How to Think About Obamacare and its Replacement

Think of it as robbing Peter to pay Paul. Paul gets a subsidy for health insurance. Peter pays by being charged higher premiums for his own insurance and by funding Medicaid with taxes or by lending to the government.

According to the Democrats and their friends in the media, if you stop paying Paul, then you are “taking away his health care,” and that is unacceptable. If the Republicans concede that, as they appear to be doing, then they are left with tinkering around the edges by shifting around the Peter burdens (probably by using more borrowing) and by cutting the subsidies for future Pauls.

The thing about health care is that it is so expensive nowadays that robbing Peter to pay Paul involves really big bucks. So if Obamacare has moved the Overton Window to the point where robbing Peter to pay Paul is entrenched policy, then the government now owns a much bigger chunk of the economy.

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57 Responses to How to Think About Obamacare and its Replacement

  1. Joseph says:

    Sick people can’t afford the health care that their doctors say they need. Healthy people will some day be sick. In addition, everyone has a relative or loved one who is sick. Everyone is terrified of becoming sick and not being able to afford the healthcare the doctor says they need to treat their illness.

    One way to address this fear is to have the government tax healthy people to pay for sick peoples healthcare. Many healthy people are okay with this since the trade off is that if they get sick then the government will pay for their healthcare too.

    The libertarian response to these fears is:
    1) you don’t really need that healthcare. Trust me not your doctor. You’ll be fine.
    2) even if you need that healthcare, it’s immoral to tax others to pay for it. You should rely on charity, begging, and being a ruinous financial burden on your family.
    3) and anyway the issue is cost!!! If we implement policies x,y, and z, cost will go down and then everyone can afford healthcare their doctors say they need.

    What I am curious about is why libertarians think that’s respsonsive to people’s concern. I am assuming they understand exactly how persuasive those arguments are.

    • asdf says:

      Yes, libertarians bang on #2 a lot, and nobody cares. In the end only #3 matters. To achieve #3 you need some credible #1 packaged with the idea that its being done credibly on your behalf and not just a way to cheat you.

      The private sector, HMOs, tried to do #1 in the 1990s. It controlled #3 for a few years but everyone felt like they were greedy assholes trying to cheat them for their own profit and there was a revolt. Then health insurers gave up on #3 for awhile.

      All countries with successful healthcare systems have credible ways of getting at #1 so they can control #3. Libertarians ignore #2, which makes people nervous about #1, and have a strange believe that individual consumers are pretty good at managing #1 when most of what we see is that they #1 doesn’t work the same for health care as it does with groceries.

    • Andrew' says:

      We don’t have time to address all the strawmen, but if I feel like it I’ll address it today.

    • Lord says:

      Bullseye. It isn’t just about health care either. It is about what it means to be part of a society. What do we owe to each other? What do we owe to ourselves? What kind of humans do we want to be? What kind of society do we want to live in? Not the kind you envision.

      • Andrew' says:

        Dear Lord

      • N. says:

        Perhaps you would like to fill me in on exactly what obligation I have to a stranger — someone I have not met and have no control over and whose life decisions I would rather not influence.

        Then, assuming you can convince me, explain to me why I have those obligations for my countrymen, but not those beyond my own boundaries.

        • asdf says:

          You have an incentive to form social groups with those around you so that you can function effectively. This is obvious even to the most ardent individualist.

          We are all expected to:

          1) Follow the law
          2) Defend the law by force if necessary

          You need to convince a big enough group of people to do these things or else some other group comes along and imposes whatever they feel like on you.

          If you can’t figure out the social principals necessary to form a strong enough group then your just prey.

      • B. Reynolds says:

        The answers to all of those questions are in the hands of politicians now. As Mencken said, we’re going to get it good and hard.

      • Emma_Dee says:

        For all those who whine on about what we owe each other, may I remind you – Jesus said YOU feed the poor, not set up a massive goverment bureaucracy to steal money from other people by force and do it for you.

        By far the best thing we as a nation can do for poor people is to develop a free market in health care. Costs would go down by more than 50% in just a few years, and would probably drop another 20-30% soon after.

        With the gigantic savings we’d get from killing off the bureaucracy, and lowered medicaid/medicare costs, etc. we could easily pay for insurance policies for everybody that needed it. With plenty left over.

