Thank you for this. I’m increasingly of the belief that alignment of profit and prevention, particularly in the US, as many publicly-funded prevention tactics are being dismantled, is necessary for enduring change. For attention, behavior change, and even widespread belief. We were trained that profit wasn’t something to seek although most clinicians are nested into systems that are forced to focus on it constantly…and those practicing are simply working towards the profit without a focus on it. I’ve just started a company working to do 2 things: a) get people outside (profound benefit through life) and decrease risks for skin cancer (the most common cancer in the US). As a pediatrician and bioethicist I genuinely believe we have to be a part of making new systems/solutions that solve prevention opportunities that are missed. Rendering advice isn’t enough. Would be delighted to talk w anyone more about my belief to encourage and teach trainees some of these tactics, especially as public health remains under siege.
Thank you for a very thought provoking article. I am not a libertarian.. I believe that access to affordable health care is a basic human right and right of citizenship and there are many other countries that do a better job of it than the US. As such affordable access to high value health services is a basic requirement. On the other hand, the dislocation of both providers and patients from the costs of the health services has created a moral hazard on both ends and there are times which both the patient and the provider and conspire. The moral hazard has gotten worse with the demise of private practice. A rational system would require both providers and patients to have skin in the game regarding services asked for or rendered. The problem is that adequate skin in the game for patients is related not only to the cost of the service but also the status of their finances. Likewise, the more discretionary (or less vital) a service is, the more skin should be in the game. Thus it is immoral for insulin to be unaffordable for Type I diabetics but there are many other services where higher out of pocket payments would achieve some of the goals which the authors addressed.
For a 'free market' to work the customers would need to be empowered to be able to choose between products at known prices. Given its the customers' health, this ideal is quickly lost and so with it any notion that the free market can work in healthcare the way we idealize it for things like sneakers. That's before you get into the reality that all markets gravitated towards monopoly which leads to price gouging. Do that for widgets...your a jerk...do it with drugs like insulin you're a monster. Harnessing profit motive has its limits.
Adding this response from Charles Silver who could not post at this time.
I love this column and the vast majority of the comments. Not being a physician, I could not understand or discuss providers' resistance to market-based arrangements from what might be called the internal perspective of health care professionals. But if resistance is to be overcome, that perspective must be understood, and the case for reform must be framed in terms that providers will respond to positively. Even with providers' support, it will be difficult to transition from existing arrangements, which neither patients nor providers like, to better ones. But over their opposition, it will likely be impossible.
Charlie (if I may), I think you’re asking a really important question about “the internal perspective of health care professionals” and why we tend to be hostile not merely to libertarian but to “small l” liberal perspectives in general. Groping my way here, I think there some elements of an answer to that question: 1) We are an expert community and therefore used to thinking in terms of epistocracy and of an expert-specific morality rather than of economic complexity, tradeoffs, and legitimate pluralism. 2) Our moral frame is one of parentalist benevolence especially to the vulnerable, which we feel we can translate into policy imperatives without the intervention of pluralist politics. 3) In the past 30 years we have become less impressed with previous professional ideals of objective inquiry and rigorous application of science to patient care in favor of an extra-caregiving professional identity as social improvers and activists. Of course this is all a sea change from a mid20th century past when physicians were small proprietors as well as caregivers and generally had a very different sense of who they were. Best!
Thank you, Mr. Silver, for your comment. I hope we have gone some way to answering your original question for why there isn't more support for free markets in healthcare.
As you will see in some of the comments to this article, part of the answer still remains concerns that free markets in healthcare wouldn't work or would fail to serve the poor.
Those concerns have been addressed by others before, and we will have to continue addressing them in our advocacy for free markets in healthcare.
But what we have tried to do in this article is to reveal an all too often neglected yet crucial part of why healthcare providers, and doctors in particular, have 'resisted' free markets in healthcare, that their view of a moral doctor conflicts with the ethos of a free market.
