1)      Health exchanges. Nearly two-thirds of the states are not fully on board with running their own exchanges as mandated by the ACA. The federal government needs the states to provide infrastructure and local-market experience.

 

2)      Medicaid expansion. Less than half the states officially support the ACA’s Medicaid expansion, and since the Supreme Court ruled that the expansion must be optional rather than mandatory, it’s likely that many of the remaining states will not implement it.

 

3)      Individual-mandate enforcement. The mandate remains unpopular and the tax penalty to enforce it is small compared to the premium costs of required coverage. Many healthy and young individuals will have a strong incentive to remain uninsured, wreaking havoc on the risk pool.

 

4)      “Minimum” health-benefits coverage. The long list of ACA “essential” benefits requirements affecting most forms of fully insured coverage will mean a spike in premiums, particularly for young adults in good health.

 

5)      Who picks up the check? Higher health-benefit costs will suppress private-sector wage and job growth as well as prevent public investment in other areas.

 

6)      Health-care provider capacity. The ACA will stimulate a great deal of demand for health care services, but it does little to incentivize an increase in supply. There is already a shortage of physicians in America.

 

7)      “Pilot” error. A variety of projects in the ACA were meant to demonstrate innovations in health care delivery systems, but most of these have failed to show positive results. It’s far more likely that spending will be controlled through across-the-board reimbursement cuts for doctors, hospitals, and producers of medical products.

 

8)      Transparency without real prices. The ACA attempts to make health care information more transparent and accountable to the consumer, but it also empowers bureaucrats to decide exactly how plans are structured and operated.

 

9)      Standardization vs. customization. The ACA treats health care as a process with uniform standards, turning patients into identical cogs in an assembly line. A competitive market would allow dynamic, bottom-up innovation.

 

These “pressure points” indicate that the ACA’s implementation will be politically and economically difficult. But they also present a final opportunity to choose a better path in health care.