        If YOU want to do more to help poor people get health care, put your money where your mouth is. Don’t force other people to join your crusade.

    • Jeff R. says:

      #3 is a legitimate, value-neutral problem, though, isn’t it? When you have Peter getting his healthcare paid for by Paul through an entity called ‘DHS,’ it eliminates incentives for the parties involved to use resources efficiently and enables healthcare providers to charge exorbitant sums for healthcare both simple and complex. The real cost is hidden from Peter and Paul doesn’t care who gets paid what.

      Maybe libertarians might harbor some pie in the sky ideas about how to fix this problem, but please do not pretend that it’s somehow not a real problem.

    • MikeP says:

      One way to address this fear is to have the government tax healthy people to pay for sick peoples healthcare. Many healthy people are okay with this since the trade off is that if they get sick then the government will pay for their healthcare too.

      The libertarian response to these fears is:

      4) Pay for the health care needed by people who cannot afford it by using the general fund to reimburse health care providers at the point of provision. This provider is likely a second tier institution such as a community clinic or emergency room.

      As evidenced by all empirical evidence, this is very much less expensive than subsidizing comprehensive health insurance for the poor and sick and it eliminates the subsidization of health care inflating arrangements such as having even expected or affordable health care paid for by insurance.

      Simply repealing Obamacare is far better than anything built on the same big lie that insuring the poor is cheaper than simply paying for their care.

    • Octavian says:

      Two can play at burning straw.

      Personally, I’ve long since accepted that those of you, the majority, who believe you and others are too stupid to make your own economic choices are likely onto something. I also recognize that, when you fail save enough money over the course of your life to finance your own health costs, you will use Democracy to force those of us who were fiscally responsible to finance your poor choices.

      For that reason, my position on healthcare isn’t that libertarian: everyone should be forced into a health savings account (tax deductible of course) which will be used to finance (at least partially, optimally most of) their health care expenditures.

      I would like to apply this model to other entitlements as well (e.g., replace social security with a mandatory IRA). Redistributive policies only make sense for providing food stamps and whatnot to the absolute poorests, but the majority of entitlement spending goes to people who don’t belong to that category and are in fact gainfully employed, and much of the need stems from low savings rates. So fine, if most Americans consider themselves children, I’m fine with treating them that way. Force them to save to finance their own entitlements.

      Frankly, I regard the whole communitarian ‘we’re all in this together’ attitude as little more than a self-interested rationalization by people who get more out that they put in and don’t want to accept the reality of their economic parasitism on the rest of society. It’s a curious thing that those who are so ardent about it tend to be the same people so furiously despise the very people and corporations that disproportionately finance our ‘public goods’, putting in far more than they get out.

      • B. Reynolds says:

        While that system, if implemented correctly, would be better than the current wealth transfer mess, it is still a political solution rather than a market solution. As such, to work correctly would require an ideal philosopher king to manage it.

        In reality, that’s a lot of money. There are plenty of people in the political class who would love to tie strings to such a large pot of dough.

        On the other hand, they have kept their hands off of 401(k)s and IRAs, for the most part, but it’s not due to their good will.

        • asdf says:

          All solutions are political solutions. Markets rely on property rights, which rely on some entity with guns enforcing your property rights. Libertarians should pay more attention to political economy and come up with realistic means to achieve their objectives.

    • Mike says:

      My libertarian response is partly your #3 (we can’t afford it), plus
      5) I don’t like so much power being concentrated in one place. Nationalized health care basically gives the power of life or death over everyone to a small number of politicians and bureaucrats in Washington. See stories about the UK NHS deciding whether or not various kinds of care are available and to whom.

      • asdf says:

        In America somebody like me working for a private insurance company decides if you get various kinds of care and at what price. All my competitors have a guy just like my making similar decisions based on similar incentive structures and arriving at roughly the same outcomes.

        That is how we got where we are in healthcare.

        • Mike says:

          But at least a dispersed system like that is preferable to a national system. Once it’s national, you’re stuck; there’s no alternative. (That does depend somewhat on the details of the national system, of course.)

    • Mike says:

      Your premise is that Jones pays for Smith’s healthcare when Jones is healthy and Smith is sick and that when Jones is sick, some healthy Smith will pay for his healthcare. If each of us is paying for each other’s healthcare, it begs the question, “Why not eliminate the administrative burden and have each of us pay for his own healthcare?”

