A Libertarian Vision for Health Care

A more libertarian health care system would mean higher quality, lower prices, more innovation, and better access for all.

Media Name: a_libertarian_vision_for_health_care.jpg
Michael F. Cannon

Michael F. Cannon is the Cato Institute’s director of health policy studies. Previously, he served as a domestic policy analyst for the U.S. Senate Republican Policy Committee, where he advised the Senate leadership on health, education, labor, welfare, and the Second Amendment. He holds a bachelor’s degree in American government (B.A.) from the University of Virginia, and master’s degrees in economics (M.A.) and law & economics (J.M.) from George Mason University.

Futurists, investors, and health law programs all try to catch a glimpse of the future of health care. Lucky for you, you’ve got … me. I’m from the future. I’ve traveled back in time from the year 2050. And I am here to tell you, the future of health care reform is awesome. 1

When I presented these observations at a Willamette University College of Law symposium in 2015, 2 I was tickled by how many people I saw using iPhones. I mean, iPhones! How quaint. Don’t get me wrong. We have iPhones in the future. Mostly they’re on display in museums as historical relics or used as a medium for artists. Hipsters—yes, we still have hipsters—wouldn’t even know how to use an iPhone and will sometimes wear them as fashion accessories. Other than that, iPhones can be found propping up wobbly restaurant tables. I also noticed you’re still operating general hospitals—in 2020! Again, how quaint. 3

Here are answers to a few questions people always ask me about the year 2050:

• Justin Bieber crashed pretty hard. He is bald, broke, overweight, and has gone home to Canada where taxpayers must now pay for his diabetes care. 4

• Skynet is not self-​aware. At least, not yet. (Fingers crossed!) 5

• The arc of history is long, but it continues to bend toward justice, equality, freedom, peace, and progress. 6

• Mortality from war and disease has continued the erratic but substantial long-​term decline that you have already begun to see in your lifetimes. 7

• Billions of people across the globe have been lifted out of poverty and saved from hunger and disease because we continue to find new, better, and cheaper ways of meeting basic human needs. 8

• Finally—and I cannot overemphasize this fact—we have more excellent water slides than any other planet we communicate with. 9

Nowhere has this progress been more astounding and rapid than in health care.

Health Care Is Easier

In the future, medicine is still complex. But health care is simpler.

Just about every health plan and provider network offers each patient a personal concierge who is equal parts counselor, clinician, and financial adviser. Your concierge helps you communicate with your medical team, helps you understand your treatment options, and even acts as a cost-​sharing consultant. As a patient, you understand how much you’re going to pay before you choose a treatment plan.

Patients can communicate with their concierges—or, if they want, with their doctors, health coaches, dieticians, geneticists, and health plans—in a variety of electronic ways. Alternatively, patients can consult diagnostic software on their own—human attention when you want it, technology when you don’t.

It’s easier to see the doctor, or even to get your teeth cleaned. Often, you don’t have to leave home. Telemedicine is a huge part of health care delivery. 10 We keep people out of waiting rooms and hospitals thanks to a revolution that began with, of all things, a car service. I think you called its first generation “Uber.” 11 If you need a doctor, even a specialist, your concierge can schedule a house call, or you can summon one yourself, at a time convenient for you. Your specialist not only comes prepared with your entire, accurate medical history but can perform an increasing number of diagnostic tests and even procedures in your own home. 12

Not everyone uses a concierge or health apps or the other cool stuff that we have and you don’t. Just as some people like to homeschool their kids, brew their own beer, raise their own chickens, and build their own log cabins, others still prefer the complexity of pure indemnity insurance, finding their own specialists, and researching their own treatment options. That choice is still there.

But generally speaking, grandparents frighten—okay, bore—their kids and grandkids with horror stories about when they had to carry all their medical records and all their prescriptions to all their doctors’ offices, trying to remember allthe often-​conflicting things each doctor told them. That’s what everyone expected. That was normal.

The kids and grandkids just shake their heads. They have health care providers who know their names, their needs, and their values. They have a single point of contact who coordinates all that complexity, so they can focus on what is important to them. That’s the new normal.

