First the forces arrayed against it tried to defeat it but failed. Then the cry was, “Repeal and Replace.” The question “Replace with what?” was never adequately answered. And so the opposition moved on to “defund Obamacare.” After all, no legislation ever enacted by Congress and signed into law by the president can be implemented without funding, and that funding was not guaranteed in perpetuity in the original bill. So perhaps we could pass a budget for the fiscal year about to begin without funding for the Affordable Care Act (ACA). Or we could say we won’t go along the next time we have to raise the ceiling on the national debt unless we abandon funding for the ACA.

What’s so bad about the ACA? Let me count the ways it will destroy our health care system, in the view of its detractors.

(1) It will put the government in charge of your health care. This one is being promoted by a television advertisement described by everyone in the media as “creepy.” It shows a young woman in a doctor’s office, apparently there for a certain kind of physical examination that is common for young women but has few (if any) fans, and the leering practitioner is wearing an Uncle Sam Halloween costume. Needless to say, the woman in the commercial is instantly far less amenable to proceeding with the visit than she was at the start.

This makes me laugh. Those of us in the health care industry know just how much the government is already in charge of your health care. This is because the feds already have very extensive control over how health care is financed, and when you control that … . Well, this seems pretty obvious. There are so many rules about what we can and cannot do that emanate from Washington. The degree of such control has been steadily increasing since the enactment of federal health insurance programs in the 1960s.

The goal is universal coverage and the ACA falls short of that. “I have to ‘like’ the ACA because I’m not willing to let the perfect be the enemy of the good.”

(2) It will create death panels. No, it won’t. What it will do is quite far from that – and arguably falls quite short of what we should be doing in this area. We spend a very large amount of money on end-of-life care. A substantial part of that spending pays for care that is very unlikely to benefit dying patients. It may prolong life without any meaningful quality. It may prolong suffering without any sort of trade-off that the patient would find worthwhile. The most common reason for the expenditure of vast sums for non-beneficial care is that no one spent time with patients and families to talk about options and how they fit with the patient’s personal values. In our health care system, the default is “do everything,” and the default is what happens when the patient and family have not given careful consideration, with advice and guidance from a trusted physician, to what they really do and don’t want. In the early debates over the ACA, there were provisions that would have required doctors to talk to patients about such things, and from the reaction I thought euthanasia for everyone over 70 was the topic of discussion. When I was a medical student I had a frank discussion with my grandmother about her options. I knew what her state of health was. I knew what CPR was like. I thought she might not want it. I talked to her about it at length, so she could give it some thought and make decisions about what sort of care she wanted. Guess who else talked with her about such things? That’s right. Nobody. And in the 30 years since she died, little has changed.