On the other hand, many low-income folks will qualify for Medicaid who currently have nothing. And many more who aren’t poor enough to qualify for Medicaid will be able, especially with the help of tax credits, to afford health insurance, when up until now it just hasn’t been an option. We tend to think of the ones whose employers haven’t offered health insurance, but there are plenty of hardworking people who have had “access” to employer-based health coverage, but it has simply exceeded what they could afford to pay. They will no longer have to go without, because under the ACA there is a limit on the percentage of your income that you’re expected to pay for coverage before you qualify for a subsidy.

So we are requiring people who heretofore have opted out to enter the risk pool, and requiring people to buy health insurance that has a higher level of coverage than what they would otherwise have chosen, thereby making insurance as a mechanism for spreading the risk truly workable. At the same time, we are adding people to the Medicaid rolls and subsidizing premiums for the working poor who are not quite poor enough to qualify for Medicaid (which will require expenditure of tax dollars). What, then, are we doing? Just ask Joe the Plumber: We are spreading the wealth around.

By now my regular readers know I’m innately conservative. I think the government wastes a lot of money. I like the Jeffersonian ideal of smaller, less intrusive government. I believe in personal responsibility. So why on earth would I like the ACA?

In all honesty, I don’t really like the ACA, because I believe the goal is universal coverage, and this will leave us well short of that. We will still have at least 20 million without health insurance coverage. That is my best estimate. Call it pessimistic, but I prefer to be pessimistic and then be pleasantly surprised if things go better than I though they would. This means I have to “like” the ACA because I am not willing to let the perfect be the enemy of the good.

Does it spread the wealth around? Absolutely. Will it personally cost me more in health insurance premiums, or taxes, or both? Guaran-damn-teed. So why am I for it?

I have spent the last 30 years practicing medicine and observing a very painful fact of life. I live in the wealthiest nation in the history of the world, a nation that is at the same time the only modern, industrialized nation on this globe that fails to provide a universal system of health care. Every single day of my working life I am face to face with people whose health has been neglected because the resources are simply not available to them to tend to it. The consequences of that neglect land them in the emergency department, far worse off than should ever have come to pass.