      The answer is, of course, that you have substituted “healthy” and “sick” for wealthy” and “poor.” The government plan is not aimed at having the healthy help the sick. It’s just a wealth transfer plan (Marxism) disguised as a healthcare plan.

      Further, when Jones pays for Smith’s healthcare, Smith has no incentive to say “No” to treatments that are of high cost and have little or no benefit – something he would be careful to consider if he was paying for his own care. This is the great danger – not only is Jones paying for Smith’s care, he’s also paying more than market price for each individual service and he’s paying for a quantity of services that Jones would not pay were he bearing the burden.

  2. Handle says:

    I fear that on this issue there is no overlap in the US between sanity and fiscal sustainability on the one hand, and what is politically possible on the other.

  3. asdf says:

    This kind of thinking is part of the problem.

    If Paul needs healthcare to live, and Peter is flush with cash, of course Paul is going to rob Peter. It’s like asking French peasants without bread not to storm the palace and take a bite out of royalties cake. “You didn’t bake that” doesn’t matter much to desperate people.

    Compounding the problem is that bad health can strike anyone. Even the well off can be ruined by unpredictable bad health. So everyone sees himself as a potential Paul, even if they are not a Paul right now. If you could get all the Peters on one side maybe they could agree to let Paul die off, but not if they are legitimately worried they could be Paul one day.

    And I’ll keep repeating this, there exists no long term guaranteed renewal major medical health insurance product in the individual market, and there never will be. As such Peter can’t offload his risk of becoming a Paul in the free market.

    Libertarians spent a few decades trying to “keep government out of medicine”. The net result is that government was still very involved, and we got higher cost inflation then the entire rest of the world with more uncertainty.

    If you want to stop Peter from robbing Paul, come up with a system that ensures necessary medical care to everyone at a reasonable price while making Paul pay his fare share.

    Did you think there would be any other outcome? What realistic steps has libertarianism taken to make free market healthcare a political reality?

    • Andrew' says:

      Despite not holding a single national elective office, things were still fine before Obamacare insofar as Obamacare made all the problems worse.

      HSAs have been tested and shown to work to lower expenditures (and costs?).

      I envision something like healthcare shares that are owned by individuals and can be transferred at job changes, plan changes, or to other people, relatives for instance. It is basically a type of HSA. The reason there is no long-term guarantee is because you aren’t allowed to build up a cache so the incentive for insurance companies to zero you at whenever they can is too high. We don’t have to do it that way.

      • Andrew' says:

        NIH should be instructed to pivot heavily towards cost-benefit optimization in developing new procedures.

      • asdf says:

        I don’t like Obamacare myself, I’m addressing the libertarian talking point that “everything should be a free market”.

        Lots of libertarians hate HSAs because they “distort the free market by subsidizing healthcare.” I agree that most countries have them and they can work well, but its hardly a “free market” solution.

        Putting money into an HSA doesn’t solve the insurance aspect. If I sock away $3,000 every year, and then I get a six figure bill ten years out, I don’t have enough money put away. Where do I come up with the remaining $70,000? Declare bankruptcy? What if treatment requires ongoing expenditures for the rest of my life. This is a situation I found myself in.

        You can solve this problem by having HSAs, forcing people to contribute to them, and if they end up with a health expenditure so bad it overwhelms your ability to pay after having put aside so much money then the government covers it (paid for by premiums collected by force throughout your lifetime). So most people pay for their own healthcare (up to a certain % of their income), and manage their own healthcare costs for non-acute situations, and the government takes care of catastrophic (and forces you to pay into it).

        Then the government also comes in and manage catastrophic care so that whats being sold is clinically effective and reasonably priced instead of a wasteful gouge of Hansonian medicine.

        You’ll notice none of that is a free market. Forced savings. Forced catastrophic premiums. Government management of medical service availability and price. The only thing sort of free market is that non-cat care you can choose how to spend your forced savings money.

        But hey, it works.

        • Andrew' says:

          That isn’t a talking point. It is a fact. And how are you addressing it?

          Yes, HSAs do address that by bending the cost curve. They are also coupled with higg-deductible.

          Let me know when government has solved it, because when I look at other countries, their costs are rising as fast or faster than ours. And our costs ramped in 1972 when government started pumping money in.

