As the "train wreck" of ACA unfolds, at every level we are facing disappointment.  We were promised that 700,000 Americans with pre-existing conditions would become insurable five years ago.  Approximately 1/10 of those actually became insured.  The predictable cost to the healthcare system averaged $1.4 million per year per person, close to $400 billion.  The insurance industry must factor in those losses to remain viable so the net effect has been to accelerate the hyperinflation of health insurance.   Four times as many people have lost their health insurance as have signed up for health insurance under the ACA.  Over half of those who signed up were given Medicaid, a program which is close to bankrupting the State of Delaware.  Those with Medicaid have very limited access to quality care and in many cases no access at all.  The hospitals that thought that they would suddenly be paid for the charity care rendered; they were proven wrong. A study published this week on the Oregon Health Experiment show that emergency room care increases when patients have Medicaid and as such, the cost of caring for the patients goes up, not down, which further stresses the system. The insurance industry that thought it would have more business from young healthy individuals, who required little healthcare, has discovered that only the sick sign up for the subsidized insurance. They are already invoking a stop-loss clause which theoretically reimburses them hundreds of billions of dollars for the failure of the sign-ups; now the federal government is now saying they will not honor that portion of the law.   Doctors who thought that they would suddenly be partially paid for those charity patients they treat are finding that their overall reimbursement is going down and the medical malpractice liability is going up without Tort reform of lawyers.   This year all of the new taxes will hit hard, including about $10 billion in tax increases on the insurance industry, which will be passed on to the consumer.  Massive taxes on small businesses began last week.  Individual health insurance policies_OLD are disappearing and the 4.7 million people who lost their insurance this past year could possibly expand to between 100-150 million people by the end of 2014 as employers drop their policies_OLD for their employees and push them into the exchanges.   There are those who are quietly gleefully that the imminent failure of Medicare, three decades from now, has been accelerated because this hastens the evolution of the "single payer" system of socializing medicine, the Holy Grail of "Progressives".  The truth is that Medicare was doomed to failure if the age was not pushed upwards commensurate with life expectancy.  For the same reason Social Security will fail unless the retirement age is pushed up with the expectation of a longer working life.   If you look at the timeline of the Affordable Care Act published in 2009 by the Congressional budget office, then known as PPACA and frequently referred to as Obamacare, you can see the intended destruction of the health insurance industry and the seizing of control of the health delivery system has exceeded expectations and is ahead of schedule.   In the words of the Chief of Staff to Obama, Rahm Emmanuel, "Never let a good crisis go to waste", his brother Ezekiel Emmanuel, one of the main authors of the Affordable Care Act seems to have taken it one step further.  I would paraphrase his ideology as follows, "If you dont have a good crisis to exploit, then create one."   Up to now, almost all of my patients and almost everyone I know has responded to the increasingly obvious disaster by saying "as long as it doesnt affect me."  Now it is going to affect everyone.  Many years ago a newspaper editor responded to a childs letter at this time of year with a now famous title "Yes Virginia, there is a Santa Claus".  I think in 2014, we regrettably, like Virginia suspected, will find there is no Santa Claus.