The doctor is out, stupid!

That's all well and good, but I would like to suggest that all of is just more misdirection. As all of the other ACA Circus acts are performing, the real show is happening in doctor's offices all over the country. If it succeeds, we may have assured ourselves of no viable option but a single payer system. Independent doctor's offices are disappearing, and this time it isn't a trick — it is real.

Part of the sales job Americans got before the law was passed was that PPACA would dramatically increase access. Those of us in the industry knew that having an insurance card in your pocket is quite different from being able to get an appointment with a doctor. The problem is deeper and more insidious than that, however. According to Scott Gottlieb, a physician and fellow at the American Enterprise Institute (writing in The Wall Street Journal), "Reforms … set to advance in the next Congress … favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices."

Imagine how easy it will be for the government to control and regulate doctors inside hospital and ACO structures that they already control and regulate. As Dr. Gottlieb points out, "Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems." He believes that as this arrangement spreads it will be more and more difficult for anyone to propose a free-market alternative to PPACA.

The hue and cry over "skinny" networks was shell shock to consumers who were used to accessing robust provider-laden networks. Soon, we may not ask, "Is my doctor in the network?" but whether the network exists at all. If and when that happens, expect the government to add regulatory structures that will seem an awful lot like single payer.

Or maybe they are just betting we are too stupid to notice until it is too late?