Health Care Is Better

Simplifying the patient experience and coordinating care has led to greater treatment compliance, fewer medical errors, and even fewer misdiagnoses. 13

Initially, there was a lot of resistance to letting nonphysician clinicians, assisted by diagnostic software, make diagnoses that government regulation previously allowed only physicians to make. But that resistance—which came exclusively from physician groups, which benefited financially—became farcical when the software reached the point where the nurse practitioners, physician assistants, and registered nurses started getting the diagnoses right more often (and at a lower cost) than the MDs. People with less education, aided by technology, started outperforming people with more education. 14 Health care prices plummeted, and thank God they did.

In the future, we also have more new treatments and total cures. I hate to depress you, dear readers, but some of you are going to die from diseases that no longer cause death in the future. Some of those diseases have cures. Other once-​fatal illnesses are now managed as chronic conditions. Many once-​difficult chronic conditions are now as easy to manage as clipping your fingernails.

Health Insurance Is Better, Especially If You’re Sick

People have an easier time believing humanity mastered time travel than believing what I tell them about the future of health insurance.

So-​called young invincibles voluntarily purchase health insurance in droves. We don’t force them to buy it or force employers to offer it. We simply removed the barriers government had put in the way of insurers offering cash back to people who don’t file claims. That made buying coverage look like a better deal to people who thought traditional health insurance was a lousy deal. 15

Insurance against preexisting conditions is easy to obtain. It costs less than powering up your self-​driving car, and a lot less than buying a health insurance policy. You don’t even have to buy health insurance to get it. Once you buy low-​cost “pre-​ex” insurance, you can wait until you get sick to buy health insurance, and you will still pay the same premium as if you were healthy:

“For these economically uncertain times, the UnitedHealth Group has a ‘first of its kind’ product: the right to buy an individual health policy at some point in the future even if you become sick.… Those who do pass a medical review, will pay 20 percent each month of the current premium on an individual policy to reserve the right to be insured under the plan at some point in the future.… But if changes to the health insurance system do occur under the Obama administration, they say, UnitedHealth’s new product may become obsolete.… It is initially available in 25 of the 40 states where UnitedHealth currently sells individual insurance, which do not include [states that have enacted community-​rating price controls like] New York and New Jersey. The company is applying to sell it in the other 15 states, including Connecticut, where it now sells to individuals.… A 50-​year-​old male in Columbus, Ohio, who planned to eventually take an individual policy in which he would be obliged to pay the first $3,500 in medical bills would pay $32 a month for the right to eventually get that coverage—or 20 percent of a policy that now costs $159 a month.” 16

Governments used to try to achieve the same thing by imposing “community-​rating” price controls on health insurance premiums. But pre-​ex insurance protects patients without the problems government price controls inevitably create. Community rating creates adverse selection, which has destroyed health insurance markets. 17 Even where markets didn’t collapse, community rating still drove average premiums higher and created a race to the bottom by forcing insurance companies to compete on the basis of who could provide the worst care to the sick. 18 And supporters of the Affordable Care Act called that consumer protection!

If you find pre-​ex insurance hard to believe, you’re going to want to sit down for this next part. In the future, health insurance comes with a total-​satisfaction guarantee. If you don’t think your health plan is managing your diabetes or cancer care well, if you think its network is too narrow, or if you are unsatisfied with your health plan for any reason, you can fire your health plan, and other health plans will compete to cover you, rather than avoid you. 19

Even Death Is Better

Some things haven’t changed. Mortality is still with us. We haven’t cured all diseases. And when people do get a fatal disease, they can fight it to the very end. They can participate in a clinical trial to help find cures that continue to elude us. It is their choice.

What might strike you the most about dying in the future is how often it happens at home. People more often choose not to die in hospitals hooked up to multiple machines, but at home, surrounded by their families. Death, dying, and bereavement are more often an intentional process. 20

How that happened was simple: we just ended government subsidies for heroic end-​of-​life measures. The government leaves that choice to the patient, without creating financial incentives to encourage patients to choose one path over another. The social and professional norms surrounding end-​of-​life care changed dramatically. Every health plan has a “life panel” to help patients make their choice by providing them with information about the cost-​effectiveness of all their treatment options. 21

Health Care Is More Universal

In the future, health care is more affordable for the poor, and they are getting better care.

