Republicans must live with Obamacare. They have few prospects for electing 60 senators needed to repeal the law, and unless they work to make it more palatable–something they have few ideas to accomplish–the nation is headed for socialized medicine.

Obamacare seeks to substantially reduce the ranks of uninsured.

It requires businesses with more than 50 employees to provide health insurance.

Requires persons without employer insurance to purchase coverage, with federal subsidies for low and moderate income households.

Expands Medicaid eligibility to many families with incomes up to 133 percent of the poverty line.

Establishes government-run exchanges to facilitate purchase of health insurance.

Imposes minimum coverage standards for private policies.

Requires that insurance companies not turn away individuals with pre-existing conditions or charge them more than healthy policyholders.

Minimum coverage requirements and the ban on factoring pre-existing conditions into rates are driving up premiums. Large businesses, like Trader Joe’s and Home Depot, are dropping coverage for part-time employees.

Smaller businesses and healthy young people are seeing premiums jump–sometimes by 300 percent. The former are finding it cheaper to drop plans for full-time employees and pay a penalty starting in 2015.

Many healthy young people will calculate it is better to forego coverage and pay a modest penalty–after all, a 30-year old earning $50,000 really can’t easily afford $4000 for insurance, making a $500 penalty appear modest. Even some middle income families will find similar math compelling.

This will leave health insurance exchanges with too many sick people and too few healthy ones. This will drive up premiums further, compel more businesses and individuals to forgo insurance, and create enormous political pressure to increase federal insurance subsidies for low and middle income individuals and families.

Medicare’s actuaries expect health costs per person across the entire population to rise from about $9,200 in 2013 to about $14,700 in 2022. That’s about 20 percent of GDP, whereas Germany spends about 12 percent and Britain even less.

Large U.S. multinationals will find providing most employees with insurance too expensive if they are to compete in global markets and dump their employees into subsidized public exchanges.

It will still be impossible for the GOP to win 60 Senate seats on a platform to repeal Obamacare. Although many folks will be without coverage, too many voters will depend on federal subsidies or Medicaid and simply won’t vote to give up those entitlements.

The burden to find solutions will take congress to places that Republicans are very reluctant to go.

The German and other European systems accomplish lower costs and universal coverage by imposing tight controls on prices for services, drugs, and devices. Britain’s National Health Service doesn’t bother with insurance companies and claims forms–by eliminating insurance company overhead it accomplishes much lower costs than even the German system.

Even before Obamacare, federal and state governments, through Medicare, Medicaid, and other programs, paid more than 50 percent of U.S. health care bills. That was more than the 9 percent of GDP, and the amount Britain spends to accomplish universal coverage–without the additional $4,600 per person American businesses and individuals pony up.

Reducing U.S. doctors fees and drug and device prices down to German levels won’t be easy or likely possible, but politicians, providers, and businesses still providing health insurance will need a solution–likely a scapegoat.

Enter the insurance companies that have been screwing down doctor’s fees, hassling everyone with mindless paperwork, and paying executives like royalty.

The federal government could probably pay doctors, drug companies, and device manufactures pretty reasonably directly, and without the insurance company middle-men, through an American National Health Service.

Peter Morici is an economist and professor at the Smith School of Business, University of Maryland, and a widely published columnist. Follow him on Twitter.