Economic arguments about the failures of government policies and the efficiencies of free markets alone are insufficient to overcome that conflict. It also leaves doctors and other providers without an answer on how to resolve that moral conflict in their own lives.
Only a moral rethinking of how freedom and the profit motive actually empowers, rather than corrupts, the relationship between providers and patients can resolve that conflict. Much of that work still remains ahead of us. I hope to share more of it with you in the future.
Mr. Silver, thank you for the encouraging comment and for your original article, which inspired me to write this.
I think we have a lot of work to do to demonstrate that a more free-market system is not inherently in conflict with a system that is compassionate and prioritizes patient care.
As always, the devil will be in the details, and any change to the system will require a carefully planned transition to avoid breaking contracts with patients and doctors who rely on the status quo. (For example, as much as I think Medicaid underpays doctors and disadvantages patients, it's terrible to take it away from people who have depended on it and haven't had the opportunity or ability to plan for that loss.)
Yes. Or even for life. That would solve the preexisting condition issue, also insurance would have incentive to subsidize or cover interventions that could improve health such as gym memberships, postpartum physical therapy, discounts for not smoking, etc.
Note: I'm a computer scientist, not a healthcare professional. As I've said before, I think it's important to remember that "He who pays the piper calls the tune". The third party payer, whether a private company or a government agency, is stuck in the position of having to justify payments, and because it doesn't have unlimited resources this inevitably means lots of bureaucracy, red tape, and disappointment for payers, providers, and patients.
With some exceptions such as children and the indigent, it is actually the patient/consumer who is paying the costs for medical care, whether through insurance premiums, deductibles or taxes. However, because health ins companies or government has inserted themselves between the patient and providers, in the role of the 'payor' , the patient loses any leverage they would have had to negotiate or 'comparison shop'.
I talk about values a lot with my patients. Trying to pay for “ideal” treatment might harm their quality of life. So I talk about what feels like good value for the quality of life they desire. We talk about it together. I have to run a sustainable business to keep providing care and patients do have to pay for their care.
The problem isn't profit per se - it is the fact that profit centers are now largely insurers, venture capitalists , third party pharmacy benefit managers and others who have no allegiance to patients or to medical ethics and the pledge to put patient interests first. Insurers make sure that cash pay isn't competitive when they require contracted physicians and hospitals to set the " rack rate" 3-4 x higher than what insurance reimburses - you almost have to buy insurance or face ridiculous charges. 25k insurance paid surgery is billed at 100K cash price . Not to mention that employer provided insurance is tax free , and cash to spend is taxable. The system is rigged to require you to have insurance , which drives cost up because now you feel entitled to use it for every little thing . Our ER s are drowning in non emergent visits because patients don't think it is a big deal to go the the ED , and because primary care says " my first available is 2 weeks ".
A " free market " system whereby patients can shop for the best price sounds good , but only works if you are a) well educated and medically literate b) have money to spend and the capacity to save for the future . Quite a large segment of our population has neither qualification , and when you are sick and in pain and frightened your first thought isn't to shop for the best price . Not to mention that " quality " in the patient mind is most often linked to bedside manner and willingness to do what the patient wants, as opposed to needs. We all know that the best surgeon isn't necessarily the nicest one. But the public chooses differently. Asking the middle class employed American to use funds wisely is one thing, but what about the addicted, the mentally ill, the unhoused , the poor , those living paycheck to paycheck . There needs to be a solution that includes care for these individuals too -
I agree that the average insured person is divorced from the actual cost of their care and as a result wants" everything " - no matter how inappropriate and pricey - but we ourselves have largely fostered this with a message that more is better - more drugs, more surgery, more imaging. Doing " something" is rewarded - cognitive skills are not . I can't tell you how many times in private practice a patient felt they didn't get their money's worth because they didn't get a prescription despite all my best efforts to spend time, educate and counsel.
