Minor Thoughts from me to you

Thanks to government policy, the word insurance has been fatally corrupted in the health care industry. Insurance arose as a way for groups of individuals to protect themselves against insolvency by pooling their risk of unlikely but highly costly happenings. Today, private and government health insurance is merely a scheme to have others—the taxpayers or other policyholders—pay one’s bills not only for rare but catastrophic events, but also for predictable and likely, that is, uninsurable, events—and even for goods and services used in freely chosen activities.

The system is so camouflaged that the privately insured are often simply prepaying for future consumption, but the prepayment includes a hefty administrative overhead charge, which means the policy would be a bad deal if customers were paying the full price with eyes open.

What makes private medical insurance look like a good deal today is that employers seem to provide it for "free" (or at low cost) as noncash compensation, or a fringe benefit, which is treated more favorably by the tax system than cash compensation. If an employer pays workers in part with a $5,000 policy, they get a policy that costs $5,000. But if the employer pays workers $5,000 in cash, they’ll have something less than $5,000 with which to buy insurance (or anything else) after the government finishes with them. That gives employer-provided insurance an appeal it would never have in a free society, where taxation would not distort decision-making. Moreover, the system creates an incentive to extend "insurance" to include noninsurable events simply to take advantage of the tax preference for noncash compensation. Today pseudo-insurance covers screening services and contraception, which of course are elective. (This does not mean they are trivial, only that they are chosen and are not happenings.)

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John Cochrane recently wrote about healthcare reform. This is the direction we need to go in, not Obamacare.

First, he talked about the insurance side of health care.

To summarize briefly, health insurance should and can be individual, portable, life-long, guaranteed-renewable, transferrable, competitive, and lightly regulated, mostly to ensure that companies keep their contractual promises. “Guaranteed renewable” means that your premiums do not increase and you can’t be dropped if you get sick. “Transferable” gives you the right to change insurance companies, increasing competition.

Insurance should be insurance, not a payment plan for routine expenses. It should protect overall wealth from large shocks, leaving as many marginal decisions unaltered as possible.

Preexisting conditions, lack of insurance by the young and healthy, and spiraling insurance costs– the main problems motivating the ACA -- are neatly addressed by this alternative. Why do we not have a system? Because law and regulation prevent it from emerging. Before ACA, the elephant in the room was the tax deduction and regulatory pressure for employer-based group plans. This distortion killed the long-term individual market and thus directly caused the pre-existing conditions mess. Anyone who might get a job in the future will not buy long-term insurance. Mandated coverage, tax deductibility of regular expenses if cloaked as “insurance,” prohibition of full rating, barriers to insurance across state lines – why buy long term insurance if you might move? – and a string of other regulations did the rest. Now, the ACA is the whale in the room: The kind of private health insurance I described is simply and explicitly illegal.

He finished by writing about the supply of health care and why we have expensive, low quality options.

So, where are the Walmarts and Southwest Airlines of health care? They are missing, and for a rather obvious reason: regulation and legal impediments.

A small example: In Illinois as in 35 other states7, every new hospital, or even major purchase, requires a “certificate of need.” This certificate is issued by our “hospital equalization board,” appointed by the governor (insert joke here) and regularly in the newspapers for various scandals. The board has an explicit mandate to defend the profitability of existing hospitals. It holds hearings at which they can complain that a new entrant would hurt their bottom line.

Specialized practices that deliver single kinds of service or targeted groups of customers cheaply face additional hurdles, as they undermine the cross-subsidization provided by “full service” hospitals. For example, the Institute for Justice is bringing a major suit8 by a specialty colonoscopy practice in Virginia, which local “full service” hospitals managed to ban.

... The increasing spread of medical tourism to cash-only offshore hospitals is a revealing trend. Why does this have to occur offshore? What’s different about the hospital location? Answer: the regulatory regime.

So, what’s the biggest thing we could do to “bend the cost curve,” as well as finally tackle the ridiculous inefficiency and consequent low quality of health-care delivery? Look for every limit on supply of health care services, especially entry by new companies, and get rid of it.

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John Goodman talks about why Obamacare was flawed from the very beginning.

