A survey this summer concluded that the Affordable Health Care Act (ACA) -- also called "ObamaCare" -- is in trouble because of limited insurance choices, rising prices, low participation by consumers, and complicated rules.

Aetna, one of the nation's largest insurers, just announced it is pulling out of two-thirds of the counties where it now provides coverage. The company claimed it was losing money. But vindictiveness over a government antitrust suit aimed at ensuring competition and lower consumer costs played a triggering role.

Even someone who shops wisely and is willing to switch plans to get the best deal will see an average premium increase of 11% next year.

According to the Congressional Budget Office (CBO), insurance firms are predicted to be handed $802 billion in taxpayer money over the period 2017-26 to subsidize their products. (The figure is obtained by adding $672 billion in premium credits + $130 billion in cost-sharing subsidies.) This money will enhance the industry's financial and political power, and with it their ability to block future reform.

It is doubtful ACA will be able to control costs. And the CBO estimates it will still leave 28 million people uninsured in 2026. Lack of insurance is linked to a higher mortality rate.

While ACA requires private plans to meet minimum standards, coverage sold on the exchanges set up under the ACA are grouped into different tiers. Health care inequality will persist.

Some say problems will be solved if the government gives more money to the insurance companies, and cracks the whip over healthy people to force them to buy insurance. Enriching the industry is ludicrous of course, and a mandate for healthy people is already the law.

Others say the answer is to offer a "public option" -- wherein government-run health insurance would compete with private health insurers.

Advocates for this approach have not spelled out the details. Anyway, for decades a public option hasn't worked in Medicare. Despite strict regulation private insurers undermine the public plan with two-tiered care remaining the norm. And administrative costs remain high.

ACA is about making sure health insurance remains in the private marketplace.

For example, Blue Cross

Non-profit Blue Cross Blue Shield of Michigan is the state's largest commercial health insurer.

  • In 2010 the US Department of Justice and other plaintiffs sued it for class action antitrust violations in Detroit federal court. The suits said that BCBSM price-fixing practices fueled increased health-services costs for millions of consumers. The Detroit court sealed nearly 200 exhibits and an expert report from public view. Then it approved a $30 million settlement. Dozens of companies objected to the settlement as too low. This last June the Cincinnati court of appeals vacated the settlement and the orders to seal, and remanded for a "vigorous" examination of the settlement's fairness.

  • Following on the heels of a $6+ million judgment for a Rochester Hills company against BCBSM for hiding fees and surcharges, Sebewaing-based Michigan Sugar sued BCBSM for fraud in June for its own losses in the scheme, which went on for 17 years. A tide of similar lawsuits is now expected.

  • In 2017 Blue Cross will raise rates for its "Plan C" Medicare supplement by a margin of $48 to $177 per month. The plan covers 200,000 seniors. The new rates will take into account a person's age, gender and geographic location. Men and older seniors will pay more than women and younger seniors. Southeast Michigan will be hardest hit.

But the marketplace -– and the attendant prioritization of profits over care -– is the root of the problems with the US health care system. In the market, money comes first. Michigan examples are in the box to the right.

ACA does have modest benefits: a decrease in the percentage of uninsured adults, an end to discrimination against pre-existing conditions, the expansion of Medicaid in states willing to expand, and a requirement that insurance companies spend a minimum percentage of premiums on care.

I support a single-payer healthcare system, such as the bill HR 676, titled the US "National Health Care Act."

HR 676 would establish a system in which the government pays for health care costs. If enacted by Congress it would be paid for in part through taxes which would replace insurance premiums, and by savings realized through the provision of preventive universal healthcare and the elimination of insurance company overhead and hospital billing costs.

HR 676 would improve patient health, restore free choice of physicians and other clinicians, and assure universal coverage for all people. No one would be uninsured. According to Physicians for a National Health Program (PNHP), it would yield savings of $350 billion/year, money that could be used for patient care. The program would also have the financial muscle to negotiate with drug and medical suppliers for lower prices.

HR 676 is sometimes also called "Medicare for All." This is not strictly accurate. It would cover 100% of medical costs, not merely 80% as with Medicare; with Medicare the remaining 20% is paid either out-of-pocket by the patient or via a privately underwritten supplemental insurance plan.

ACA is not a stepping stone to single-payer.

PNHP has detailed answers to dozens of questions about single-payer health care including: Is it rationing, what about medical research, keeping drug prices under control, shouldn't high-risk patients pay higher premiums, undocumented immigrants, malpractice costs, retraining of displaced workers from the insurance industry.

As PNHP says, health care should be organized as a public service, like a fire department. Copayments and deductibles are highly regressive. Genetic conditions, childhood diseases, accidents, injuries and income distribution play a bigger role in people’s health than individual lifestyle factors. Even for motivated patients, alcohol and tobacco cessation are difficult, and medical weight loss nearly impossible. We need public health, primary care and education programs to try to prevent disease, but punishing patients once they are ill is inhumane and counterproductive.

HR 676 is not a new concept. It would be a government takeover of the health insurance industry, but not of health care delivery itself. Takeover of health care delivery, also called socialized medicine, is what the Veterans Administration does. Despite the 2014 falsification wait-time scandal which resulted in multiple discharges and resignations, in general the VA provides good care at low cost.

In recent years, public opinion polls have varied as to support of single-payer. Some have shown majority support for it, and some not.

Some people object to government involvement in anything. My answer: Today healthcare funding is handled by some 1300 private insurance companies. The first obligation of the for-profit insurers is to make a profit for their shareholders. Even for non-profit insurers (and for-profit insurers), there is zero small-d democratic control by the people.

Certainly the US government has lots of problems being democratic. But at least voters retain a remnant of control over government as illustrated by the fact of this congressional race. I prefer governmental control over unaccountable bureaucratic control.