Personally , I like direct pay primary care ( not " concierge" medicine - 2 different things) . I pay my PCP a set monthly fee and he is accessible when I need him - which is rarely for me and a lot for my elderly mother ( who also subscribes despite being on Medicare because otherwise she would see a NP two weeks out or get sent to the ED ) . At 88 she has been to the ED 2x in the past 2 years because he keeps close tabs on her and resists the urge to do things to a frail elderly woman. If we could have Direct Pay primary care for everyone and insurance only for specialty care , surgery and catastrophic medical diagnoses ( kind of like car insurance ) the system would likely self regulate better. But we would need 3-4 x more primary care doctors to do this. And doctors willing to run their own businesses without huge subsidies from large hospital groups that then hold them captive after they sign for the money . I know so many young FM docs who sign with these groups because they a) have huge student loans and b) are exhausted , have no business training , and no means to acquire a business loan to start a practice .
Great article. What's interesting about physician-written articles about the healthcare marketplace is that the author rarely views themselves as not just the clinician but also the patient. We are always both.
The short answer is fear of freedom and a (mistaken) faith in "regulation" by supposedly objective third parties. The source of the problem is always government intervention that always evolves into a bureaucratic nightmare. Collectivistic thinking works against the realization of these simple elements.
I am going to touch the 3rd rail here. What about all the "free care" we give to illegal immigrants, people on "vacation" and those that walk into a urgi-care for a cold? I knew a MD in East Boston. On handfuls of occasions, 6 men from a foreign country (I won't name it) arrive in the walk in center all complaining of blood in their urine. They are worked up and all of them have bladder cancer. They are provided cancer care free of charge because they are not from here and at the end of it, they all leave home together. I may have the details a bit medically off, but I hope you get my point. And this doc was originally from China and he saw the corruption in the groups of people coming the the US to get "vacation cancer care" and then go home. I have foreign friends who bring their elderly parents here for medical care and then they go home and it is all free. And that doesn't begin to cover the millions upon millions of illegal people who have come here and get free care. We wonder why our healthcare is tapped out and unaffordable? I pay 10-15K a year (through my insurance and out of pocket for non-covered care. Then I pay 6K for my health insurance. And I am healthy! So we have a serious problem when I am paying for someone else's care and I can't get any care covered myself. Sometimes I think it would be better to not be from this country, apply for free care or maybe not have a job! Then I could qualify for free care. I own a health care business and take every insurance. And the only way to survive is to hope the mix pf payments works out so that the free care patients are outweighed by the better paying products. And I live in an area where we have lots of free care at one end and Medicare at the other end. It is not sustainable. This is the first year I have gone into a new year feeling like this business can't carry on. The other thing not talked too much about, admin burden. I have insurances that require an authorization. Now the allowable is $60/visit and the copay is $60/visit. Basically the patient will be paying me every time they come. So why make me take time to fill out forms, fax them, follow up, to approve a service the INSURANCE IS NEVER GOING TO PAY FOR! And we do this because we want the care to go tot he patient's deductible. This requires authorization. Totally ludicrous.
Given decades of extremely aggressive AMA lobbying against what they like to call "mid-levels", against evidence-based maternity care and against midwifery, against universal health care; for basically the longest and most expensive medical education in the developed world, for an artificial scarcity of spots at med schools, for specialist salaries at the expensive of preventative and primary care... I guess you could say medicine is "anti-free-market" but only inasmuch as it's defined by the worst kind of crony capitalism.
Without meaning any disrespect whatsoever, I'm surprised to see that one of the authors is an Emergency physician.
The authors say the free-market is "a situation in which buyers seek the best quality at the lowest prices, and sellers compete for buyers by improving quality, lowering prices, or both.". But Emergency medicine highlights exactly why these principles can be useless. In the middle of a cardiac arrest no-one is in a position to do either.
But that's just the most extreme case. I think that even in more routine cases the information asymmetry between consumer and provider means free-market mechanisms will fail. On top of that, outside of major urban centers natural monopolies would quite likely form, causing market failure in another way.