Do you remember the debates over the Affordable Care Act, aka ObamaCare? Now that repeal of the law has become a major campaign issue, it may be helpful to remember why Congress passed it in the first place.

Early in 2010, as the climactic votes neared, a parade of the legislation's defenders—from the House, Senate and Obama administration—appeared across the media. All had the same message: pre-existing conditions. They named the names of families "victimized" by companies that had refused to sell them insurance, had canceled their coverage or had refused to pay their medical bills.

The message surely resonated, but how many people have actually been affected since the law passed? The Affordable Care Act established a federally funded risk pool—the Pre-Existing Condition Insurance Plan—that allows individuals with such disqualifying conditions to buy a policy for the same premium a healthy person would pay. About 82,000 people have signed up as of July 31, according to the Kaiser Family Foundation's statehealthfacts.org.

That is not a misprint. Out of a population of more than 300 million, some 82,000 have the problem that was cited as the principal reason for spending $1.8 trillion over the next 10 years and in the process turning the entire health-care system upside down.

There is a much better way to ensure people with pre-existing conditions and you don't have to federalize health care in order to do it.

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Dr. Rob Lamberts isn't going to deal with third party payments anymore.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job. The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve. The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk. I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

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Economists agree on theoretical grounds and have shown empirically that all contributions toward premiums—those made by employers and workers alike—are forgone wages. In other words, wages are lower by exactly the amount of the premium, even when the employer seems to pay it. What’s going on here is that employers are shifting compensation from wages to premiums. The preferential tax treatment of the latter encourages this.

Because wages are taxed, compensation in the form of health insurance in lieu of wages reduces government revenue. In fact, it reduces it a lot: $250 billion per year. Just to put that figure in perspective, $250 billion is almost half the Medicare budget. It is more than 3½ times the average annual cost of the Affordable Care Act’s low-income health insurance subsidies. Employer-sponsored health insurance is among the most subsidized types of health insurance in America, almost as subsidized as Medicaid.

The preferential tax treatment of employer-sponsored health insurance also encourages more generous coverage and higher health care spending. By one estimate, health spending among insured workers is 26% higher than it otherwise would be if not for the tax break.

We should get rid of the employer healthcare tax subsidy. It distorts purchasing incentives, it's a massive middle class welfare program, and it drives up the cost of healthcare. It's toxic and it needs to go. (McCain's healthcare plan would have accomplished that. The Obama campaign blatantly lied about it for 6 months and we got Obamacare instead. I'm still angry about that.)

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John Goodman talks about how HSA's help customers save money and help lower costs for the overall healthcare system. Too bad the Obama administration, through Obamacare, wants to get rid of HSAs.

Megan Johnson, a self-employed single mother in Dallas, had severe pains in her side and back, just below the ribs. Her doctor said it was possibly kidney stones, but a CT scan would be necessary to confirm the diagnosis. Megan's doctor gave her the name of an outpatient radiology department near her home. A call to the hospital revealed her share of the cost would be more than $2,800. Because Megan's health insurance had a $5,000 deductible, she decided to ask some questions: Do I really need this? Is it less expensive anywhere else?

A quick search of HealthcareBlueBook.com confirmed a reasonable price for an abdominal CT scan was about $800 - not $2,800. More online research identified dozens of medical imaging centers - including one next to the doctor's office. The insurance company negotiated price was $407 - a fraction of the initial price the hospital quoted. Megan was able to save nearly $2,400 by simply doing a little research online.

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Former "car czar" Steven Rattner, fresh off of "rescuing" GM, is in favor of healthcare rationing by government bureaucrat.

We need death panels.

Well, maybe not death panels, exactly, but unless we start allocating health care resources more prudently — rationing, by its proper name — the exploding cost of Medicare will swamp the federal budget.

This is the inevitable result of third-party payment: some paper pusher will arbitrarily cut off care once you've "had enough". Or we can move back to buying healthcare like we buy everything else in life: paying for healthcare out of a mix of savings and insurance, shopping for the lowest price, and taking responsibility for deciding what is and isn't necessary. There is no middle ground here.

I know which way I want to go and it's not through rationing by a board of government "specialists".

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Austin Frakt, at The Incidental Economist, leads his readers through an exercise demonstrating that total employee compensation is a mix of salary and healthcare benefits. He demonstrates that if healthcare costs went away, employers would have to offer a higher salary.

