When it comes to health insurance many consumers apparently have the same cavalier attitude that they have about their own medical care.

A recent survey for online broker InsuranceQuotes.compolled over 1, 000 adult consumers about their knowledge of insurance and the Affordable Care Act. Among the findings:

Worse than that, nearly two-thirds of respondents say the new law will result in more, not less, expensive healthcare. Fewer than half said the law would result in an improvement in the health of Americans.

The law’s proponents say that the survey results prove that consumers are misinformed about the new health law.  I disagree. Especially when a search of the term “Affordable Care Act” leads you directly to a variety of the government’s own sites, including the White House.

The only thing easier than finding information on the ACA is blaming the law’s opponents for survey results like these. Ten percent uninformed about the law I could see. Twenty percent. But when you’re looking at two thirds of the people the law was intended to help unsure and apparently unconcerned about whether they’ll take advantage of the ACA’s benefits, I don’t think you can pin it on cable TV or insurance companies.

I think if the survey proves anything it proves that no matter how much government might like to help people, some people don’t want the help. Think about it: How much have we as a nation, through our taxes, insurance rates and cost of goods purchased, paid for wellness programs? Smoking cessation advertising and classes? Gym memberships? The results? Conditions like obesity, diabetes and heart disease are at still at epidemic levels. And still you have consumers, including children, sitting on their butts for hours at a time, watching TV, chowing down a bag of Fritos and washing them down with a liter of their favorite sugary drink.

Let’s face it. Consumers themselves shoulder a lot of the blame for the nation’s health crisis. Congress and the president engineer a law to re-shape what by year 2021 will be 20% of the economy, and you ask those people the law was intended to help if they’re going to take advantage of it and the answer is a shake of the double chins and a puzzled “I dunno.”

Call it misinformed or uninformed; it’s the same thing. You live in this country for four years of screaming 105 decibel debates over the ACA and you still don’t know whether you’re going to buy insurance, or if you’re even eligible for it? That’s the real problem with the ACA. Being uninformed and unsure about the law goes hand in hand with bad lifestyle choices, overeating, not taking your meds, or not getting checkups.

The fact is that too many consumers are divorced from their own health care.

They’re divorced from the responsibility of keeping themselves healthy and figuring a way to pay for it so the rest of us don’t have to.

That’s the real problem with the ACA. And until you solve that, until you make people responsible for their own well-being, you’re going to continue to have this rancorous and now pointless debate. 

In a “Man Bites Dog” lead, we’re pleased to announce that healthcare spending appears to be declining. As of now.

Earlier this month, the Wall Street Journal editorialized that the growth in health spending has leveled out at about 4% over the last three years. That’s lower than it’s been for 40 years and way down from its mark of 6% to 10% over the last decade.

At first glance it looks like the decline is tied to the continuing weak economy: fewer jobs mean less employer-subsidized health insurance and medical treatment. In fact, according to the Journal, the Kaiser Family Foundation recently estimated that nearly 80% of the health spending slowdown can be attributed to economic conditions.

If that’s the case, then we can expect an explosion in health care costs as the economy improves. Right? Not so fast.

There is also evidence that the change in healthcare spending has been going on for longer than thought and that it may indicate a permanent leveling of cost. If so, this would be contrary to everything we think about healthcare.

In fact, another economic model now shows that the slowdown has been going on for a long time. That it is systemic, durable and, perhaps, permanent. Economist David Cutlerand Nikhil Sagni say that their model shows that the recession of 2007 only accounts for about 45% of the decline in spending. That’s about half of the Kaiser estimate.

Taking it a step further, another model by Michael Chernow of the Harvard Medical School has suggested that the spending decline is the result of market choice and competition, introduced into the healthcare market beginning in the last decade. Investigating changes in the large market insurance business he found that these firms did better than smaller ones controlling cost through the use of higher deductibles and co-pays, as well as innovative program designs. These changes account for 20% of the slowdown, the model suggests.

When patients, rather than a third party, are empowered to make their own spending decisions about healthcare, they tend to be more frugal. Over the long haul this lowers overall costs, the models seem to suggest.

During World War II the War Labor Board determined that wage and price controls did not apply to fringe benefits, including health insurance. Providing health insurance was a way employers could retain workers—by raising their overall standard of living without fattening the pay envelop.  In today’s healthcare market there are those who suggest that large companies can reverse the effect of the Board’s wartime decision by plowing money saved by these new high deductible/co-pay models into workers’ paychecks. What would be nice would be a study to validate whether this theory is true.

Which brings us back to today’s current healthcare morass. The Affordable Care Act outlaws most of the types of plan innovation that seem responsible for the slowdown in health spending. For example, the law’s arcane rules outlaw what the government considers to be excessive cost-sharing with beneficiaries.  There go the higher deductibles and co-pays.

Cutler estimates that entitlement spending in healthcare will be about three-quarters of a trillion dollars lower over the next decade if the current slowdown in spending continues. But that doesn’t seem possible under the current ACA rules.

Look for costs to start rising again as the ACA kicks in in 2014. The government will mitigate this effect on consumers by injecting money to inflate the healthcare system. But that money will come out of the left pocket of consumers and go back into their right pocket as a subsidy. The resulting loss in price stability will be greater than the entitlement gain.

After being told that the Affordable Care Act would increase access to health care, Americans are waking up this week to find that’s not necessarily the case. As companies try to comply with the healthcare mandate and still preserve their margins and the jobs of their workers, those with high numbers of low-skill workers are turning to what the Wall Street Journal calls “bare-bones health plans.” Employers fitting this profile can get by with offering preventive care and little else and still avoid the law’s penalties.

These plans defy the predictions that the ACA would result in more coverage for more people. Instead, these so-called “skinny plans” provide minimal coverage. If you’re covered by one of these plans and you need an X-ray, prenatal care or surgery, you may be out of luck.

The law requires that employers with 50 or more workers have to provide health insurance or pay a $2,000 penalty per employer. Up till now this has generally been interpreted as meaning a full range of benefits. But apparently this requirement applies to those plans sold to small businesses and individuals. These are the two groups that typically have had the most difficulty obtaining reasonably priced insurance.

The feds say that these skinny plans appear to answer the mail with respect to larger companies that employ lots of low-wage workers. With typical American ingenuity a cottage industry may be developing around the need for these stripped down plans, which allow employers to comply with the law but not at a cost that would cost jobs. When the ACA bill was passed by Congress, accompanied by emotional speeches from its supporters, I don’t think this is what they had in mind.

The ACA is another example of what can go wrong when you try to carve things like technology or social policy into federal legislation. You may not end up with what you thought you were going to have. More importantly, while the law ossifies on the books, technology, policy and business practices change, creating a law that can obsolesce before anyone realizes it (Hello, Alternative Minimum Tax).

Look for the bill’s supporters to bob for another bite at the apple and close what they see as a loophole in the law’s application. But with the House controlled by Republicans this time around, don’t look for ACA II anytime soon. Lawmakers who try to out think and out pace a free market are most often on a fool’s errand.