          • asdf says:

            I’m addressing it in that lots of countries with HSAs don’t have broken healthcare sectors, so obviously the tax deductibility of HSAs isn’t the major problem with our health sector.

            Getting people to save for their own healthcare is actually an important part of having a functioning healthcare sector. Otherwise broke people show up when they get sick and that causes problems.

            The government solved it in Singapore and there was nothing libertarian about it. It’s more or less what I outlined above.

            The government also solved it to greater or lesser degrees in other countries. At least better then the USA.

            What does solving look like to you? Demographics + new medical technology assured that health spending was going to go up. The question is whether it was going to grow wildly faster then CPI or not. Saving even a few percent a year on cost trend adds up to a lot over a generation or two.

            If you idea of solve is “health costs go down 50% in one year” I think your living in a fantasy world. That’s not how other countries got to be half as expensive as us. They just had lower cost trend for a few decades, despite the fact that their government “started pumping money in” around the same time.

          • Andrew' says:

            “The government solved it in Singapore and there was nothing libertarian about it.”

            I bet I would disagree with both of those assertions. And not just in the way I’d disagree with a statement like “Singapore solved the problem of bubble gum on the sidewalk.”

            “Within Medisave, each citizen accumulates funds that are individually tracked, and such funds can be pooled within and across an entire extended family. ”

            Sounds like what I proposed earlier, ideated independently.

          • asdf says:

            It’s a *forced* savings account. Singapore:

            1) Forces you to save
            2) Forces you to buy insurance
            3) Forces you to turn to family first
            4) …but if all that fails, picks up the tab itself.
            5) Makes sure that when its picking up the tab its done in a cost controlled regulated environment that minimizes wasteful practices and price gouging.

            If you force someone to save, that’s not libertarian. Even if the account remains earmarked to that person. That’s better then not earmarked, but its still not libertarian.

            If you force someone to purchase a product, its not libertarian.

            If the government is subsidizing someone at any point, that’s not libertarian.

            If the government is regulating price and availability, that’s not libertarian.

            It may well be a way to promote individual responsibility, align incentive structures, and use as light a government hand as possible while achieving efficient and effective outcomes, but its still a government hand.

          • Andrew' says:

            I am perfectly happy dealing in degrees of libertarianism.

            If you say that someone has to pay for your healthcare (because “OMG, people are bleeding to death in the streets!”). And then say that someone has to be you, that strikes me as more libertarian than forcing me to pay for your healthcare.

            And there are degrees of force. Tax incentives are more libertarian than caning, for example.

            The family thing, to me, is just a small network insurance company. I did some back of the envelope calcs one time and decided that about 100 people are all it takes to be “covered.” So, a reasonably sized church could have a health insurance network. They would also know that Joe is not looking after his health and is drinking away his money and needs to be talked to.

            The parallels of TBTF banking come to mind. Beyond a certain size (around 100 members) bigger insurance serves to reduce accountability and management. And since you don’t know anyone, it is easier to shirk.

            Anyway, what you describe for Singapore is not far off from close enough, to me.

          • asdf says:

            The whole post is about “Robbing Peter to Pay Paul”. It screams non-aggression principle autism.

            If libertarians weren’t fanatical about that it would have been much easier to come up with a system where “Paul mostly pays for his own healthcare within his means (and isn’t allowed to shirk), but Peter helps out in rare cases”.

            Libertarians also have an aversion to regulation, but Hansonian medicine shows that there is an awful lot of waste that should be regulated away, especially when a third part payer is involved.

            To my knowledge nobody gets caned over health insurance (nor for that matter over gum, despite urban legends). The list of crimes punishable by caning is mostly limited to serious violent crimes: rape, mugging, gang activity.

            The most well known example from America was from an expat student willfully planned out and committed mass vandalism. Hardly spitting gum on the sidewalk. Whatever, let’s not get sidetracked.

        • B. Reynolds says:

          The problem with the HSA in the US is that it is simply thrown on top of all the market-distorting regulations and subsidies.

      • true libertarian says:

        “things were still fine before Obamacare”

        I feel your pain, Now all those people with pre-exisitng and congenital health conditions have to be given health care! That’s outrageous. Why is health care any different than transportation? Do we owe everyone a vehicle?