Of course, the reverse is also true: if health insurance gets more expensive, employers will offer a lower salary (or just postpone raises indefinitely). Salary stagnation, then, is an artifact of increasing health insurance costs, not a sign of a poor economy.

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John Goodman, making sense on health insurance and third-party payment.

The fact is that health insurance is complicated because health care is complicated. Congress may think it can wave a magic wand and declare that it should be simple, but that is like passing a law that declares ice should not be so damned cold.

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The biggest complicating factor is third-party payment. It is incredibly complicated to pay someone else’s bills — for anything. How would you like to be responsible for paying my grocery bills? Or my clothing bills? Or my transportation bills? How would you write the contract for any of that?

It is far easier to make a sum of money available to me and let me go get my own services and pay the bills myself. Now that would be an easy-to-understand contract! It would be one sentence — “Here’s $XXX. Go get your own services.”

If Congress wants health care financing to be “easy to understand,” it should remove the third-party from the mix.

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If I was going to sum up my political philosophy as succinctly as possible, I think this is how I’d do it.

Perhaps the difference that most fundamentally separates true liberals and libertarians from others is that, to one degree or another, true liberals and libertarians are, unlike non-liberals and non-libertarians, dutiful sons and daughters of the Scottish Enlightenment. And one of the great lessons of that remarkable intellectual movement is the refinement of the understanding that state and society are not the same thing. Society is not created by the state, and the state’s activities not only do not define those of society but often diminish society’s activities.

Professor Don Boudreaux says this in the course of pointing out that FDR did much to destroy the private market for unemployment insurance. Prior to governments providing “free” unemployment insurance, many religious organizations, charities, businesses, and private societies provided it. People helping each other, reaching out, lending a hand to a neighbor in need. All of that was blown away and destroyed once the federal and state governments started providing unemployment insurance.

I found out today that it is possible to buy supplemental unemployment insurance to augment what the government provides. That’s welcome news but it’s a far cry from the vibrant assistance provided by society prior to the government’s take over.

Government has not brought us closer together by providing services that the private sector used to provide. Instead, it has pushed us further apart and made us less reliant on each other. That’s the exact opposite of the brotherly love and caring that President Obama constantly claims to want.

If you want a close knit society of caring people that look out for each other—slash government spending and get government out of the business of replacing society with bureaucracy.

Congratulations, you're Medicaid eligible! You now have health insurance. What's that? You actually wanted health care? Oh, well, that's something different. Why didn't you say so?

Children with Medicaid are far more likely than those with private insurance to be turned away by medical specialists or be made to wait more than a month for an appointment, even for serious medical problems, a new study finds.

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The study used a “secret shopper” technique in which researchers posed as the parent of a sick or injured child and called 273 specialty practices in Cook County, Ill., to schedule appointments. The callers, working from January to May 2010, described problems that were urgent but not emergencies, like diabetes, seizures, uncontrolled asthma, a broken bone or severe depression. If they were asked, they said that primary care doctors or emergency departments had referred them.

Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine.

In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer.

Health insurance isn't the same thing as health care. Not by a long shot. By focusing the national debate on who has health insurance we're missing the far bigger problem of who actually has access to care. That's what we should be focused on instead of obsessing over how many people are subscribers to a particular type of insurance product.

John Goodman recommends A Radically Different Approach to Health Insurance:

Middle-class families need health insurance to protect themselves from the financial devastation of a catastrophic illness. But many (arguably, almost all) of the most serious defects of the health care system are created by third-party payment of medical bills.

After 5 years of supporting the billing departments of different healthcare organizations (and using my own healthcare), I've come to agree. Increasingly, I want the choice to spend my own healthcare dollars with the doctor of my choice, for the services of my choice, without having to get approval from an insurance company first.

I truly believe that the lack of competition in our current healthcare system is what's killing American healthcare. And we won't see true competition until we stop relying on someone else to pay our healthcare bills. Sadly, Obamacare will only make this problem worse.

Do read John Goodman's recommendation. He describes how you could pay for healthcare yourself without bankrupting yourself.

