The fundamental underpinning of the math and costs under mandated universal care NOT paid for by the government is people who have continuously paid for insurance are now pooled with folks who previously rolled the dice on the costs of chronic ailments. There is no reward for having paid to not take the risk over a long period and we are now burdened directly with the cost of the losers. Now, historically the culture in this country is that buying insurance is an individual risk choice. Don’t buy fire insurance? If your house does not burn down, big win. Most people choose to not take that risk and if you have a mortgage the bank makes the safe choice for you because their experience is based on a pretty good proxy for the entire risk pool. It would be entirely possible to craft a system that rewarded people for their past contributions to the shared risk, but that was not done. In the name of helping the poor, the ACA has taken advantage of and done damage to those who have previously paid for insurance. We would be far better off to deal directly with ending poverty for those legally resident in the US with something like the Friedman-Moynihan-Nixon plan and allowing a choice of whether to buy insurance. Or, in addition to a F-M-N negative income tax plan we could just pay for “A and E” (accident and emergency) care from the federal level with a credit over time to the folks who previously paid for insurance and let insurance for chronic problems remain a choice. Of course the most expensive choice is universal coverage of both “A and E” and chronic problems. There is zero chance we can meet everyone’s every need until we routinely have “Star Trek” era technology, so don’t hold your breath, and plan for rationed care if you want that option. Just like phasing out the Ponzi scheme of social security, we should pay off our obligations to those with sunk cost in the prior system when we completely change the rules of the “game.” This just in from the feds: The reason exchange coverage in Vermont is so high is lack of competition. Sigh. No kidding.