Lower-​skilled clinicians like nurse practitioners, physician assistants, registered nurses, and dental hygienists are providing an ever-​increasing range of services, and at lower prices than physicians and dentists did. It is not just diagnostics. Lower-​cost clinicians are writing prescriptions and performing procedures that used to be the sole province of high-​cost clinicians. 22 The quality is higher, with fewer medication errors and complications.

Health care is also more universal in the future because, as I mentioned at the outset, the future has less poverty—in part because we stopped forcing the poor to surrender so much of their income to an unconscionably wasteful health care system. 23

How Did It Happen?

The health care revolution occurred when we realized that whenever we tried to legislate better, more affordable, and more secure health care, it never happened. We could never legislate or regulate our way to higher-​quality, lower-​cost care. And we figured out why.

Better, more affordable health care represents a threat to the revenue streams of existing high-​cost and low-​quality providers. That is true whether you are trying to get them to change their business model directly 24 or trying to change legal rules to enable competitors to offer better and lower-​cost services. 25 The dinosaurs do not like it when you disrupt their revenue streams. But imagine where humanity would be if government had made it illegal to introduce lower-​cost ways of producing food unless high-​cost farmers were held harmless. We’d all still be doing backbreaking physical labor on farms, if not starving. (Actually, that’s not a bad analogy for health care in 2020.)

Whenever we tried to legislate our way to better health care, the dinosaurs thwarted us at every turn. The political process responds to whoever has the resources and the incentive to organize and engage in politics, especially legislative and administrative lobbying. In those contests, consumers and innovators cannot compete with incumbent providers. Those providers can therefore bend any new legislation or regulation to protect themselves from competition. 26 As a result, the political process protects the very providers of high-​cost and low-​quality care we hoped to reform. We realized we had to get those decisions out of the political process and reassign them to the market process, where the dinosaurs have no choice but to compete.

Another impetus to change occurred when we stopped trying to pretend health insurance is the solution to every problem. We learned that beyond a certain point, more health insurance actually makes access worse. A couple of decades ago, we had a president who is now hailed as our greatest health care reformer. One of her most quoted slogans was, “I would rather have $50 MRIs and no health insurance than $1,000 MRIs and universal coverage.” 27 Of course, that was back when people still used MRIs.

Change was set in motion when Congress and the president repealed a law that was supposed to protect patients and make health care affordable. 28 That one step jettisoned the preexisting condition regulations that were preventing innovators from protecting people against preexisting conditions. It made coverage more affordable by restoring people’s freedom to purchase or not purchase coverage. It led to a rethinking of the entire enterprise and a flood of reform. 29

States began to recognize that beyond a certain point, consumer protection regulation makes health insurance and health care so expensive that it actually hurts consumers rather than helps them. So states let consumers decide where that point is by letting them choose the consumer protections offered by regulators in other states.

Around the same time we noticed that the mid-​level clinicians were beating the doctors on diagnoses, we noticed that medical licensing doesn’t improve quality at all. 30 On top of being just an income transfer from patients and lower-​skilled clinicians (e.g., dental hygienists) to higher-​skilled clinicians (e.g., dentists), 31 licensing increased prices, reduced the availability of services, 32 blocked new delivery models, and reduced quality.

What really crystallized the licensing issue for policymakers was how each state’s physician lobby used licensing laws to prevent out-​of-​state clinicians from treating the poor for free. 33 Starting around 2010, states started fixing that problem. 34 After that, the floodgates opened. The more states liberalized their health care markets, the more innovation we saw and the more access to quality health care surged. Support for medical licensing plummeted, and states repealed it. The poor benefited most of all.

The single most transformative thing we did was to change who controls the money. We took all the health care dollars that government controls and spends on behalf of patients and gave it to the patients. 35 We took all the health care dollars employers control and spend on behalf of workers, and we gave it to the workers who earned it. 36 Patients now control that money and spend it on their own behalf. We let them choose which, and how much, coverage to purchase.

That change was also the single most powerful thing we did to improve access for the poor. We did so not so much because the poor get to control more of their own money—although that certainly matters a lot to them—but because those changes turned the other 300 million Americans into more cost-​conscious and demanding consumers.