Obamacare delenda est

Insurer's Gone Wild

"We allow the insurance industry to run wild in this country," President Obama declared on Monday. "We can't have a system that works better for the insurance companies than it does for the American people."

Yet Obama's plan to tame health insurers would boost their business, protect them from competition, and guarantee their profits, all at the expense of consumers and taxpayers. It is therefore not surprising that the insurance companies, while they object to the president's rhetoric and quibble over some of the details, are happy to be domesticated. Here are five ways in which Obama would help insurers while pretending to fight them.

There's nothing progressive about a plan that forces people to buy products from specific companies, under penalty of law. And there's nothing conservative about that plan either. It guarantees profits, eliminates risks, and rips off the American public. Is it any wonder that the American public opposes this plan 2-1?

At the request of BlueCross BlueShield, Oliver Wyman did a study of the Senate health care bill. Unsurprisingly, this study estimates that the bill will cost consumers quite a bit more than the CBO estimated.

John Goodman summarized the findings this way:

Premiums for individuals and families purchasing coverage on their own will go up 54%. Premiums for small businesses will go up 20%. Both numbers are over 5 years and both numbers exclude the impact of medical inflation.

I skimmed through the study and it looks pretty interesting. The study points out that reform won't work unless everyone is forced to purchase insurance.

The key implication of our analysis is simple: For these types of insurance reforms to be successful and sustainable, it is imperative to get broad participation. Young and healthy people need to be part of the insurance pool, and people cannot defer buying insurance until they are sick or at high risk. This is true no matter who is paying the premiums--individuals, employers, or the government.

The study then goes on to indicate that the current bill likely will allow people to free-ride, with bad results. They're basing their conclusions on several states' experiments with healthcare reform.

• New York and Vermont: Average premiums in the individual market today are about 60% higher than the national average

• New Jersey: Reform caused much higher premiums forcing thousands of individuals to drop coverage. The individual market decreased from 157,000 people in 1993 to 88,000 in 2007

• Maine: Individual market enrollment in Maine dropped from 90,000 to 41,000 between 1993 and 2007 following the state's reforms.

Even in Massachusetts, there is evidence that individuals are selectively jumping in and out of the market when they need healthcare. Data from health insurers in Massachusetts indicate that the number of peopl ein the individual market with coverage of less than 12 months has doubled post reform. These individuals have a significantly higher claims to premium ration when compared to those who had coverage for more than 12 months but let it lapse or those that are active.

Without strong penalties, similar types of behavior are likely to emerge in the reformed individual market--resulting in significantly higher premiums for the insured.

This is one of the reasons why I believe that the "reform" bills will just make American healthcare worse than it already is.

This morning I saw a new Facebook poll: "Is Health Care a Human Right?". I voted no.

Do you have a right to health care? Yes. And no. My answer ultimately depends on what you mean by a "right" to health care.

Rights come in two varieties: negative and positive. A negative right can be thought of as the right to be left alone. It's the right to do something without the fear that someone else will restrain you. A positive right can be thought of as the right to be served. While a negative right requires only that someone leave you in peace, a positive right requires that someone actively do something for you.

I believe you have the right to work with the doctor of your choice -- whether or not that doctor has been credentialed by a government.

I believe you have the right to take the drugs of your choice -- whether or not those drugs have been approved by a government panel of experts. I believe you have the right to take experimental cancer drugs, especially as a last ditch attempt to save your life. I believe you have the right to take marijuana to treat pain, to build appetite, and to relax.

I believe you have the right to buy insurance from any company, located in any state, covering any combination of conditions. I belive you shouldn't be limited to only the health insurance that covers a government approved list of condition from a government approved list of companies.

I believe in a strong negative right to health care. That's something that doesn't really exist in America today. Right now, you are not free to receive health care from anyone you trust, you are not free to take the drugs of your choice, and you are not free to buy whatever health care you desire. I am in favor of more freedom in health care. I believe you have a right to consume health care as you see fit, even if the majority of people around you disagree with your decisions. That's freedom.

I don't believe you have a right to force someone else to pay for treatment, medications, or medical supplies. I don't believe you have a right to force a doctor to work with you. It's one thing if you and the doctor can come to a mutual agreement regarding pay and hours of availability. It's something else entirely to require a doctor to treat you at a price of your choosing (not his) and at a time of your choosing (not his). I don't believe you have a positive right to health care.

