Leading from behind is a business concept where leaders steer their organizations much as shepherds guiding their flocks, from behind. It is contingent on a basic reality, “One can lead from behind only if one knows what lies ahead and what it will take to get there.” President Obama’s foreign policy style has been described as “leading from behind” particularly in the Middle East. Another view of Obama’s style: “A foreign policy of hesitation, delay and indecision.” One look at the current Middle East shows how that is working out.

Shifting from foreign to domestic affairs, how has the President’s leadership worked with Obamacare? Does Mr. Obama know what lies ahead and how to get there in the world of healthcare? Or have the past six years since passage of the Affordable Care Act been one of hesitation, delay and indecision? Has the President’s signature piece of legislation, bearing his name, been shepherded forward in a thoughtful and logical manner, responsive to the needs of patients, providers, and the insurance entities footing much of the bill? It’s quite obvious that just as with foreign policy, Obamacare is failing from behind.

Given the run of Obamacare co-op closures, it seems the President is not tending his flock, instead allowing predators, harsh weather, and lack of food to decimate his sheep. This week the Illinois Department of Insurance shut down the Land of Lincoln co-op, leaving nearly 50,000 policyholders high and dry.

For those losing their insurance, there is good and bad news. The good news is, “Policyholders will be able to buy insurance from a different carrier to cover them for the rest of 2016.” The bad news is, “The co-pays and deductibles enrollees have been paying since January will not transfer to new plans.” A double whammy for those who have already met their deductible and out-of-pocket maximums for the year and now have to do it all again now. And then again in January 2017.

We all remember the President’s big lie, “If you like your health care plan, you can keep it.” Except when insurance companies go broke due to a variety of unfavorable business conditions and regulations. These include essential benefits, making everyone purchase insurance to provide coverage they don’t want or need. Then there is guaranteed issue, allowing one to purchase insurance after they are sick, not quite the concept of insurance. And adverse selection where sick people purchase insurance and healthy people don’t, leaving the insurance companies covering a sick and expensive group of individuals.

These forces choked the Illinois exchange. They lost $90 million in 2015 with incoming premiums far below the outgoing healthcare costs of its enrollees. They ran into Captain Obvious, “The newly insured were sicker than carriers had expected.”

For all the hype and fanfare, only 11.3 million people have signed up for health insurance under the Affordable Care Act, just over 3 percent of the US population. And in the process, how many more have had their lives and wallets disrupted by Obamacare?

Higher premiums are a fact of life under Obamacare. And they continue to go up each year. But that’s only the beginning. Pay the premium to have insurance, not to use it. That carries another cost, the deductible, which must be paid in full before any insurance benefits kick in. Even after you pay the deductible your healthcare is still not free. Don’t forget the copay, anywhere from 10 to 40% of your bill that you must pay, on top of the deductible and monthly premium. This also assumes the doctor or hospital you choose is in-network, otherwise insurance may not cover anything.

Imagine a monthly premium of $500 for your family, a $6000 deductible and a 20 percent copay. Pay $12,000 out of pocket to reach the point of having to pay 20 percent of prescriptions, lab tests, doctor visits or hospitalizations. Fortunately, most policies have an out of pocket maximum, but if it’s tens of thousands of dollars, you may be bankrupt before ever reaching the maximum. And this is for the year. Ring in the New Year and the financial clock starts all over again.

The Illinois co-op was one of 23 co-ops created under Obamacare. Only 7 remain open for business. Three-quarters of the co-ops have gone the way of Donald Trump’s primary opponents. And of those still open, for how long? What happens when they close? Obama the shepherd has a rapidly thinning flock of insurance co-ops, which he is leading from behind, assuming he even knows where it is going or how to get there. Most of the flock already have been led off a cliff.

What if he does know where he is going? What if his goal is well beyond Obamacare into the realm of single-payer? It struck out in Vermont, but is on the ballot in Colorado. Obama is a fan of single-payer plans. Could he actually and cleverly be leading the country from behind into a national single-payer plan, one that Bernie Sanders enthusiastically supports and Hillary Clinton dances around depending on her political audience at the moment.

In 2003, as a state senator, Obama said of single-payer, “We may not get there immediately.” As President, has his shepherding of Obamacare been “failing from behind” as it looks to the casual observer? Or is he truly, but craftily, “leading from behind”, using Obamacare to create chaos and financial collapse to the point where the only solution is for a government rescue? It’s looking more and more like the latter option.

Brian C Joondeph, MD, MPS, a Denver based retina surgeon, radio personality, and writer. Follow him on Facebook  and Twitter.