I advocated for the Affordable Care Act, and celebrated when it was passed.

It’s good to have everyone covered, I thought.

Insurance for everyone is the first step to health care for all.

Alas, access to health insurance isn’t the same as access to health care.

First there is the niggling detail of providers. We already have a primary care provider shortage.  Internists, pediatricians, family physicians are already working at full capacity in caring for the general health needs of a community. The poorest neighborhoods with the worse reimbursements already have a severe shortage of providers. More people with health care coverage, means more people will be seeking routine care, and we don’t have more providers ready to see them all.

For patients, this will mean longer waits to see a provider.  Or for providers, it will mean longer hours at work to see more patients.

Second, the ability to buy subsidized health insurance doesn’t automatically mean the ability to pay for health care.

I just learned that patients who are unable to pay their co-pays within 90 days may then need to face the entire medical bill on their own. How bad can a co-pay be, you may ask?

“When I say I have zero income, that means I have no money. None,” said one of my patients from the community health center where I work as a family physician on the South Side of Chicago, when I was encouraging him to buy generic medications at Walmart or Target. “$4 is too much for me,” he said.  “I’d need to steal to buy it. “

Zero income means an enormous challenge to pay anything, borrowing from a network of friends and relatives and searching out social programs for medical assistance. In some states, Medicaid will be expanded to cover everyone who is near the federal poverty line.  Other states are choosing not to expand coverage to young men.  Private insurance plans may effectively leave them unable to afford health care, even if they are able to afford subsidized health insurance on the state exchanges.

When patients who live on the financial edge, who currently don’t have health insurance miss their co-payments, they will become liable to pay the entire cost of the doctor’s visit.  After 90 days with no co-pay, then insurance companies would owe nothing.  The people who are poorest, who have the toughest time scraping together the money to cover their co-pays, may ultimately be responsible for paying not only their co-pay, but the entire medical bill, while also paying insurance premiums.

This would be unfortunate.

I wish we could turn back the clock and create a simpler system where everyone had access to care without needing to worry about who pays what.  Instead we have recreated pricing mechanisms that in effect result in tiered payments where the poorest patients continue to pay the most.

People are poised to buy into a broken system at the stroke of midnight announcing January 1, 2014.

The health insurance exchanges are coming—facilitating the buying and selling of imperfect products that promise access they can’t fully deliver, while potentially leaving vulnerable patients without full access to health care.

And still this is better than the alternative, where patients had no coverage at all, and the system wasn’t incentivized to find ways to become more efficient and more effective.

There will be new incentives in healthcare.  We’ll see what happens. The American healthcare system will need to continue to adjust to the needs of patients, to be responsive to the most vulnerable, in order to ensure a healthier America.

Kohar Jones is a family physician who blogs at Progress Notes.