On the one hand, I agree that the idea of a mid-cardiac-arrest bill is tragically laughable. But this is the sort of thing that real, catastrophic insurance would be for, if it were available. To some extent, people would have an obligation to buy that insurance or expect to slowly pay off the hospital debt in exchange for their life. What is too much to pay for your life?
On the other hand, this comment presupposes our (U.S.) current, non-free-market system, where the cost after a severe, unexpected medical event *is* unbelievably high - maybe too high - even with health insurance.
We can think creatively and entrepreneurially about other models that could exist in a free-market system to appropriately disincentivize the overuse of emergency care and also drive down its costs. Off the top of my head: expansion of HSAs, legalizing true catastrophic plans, and allowing physician-owned group practices that include urgent, emergency, and specialty care at annual subscription rates.
I think the info assymmetry problem is less than it appears. Patients shop for doctors when they're well rather than when they're sick (yes, not all the time but they can). And reputation is often reliable--most consumers dont know much about cars but its hard to buy a lemon these days--because there's a working market with competition including on price. If physician group practices competed on both price and quality to patients paying in cash for routine expenses and relying on insurance for major illnesses, etc we'd be in a very different place than we are.
This article is nice in the abstract but there is not even a passing effort to address the elephant in the room. Are we OK with poor people dying if they cannot afford a visit? I'd like to see more "libertarian" doctors speak in detail about what their plan is to ensure that the poorest in our society continue to have access to the standard of care. I think we all agree that "they shouldn't have access" is a non-starter.
An essential component of free market is price transparency. We should all be working to encourage more of it. Large corporate entities tend to benefit more from price opacity.
Yes exactly the case with PBMs, who claim to negotiate the best price on pharmaceuticals, but patients often pay full retail price on drugs in their insurance plans' formularies.
There have been plenty of doctors who were/are snake oil salesmen not putting patient welfare above profits.
Thank you for this. I’m increasingly of the belief that alignment of profit and prevention, particularly in the US, as many publicly-funded prevention tactics are being dismantled, is necessary for enduring change. For attention, behavior change, and even widespread belief. We were trained that profit wasn’t something to seek although most clinicians are nested into systems that are forced to focus on it constantly…and those practicing are simply working towards the profit without a focus on it. I’ve just started a company working to do 2 things: a) get people outside (profound benefit through life) and decrease risks for skin cancer (the most common cancer in the US). As a pediatrician and bioethicist I genuinely believe we have to be a part of making new systems/solutions that solve prevention opportunities that are missed. Rendering advice isn’t enough. Would be delighted to talk w anyone more about my belief to encourage and teach trainees some of these tactics, especially as public health remains under siege.
Thank you for a very thought provoking article. I am not a libertarian.. I believe that access to affordable health care is a basic human right and right of citizenship and there are many other countries that do a better job of it than the US. As such affordable access to high value health services is a basic requirement. On the other hand, the dislocation of both providers and patients from the costs of the health services has created a moral hazard on both ends and there are times which both the patient and the provider and conspire. The moral hazard has gotten worse with the demise of private practice. A rational system would require both providers and patients to have skin in the game regarding services asked for or rendered. The problem is that adequate skin in the game for patients is related not only to the cost of the service but also the status of their finances. Likewise, the more discretionary (or less vital) a service is, the more skin should be in the game. Thus it is immoral for insulin to be unaffordable for Type I diabetics but there are many other services where higher out of pocket payments would achieve some of the goals which the authors addressed.
For a 'free market' to work the customers would need to be empowered to be able to choose between products at known prices. Given its the customers' health, this ideal is quickly lost and so with it any notion that the free market can work in healthcare the way we idealize it for things like sneakers. That's before you get into the reality that all markets gravitated towards monopoly which leads to price gouging. Do that for widgets...your a jerk...do it with drugs like insulin you're a monster. Harnessing profit motive has its limits.
Adding this response from Charles Silver who could not post at this time.
