I have nothing to add to the discussion about the merits of the ACA otherwise known as Obamacare. Everyone who wants information about it has had more than enough offered to him. It’s not the real problem with our medical system. The kernel of our dilemma is us. We are the problem and congress can’t fix us. Consider the following:

1) Paul D. Donahue and his wife, Angela, are among more than a million Americans who have signed up for health coverage through the federal insurance exchange. Mr. Donahue has a card in his wallet from his insurer to prove it. But when he tried to use it to get a flu shot and fill prescriptions this week, local pharmacies could not confirm his coverage, so he left without his medications.

2) In Langley, Wash., north of Seattle, Erin Waterman was able to see a primary care doctor on Jan. 3 with a temporary identification card printed from the website of her new insurer, LifeWise Health Plan of Washington. But when Ms. Waterman, 47, tried to fill a prescription for a new asthma inhaler, the pharmacy could not verify her coverage even though she had paid her first month’s premium on Dec.23. Ms. Waterman was given the option of paying full price — $187, instead of the $50 co-payment required under her new plan — and eventually being reimbursed. But she decided to wait, and hope that she does not have an asthma attack in the meantime.

Both items from the NY Times Jan 10, 2014.

These individuals were apparently unwilling to pay for medications important for their well being or perhaps their very survival. They were so used to having a third party pay for routine care that they couldn’t face paying for needed and not exorbitant services themselves. I don’t know these people, but I do know patients just like them. They will pay hundreds of dollars, up front, to a vet for their dog or cat, but will balk at spending $100 on their child or themselves. They’ll spend thousands on their cell phone over the course of a year. When asked which is more important medical care or their phone, they’ll immediately say medical care. But they don’t want to pay for it.

This bizarre payment system, and the pattern of behavior it has induced, for an important service has so distorted the medical market that its cost curve threatens to reach the sun. Medical economists and politicians love to talk about bending this curve downwards, but they don’t want to confront the reality of whats drawing it the other way. It’s health insurance itself. Over the past 70 years medical insurance has gone from a temporary benefit for workers during World War II, prices and wages were frozen as a war time expedient, to a monster that bears no resemblance to insurance save for its name.

An insurance policy that covers your for something that has already happened, ie pre-existing conditions, is not insurance; it’s a handout. The birth control mandate which seems to have become a constitutional crisis show just how far down the road of craziness we’ve gone. We are going to the mattresses over something that costs $9/month.

The reason for all this angst is that we have become medical cripples. We seem unable to accept any responsibility for our own care. The only kind of medical insurance that is workable is catastrophic coverage. Such a policy contains costs. When people have to pay up front for a service they shop around and induce competition among providers. Most medical care is not an emergency and is subject to market forces if a market is allowed to work. Catastrophic insurance, which is real insurance, also prevents financial ruin. Thus the ACA’s policies with their high deductibles actually make some sense. It’s the mandates that are crazy as is the public’s inability to consider that they should pay for medical care on their own under almost any circumstance.

If medical care were dispensed like any other important service its cost would come down as a result of price competition. Just look at computers for the telling comparison. If computers were provided like medical care your laptop would cost $1 million and the government would have 65 programs that oversaw its provision. But the medical game is over. We surrendered and will have to face the consequences of our failure. They are those of an addict – habituation, tolerance, dependence, and withdrawal.

Don’t blame the insurance companies or the politicians, they’re just enablers. The fault is ours and our problem is incurable. When you insist on something for nothing you can expect nothing for a lot of something.