It appears more and more each day that the ultimate goal of the ACA is the institution of a single payer national healthcare delivery system similar to those of all socialized countries.  While the purported driver of healthcare reform was the uninsured population and the effort to provide something similar to Medicare or Medicaid to that population, the underlying economic driver of healthcare reform was, in fact, the overwhelming demographic data that both Medicare and Medicaid were clearly unsustainable in the near future especially given the increasingly aging population and retirement of the "baby boom" population which funded both programs for the last 50 years. The undeniable truth is that Medicare and Medicaid are both headed for insolvency and that imminent reality has moved decidedly closer with high unemployment and a disappointingly still-weak economy.       Medicaid and Medicare are a form of government provided health insurance and utilize private sector healthcare delivery. In general, those providing healthcare are not employed by the government.  In a similar fashion, The Military Health Service, a division of the Department of Defense, offers Tricare insurance and provides some health delivery in the form of military hospitals such as the Bethesda Naval Hospital, and Walter Reed. Now the VA is a completely separate branch of government; The difference lies in the fact that MHS employees are generally all military personnel, active duty or reserve.  Retired military personnel can choose Tricare insurance from the MHS, instead of going to the VA health system, where most of the employees are non-military government employees. The problems with the Veterans Administration health system are legion. My father, a physician and trauma surgeon during World War II had full VA benefits because of a service-connected disability and chose never to use those VA facilities because of such poor quality healthcare delivery.  The VA is a bureaucratic mess by everyones assessment and has been since World War II.  There have been 2 major fires that destroyed all of the records such that veterans can easily be denied service based upon lack of available documentation, the most recent one shortly after the Vietnam War.  The net result has been delay and denial of services healthcare to our veterans.       If you examine who chooses what form of healthcare delivery among military veterans, those who can choose private health insurance provided by their employer. Retired officers uniformly choose the MHS and avoid the VA system, preferring to use the TRICARE system of health insurance rather than government employed healthcare workers.  You simply do not see officers as patients in the VA system.       Simply put, if given a choice, people avoid government employed healthcare service. And yet, the VA health system is not the best example of dysfunctional government delivery of healthcare, much to the disappointment of columnist/economist, Paul Krugman, who has often touted the efficiency and economic beauty of the VA system, which quite obviously is incredibly inefficient and only survives by rationing of care. A perfect example of cradle-to-grave government single payer healthcare delivery offered by the U.S. Federal Government is the Indian Health Services.       Let us examine the numbers as provided by the government. (www.ihs.gov).  The Indian Health Services has a budget of $500,762,000 for 2014, and has asked for an increase of $478,373,000, almost double.  For this amount of money the IHS results in Native American males and Native Alaskan males having a mortality rate 83% higher than the rest of the male population in the country.  Native American females, and Native Alaskan females fair much better with a mortality rate only 66% higher than the rest of women. Overall, life expectancy for those with IHS care is over 4 years shorter than the whole rest of the population, insured and uninsured. That is damning.  The governments internal analysis of the Indian Health Services program is that much of the blame can be laid on incredibly high indices of "hopelessness" and "worthlessness" within the population, (their index, not mine) but clearly social disease unaided by the system.  While the apologists hint at intrinsic behaviors within the demographic, I find that racist. Social disease should be addressed by any healthcare delivery system. Is it possible that "worthlessness" and "hopelessness" are actually byproducts of the government system? Is social dependency a good thing? The Health and Human Services data is telling.       Medicare can still be fixed, by doing what the actuaries and demographics tell us to do. Change the age of Medicare eligibility to match the increasing length of life and match the funds available from Medicare payroll taxes from those who are still working.  It would also help to have a growing economy and more people working.       As far as attempting to permanently install a single payer national health system, the United States Government has not shown any such capability, as witnessed by the abject failure of both the VA health system, and the Indian Health Services.     C.D.Casscells, MD