I love this column and the vast majority of the comments. Not being a physician, I could not understand or discuss providers' resistance to market-based arrangements from what might be called the internal perspective of health care professionals. But if resistance is to be overcome, that perspective must be understood, and the case for reform must be framed in terms that providers will respond to positively. Even with providers' support, it will be difficult to transition from existing arrangements, which neither patients nor providers like, to better ones. But over their opposition, it will likely be impossible.
Best wishes,
Charlie
Charlie (if I may), I think you’re asking a really important question about “the internal perspective of health care professionals” and why we tend to be hostile not merely to libertarian but to “small l” liberal perspectives in general. Groping my way here, I think there some elements of an answer to that question: 1) We are an expert community and therefore used to thinking in terms of epistocracy and of an expert-specific morality rather than of economic complexity, tradeoffs, and legitimate pluralism. 2) Our moral frame is one of parentalist benevolence especially to the vulnerable, which we feel we can translate into policy imperatives without the intervention of pluralist politics. 3) In the past 30 years we have become less impressed with previous professional ideals of objective inquiry and rigorous application of science to patient care in favor of an extra-caregiving professional identity as social improvers and activists. Of course this is all a sea change from a mid20th century past when physicians were small proprietors as well as caregivers and generally had a very different sense of who they were. Best!
Thank you, Mr. Silver, for your comment. I hope we have gone some way to answering your original question for why there isn't more support for free markets in healthcare.
As you will see in some of the comments to this article, part of the answer still remains concerns that free markets in healthcare wouldn't work or would fail to serve the poor.
Those concerns have been addressed by others before, and we will have to continue addressing them in our advocacy for free markets in healthcare.
But what we have tried to do in this article is to reveal an all too often neglected yet crucial part of why healthcare providers, and doctors in particular, have 'resisted' free markets in healthcare, that their view of a moral doctor conflicts with the ethos of a free market.
Economic arguments about the failures of government policies and the efficiencies of free markets alone are insufficient to overcome that conflict. It also leaves doctors and other providers without an answer on how to resolve that moral conflict in their own lives.
Only a moral rethinking of how freedom and the profit motive actually empowers, rather than corrupts, the relationship between providers and patients can resolve that conflict. Much of that work still remains ahead of us. I hope to share more of it with you in the future.
Mr. Silver, thank you for the encouraging comment and for your original article, which inspired me to write this.
I think we have a lot of work to do to demonstrate that a more free-market system is not inherently in conflict with a system that is compassionate and prioritizes patient care.
As always, the devil will be in the details, and any change to the system will require a carefully planned transition to avoid breaking contracts with patients and doctors who rely on the status quo. (For example, as much as I think Medicaid underpays doctors and disadvantages patients, it's terrible to take it away from people who have depended on it and haven't had the opportunity or ability to plan for that loss.)
I have long thought requiring insurance to be a longer contract maybe 5 years, could stimulate a lot of change.
Yes. Or even for life. That would solve the preexisting condition issue, also insurance would have incentive to subsidize or cover interventions that could improve health such as gym memberships, postpartum physical therapy, discounts for not smoking, etc.
Note: I'm a computer scientist, not a healthcare professional. As I've said before, I think it's important to remember that "He who pays the piper calls the tune". The third party payer, whether a private company or a government agency, is stuck in the position of having to justify payments, and because it doesn't have unlimited resources this inevitably means lots of bureaucracy, red tape, and disappointment for payers, providers, and patients.
With some exceptions such as children and the indigent, it is actually the patient/consumer who is paying the costs for medical care, whether through insurance premiums, deductibles or taxes. However, because health ins companies or government has inserted themselves between the patient and providers, in the role of the 'payor' , the patient loses any leverage they would have had to negotiate or 'comparison shop'.
Agreed.
I talk about values a lot with my patients. Trying to pay for “ideal” treatment might harm their quality of life. So I talk about what feels like good value for the quality of life they desire. We talk about it together. I have to run a sustainable business to keep providing care and patients do have to pay for their care.