When those 330 million consumers got control of the $4 trillion this nation spends on medical care, 37 they changed their behavior, which in turn transformed health care. All 330 million of them became more careful and demanding consumers. They demanded lower prices and higher quality in a way they never had before. Competition forced prices down, aided by the elimination of regulations that had been protecting high-​cost and low-​quality providers. Political support from hundreds of millions of newly cost-​conscious “health care voters” helped us eliminate even more cost-​increasing regulation. That’s when we really saw an innovation explosion in both health insurance and health care delivery.

Once we eliminated the price controls that were supposed to protect against preexisting conditions and gave consumers the freedom to choose their own health plans, consumers demanded protection from the risks of high premiums and uninsurability. Insurers responded with innovations like pre-​ex insurance, total-​satisfaction guarantees, and more. It all began with a seemingly small change that created a free, parallel market in health insurance to compete with the government-​run market. 38

We saw an explosion in integrated delivery systems and prepaid group plans like Kaiser Permanente, which delivered innovations in coordinated care, concierge care, medical teams, e-​health, and life panels. 39

We’re even solving public-​goods problems like those surrounding effectiveness research. 40 We have more information on the effectiveness, comparative effectiveness, and cost-​effectiveness of medical treatments than ever before.

Integrated prepaid group plans were doing so much effectiveness research and quality certification of medical technologies, one day we woke up and realized we were sitting on a private-​sector alternative to the Food and Drug Administration (FDA). So we got rid of the FDA. We don’t even miss it. In its place, private, integrated health plans are evaluating the safety and efficacy of drugs, medical devices, nutritional supplements, and health claims faster—and in a way that doesn’t deny patients the right to make their own health decisions. 41 Health plans attract enrollees by competing to have the most reliable quality seal of approval.

Conclusion

In the future, we are making health care better, more affordable, and more secure every day. We have given consumers greater protections against illness and financial insecurity than when we tried to legislate our way to better health care. And the progress never ends.

We still have gaps in our health care sector. We still have to worry about quality. We still have to worry about effectiveness. We still have to worry about insurance carriers’ solvency. Not everyone has health insurance. Then again, health insurance is a lot less necessary.

Yet all of these challenges are smaller than they were in 2020. No one wants to go back to the bad old days of the so-​called Affordable Care Act, when an obsession with health insurance got in the way of providing everyone with health care. Access to care is now more universal than when we tried to legislate our way to universal coverage. The future of health care is so bright, I prescribe sunglasses. 42

Now, forgive me, before I can return to the year 2050, I need to pop down to the corner drugstore for a little plutonium. 43 If you happen to run into my past self, do me a favor and distract him. Otherwise, well … things could get ugly. 44

1. See Kevin D. Williamson, The End Is Near and It’s Going to Be Awesome: How Going Broke Will Leave America Richer, Happier, and More Secure (New York: HarperCollins, 2013).

2. See “21st Century Healthcare Symposium: Can We Harmonize Access, Quality & Cost?” Willamette University College of Law, Salem, OR, February 27, 2015. See also Michael F. Cannon, “Health Care’s Future Is So Bright, I Gotta Wear Shades,” Willamette Law Review 51, no. 4 (2015): 559–71.

3. “Were it not for today’s tangled web of subsidies, administered prices, and regulations that constrain competition, today’s general hospitals would not be economically or competitively viable.… The Coxa Hospital for Joint Replacement in Tampere, Finland, achieves similarly better costs than general hospitals. The 64 general hospitals in Finland that perform similar surgeries average unanticipated complication rates of 10 to 12 percent; the rate at Coxa is 0.1 percent.… The high cost of hospitalization isn’t driven by the excess profits of general hospitals.… The costs are simply inherent to the one-​size-​fits-​all value proposition they offer.” Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang, The Innovator’s Prescription: A Disruptive Solution for Health Care (New York: McGraw-​Hill, 2009), pp. 76, 82, 237.

4. “The Canadian-​born Bieber never plans on becoming an American citizen. ‘You guys are evil,’ he jokes. ‘Canada’s the best country in the world.’ He adds, ‘We go to the doctor and we don’t need to worry about paying him, but here, your whole life, you’re broke because of medical bills. My bodyguard’s baby was premature, and now he has to pay for it. In Canada, if your baby’s premature, he stays in the hospital as long as he needs to, and then you go home.’” “Justin Bieber Talks Sex, Politics, Music and Puberty,” Rolling Stone, February 16, 2011.