To be blunt, I don't believe you have a right to turn doctors into slaves (by requiring them to treat for free or at a steep discount) or a right to turn your fellow citizens into slaves (by requiring them to work in order to pay the bills for your health care).

The current discussion of health care rights revolves almost entirely around positive rights -- getting someone else to pay for our health care. It includes an "exchange" that would strictly limit the options available. It includes subsidies forcibly taken from some people through taxes and used to pay for someone else's health care.

It includes a requirement for insurance companies to charge everyone the same price for health care. This practice, known as community rating, allows sicker people to pay less than the cost of their care and requires healthier people to pay more. In effect, community rating is a subsidy to the sick courtesy of the healthy. Community rated health care is a very bad deal for young, healthy individuals. So the current discussion revolves around a health care mandate. Most of the plans under consideration would require young people to purchase something that's a bad deal. They would be required to do this solely to provide a good deal to sick people and the elderly.

Claiming a positive right to health care is nothing more nor less than the claiming the right to enslave your fellow man. I don't believe you have that right.

Here's Warren Meyer, talking about the different types of rationing.

So here is what it boils down to: For every product or service purchase, someone makes a price-value trade-off to determine if that product or service should be purchased for a given price in that particular instance.

One option for making this decision is to have the person who actually will consume the product or service — and whose money will also be used to complete the transaction — make this price-value tradeoff.

... A second way to do this would be to have someone who has you specifically in mind make the price value tradeoffs for you. This might be like your wife volunteering to go out to buy you some new underwear.

... So a third model, and almost certainly the worst in terms of individual satisfaction, is to have a third party make price-value tradeoffs for me only with some notion of average preferences for average people, or worse, with an incentive system that has absolutely nothing to do with my satisfaction at all. This is clearly the case for the government, and is probably the case for many private insurers today[.]

When it comes to your health care choices, who do you want making your decisions? I definitely want to make my own decisions and I think most Americans would agree with me. But the reforms that are on the table would cement the status-quo. The status-quo overwhelmingly encourages us to pre-purchase our health care through expensive health "insurance" policies. Then a bureaucracy will take a look at our care and decide what to reimburse and what to deny. That's true whether you're on an HMO plan, a PPO plan, or a government (Medicare / Medicaid) plan.

Isn't it time that we had real reform? Isn't it time that we put patients back in charge of their own health care decisions?

The National Center for Policy Analysis published a press release from the HealthPlanWire today, showing the grow in private insurance world wide.

HPW follows health insurance markets globally, and is projecting that total covered lives will exceed one billion by 2012. Single-payer systems are declining world-wide because they are primarily based in countries which have static or declining populations, while private insurance is growing rapidly in countries with the fastest population growth.

Most of this is coming from developing countries which are for the first time ever building out a health financing system, choosing to encourage private health insurance over single-payer on five continents. Examples include China, Columbia, South Africa, Mexico, India, Australia and most of eastern Europe. Most of these countries considered and rejected a single-payer system in favor of a private insurance system, and more than a dozen more are following suit in the same regions.

Private insurance is the chosen system for several reasons. In developing countries in eastern Europe there is a strong aversion to the former Soviet-style model, and western European global insurers like Allianz and Vienna Insurance Group have actually acquired the entire single payer system from the government and turned it private.

Cool.

I should know by now that whenever I try to explain something John Stossel has already explained it better. First, he delivers a great quote about why competition keeps prices low.

In a free market, a business that is complacent about costs learns that its prices are too high when it sees lower-cost competitors winning over its customers.

I posted yesterday about why "exchanges" are worse than free markets. Stossel takes that on too and does a far better job than I did.

... Competition is not a bunch of companies offering the same products and services in the same way. That sterile notion of competition assumes we already know all that there is to know.

But consumers often don't know what they want until it's offered, and their preferences and requirements change. Businesses don't know exactly what consumers want or the most efficient way to produce it until they are in the thick of the competitive hustle and bustle.

Nobel laureate F.A. Hayek taught that competition is a "discovery procedure." In other words, the "data" of supply and demand emerge only through the market process. We need open-ended competition not merely to see which rival is better, but to learn things we didn't know before and aren't likely to learn any other way.