The problem isn't profit per se - it is the fact that profit centers are now largely insurers, venture capitalists , third party pharmacy benefit managers and others who have no allegiance to patients or to medical ethics and the pledge to put patient interests first. Insurers make sure that cash pay isn't competitive when they require contracted physicians and hospitals to set the " rack rate" 3-4 x higher than what insurance reimburses - you almost have to buy insurance or face ridiculous charges. 25k insurance paid surgery is billed at 100K cash price . Not to mention that employer provided insurance is tax free , and cash to spend is taxable. The system is rigged to require you to have insurance , which drives cost up because now you feel entitled to use it for every little thing . Our ER s are drowning in non emergent visits because patients don't think it is a big deal to go the the ED , and because primary care says " my first available is 2 weeks ".
A " free market " system whereby patients can shop for the best price sounds good , but only works if you are a) well educated and medically literate b) have money to spend and the capacity to save for the future . Quite a large segment of our population has neither qualification , and when you are sick and in pain and frightened your first thought isn't to shop for the best price . Not to mention that " quality " in the patient mind is most often linked to bedside manner and willingness to do what the patient wants, as opposed to needs. We all know that the best surgeon isn't necessarily the nicest one. But the public chooses differently. Asking the middle class employed American to use funds wisely is one thing, but what about the addicted, the mentally ill, the unhoused , the poor , those living paycheck to paycheck . There needs to be a solution that includes care for these individuals too -
I agree that the average insured person is divorced from the actual cost of their care and as a result wants" everything " - no matter how inappropriate and pricey - but we ourselves have largely fostered this with a message that more is better - more drugs, more surgery, more imaging. Doing " something" is rewarded - cognitive skills are not . I can't tell you how many times in private practice a patient felt they didn't get their money's worth because they didn't get a prescription despite all my best efforts to spend time, educate and counsel.
Personally , I like direct pay primary care ( not " concierge" medicine - 2 different things) . I pay my PCP a set monthly fee and he is accessible when I need him - which is rarely for me and a lot for my elderly mother ( who also subscribes despite being on Medicare because otherwise she would see a NP two weeks out or get sent to the ED ) . At 88 she has been to the ED 2x in the past 2 years because he keeps close tabs on her and resists the urge to do things to a frail elderly woman. If we could have Direct Pay primary care for everyone and insurance only for specialty care , surgery and catastrophic medical diagnoses ( kind of like car insurance ) the system would likely self regulate better. But we would need 3-4 x more primary care doctors to do this. And doctors willing to run their own businesses without huge subsidies from large hospital groups that then hold them captive after they sign for the money . I know so many young FM docs who sign with these groups because they a) have huge student loans and b) are exhausted , have no business training , and no means to acquire a business loan to start a practice .
Great article. What's interesting about physician-written articles about the healthcare marketplace is that the author rarely views themselves as not just the clinician but also the patient. We are always both.
The short answer is fear of freedom and a (mistaken) faith in "regulation" by supposedly objective third parties. The source of the problem is always government intervention that always evolves into a bureaucratic nightmare. Collectivistic thinking works against the realization of these simple elements.
I am going to touch the 3rd rail here. What about all the "free care" we give to illegal immigrants, people on "vacation" and those that walk into a urgi-care for a cold? I knew a MD in East Boston. On handfuls of occasions, 6 men from a foreign country (I won't name it) arrive in the walk in center all complaining of blood in their urine. They are worked up and all of them have bladder cancer. They are provided cancer care free of charge because they are not from here and at the end of it, they all leave home together. I may have the details a bit medically off, but I hope you get my point. And this doc was originally from China and he saw the corruption in the groups of people coming the the US to get "vacation cancer care" and then go home. I have foreign friends who bring their elderly parents here for medical care and then they go home and it is all free. And that doesn't begin to cover the millions upon millions of illegal people who have come here and get free care. We wonder why our healthcare is tapped out and unaffordable? I pay 10-15K a year (through my insurance and out of pocket for non-covered care. Then I pay 6K for my health insurance. And I am healthy! So we have a serious problem when I am paying for someone else's care and I can't get any care covered myself. Sometimes I think it would be better to not be from this country, apply for free care or maybe not have a job! Then I could qualify for free care. I own a health care business and take every insurance. And the only way to survive is to hope the mix pf payments works out so that the free care patients are outweighed by the better paying products. And I live in an area where we have lots of free care at one end and Medicare at the other end. It is not sustainable. This is the first year I have gone into a new year feeling like this business can't carry on. The other thing not talked too much about, admin burden. I have insurances that require an authorization. Now the allowable is $60/visit and the copay is $60/visit. Basically the patient will be paying me every time they come. So why make me take time to fill out forms, fax them, follow up, to approve a service the INSURANCE IS NEVER GOING TO PAY FOR! And we do this because we want the care to go tot he patient's deductible. This requires authorization. Totally ludicrous.
