"Yeah, we're coming from different directions. I see it like this: I'm criticizing the design. And you're defending it as something as better than nothing, no matter how bad it is. And I am wondering why you are still fighting a propaganda fight for it when it's the law of the land, and you don't seem to want to see anything in the ACA as a flaw that should be fixed, but that it should just be accepted as is because the Republicans are against it. And you're like going out of your way digging deep for good in it anywhere you can find it."

This is a cartoon. I don't have to dig deep to find the good in it at all. All I have to do is look at: no pre-existing exclusions. That's a huge good and right on the surface. And, it accounts for much of what people find bad in the plan.

All I have to do is look at the huge number of choices I'd have now versus what I had before--choices that did NOT include "my" doctors.

All I have to do is look at the inclusion of mental health, which I paid for out of pocket for 25 years.

All I have to do is look at my last policy, which cost me $600 a month with a $3,000-$5,000 deductible for in-network and another, higher one for out of network versus an ACA policy that costs $600 and has a $0 deductible. Maybe in your world going from a 3K deductible to a $0 deductible is nothing, but not in mine.

All I have to do is read where my friend on SSI is going to save $800 a month on premiums for better coverage over what her insurance company was giving her before. Maybe you think that's nothing or "better than nothing," but saving $9600 is no small deal for her.

As far as the fight being over, you must have your head in the sand. That's all I can say. Even leaving aside the SCOTUS fight, you have states refusing Medicaid on party line bases. You have states outlawing navigators on party line bases. You have the GOP blocking any of the fixes you might like on party line bases and then accusing Obama of overstepping his constitutional bounds when he tries to make the fixes on his own. In short, you have an entire party still dedicated to making sure the program fails in order to kill it off. Where have you been?

"And the use of a HSA would be a great help for those who are above subsidy level, but not that high income, where they get a tax deduction for out-of-pocket. I recall you didn't understand that well how these work..."

Then I must not have been clear, or perhaps you misread. I am one of those people and had an HSA for years and know very well how they work. I also know how they were sold, which has turned out to be false.

They were sold as a way to reduce medical spending. If folks were spending their own money, they'd be more careful, shop around, and prices would come down. Apparently not. It was also envisioned that a young person, starting early, could save up a big pot of dough--saving both for medical expenses and retirement simultaneously--and pay out of pocket for big expenses which wouldn't hit until he was older. Not likely.

HSAs are a fine way to deduct your medical expenses. This assumes you have the money to pay for medical expenses in the first place. But as you noted elsewhere, even non-catastrophic events can easily spiral up into the five figure realm.

I myself forewent a procedure by an opthamological plastic surgeon because it was 3K and I hadn't met my deductible. I didn't have the dough at the moment. Had it been cancer, I'd have been in the soup. At that moment, I'd have rejoiced had I had a "better than nothing" policy with no deductible. And, I'd have gone to different, but no doubt perfectly fine, doctor for the procedure.

HSAs were based on the assumption, incorrect I think, that under-10K expenditures were what was driving up health care costs. I'd put the blame on high end procedures and chronic disease management. Also, I don't think people run to the doctor every chance they get just because they can charge it to insurance. I'm not a typical male in my aversion to doctors, but I don't go at the drop of a hat. I go when I need to. I didn't skip that eye procedure because I was having to spend my own money; I skipped it because I didn't have the money. And when I had the money, finally, and went, it was not a day in the park.

Shifting gears...

As long as you have private insurance, and maybe even with public insurance, deductibles will move inversely to premiums. The lower the premium, the higher the deductible, and vice versa. It's designed this way to mitigate the insurer's risk. Issues around how much a person makes or how much he's likely to use or overuse his plan don't fit neatly into this. Poor people often have very high bills. Rich people, who could afford high medical expenses, often have relatively low medical expenses.

Poor people need low premiums, for obvious reasons. Lower premiums come with higher deductibles. But if the max is 6,350 out of pocket, it is still a better deal for someone without much money than what was the case pre-ACA. As you say, the cost doesn't come crashing down all at once and, in fact, many hospitals will write off these expenses. In any event, it is FAR better than the 300K bill for heart work incurred by the Eritrean refugee couple (he made $10 an hour) my wife pleaded for. Capping a person's liability at 6,350 is a pretty good thing. It would be better if it were lower or $0. But it's far better than having it go up to $300,000.

Could we have low premiums and low-to-no deductibles? IMO, not without massive government backstopping or government capping the amount doctors and hospitals can charge. Ezra has pointed out that EVERY country which has successfully cut medical expenses has used government to cap prices (and also used personal incentives to help keep costs down, cf Japan and Singapore).

The right seems to think that empowering health care consumers to shop will do it--IMO, not unless they acquire tremendous leverage by banding together into very large groups with market pricing power. Doctors and hospitals hold a commodity of ultimate value to buyers--their lives and health.

Of course, if "we all" decided en masse to live ultra-healthy lives and bring down cancer and diabetes and heart disease to historic lows, we MIGHT move the needle. If, at the same time, we all decided that living beyond, say, 85 or 95, should be treated as life's lagniappe to us, we could probably eliminate a good chunk of the very expensive spending. I bet this would be Dasani's advice.

Just to finish on a different point: What's all this bitching about having to give up one's doctors? I never had a doctor who was in-network. And with the way Americans move, they are constantly giving up their doctors and finding new ones. Why does anyone think that a doctor who is in-network is worse than a doctor who is out of network? I could've saved a good bit of money years ago had I clued into this reality before. I recently switched to a doctor in-network who is just fine. Plus, she's ALWAYS on time and time manages throughout the day very efficiently. If I want a doctor willing to lollygag with me, then I'm going to have to pay more for it. But again, a doctor's office is not a place I rush to visit for overtreatments every chance I get.