        • Octavian says:

          I know right! If it weren’t for Obamacare we wouldn’t be enjoying these plummeting premiums and deductibles and health outcomes wouldn’t be rapidly approaching northern European level quality! Thanks Obama!

    • Octavian says:

      I would consider myself a classical liberal and I really don’t care much for ‘pure’ Rothbardian libertarianism, but I’d say I’m more or less libertarian.

      The issue here, ultimately, is that Paul should save up to finance his own healthcare. More often than not, the reason Paul has to leech off of Peter isn’t because he couldn’t afford health care; he could have, but he chose not to and chose to buy other less necessary things instead.

      You are right, of course, that Paul is never just going to accept the dire consequences, and even if he knows it’s entirely his own fault, he’ll still sooner murder Peter and loot his house for spare change than just accept it and die. Moreover, the voting public will sympathize with Paul and make Peter donate to his cause at gunpoint.

      These are, imo, inevitabilities. The best we can do is force Paul to save up for his own costs to save Peter the trouble of having to bail him out later, as he will surely be forced to do. I’m not sure Dr. Kling is this cynical, but I am.

      Unfortunately it’s a moot point. It doesn’t obscure the costs enough to allow voters to pretend that no one (at least not them) is really going to have to pay for it, and therefore they would never support it. IMO, democracy is at least as much an exercise in collective self-delusion as collective self-governance.

  4. andrewknoor says:

    The conservative arguments against welfare (it saps initiative, creates dependence) don’t really apply to free healthcare. Nobody says “I’m going to loaf today because I’ve got free healthcare.” The best conservative arguments against big government (it saps society of moral fiber and economic dynamism) don’t actually apply to free gov’t healthcare. The libertarian argument, as stated above, isn’t persuasive to very many people: Peter is robbed to pay Paul all the time. So then it comes down to which system is more efficient, and I support McCain’s plan from 08. I don’t see why Republicans don’t elminate the exemption, it’s an invisible tax and it would be easy to say, “hey, we’re flattening the tax code by broadening the base.”

    • Yancey Ward says:

      Nobody says “I’m going to loaf today because I’ve got free healthcare.”

      Loaf? Maybe not, but what they actually do is spend the money they might have set aside for healthcare on some other consumption item.

      • andrewknoor says:

        That might be frivolous spending compared to health insurance but it doesn’t constitute moral turpitude, initiative -sapping gov’t dependency, or a brake on economic dynamism, all the reasons that conservatives have typically opposed gov’t programs. Although I suspect most Republicans don’t really know the reasons why they’re opposed to big government, and so don’t distinguish between healthcare insurance and unemployment insurance.

  5. R Richard Schweitzer says:

    “Health” INSURANCE contracts transfer and spread RISKS..
    (not to, but through, insurers, but over larger bodies of revenues from larger groups of insureds)

    Heath CARE contracts (while they may transfer some risks) transfer and spread COSTS.

    Where those cost transfers, through insurers, are spread over a specific and narrower base of participants, the costs of some (maternity, e.g.) are added to the existing costs other others in the narrow range – intensifying the impacts.

    Until there is a return to the “splitting” of insurance” from “care” and separate contracting is provided for each, these issues, arising from cost transfers, will increase in secerity and destroy the capacities to deal with risks.

  6. Andrew' says:

    If insurance is just a transfer, then it is indeed hopeless. If it can be reformed back into insurance, then we need not despair. Obamacare made it worse, so, it is technically trivial to make it better. I’ll happily take 2008 insurance premium prices and so will everyone else. To avoid pulling the rug out from people, they could be ramped down to lower cost packages. We don’t actually believe people would choose not to be insured if it were affordable. When it is insurance rather than an inefficient transfer, it will be affordable.

  7. Bryan Willman says:

    The worst issue is probably this – A very large fraction of the population (order 40%) get their healthcare via their employer, and thus are not part of the same risk pool as the “private insurance market” (which never applied to more than about 16% of the population.)
    Further, by dint of being healthy enough to be employed, those 40% are healthy entrants the risk pool really needs.

    Because of this, I now believe that no useful reform in health insurance or healthcare provision can occur in the united states until employer provided health insurance is outright banned.

    Since the 40% or so of the population this would affect, and their proxies (union leaders, compensation managers) wildly oppose this, it will not happen.

    The non-big-employer non-medicare health insurance pool is and will be a toxic tarpit in which political parties, law, and logic, are murdered over and over until employer provided healthcare is abolished.

