Jeff Jacoby's analysis is inaccurate on many levels.  In spite of many promulgations that people should be steeped in preventive care it is when they are sick, really sick, they seek care.  Therefore this is the main job of health insurance.  It allows someone to get timely treatment without financial worries.  Under our present "market system" over 50 million people are uninsured or under-insured.  That leaves them one serious illness away from a poor outcome and bankruptcy.  There are 45,000 excess deaths per year among those without insurance.  Private insurers are looking to cherry pick and avoid paying when disease strikes.  They market to healthier populations and thank the Lord that Medicare takes care of the most ill in this country.  Medicare was passed in the first place because the health insurance industry would not take on this group of citizens as subscribers.  The real so called market competition should be a patient's choice of who they want to take care of them not the selection of an insurer.  Every other developed country has figured out a universal system.  A good number use private insurers but their overhead, benefits, and who is eligible are regulated.  Here what is called "competition" is market share as each insurer offers goodies to carefully chosen populations and then raises rates on those who don't have much economic clout. This leads to uneven pricing for services, large negotiating staffs, and inflated billing departments to play this silly dangerous game.  It costs $400 billion dollars a year.  By any account a Medicare for all system brings the lowest costs and the most satisfaction and most importantly the best outcomes.  In short Mr. Jacoby has not done his homework either on purpose to suit his etiology or out of sheer lack of intellectual curiosity.  As for the neurologists they are suppose to make their income by attending to patients not padding their intake by doing quasi needed tests.  The median income for neurologists is over $213,000, tidy sum, and lands them in the top 5% of income earners in this country.  Should they be allowed to put even more into their column by being overpaid for procedures or by actually attending to patients and doing careful follow up?  

Jeff continues with this nonsensical argument that the "free market" can rule in the medical world.  No matter how often this is proven to be not true, regardless ofhow many times it is factually expressed or simply morally shown, Jeff returns to the same flawed argument.  He even admits to the dire emergency scenario, admits consumers can't figure out the complicated issues related to medical care and then simply falls back on "trust".

Trust, I trust my doctor that's why I don't shop around.  Medicine, good medicine is based upon a working relationship between the patient and the doctor.  After ten years of seeing the same cardiologist Jeff would have me march down the street to see the guy who cots ten dollars less but I don't know from Adam. 

There are two way to bring down health care costs.  One is through efficiencies which the ACA and Medicare work at.  The other is reforming the tort system.  Many dems fight this but the fact is doctor's will overdue tests, be excessively cautious in fear of lawsuits.  Let the feds set the standards, shield doctors from legal damages outside of gross neglect and the cost of medical care will stabilize.  To me both parties have the problem partially right, the dems want efficiencies and the Repubs want tort reform. Why don't we try both and see if we can contain costs.

But the free market?  Jeff, please go back to bed.

Great column. Jeff.  I have been saying since the beginning of the debate, that Obamacare will work only if the president can suspend the laws of economics.   While he may be able to walk on water, even he cannot control a market by setting price controls.  It will be a crushing blow to so many people when the availibilty of needed health care vanishes, as price controls always lead to shortages.  The sad part is, prices will not come down.

The president has won, and will get his way.  But the people will lose, and swill suffer greatly.

For a procedure that takes one second to actually perform and one where you could train an average Barista to set up, $1350.00 is too much money to pay for Lasik. Jeff, why not let your argument follow to it's ultimate conclusion? Just let the insurance companies make all the health care decisions for people.  That's your "free market" in action. The problem is that insurance companies are involved in the process at all. 

Your argument here based on what Newt Gingrich -- one of your vanguards of conservative thought -- refereed to as “Systemic Avoidance of Reality”. It seems as though once again you're just propagating the old tire Republican platitude of "free market" as cure-all. Healthcare is unique. How many times does it have to be said. Despite you unrealistic positing it's not like shopping for food, cars and cellphones. And your Lasik example is just another false equivalency. 99.99% of Hospitals and doctors don't advertise their prices, take coupons or hold Columbus Day specials. This is a sphere that is as complicated as the military industrial complex and a landscape that for most is difficult to overwhelming to negotiate. Patients, often sick, do not have the luxury to pontificate over a decision as though they're purchasing the latest wi-fi tablet. The irrefutable facts are that your free-market solution doesn't work now, hasn't worked in the past and won't in the future.

Neurologists freely admit that they use the current policy to cover costs in other areas of their  practice. Why should Medicare overpay for one procedure to make up for other costs, especially administrative costs. Of course the American Academy of Nerology complains, but it is time for Medicare to pay for actual costs, not trumped up costs. It is sort of like paying $500 for an oil change, so the garage can have flat screen televisions and free food. Their is certainly overhead costs in any payment, but it should be in proportion to the rest of the business, not a cash cow.