5. Contrary to Terminator 2: Judgment Day, directed by James Cameron (Los Angeles: Orion Pictures 1991):T-800 TERMINATOR: The Skynet Funding bill is passed. The system goes online August 4th, 1997. Human decisions are removed from strategic defense. Skynet begins to learn at a geometric rate. It becomes self-​aware at 2:14 a.m. Eastern time, August 29th. In a panic, they try to pull the plug. SARAH CONNOR: Skynet fights back. T-800 TERMINATOR: Yes. It launches its missiles against the targets in Russia. JOHN CONNOR: Why attack Russia? Aren’t they our friends now? T-800 TERMINATOR: Because Skynet knows the Russian counter-​attack will eliminate its enemies over here.

6. “Let us realize that the arc of the moral universe is long, but it bends toward justice.” Clayborne Carson and Kris Shepard, eds., A Call to Conscience: The Landmark Speeches of Dr. Martin Luther King, Jr. (New York: Intellectual Properties Management, 2001), p. 199. See generally Theodore Parker, Ten Sermons of Religion (Boston: Crosby Nichols; New York: C. S. Francis, 1853), pp. 84–85. Steven Pinker argues that this is the most peaceful era yet. Steven Pinker, The Better Angels of Our Nature: Why Violence Has Declined (New York: Viking, 2011).

7. Pinker, Better Angels, p. 304.

8. “Commerce, entrepreneurial capitalism takes more people out of poverty than aid, of course, we know that.” Bono, address at Georgetown University, Washington, November 12, 2012. According to Brookings Institution researchers Laurence Chandy and Geoffrey Gertz, “Poverty reduction of this magnitude is unparalleled in history: never before have so many people been lifted out of poverty over such a brief period of time.” Chandy and Gertz, “Poverty in Numbers: The Changing State of Global Poverty from 2005 to 2015,” Brookings Institution Report, January 2011, p. 3. See also Marian L. Tupy, “Bono: Only Capitalism Can End Poverty,” Cato at Liberty (blog), July 31, 2013.

9. “Hi, welcome to the future. San Dimas, California, 2688. And I’m telling you it’s great here. The air is clean. The water’s clean. Even the dirt—it’s clean! Bowling averages are way up. Mini-​golf scores are way down. And we have more excellent water slides than any other planet we communicate with. I’m telling you, this place is great!” Bill & Ted’s Excellent Adventure, directed by Stephen Herek (Los Angeles: Orion Pictures, 1989).

10. See Shirley V. Svorny, “Liberating Telemedicine: Options to Eliminate the State-​Licensing Roadblock,” Cato Institute Policy Analysis no. 826, November 15, 2017.

11. Peter Van Doren, “Uber Provides Case against Occupational Licensing,” Cato at Liberty (blog), January 28, 2015.

12. For example: “Pager, in New York City, dispatches doctors or nurse practitioners via Uber, for $200. Heal, in Los Angeles, San Francisco and Orange County, Calif., promises to ‘get a doctor to your sofa in under an hour’ for $99. (A medical assistant goes along to do the driving and parking.) RetraceHealth, in Minneapolis, has a nurse practitioner consult with patients via video (for $50), and only comes to their homes if hands-​on care like a throat swab or blood draw is necessary (for $150). Atlanta-​based MedZed sends a nurse to a patient’s home to do a preliminary exam. Then the nurse connects via laptop with a doctor who provides a treatment plan remotely.… And thanks to the boom in mobile-​medical technology, providers can carry key equipment with them, from portable blood analyzers to hand-​held ultrasounds.… ‘Health checks,’ in which a nurse does cholesterol, blood pressure, blood sugar and other tests for $75, are also popular—even in office settings.” Melinda Beck, “Startups Vie to Build an Uber for Health Care,” Wall Street Journal, August 11, 2015.

13. See Kaveh G. Shojania et al., “Changes in Rates of Autopsy-​Detected Diagnostic Errors over Time: A Systematic Review,” Journal of the American Medical Association 289, no. 21 (June 4, 2003): 2849-2856. The analysis of 53 distinct autopsy series over a 40-​year period showed a significant decrease over time for major diagnostic errors detected at autopsy.