    Have A Nice Day

    • asdf says:

      What assurance do those with employer health coverage have that they will:

      1) Get adequate healthcare under an alternative plan
      2) Should trust the people doing the reforming

      Until those questions are answered, nobody is going to give an inch. And why should they? Employer coverage saved my life. My fathers life. I would love to be untethered to a job for healthcare, but at least today I know that my family and I are covered.

      Obamacare turned out to be little more then mugging employer plans to squander on exchanges. After getting burned like that, why should anyone want to go for round 2.

    • Octavian says:

      There is no need (or point, really) to banning it. Just extent the tax credit (or, under the current system, income-based subsidies, though preferably refundable tax credit) to all insurance purchased in the market, allow employers to pay into portable individual plans (like with retirement accounts) rather than buying group plans and eliminate fines for failure to provide coverage.

      In this setting, most businesses (probably almost all small and medium sized) would stop offering group plans, but would pay higher wages and hire more. Job lock would not be such a big problem. Some big companies would still pay for employee’s insurance, but they would pay into tailored individual accounts rather than group plans that cover things many employees find unnecessary.

      Some large companies may find it expedient or attractive to employees to contribute to employee’s insurance; that’s fine. The issue isn’t employer health care per se, but all the tax benefits allotted to it combined with the regulations and fines creating a host of perverse incentives that unnecessarily drive up costs and, very importantly, kill portability.

      • B. Reynolds says:

        Yes…. and why Republicans have *never* spent an ounce of serious political capital on getting rid of this tax distortion tells us a lot about Republicans.

  8. BenK says:

    We have several coupled problems. They aren’t being fairly addressed. One reason that health insurers are inclined to cover inexpensive care that doesn’t actually require any insurance is that with health, a stitch in time saves nine. Preventative medicine, in short. Auto insurance deals with this differently; mostly because it covers damage to other people and it pays out less for a car in poor condition. So, if you were in bad shape and became ill… you would get less money. Homeowner insurance is once again different; because if there is a major claim, an investigation will determine fault – and can prevent any payout.

    So this is the first problem. The assumption that people will assiduously protect their own health is not accurate; and there is no strategy for creating accountability beside the obvious suffering that will later be endured, with great regret.

    The second problem is cost disease, where unrestrained pricing does not lead, precisely, to unrestrained profits – but instead, leads regulators and suppliers to effectively raise prices, on materials, on education, on facilities, siphoning off the profits piecemeal. Clawing all this back becomes effectively impossible, as the related industries become bloated. Everybody along the chain has an incentive to claim that cutting costs will result in simple collapse of supply. As a result, costs are a unidirectional ratchet, unless one is willing to destroy the entire edifice and start over.

    • Matt says:

      SOME early or preventative care saves money. But across large numbers, it is actually MORE costly.

      That’s why there is pressure to lower the amount of screening done in this country (see: HHS changing recommendations for Mammograms, Pap smears and colonoscopies in the last several years).

      That is why health care costs have increased as insurance has been expected to cover more and more preventative and general care rather than decreased.

  9. Les Cargill says:

    The top 5% of health care consumers use half of the resources. The top 1% ( 3.3 million people in the US ) all bill something like $1M each.

    The median user costs close to nothing.

    You can’t fix this in any way that I can think of.

  10. Guest says:

    Just once, I want to see a politician stand up and state the obvious: Buy your own damn health insurance.

  11. EMichael says:

    It takes both Peter and Paul to make a civilization.

    Libertarians dispute this, despite their thoughts never, ever being responsible for the creation of any civilization.

    • Andrew' says:

      Except for, oh, The Declaration of Independence.

      And we didn’t bring this up. Democrats scared to death of their beloved behemoth going bankrupt did.

  12. Massimo Heitor says:

    I agree with Kling about the immorality of robbing Peter to pay Paul. But as commenter asdf says, libertarians bang on that a lot and nobody cares.” Libertarian types like Kling need more creative messaging.

    One option I like, is giving everyone “coverage” and “insurance” but ultimately expecting people to pay for what they use. There should be some safety net and some risk pooling which involves money transfer from healthy people to sick people, but the average American already pays a lot of money for health care, and they should have more direct control over that, there should be more transparent pricing and more of a transparent market for health services.

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