Sorry Jeff - the economics of a free market in regular health care is part of what has brought us to this place. We have had double digit inflation in health care costs for years, thanks to a "free market" approach. What other segment of our economy has grown costs at such a rapid pace? The evidence is that the free market is not working in health care and has not for years.

The analogy to legal help is self-defeating-- does anyone, anyone, believe that access to legal representation is really universal and fair?  I know very well that in a legal fight, rich people do much, much better because they can afford lawyers.  Poor and middle class people often cannot and either go unrepresented, poorly represented, or they don't fight in a court at all.  In health care, an entirely free market means illness and death to those who cannot afford it.  That experiment has been tried, and people across the world have found it unacceptable.

Oh, please. First of all, the neurologist's complaint boils down to this: "Woe is us, we will now have to find another way to game the system, because the mean government is closing the loophole we've been exploiting for years. We will thus throw a tantrum, threaten to take it out on our patients, and generally act like 5 year olds." The reason they do this is because in the past, it has always worked. We are, however, reaching the point where it *can't* work; we're too broke to keep overpaying for procedures and deprecating the actual work that is medicine, which mostly involves listening to patients, and occasionally advising them. As for your example: Oh, well done, sir. Choose a procedure that is more optional, could you? LASIK has become cheaper because it is not mandatory for health-if you can't afford LASIK, there's always the option of good, old fashioned spectacles, or contacts for the truly vain among us (I've worn glasses since the 8th grade; I am deaf to most complaints about them. A *very* few patients truly deserve LASIK, because their refractive error really *cannot* be corrected with lenses reasonably. The rest of the people who get LASIK are getting it because they don't want the bother of glasses or contacts. Boo hoo. Plastic surgery has gotten cheaper over the years also-because it's optional, and people can simply choose not to have it if they cannot afford it, at the price of having flabby thighs, or looking their age. Again, not a problem. Real health care (read: the stuff that isn't optional) can also be cheaper; I don't disagree with the premise that health care is mispriced, or that physicians recommend procedures patients may not really need, underplay the risks and overplay the benefits, and in general make sure their incomes are maximized. I would argue that *most* physicians do this more or less unconsciously-the invisible hand is, to most of us, invisible. We really believe that the patient's health will benefit from our proposed procedure, test, or drug-it's just a nice side effect that our wallet will also benefit. And the patient is in a bind; s/he can't tell, often, whether what we propose is worthwhile or not. They're frightened (health problems are scary), and here is someone telling them they can help, they can fix the problem, they can make it all go away. What would you pay not to die? Not to hurt anymore? You'd pay a lot, as long as you had a lot. If you do't have a lot, your options dwindle down to "We can give you some of this nice, free morphine; roll over to that corner, take your morphine, and die quietly, would you please?" But having cutting edge health care available, at all, is expensive. And the *unregulated* market sucks at figuring out how to both make health care less expensive *and* universally accessible. You can have either, apparently, but not both. It can never, by the way, be "cheap"; if you want cheap, I can give you that right now, but you'll be limited to the interventions and medications that were available in, say, 1975. Those are now cheap, and most of them work pretty well. But you'll be giving up cardiac stents, a bunch of *major* advances in cancer care, all the biologics that keep things like rheumatoid arthritis, Crohn's disease, and a host of other autoimmune disorders (and a few cancers) at bay...you can't have any of that. And your health care will be cheap; I don't know how much columnists make, but I could afford it easily, and my partners could afford it with some difficulty. A friend of mine, a consultant in historic preservation (not a well paid field, despite the skills required) almost certainly could not. I would love to hear your answer to the quandary of universally available. Because it has to be *universal*; you can't fob it off on the emergency departments of the world, like a recent presidential candidate did, saying "well, they can always get care, in the emergency department." Because I work in the ED, and so do a lot of nurses, techs, and other professionals. We don't work for free-we expect to be paid. So does the hospital-and the law referenced requires the hospital to use all it's resources to "stabilize the emergency condition". Which may mean stenting the heart attack patient from Mexico, or taking out the appendix of the patient from Guatemala or wherever, here without papers. Everyone has to be covered-because they are anyway, like it or not. Those patients don't have the $300 it costs to simply walk into the emergency department-or the $150 it might cost if it were "market regulated", because keeping people up at night so they're available for your American health is still expensive, no matter what. (People like to sleep-if you want them to be awake at night taking care of you, you'd best pay them pretty well.) If you don't cover everyone, you still fail. Show me the market analysis that does that. Because most "markets" are for optional goods-if you can't afford it, you don't get it; or you get it not as good (like cheap food). Not for goods which, most people agree, must be cutting edge and excellent, every time (even if they aren't that now).

yet the cost to become a surgeon will continue to rise....