Given decades of extremely aggressive AMA lobbying against what they like to call "mid-levels", against evidence-based maternity care and against midwifery, against universal health care; for basically the longest and most expensive medical education in the developed world, for an artificial scarcity of spots at med schools, for specialist salaries at the expensive of preventative and primary care... I guess you could say medicine is "anti-free-market" but only inasmuch as it's defined by the worst kind of crony capitalism.
Yes - and that "crony capitalism" is not a free market, it's not capitalism, and it's not working.
Without meaning any disrespect whatsoever, I'm surprised to see that one of the authors is an Emergency physician.
The authors say the free-market is "a situation in which buyers seek the best quality at the lowest prices, and sellers compete for buyers by improving quality, lowering prices, or both.". But Emergency medicine highlights exactly why these principles can be useless. In the middle of a cardiac arrest no-one is in a position to do either.
But that's just the most extreme case. I think that even in more routine cases the information asymmetry between consumer and provider means free-market mechanisms will fail. On top of that, outside of major urban centers natural monopolies would quite likely form, causing market failure in another way.
On the one hand, I agree that the idea of a mid-cardiac-arrest bill is tragically laughable. But this is the sort of thing that real, catastrophic insurance would be for, if it were available. To some extent, people would have an obligation to buy that insurance or expect to slowly pay off the hospital debt in exchange for their life. What is too much to pay for your life?
On the other hand, this comment presupposes our (U.S.) current, non-free-market system, where the cost after a severe, unexpected medical event *is* unbelievably high - maybe too high - even with health insurance.
We can think creatively and entrepreneurially about other models that could exist in a free-market system to appropriately disincentivize the overuse of emergency care and also drive down its costs. Off the top of my head: expansion of HSAs, legalizing true catastrophic plans, and allowing physician-owned group practices that include urgent, emergency, and specialty care at annual subscription rates.
I think the info assymmetry problem is less than it appears. Patients shop for doctors when they're well rather than when they're sick (yes, not all the time but they can). And reputation is often reliable--most consumers dont know much about cars but its hard to buy a lemon these days--because there's a working market with competition including on price. If physician group practices competed on both price and quality to patients paying in cash for routine expenses and relying on insurance for major illnesses, etc we'd be in a very different place than we are.
This article is nice in the abstract but there is not even a passing effort to address the elephant in the room. Are we OK with poor people dying if they cannot afford a visit? I'd like to see more "libertarian" doctors speak in detail about what their plan is to ensure that the poorest in our society continue to have access to the standard of care. I think we all agree that "they shouldn't have access" is a non-starter.
There are ways to subsidize poor people without relying on the government's long arm to regulate every aspect of healthcare. Check out this idea of Freedom Funds (https://www.offlabelideas.com/p/universal-healthcare-the-american) for one way to do this.
An essential component of free market is price transparency. We should all be working to encourage more of it. Large corporate entities tend to benefit more from price opacity.
Yes exactly the case with PBMs, who claim to negotiate the best price on pharmaceuticals, but patients often pay full retail price on drugs in their insurance plans' formularies.