Read: PPACA public support on the upswing

What do the facts say?

• Thirty-nine percent of consumers favor the law and 54 percent oppose it, according to the latest ABC News/Washington Post poll.

• Almost one-half of Americans with health insurance say it is "very" or "somewhat" difficult to afford monthly premiums, according to a Kaiser Family Foundation survey.

• More than 20 new taxes on individuals and businesses will amount to over $500 billion by 2023.

• A poll released in May by the American College of Emergency Room Physicians found that 28 percent of emergency room doctors had seen large increases in patient volume since Jan. 1, 2014.

• The nonpartisan Congressional Budget Office estimated that over the next decade, PPACA will cost $1.35 trillion, or $50,000 per person. The law still leaves between 29 million and 31 million uninsured.

The "affordable" part of the name has many observers concerned. Data from the Wall Street Journal show that several providers already are requesting massive premium increases for 2016:

• Health Care Service Corp., New Mexico, 52 percent.

• BlueCross BlueShield of Tennessee, 36 percent.

• CareFirst BlueCross BlueShield of Maryland, 30 percent.

• Modal Health of Oregon, 25 percent.

Health insurance or health coverage?

None of this comes as a surprise to Eric Wilson, principal of I Sell Health near Chicago. His company works with consumers in Illinois, Indiana, Wisconsin, Iowa, Ohio, Georgia, South Carolina and Texas.

"Back in 2010, I saw the objectives as being very difficult to accomplish," he says. "Doctors were saying you would be forced to change doctors, while the president was saying, `If you like your doctor, you can keep your doctor.'"

At the root of the problem, he believes, is confusion over terminology.

"Health care is the treatment you receive at the doctor's office, hospital or pharmacy," Wilson says. "Insurance is how you pay for that treatment. This got lost in the debate. If you want to reform health care, you don't just reform the insurance component."

Car insurance is a good analogy, he says.

"Your auto insurance does not cover maintenance, but most people still get their tires changed when needed and get their oil changed every 3,000 miles," Wilson says. "These are services that we can afford to pay for, while a larger out-of-pocket of $12,700 or $13,200 is a lot to pay when you are sick and perhaps not able to work."

Insurance rates are a derivative of the costs of the insurance carrier's claims in relation to the premiums collected, he explains. Now that there is no more underwriting, it is reasonable to see the insurance carrier's claims expense going up as they are adding additional risk to their portfolio.

"To offset some of this cost, many insurance companies have narrowed their networks of doctors and hospitals," Wilson says. "This means that you may have to change doctors or change insurance carriers depending on your plan. If you choose to go out-of-network, the costs get more out of control."

Ironically, even if more Americans gain access to insurance, fewer may be accessing routine health care because of high deductibles and out-of-pocket expenses.

"Most plans now in both the silver and bronze product lines have family deductibles of more than $6,000 and family out-of-pocket maximums of over $12,000," he says. "Many Americans who purchase insurance on the individual market are self-employed or small- business owners. If you are self-employed and have a major illness such as a heart attack, not only would you have to pay the $12,000 out of pocket, you probably would not be going to work for a while to earn income." 

Brokers also have taken a hit, he adds.

"It was tough when the law first passed," Wilson says. "It cut our commissions in half, which makes life difficult. That business is coming back now, because so many people have left and there are fewer brokers to use. We used to be busy every day. Now, with open enrollment, we are really busy for three or four months, and then it's all service work. The law sometimes seems to change daily, so you have to spend a lot more time studying."

He also notes that 14 insurance carriers have gone under since PPACA was enacted, Assurant Health the most recent.

Commonsense reforms

Replacing PPACA is a tall order, with so many stakeholders involved and a presidential election year approaching, Wilson said. However, several commonsense measures can improve the law.

"What they really ought to do is keep PPACA but repeal the garbage that is in it," he says. "I agree with the plan of Dr. Avik Roy of the Manhattan Institute, which includes more free-market ideas."

The biggest change would be redefining insurance as providing payment for major conditions, not routine health care expenses.

"People need to understand what health insurance is," Wilson says. "For example, most cosmetic surgery is not covered by insurance. But [cosmetic surgery is] not as expensive as you would think, because people pay for it themselves."

Competition, combined with price transparency, likely would drive expenses down.

"For example, I shop at Walmart, but I don't buy high-end items such as suits there," he says. "If I need cancer treatment or a heart transplant, I will seek the best doctors I can find, regardless of the cost. But if my doctor charges $250 for a physical and the one down the street charges $125, I may be tempted to go there, even if I really love my doctor."

Another key change would be to allow consumers to purchase only the coverage they need.

"I once had a 23-year-old client who had a $15,000 deductible, because that is what he felt comfortable with," Wilson says. "He couldn't do that now. You also have to take maternity coverage even if you are 62 and don't need it.

"It makes more sense to tell companies that they have to offer these services, but not that it's mandatory for consumers to purchase them. If I don't need maternity coverage, I may save $100 a month on my insurance plan."

These and similar reforms would make PPACA more effective and affordable, he says. In the meantime, he encourages consumers not to wade through the regulations by themselves.

"My advice to clients is `don't do this on your own'," Wilson says. "There is more to selecting a policy than price and deductible. Is your doctor part of the network? What if you live in different places throughout the year? The plans may look the same, but you need to go deeper. Plus, you can call your broker if you have a problem. You can't call the Internet."

Ultimately, he believes the future of PPACA hinges on the age-old debate between government involvement and individual autonomy: "Assume the American people know best what they want instead of telling them what they need."