14. See generally Christensen, Grossman, and Hwang, The Innovator’s Prescription.

15. “Ordinary health insurance provides a tangible benefit only when you need health care. Tontine insurance pays a cash benefit when you don’t use it, as well as covering your medical expenses when you do. As such, tontine insurance is structured to be maximally attractive to those who have an overly optimistic assessment of risk.… Tontine health insurance should be especially enticing to people who do not purchase coverage because they think they would ‘lose’ the ordinary health insurance bet by being healthy—the invincibles.” Tom Baker and Peter Siegelman, “Tontines for the Young Invincibles,” Regulation 32, no. 4 (Winter 2009/2010): 4, 20. See generally Jeff Guo, “It’s Sleazy, It’s Totally Illegal, and Yet It Could Become the Future of Retirement,” Washington Post, September 28, 2015.

16. Reed Abelson, “UnitedHealth to Insure the Right to Insurance,” New York Times, December 2, 2008. See also Michael F. Cannon, “ObamaCare Is Now Optional,” Washington Examiner, August 1, 2018. On health insurance innovation, see generally John H. Cochrane, “Health-​Status Insurance: How Markets Can Provide Health Security,” Cato Institute Policy Analysis no. 633, February 18, 2009.

17. “The PPACA’s ‘community rating’ price controls will destroy innovations that make health insurance better and more secure. They have already caused the markets for child-​only health insurance to collapse in 17 states and caused insurers to flee the child-​only market in a further 18 states. When implemented elsewhere, these price controls have forced health insurance companies to compete to avoid and mistreat the sick. Millions of Americans will suffer those consequences if these price controls take full effect in 2014. When informed that these price controls will reduce the quality of care their families receive, consumers overwhelmingly oppose these supposedly popular provisions.” Michael F. Cannon, director of health policy studies, Cato Institute, “The PPACA’s Health Insurance Exchanges and Medicaid Expansion,” Testimony before the Florida House Select Committee on Patient Protection and Affordable Care Act, January 22, 2013.

18. “Republicans are nervous about repealing ObamaCare’s supposed ban on discrimination against patients with pre-​existing conditions. But a new study by Harvard and the University of Texas-​Austin finds those rules penalize high-​quality coverage for the sick, reward insurers who slash coverage for the sick, and leave patients unable to obtain adequate insurance.” Michael F. Cannon, “How ObamaCare Punishes the Sick,” Wall Street Journal, February 28, 2017. According to economist John C. Goodman: “Many of the country’s top hospitals are off limits to patients covered by ObamaCare’s current plans. Take Houston’s MD Anderson Cancer Center, which was named America’s best cancer-​care hospital by U.S. News & World Report in 13 of the past 16 years. The hospital’s website suggests that it takes even Medicaid, but it doesn’t accept a single private health-​insurance plan sold on the individual market in Texas. Since Blue Cross of Minnesota withdrew from the individual market in 2016, the state’s Mayo Clinic—once cited by President Obama as a model for the nation—has been off limits to Minnesotans covered by ObamaCare exchange plans. Memorial Sloan Kettering appears out of bounds for every exchange plan in New York. Both of these hospitals are open to some Medicaid patients, though Mayo’s chief executive has predicted publicly that Medicaid patients may eventually have to queue behind their privately insured peers.” Goodman, “ObamaCare Can Be Worse than Medicaid,” Wall Street Journal, June 26, 2018. See also Michael F. Cannon, “Is ObamaCare Harming Quality? (Part 1),” Health Affairs (blog), January 4, 2018; and Michael F. Cannon, “How to Ensure Quality Health Coverage (Part 2),” Health Affairs (blog), January 5, 2018. See generally Jeffrey Young, “How Your Health Insurance Company Can Still Screw You, Despite Obamacare,” Huffington Post, July 21, 2014.

19. “The individual health insurance market is already moving in the direction of [a total-​satisfaction guarantee]. To let [such] insurance emerge fully, we must remove the legal and regulatory pressure to provide employer-​based group insurance over individual insurance and remove regulations limiting risk-​based pricing and competition among health insurers.” Cochrane, “Health-​Status Insurance,” p. 1.

