More than half of the counties in 34 states using the federal health insurance exchange lack even a bronze plan that’s affordable — by the government’s own definition — for 40-year-old couples who make just a little too much for financial assistance, a USA TODAY analysis shows…

“The ACA was not designed to reduce costs or, the law’s name notwithstanding, to make health insurance coverage affordable for the vast majority of Americans,” says health care consultant Kip Piper, a former government and insurance industry official. “The law uses taxpayer dollars to lower costs for the low-income uninsured but it also increases costs overall and shifts costs within the marketplace.”…

Karen Pollitz, a senior fellow at the Kaiser Family Foundation, acknowledges that catastrophic and even bronze plans would be very difficult for many 40 or 50-something consumers to afford with their $5,000-$6,000 annual deductibles.

“Most people don’t have that kind of money in the bank, and I think it’s going to create problems for people,” Pollitz says.

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As hundreds of thousands enroll for coverage beginning Jan. 1, analysts are warning that the plans are likely to give them access to fewer doctors and hospitals. So much so, they warn, that the system could begin to resemble Medicaid, the health care program for low-income Americans.

“Indeed, I think this will eventually be like Medicaid,” said Merrill Matthews, director of the Council for Affordable Health Insurance…

Just as with Medicaid, analysts warn that if payments get too low, many doctors might start refusing to see patients. That will leave more and more patients jockeying to see fewer and fewer doctors…

“These networks are going to be jammed with people,” Robert Laszewski, president of Health Policy and Strategy Associates, said. “Far more than they’re treating now, and I don’t doubt that we’re going to have problems with access to these doctors. There just aren’t going to be enough of them.”

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If the Affordable Care Act can get through its first days of actual health coverage without big eruptions, the Obama administration may finally be able to move toward a narrative that focuses on how the law can work. But if it has to spend those days putting out more fires, the phrase “troubled rollout” won’t be going away anytime soon…

The point of the Affordable Care Act is to cover people who haven’t had health insurance before, and it may have already reached some of those people. But because they’re new to health insurance, they may be in for a rude shock: It doesn’t cover everything.

There are deductibles, for example — the amount of money you have to spend out of pocket before coverage kicks in — which can be very high with “bronze” Obamacare plans, the cheapest kind. There are also co-payments for office visits, as well as co-insurance, the percentage of medical expenses you have to pay even if most are covered by your insurance.

There’s no way to know how big an issue this could be before January arrives — but if newly insured people think they’re getting free health care, or just think the deductibles are too high, they could be disappointed with their first experiences with Obamacare.

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After a month of trying, I still can’t complete an application to join the D.C. Health Exchange. For a week, the Obamacare marketplace asked me to prove my citizenship, my daughter’s existence, and my fixed address in the District of Columbia, but it would not allow me to submit the requested material…

But it’s not all bad. What I like is that I can access the D.C. exchange in twenty different languages, including Apache, Navajo, and Irish. Which is great because I see so many Irish here who have a heck of a time assimilating, what with the fact that they only speak Irish and not the King’s English. (You can also receive notices in American Sign Language—l’d make a joke here but I might offend the deaf. But I guess since they can’t read and need American Sign Language I might as well let one rip. But I’ll refrain nevertheless.)…

Obeisance to some banal multicultural diktat isn’t costless, and since I’m mad as hell about having wasted a good chunk of a month on this dysfunctional website and can’t find an obvious villain, I will hold in enmity whoever decided that the Navajo and the Irish needed to be able to navigate the D.C. Health Exchange in their native tongue, and condemn the system that concluded it was a necessary thing to do.

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COLBY: What do you think about these bailouts of insurance companies, as well? Could that happen?

YORK: It absolutely will happen –

COLBY: Will happen?!

YORK: As a matter of fact, it’s written into the law. There’s something called “risk corridors,” which basically ensure that if an insurance company ends up paying a lot more in benefits than it takes in in premiums, then the federal government will bail it out — it will make it good. And it looks like we are entering a situation — certainly in the first month of January — where the insurance companies will be in that situation. And they’e not going to take the losses. It will be the taxpayer who makes up for those losses.

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The enrollment figures may be well short of what the Obama administration had hoped for. But the fact that a significant number of Americans are now benefiting from the program is resulting in a subtle shift among Republicans.

“It’s no longer just a piece of paper that you can repeal and it goes away,” said Senator Ron Johnson, Republican of Wisconsin and a Tea Party favorite. “There’s something there. We have to recognize that reality. We have to deal with the people that are currently covered under Obamacare.”

And that underscores a central fact of American politics since Franklin D. Roosevelt signed the Social Security Act during the Depression: Once a benefit has been bestowed, it is nearly impossible to take it away.

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It’s almost impressive how poorly the Obama administration managed the start of its signature achievement. What many envisioned as American liberalism’s crowning modern achievement looked instead like something out of a Marx Brothers movie—a comedy of errors, with each glitch leading to another larger failure.

Equally impressive, however, is the law’s staying power, at least so far. Liberal activists are weary, but still hopeful. Democrats in Congress are anxious and watchful, but only a few have started to defect. And the administration remains as firm in its defenses of the law as ever, even as the president’s poll numbers sag, and long-soft support for the law grows softer still.

What Obamacare has proven this year is not that it can work, but that it can survive, not so much as a specific legislative initiative, but as a policy idea and a political vision. Whether it can do more than that will require another year, at least, to know for sure.

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Yet opponents should not sit back and revel in dysfunction. The Affordable Care Act was enacted in response to genuine problems. Without a clear alternative, we will simply patch more, subsidize more, and ignore frauds and scandals, as we do in Medicare and other programs…

We can have a single government-run airline too. We can ban FedEx and UPS, and have a single-payer post office. We can have government-run telephones and TV. Thirty years ago every other country had all of these, and worthies said that markets couldn’t work for travel, package delivery, the “natural monopoly” of telephones and TV. Until we tried it. That the rest of the world spends less just shows how dysfunctional our current system is, not how a free market would work.

While economically straightforward, liberalization is always politically hard. Innovation and cost reduction require new businesses to displace familiar, well-connected incumbents. Protected businesses spawn “good jobs” for protected workers, dues for their unions, easy lives for their managers, political support for their regulators and politicians, and cushy jobs for health-policy wonks. Protection from competition allows private insurance to cross-subsidize Medicare, Medicaid, and emergency rooms.

But it can happen. The first step is, the American public must understand that there is an alternative. Stand up and demand it.

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