On health care, we can't have it both ways

Despite a last-minute surge in sign-ups for medical insurance under the Affordable Care Act, a new poll shows Americans don't like it. Is that shocking?
Of course, the numbers show Americans are wild about provisions of the act -- especially a ban on using pre-existing conditions to deny coverage -- they just don't like being forced to participate.
A mere 26 percent of those polled in the Associated Press/GfK survey support the ACA (oddly, only 13 percent think it will ever be repealed).
"I like the idea that if you have a pre-existing condition you can't be turned down," Dallas resident and Democrat Gwen Sliger told the AP, "but I don't like the idea if you don't have health insurance you'll be fined."
Obviously though, if you're going to have an insurance system it can't work the way Sliger would like. If insurers are banned from refusing to cover the sick, they need some way of making sure people don't wait to sign up until they're sick. There's no economic way to make a system like that work. The insurance pool has to be broad and deep -- that is, full of young, healthy people paying premiums and not just the old or the chronically sick who are the most likely to need expensive, on-going care.
That isn't exactly how enrollment is working out. Only about a quarter of enrollees are between 18 and 34, according to U.S. Department of Health and Human Services figures. That's well below the 40 percent enrollment target the Congressional Budget Office estimates is needed to balance out the risk pool for insurers (some insurers say the 40 percent figure is too high).
Young people tend to be the healthiest. They also tend to have lower incomes as they launch their careers and higher expenses as they start families, buy a first home and pay off student debt. But included in that group also are people who can remain on their parents' health insurance policies until age 26 because of the ACA.
Still despite grumblings, Americans are signing up. Some 6 million have enrolled as the open sign-up deadline of March 31 nears. That's short of the 7 million the Obama administration had predicted, but much better than some expected given the rocky way the government website operated during the first two months of sign-ups.
The reality is this: we can pay through the ACA -- although a single-payer, Medicare-for-all system would be cheaper and more efficient -- or we can continue to pretend we have everyone covered as former President George W. Bush did when he said hospital emergency rooms are the nation's "universal" health care system.