20. See generally Elisabeth Kübler-​Ross, On Death and Dying (New York: Macmillan, 1969).

21. “Critics therefore call [the Independent Payment Advisory Board] a ‘death panel,’ but one could just as defensibly call it a ‘life panel.’” Michael F. Cannon, “More Reasons Why IPAB, ObamaCare’s ‘Death Panel,’ Is Relevant to Sylvia Burwell’s Nomination,” Forbes, April 15, 2014.

22. “Caren Misky, a nurse practitioner with True North Health Navigation in Denver, says she recently responded to a call where an Alzheimer’s patient had fallen and cut his head. She was able to staple his wound at the kitchen table while he had breakfast. ‘His wife said the last time that happened, they spent eight hours in the ER and had a $10,000 bill,’ Ms. Misky says.… [T]he True North mobile unit goes to the scene along with the fire department’s paramedics. Once the paramedics confirm the situation isn’t life-​threatening, the caller can choose between being treated by a nurse practitioner on the spot, for $200 to $300 (which is covered by most Colorado insurance plans), or going by ambulance to the ER, which typically costs $3,000 or more.” Beck, “Startups Vie to Build an Uber.”

23. “We may be wasting perhaps 30% of U.S. health care spending on medical care that does not appear to improve our health.” Elliott S. Fisher, “More Care Is Not Better Care,” National Institute for Health Care Management Foundation, Expert Voices 7 (January 2005): 2.

24. See, for example, Charles Lane, “Medicare Reform’s Slow Progress,” Washington Post, March 4, 2013. Lane describes industry resistance to a proposal to use competitive bidding to reduce the prices that Medicare pays for medical equipment: “One man’s absurd waste of taxpayer funds, however, is another man’s rice bowl. Organized into an effective lobby, medical equipment manufacturers and distributors resisted change.”

25. “A powerful physician lobby can block changes to the scopes of practice of mid-​level practitioners that would impinge on its members’ turf.” Shirley V. Svorny, “Medical Licensing: An Obstacle to Affordable, Quality Care,” Cato Policy Analysis no. 621, September 17, 2008, p. 2.

26. See, for example, Margot Sanger-​Katz, “Why Doctors Dictate How Much the Government Pays Them,” National Journal, May 18, 2013. Medicare accepts most recommendations proposed by the Relative Value Scale Update Committee, an advisory panel of 31 doctors from different specialties.

27. Cf. Thomas Jefferson’s letter of January 16, 1787, to Edward Carrington, in which he said, “And were it left to me to decide whether we should have a government without newspapers, or newspapers without a government, I should not hesitate a moment to prefer the latter.” Jefferson, in The Founders’ Constitution, vol. 5, eds. Philip B. Kurland and Ralph Lerner (Chicago: University of Chicago Press, 1987), pp. 121–22.

28. See Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010).

29. See generally Michael F. Cannon, “Yes, Mr. President: A Free Market Can Fix Health Care,” Cato Policy Analysis no. 650, October 21, 2009, which offers an agenda for liberalizing health care.

30. “Quality assurance in today’s medical marketplace doesn’t come from state medical [licensing] boards but from the fear of medical malpractice liability and from market mechanisms such as malpractice insurers; independent certification agencies like the Joint Commission, specialty boards, and credentials verification organizations; consumer guides such as Consumer Reports, HealthGrades, and Angie’s List; and insurers’ and providers’ interest in protecting their reputations and brand names.” Svorny, “Medical Licensing,” p. 12.

31. Morris M. Kleiner and Kyoung Won Park estimate that “greater autonomy by legally allowing hygienists to work independently of dentists is associated with an approximately 10 percent higher wage and a 6 percent increase in the employment growth of dental hygienists. In contrast, these state provisions are associated with approximately a 16 percent reduction in dental hourly earnings and a 26 percent reduction in dental employment growth in the states.” Kleiner and Park, “Battles among Licensed Occupations: Analyzing Government Regulations on Labor Market Outcomes for Dentists and Hygienists”, National Bureau of Economic Research Working Paper no. 16560, November 2010, pp. 19–20.

32. See Kleiner and Park, “Battles among Licensed Occupations,” noting that states lose approximately 1 percent of output of dental services by not allowing hygienists to practice on their own.