Where a critical change should be made is to set a standard package of insurance coverage, not one-offs between every state. Allow people to buy standard packages, in any state, and pay for other services as add-ons w/ some sort of tax treatment of refund to help.

I was reading Jacoby's column with great interest until the final paragraphs. There is absolutely no correlation between elective lasix eye surgery to avoid the inconvenience of wearing glasses and neurological testing procedures to determine disease. It's like comparing liposuction to brain surgery. This is the trouble with the conservative entertainment complex. If you scratch just below the surface of their arguments, there is a lack of substantive information and credibility. THe Affordable Care Act is the law of the land. Time to move on.

The best way to save Medicare is to fix it by reducing costs. How can you be against that? Your concept of the Holy Market is to always maximize profiteering at all costs. The main reason why Obamacare got passed is that it enriches the insurance company's profits. Once you greed-head right-wingers realized that, it got made into law, forcing people to get insurance and enriching the powerful insurance industry. Real reform would have been in the form of a single-payer system, like the one most other industrialized countries have. Medicare for all; free health care from cradle to grave. But that might hurt your unearned income from your stock portfolio, taxed at a lower rate than earned income. Judas goat.

The health care market is anything but a free market at this point.  Getting Medicare out of it won't change that a bit.  The private insurers are every bit the controlling hand that Medicare is.  Some combination of group coverage for basics and personal contribution to more optional care would be the most effective combination.  That probably should entail a change in the co-pay structure.  As it stands now, providers are prevented from balance billing.  This has way too many nuances to deal with in a comments section.

I didn't realize that the Globe was using syndicated articles from The Onion.

You have got to be kidding me. As health care companies, not the government, has reaped profits that  have set records the last ten years, Ideologues clamor for less control over the heartless titans, who continue to bask in an industry that has America in a chokehold. Lets wait until the "market" dictates prices, that way, the average American can "shop" around for better "prices", and take "more control" over their health...please! The lack of regulation of the health industry, in an effort to avoid the socialist boggie man, has created an health industry that stands alone in the world, on how it approaches the health of its citizens.

I can agree with much of wht you say here Jeff. However, I lose the thread of your argument when you compare Lasik eye surgery to other forms of medical procedures. For one thing: Lasik is more of a cosmetic procedure. How so? Because it is not usually a necessary procedure or a emergency procedure. It is an elective procedure. A little bit like cosmetic plastic surgery many people have to make the look younger than their actual age, or to cover up some blemish they are not comfortable with. The free market system works great in that environment. But, not so much when the procedure is a life saving or life prolonging one. The free market system is the very reason for National Healthcare (yes, I know you neo cons love to disparage it by calling it "Obmacare"). Greed and corporate profit cannot be the only factor in decisions on health care. Which is the way it was prior to National Healthcare. The medical community must find a way to control costs rather than let them sky rocket out of control. And big insurance needs to be a big part of this discussion.

Here's a little video about free-market health care (starting at 3 minutes 40 seconds "You are surgery, which is the loss-leader..."): http://www.youtube.com/watch?v=GEO4zTKIFog&feature=share&list=PL83E5EAD46D2CD0EC

Remind me again, Mr Jacoby. The "market is best" argument is that offering the best product at the lowest cost will have buyers beating a path to your door, while making the seller a handy profit. Haven't we had that for....ever. Why do our costs keep rising? Oh, that's right, profits sink when insurers actually have to pay. Keep on beating this drum and proving the argument that I make almost every week. You never disappoint. Plastics!

Jeff, even Romney in 2006 recognized that the "free market" healthcare in the United States did not work.  The RomneyCare that was so highly praised at that time by his future Republican rivals was at least a viable alternative to Hilary's 1993 single payer plan.  As I've said before this Affordable Care Act has its genesis in Republican health strategies.  Not much argument or discussion in the 2008 primary campaigns or presidential campaign.  It's only when the Republican Party en masse declared political war on President Obama, Senator McConnell's famous dictum that his "most important" mission was to make "this President" a one term President that anything and everything that President Obama passed or promoted was to be attacked relentlessly.  No alternative ideas on healthcare, the economy, the budget, the environment, etc., just be obstructionist.  I see a parallel now in this column.  As so many below have stated better than I can, the system you're proposing didn't work back then.  Time to move on with the Republican based Obamney HealthCare plan.