problem -- and that is, at the time one is deciding whether or not to go ahead with a particular procedure (which may or may not be a good idea), the entity that actually bears the cost for that procedure is nowhere in the room.

For reasons that escape me, Americans don't seem to understand how good health insurance works. Essentially, it is a solidarity system where everybody pays their premiums into a big pot so that if they (or anyone else) gets sick, their expenses are covered. The motto here is "all for one and one for all", like the Three Musketeers.This only works, of course, if everybody contributes. If someone refuses to pay into the system, everybody else must make up the difference, so not contributing is selfish and antisocial.That's what America has today, and its motto is "every man for himself and the devil take the hindmost".In the current discussion, a lot of buzzword are being bandied about, including "Medicare for all", "single-payer" and "universal coverage." Lets look at what each of these means.In the United States, Medicare and the Veterans Health Administration are actually very like single-payer systems, except that they aren't really, because they allow private insurance companies to manage care in the program, which means the government is not the only payer of claims. Medicaid, on the other hand, is jointly funded by the federal government and each state government. So, although it's a form of government-funded health coverage, the funding comes from two sources rather than one.Universal coverage refers to a health care system where every individual has health coverage. To date, there are no less 32 countries with some for some form of universal health coverage. In Canada, for instance, there are no uninsured Canadian citizens; their government-run system provides universal coverage. BTW: Canada's government-run system does not provide coverage to undocumented immigrants, which apparently worries some Americans who would prefer to watch illegal immigrants die in the streets than offer them any kind of health assistance. So much for Christian values.Finally, there is something called "socialized medicine" which really scares the pants off lots of people in America. In fact, the U.S. Veterans Administration (VA) is already a good example of socialized medicine because the government not only pays for the healthcare but operates the hospitals and employs the medical staff. In Great Britain, the NHS, or National Health Service, works that way. It is often criticized for inefficiency, but in fact it works in so far as everyone in the United Kingdom can simply make an appointment and be treated with no questions asked (and no bills to pay). This is, of course, because everybody has already paid their premiums in the form of taxes.Today, 18 countries offer true universal health coverage: Australia, Canada, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, the Netherlands, New Zealand, Norway, Portugal, the Slovak Republic, Slovenia, Sweden, Switzerland, and the United Kingdom. Others, including Austria, Belgium, Japan, and Spain, have near-universal coverage for more than 98 percent of their population.Where I used to live in Germany, there is universal coverage but no single-payer system. Instead, everyone in Germany is required by law to have health insurance through their employer who automatically enrolls you in one of more than 100 non-profit "sickness funds," jointly paid for by employees and employers.Alternatively, there are private health insurance plans available that offer benefits like single rooms in hospitals and the right to be treated by the head physician, but only about 11 percent of German residents choose them because they can be very expensive.Some experts have suggested that in the United States, government should fund a safety net for the sick and poor (sort of a deluxe version of Medicaid expansion) while requiring those who are more fortunate health-wise and financially to purchase their own policies. Theoretically, this would mean a national single-payer system without universal health coverage; given the political gridlock in America this is unlikely to happen anytime soon.My bet is that the U.S. will eventually wind up with some kind of "Medicare for all", which would at least be a lot better than today's dysfunctional system. In 2016, according to the U.S. Census Bureau, 28.1 million Americans were without any kind of health insurance at all. Yes, that’s lots better than the 46.6 million who had been uninsured before Obamacare was introduced, but it still means that the healthcare system in United States, while remaining the most expensive in the world, continues to lag far behind the rest of developed countries in terms medical assistance provided to its citizens.