33. See generally “Should Ohio Expand Medicaid?,” Michael F. Cannon, director of health policy studies, Cato Institute, Testimony before the Ohio House Subcommittee on Health and Human Services, March 13, 2013. Volunteer groups engage doctors and other clinicians from around the country to treat indigent patients in rural and inner-​city areas. Because they are not licensed to practice medicine in the states they are visiting, those clinicians are prevented from providing free medical care to the poor. See also Jeff Reichert and Farihah Zaman, “Dear New York City’s Uninsured: Screw You, Love Governor Cuomo,” Huffington Post, November 19, 2014, criticizing New York governor Andrew Cuomo for not allowing a Remote Area Medical free clinic in New York City.

34. “Missouri now joins states like Tennessee, Illinois, and Connecticut that have enacted similar Good Samaritan laws.” Michael F. Cannon, “Missouri Lawmakers Override Veto to Enact Good Samaritan Law,” Cato at Liberty (blog), September 12, 2013.

35. “Medicare reforms that allow individuals to control their health care dollars would eliminate wasteful spending, would provide enrollees better choices and better medical care, and would do so at a lower cost to taxpayers. Congress should move retiree health care from today’s dysfunctional system of central planning to an innovative system based on personal savings, individual choice, and competition.” Michael F. Cannon and Chris Edwards, “Medicare Reforms,” Downsizing the Federal Government, September 1, 2010.

36. “The creation of tax-​free health savings accounts presents a new opportunity to reduce the distortions created by federal tax preferences for health-​related expenditures that ultimately could help eliminate those distortions.” Michael F. Cannon, “Large Health Savings Accounts: A Step toward Tax Neutrality for Health Care,” Forum for Health Economics and Policy 11, no. 2 (2008): 1080. See also Michael F. Cannon, “On Health Care, Walker and Rubio Offer Obamacare Lite,” Manchester Union-​Leader, August 27, 2015.

37. Gigi A. Cuckler et al., “National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth,” Health Affairs 37, no. 3 (March 2018): 482–83. The figure is the projected U.S. national health expenditures for 2020.

38. “At long last, the Trump administration has created a ‘freedom option’ for people suffering under Obamacare. A final rulemaking issued Wednesday reverses an Obama-​era regulation that exposed the sick to medical underwriting. The new rule will expand consumer protections for the sick, cover up to two million uninsured people, reduce premiums for millions more, protect conscience rights, and make Obamacare’s costs more transparent. And unlike President Barack Obama’s implementation of his signature healthcare legislation, it works within the confines of the law.” Cannon, “ObamaCare Is Now Optional.”

39. See generally Christy Ford Chapin, Ensuring America’s Health: The Public Creation of the Corporate Health Care System (New York: Cambridge University Press, 2015); Alain C. Enthoven and Laura A. Tollen, eds., Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice (San Francisco: Jossey-​Bass, 2004); and Shannon Brownlee, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (New York: Bloomsbury, 2008).

40. “A better way to generate comparative-​effectiveness information would be for Congress to eliminate government activities that suppress private production.… That laissez-​faire approach would both increase comparative-​effectiveness research and increase the likelihood that patients and providers would use it.” Michael F. Cannon, “A Better Way to Generate and Use Comparative-​Effectiveness Research,” Cato Institute Policy Analysis no. 632, February 2, 2009, p. 1.

41. See Darcy Olsen, The Right to Try: How the Federal Government Prevents Americans from Getting the Lifesaving Treatments They Need (New York: Harper, 2015).

42. Timbuk 3, “The Future’s So Bright, I Gotta Wear Shades,” on Greetings from Timbuk 3, I.R.S. Records, released 1986.

43. “I’m sure that in 1985, plutonium is available in every corner drugstore, but in 1955, it’s a little hard to come by.” Back to the Future, directed by Robert Zemeckis (Universal City, CA: Universal Pictures, 1985).

44. Back to the Future: Part II, directed by Robert Zemeckis (Universal City, CA: Universal Pictures, 1989). DOC BROWN: The shock of coming face to face with oneself 30 years older … would create a time paradox, which would unravel the very fabric of the space-​time continuum and destroy the entire universe. Granted, that’s a worst-​case scenario. The destruction might in fact be very localized, limited to merely our own galaxy. MARTY MCFLY: Oh, hey, well, that’s a relief.