"Competition is valuable only because, and so far as, its results are unpredictable and on the whole different from those which anyone has, or could have, deliberately aimed at," Hayek wrote.

The health care bills are perfect examples. If competition is a discovery process, the congressional bills would impose the opposite of competition. They would forbid real choice.

In place of the variety of products that competition would generate, we would be forced "choose" among virtually identical insurance plans. Government would define these plans down to the last detail. Every one would have at least the same "basic" coverage, including physical exams, maternity benefits, well-baby care, alcoholism treatment, and mental-health services. Consumers could not buy a cheap, high-deductible catastrophic policy. Every insurance company would have to use an identical government-designed pricing structure. Prices would be the same for sick and healthy.

In today's New York Times, David Leonhardt talks about the problem of health care choice. Specifically, the fact that most people don't have any choice. He starts out making a lot of sense.

Health insurers often act like monopolies -- like a cable company or the Department of Motor Vehicles -- because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.

But then, discussing the Wyden-Bennett bill, he makes less sense.

In the simplest version, families would receive a voucher worth as much as their employer spends on their health insurance. They would then buy an insurance plan on an "exchange" where insurers would compete for their business. The government would regulate this exchange. Insurers would be required to offer basic benefits, and insurers that attracted a sicker group of patients would be subsidized by those that attracted a healthier group.

The immediate advantage would be that people could choose a plan that fit their own preferences, rather than having to accept a plan chosen by human resources. You would be able to carry your plan from one job to the next -- or hold onto it if you found yourself unemployed. You would never have to switch doctors because your employer switched insurance plans.

The problem with this idea is that it really doesn't offer much choice. Insurance companies are still protected from competition by the friendly confines of a government controlled "exchange". True choice would consist of an open market place where any entrepreneur can offer any product to any interested consumer. The success or failure of the product would depend on one all important criteria: whether or not consumers saw any value in it. Insurers would no longer be able to foist their plans on consumers who don't want them. And entrepreneurs would be free to introduce radical, new products that threaten the current insurance companies.

That kind of free choice wouldn't exist under an insurance "exchange". Each new product would have to be carefully weighed and analyzed by government bureaucrats. Nothing new would be approved unless they determined that it was worthwhile and useful. Existing insurance companies would have a hand in writing the regulations and only products that conform to the current status-quo would be allowed in. Anything that threatens that status-quo would be barred from the "exchange" and never offered to consumers. The end result would be akin to Ford's infamous statement that consumers could buy any color car they wanted -- as long as it was black.

Instead of fostering innovation and creativity in health care, the Wyden-Bennett bill would take the current "insurance" industry and lock it in cement. Consumers would continue to be forced to buy health insurance not health care and bureaucrats would continue to dicatate how, when, and where their health care dollars can be spent.

All of this makes me happy to hear that Wyden-Bennett doesn't have much support in the Senate.

Any bureaucracy -- public or private -- is going to make pointless decisions and complicate your life. This applies to health "insurance" as much as it applies to anything else. It's easy to find stories of people who were heartlessly treated by their health bureaucracy. In Britain, the bureaucracy is the government run NHS. In America, it's often a private company. But the end result is often the same.

John Goodman points to a recent story and then offers an alternative.

Is there a better way? Yes. It's called casualty insurance -- similar to the kind of insurance most people have on their homes and automobiles. In the case of a catastrophic illness, the insurer makes a lump sum available -- ideally enough to cover all reasonable care. But when there are differences of opinion, patients can add their own funds to the insurer's payment and buy any type of care from any provider. For Medicaid, additional funds could be provided by private charity (which is what is happening anyway for Dr. Pollard's patients).

This is not a small change from the current system. It is a huge change. It would lead to a real market for catastrophic care in which patients and their families become real, empowered buyers. Providers would compete for patients based on price and, therefore, on quality. Doctors would be free to act as the agents of their patients rather than agents of third-party-payer bureaucracies.

Why would you want to hand control over your health care over to a bureaucracy? And why would you believe that a government bureaucracy would run more smoothly -- and treat you more fairly -- than a private bureaucracy?