Health Care: The Myth of Free Choice

By David K. Shipler
If the Supreme Court overturns the health care law, the best response would be to enact a single-payer system, possibly by expanding Medicare downward by age until everyone is covered: in other words, a tax-funded service that is clearly constitutional.

Democrats in Congress toyed with the idea, but it won’t happen, of course, because Republicans who don’t know what socialism is will scream, “Socialism!” Nor are we open to learning from other industrialized countries, which have fashioned an array of methods to finance and deliver medical care to their populations. Our pride in American exceptionalism seems to make us impervious to others’ experiences.

Therefore, as seems likely after today’s skeptical questioning by conservative justices, the United States will remain buffeted by a semi-private system that creates the illusion of free choice.


We are fooling ourselves to think that health care exists largely within the private sector. True, unlike in Britain, most American physicians are not state employees. But just over half the dollars spent in the U.S. are government dollars: through Medicare, Medicaid, the State Children’s Health Insurance Program, insurance for government employees, the active-duty military system, and veterans’ benefits. Add the tax deductions for business and self-employed insurance premiums, plus government grants used by hospitals to defray some administrative costs, and we already have extensive government financing of health care.

Furthermore, even in its private attributes, medicine doesn't operate like a normal market economy. You can’t really shop around for health care as you would a car, and if you’re insured, you have little motive to do so. You don’t usually ask about the doctor’s fee before taking the service or decide against the purchase because of the price. Your health is too precious for negotiation, and besides, the money doesn’t come directly out of your pocket. You, the consumer, are cut out of the bargaining process that greases the wheels of a typical free-market transaction. Doctors don’t have much to say about it either: Their charges are mostly dictated by the insurers.

A truly private marketplace seeks efficiencies. Not so American medicine. The uninsured are driven to the most expensive providers—hospital emergency rooms—where the high costs are paid not by those receiving treatment but by the increased fees imposed on the insured.

The prices paid by the uninsured are measured differently—in health and financial impairment. In the Denton (Texas) Record-Chronicle, for example, Brian Rash writes about Frances “Frankie” Rodriguez, 54, who “says she would buy health insurance if she could afford it,” but who gets superficial medical checkups by selling her blood to a clinic that screens donors for hepatitis, HIV, and syphilis. “I figure they would tell me if something were really wrong,” Rash quotes her as saying. “Then I would do my best to find the cheapest doctor around.” So, only by being left out of the prevailing health care system is she compelled to go shopping as if she were in a free market.

I’ve heard low-wage workers explain that they decided not to take the insurance offered by their employers because they couldn’t afford even a modest premium. Every dime that came in went out for rent, phone, electricity, car payments, cable, food, and other essentials. They were healthy, and their timelines were short as they lived paycheck to paycheck. They had little inclination to calculate the long-term gain of short-term investment.

The syndrome will not be easy to change, for dealing with current reality is hard enough without trying to imagine hypotheticals. Medical expenses that you don’t now have lie far over the horizon of concern. Therefore, despite its generous subsidies, the health law may not eliminate this pattern even if the individual mandate is upheld, for many of those uncovered may be more willing to pay the penalty to the IRS than the larger cost of insurance.

Without medical care, the uninsured suffer financial handicaps that go largely unmeasured by the usual poverty statistics, which offer only a still photograph of a year’s income, not the moving picture of indebtedness. Willie Goodell, whom I met years ago in New Hampshire, was plagued by debt incurred when he had no insurance and couldn’t afford a dentist. Whenever an abscess developed, he went to the nearest emergency room for painkillers and antibiotics.

The law requires hospitals to treat you for emergencies, but they may also bill you for the services, and Willie’s unpaid bills eventually reached $10,000. They ruined his credit rating, so even after he was earning decent pay as a roofer, the phone company refused to install a line in his house.

Moreover, the debt became a heavy burden on his sense of possibility. He saw no way of escape. I think his feeling of helplessness sapped his imagination about what he could do.

Yet he and his wife remained believers in the myth of free choice. “It’s our own fault,” he told me. “I’m not blaming it on anybody else.”