You know the game with three shells, or even bottle tops, that street con men use to separate you from your money?  They place a pea under one of three shells, move the shells around very rapidly, and then challenge you find the pea.  How would you feel if you turned over all three shells and found no pea?

The ACA is the shell game, President Obama is the man with fast hands, and cost reduction is the pea. 

Among the numerous contradictions offered by the president about his Healthcare Exacerbation Plan (he calls it reform; I call it what it is), one of the most egregious now stands fully exposed.

The president promised the American people that the ACA would save money.  Former House Speaker Nancy Pelosi waxed eloquent about this on the Charlie Rose TV show, as did Senator Harry Reid before a sea of microphones.

Their rationale was as follows.  By insuring every American, the ACA would eliminate the huge expenses associated with unnecessary emergency room visits, preventable illness, and inappropriately delayed care.  They even pointed to a (second, drastically revised) prediction by the GAO saying that the ACA would save a trillion dollars.  Their original report said the ACA would cost (spend) well over $1 trillion, and this was clearly unacceptable politically.

The first problem is the government's track record on calculating the costs of entitlement programs.  In 1990, the GAO accounted how much Medicare actually cost in its first twenty-five years and compared it to the original congressional estimate.  Actual cost was 854% more than what they projected.

Second problem is the government presented no proof at all that the ACA would work: for "Patient Protection," that it was "Affordable," or that "You can keep your doctor if you like him."  Hard evidence points to the opposite in all cases.

Patient welfare suffers from the ACA.  The law's IPAB (Independent Payment Advisory Board) is the proof -- an agency that puts welfare of the budget before welfare of the patient.

A 20%-30% increase in insurance premiums since the ACA was passed is hardly what you would call affordable.  As for keeping your doctor, she or he can't keep you.  With repeated reductions in provider reimbursements, more and more and more doctors refuse to see Medicare or Medicaid patients.  They can't if they want to stay in business. 

Now comes the government's shell game with no pea.

Remember all that money that the ACA was going to save by insuring everyone?  What group is the biggest user of ERs?  What group of Americans assiduously avoid the doctor until they absolutely can't delay any longer and then go to the ER?  What group doesn't sign up for government aid even when they are eligible for "free" support?  As such, what group is the biggest user of medical services that go unreimbursed?  You know the answer: illegal residents.

Continuing the shell game reasoning: by insuring everyone, the ACA would save the country gobs of money.  Everyone would use a doctor instead of an ER.  Everyone would nip illness in the bud before it required an ICU.  And of course, those who had avoided signing up would now do so with enthusiasm.  But...

The federal Department of Health and Human Services released a rule amendment to clarify that the Affordable Care Act offers coverage only to those who are "lawfully present" in the United States. There goes all those touted "savings" from health care.

This is not the first time the president played fast and furious (oops, I mean fast and loose) with illegal residents.  In early 2010, the GAO released a report on uninsured Americans, numbering them at close to 45 million.  President Obama immediately used this as ammunition to push the then-PPAHCA, now ACA, toward passage.  He called the fact that 45 million Americans were uninsured a "national disgrace."

But eventually some staffer actually read the full GAO report, and suddenly, the number of uninsured was 30 million.  Why?  Because the report showed that 12-15 million of those uninsured Americans were in this country illegally, some for decades.  The president did not want to deal with this politically explosive issue.  He just changed the number, hoped we wouldn't notice, and ignored the inconsistencies.

The problem of health care for illegal American residents is huge.  It will never be fixed until we face it.  We are the only country that provides unlimited health care for those here illegally, fails to pay for it, and then forces health care institutions to find that money elsewhere or go out of business.

My own medical center consistently provides over $100,000,000 of uncompensated care per annum.  Can any business stay in business if it keeps losing 16% each and every year?  Answer: it can't -- not without finding offsetting profit from "paying" customers.

It is pertinent to note that Spain, where the government accepts full responsibility for the health of all residents, has declared, as of Sept 1, 2012, official "health apartheid" -- i.e., no more free health care for illegal immigrants.

I do not know the right answer about health care for illegal residents in the U.S.  I do know the wrong answer: ignoring and avoiding the issue.

A real (effective) leader, a true U.S. problem-solver, would bring this out into the open, help us discuss it at the ground level, and build a national consensus for a just, honorable, and workable solution.

Deane Waldman, M.D., MBA is the author of Uproot US Healthcare as well as Not Right! (January 2013).  He is a tenured professor of pediatrics, pathology, and decision science and an adjunct scholar for the Rio Grande Foundation in New Mexico.