Dale M. Posthumus
Can we agree that, although ACA is "similar", "modeled", etc. to the MA law, it is not the same? I doubt the MA law covers anywhere near the number of pages of ACA. And, as you point out, the political dynamics influenced many of the provisions, which were much different than in MA.
Poorly designed partly because virtually nobody ever read the entire bill and analysed its impacts. Something as complicated as ACA, or any similar attempt at healthcare reform, surely required more than a few months of review. What works at the state level, may or may not necessarily work at the national level. One example is the provision about subsidies. ACA explicit says these subsidies are for the states who operate exchanges. It is mum on whether the Federal exchange can apply these subsidies. This issue will likely end up in court. It could break ACA, if the Federal exchange cannot offer subsidies. I doubt that is what supporters wanted.
Although the Supreme Court created a complication by holding the Feds can't penalize the states, creating the opt-out (BTW, that was for Medicaid expansion, not for the exchanges themselves), SC also saved ACA by calling the penalty for not buying insurance a "tax", when the full campaign around it, up to the SC decision, had been it not being a "tax". So, you win some, you lose some.
You are correct that we already make those kinds of "forced" decisions. Once we have any law, we are forcing people to either do or not do something. My point is where do we draw the line? Food stamps used to be pretty open, allowing even the purchase of beer and wine. People bought and sold food stamps to get what they wanted. Restrictions are generally designed to address issues of what people can buy with SNAP. There are many, not just those ideologically opposed to the program, who want to ban the purchase of soda, snacks, etc., the so-called "empty calories" foods, as well. I can assure you there are people who seek to limit or even eliminate meat from SNAP. These are not conservatives.
There are parts of the ACA that seek to encourage, if not force changes, for example the higher premiums for smokers. My point again is we need to decide the extent of "forcing" people to act some way. The examples I raised are not in ACA, but they have been part of the healthcare debate for decades. Many do not want to pay for the riskier lifestyles of others. I accept that is the way the insurance market works (although ACA includes new limitations on the way the market works). But, I can assure you the discussion has long begun to use ACA to encourage or even force certain lifestyles. I am only asking all of us to think about what are the limits we are willing to work with?