The Affordable Care Act (ACA), aka Obamacare, is law.  And its implementation is moving along slowly, but steadily.

You have to give credit to the folks who believed in it, whether grass-roots supporters or highly placed politicians.  They rammed it down the American gullet like a lead ball down the muzzle of a Hawken rifle.  The problem is, once it goes off, the whole thing is going to explode.

The reasons are many, but from my perspective in emergency medicine, there are some very important issues that the crafters and supporters of the law either failed to notice or (more likely) intentionally ignored.  While I’m not a medical economist, or a politician for that matter, I am a physician. And as a physician, I pretty darn good observer of humanity.

As the cost of insurance rises, people with limited incomes are simply going to pay the fine and go without insurance.  Rather than pay $900/month for their families, they’ll pay the $695 yearly fine … unless of course the qualify for various exemptions.  For some young people, this will be fine.  But many will still be ill and will still show up in emergency rooms, as they have for decades, in the full knowledge that they’ll receive good care and simply be billed later.  But not to worry!  They can still apply for insurance as soon as they need it and not be denied.  Problem is, the concept of insurance then fails. They won’t have put any money into the system, which could have been making money for the company until they became ill or injured.

Of course, many won’t bother with the fine either.  And it’s the height of lunacy to believe that the government (which simply can’t imagine imposing voter ID) will actually track down and prosecute those who don’t pay.  If it did, they would just call a reporter and talk about how they have no money for insurance and the fine would be dropped.

I take care of a lot of folks in this demographic.  Some genuinely have financial struggles and try their best. I love them.  But a not-insignificant group of patients will continue to find ways to move from ER to ER, from narcotic prescription to narcotic prescription, state Medicaid to state Medicaid.  They will still find money for a smartphone, cigarettes and methamphetamine.  They will continue to drive large, late model trucks and fish whenever possible.  They will not give accurate addresses, either to the government or to the hospitals who treat them.  And they will not abide by the rules of the Affordable Care Act.  That is, they’ll find a way to have money. But they aren’t foolish enough to use it for insurance.

Added to the problem with the ACA is the issue of pre-existing conditions.  I’m sympathetic here. I have a son with type-I diabetes and a wife who is a cancer survivor. Insurance will be tough for them to obtain without some government mandate.  On the other hand, what about the patient who intentionally does things, or has habits, which make him or her a costly investment?  For instance, the recreational cocaine user?  The heroin addict who has no interest in rehab, only in treatment when things go wrong? The gangbanger whose hobby is shooting others and being shot? It may seem compassionate to offer them help; but it’s cruel to those who will be ultimately paying the costs for those who refuse. It’s a huge drain on a system when people do nothing to care for themselves.

Finally, what does the president intend to do about the fact that physicians are retiring early, and moving into practices that don’t take insurance?  What about the fact that there aren’t nearly enough physicians in primary care, nor will there be for at least the next 20 years or more? What about the fact that patients who are difficult are often dismissed from practices?  What do we do with the angry, the addicted, the dangerous, the non-compliant?  Even with insurance, nobody will take care of them for long.

I’ll try to be generous here. The ACA exists in part because of compassion for the sick and needy.  I’ve known patients who simply put off necessary care for lack of insurance.  But the ACA is far too large, far too expensive and ignores simple issues of human nature and behavior like those I listed above.  It also ignores other inconvenient truths; like employers changing employees to part-time because they can’t afford insurance, or the impending explosion of patients who haven’t paid into any plan, private or public, because they were illegal immigrants.

Frankly, I’m worried. When government, so far out of touch with reality, imposes its social philosophy on people who do live in reality, only tragedy can result.  What a pity that when it happens, the political class (left and right) will only wring their hands, say ‘tsk, tsk, we didn’t think that would happen,’ and slip off to their private physicians, with their Cadillac, tax-dollar insurance plans, and get more pills for anxiety.

And the masses be damned, or fined, or ignored.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.