Issue 1) I think the fundamental problem is that unlike most other things that the free market does just fine with, our society has made a clear and conscious choice that on this front, we’re not going to let people suffer the true consequences of their actions. You can argue whether that’s a good idea or not – I think it is, since I can’t imagine a society that decides that well, actually, we’re ok with people dying in the streets when they can’t afford care, after all could be a very good one – but either way, it’s a choice our society has made. And given that it’s been made, this issue becomes one that no longer falls into the “I can decide whether to buy a TV set or not, gosh darn it” type category.

Issue #2) It’s not the uninsured that pay for most of care-to-the-uninsured. In fact, it’s the insured that cover it. Yes, you are right that if you are uninsured, your official charges will be higher than if you are insured. But do you have any idea what a low fraction of those charges are ever paid? The vast majority of care to the uninsured is provided as charity care by major hospitals, most often by emergency rooms. This means that something that could have been handled in an office for $50 is costing hundreds-to-thousands in facilities costs. It also means that ER’s cost their hospitals far more than they make – one of the major reasons that many hospitals are closing their ER’s; hospitals that aren’t are generally subsidizing them heavily with, you guessed it, the extra they make off your insurance costs (I don’t hold this against them – I don’t see what else they can do). And in the meantime, I don’t know if you’ve gone to an urban ER lately, but they are so crowded that if you’re not bleeding out you can spend 6-12 hours waiting; where I work so people have realized the only way to see someone fast is to lie and pretend to have symptoms of a heart attack that when my neighbor really did have heart attack symptoms and was rushed to the ER in an ambulance, he was then dumped in a chair to wait for FOUR HOURS before being seen.

You may be noticing that to some extent I am blurring two groups of the uninsured – low income groups with chronic health issues, and healthy young people who just feel invulnerable. From your post, I get the feeling that you assume that the latter category, when something does go wrong (as it did for a friend of mine who had a 3 month gap in her insurance – and in the last two weeks was hit by a car riding her bike and racked up over $100,000 in costs in just over a week), the person ends up paying for it. Almost always, however, that’s not the case. The person may end up saddled with enough debt to last them years of financial hardship – but hospitals know that if they try to bill a 23 year old english lit graduate student $100,000 one fine morning that even if that student struggles for years, they will almost certainly eventually declare bankruptcy – and the hospital will be left with having spent probably as much in collection costs as they recovered in payments. Instead, almost every hospital will end up shouldering most of the cost themselves (again, out of your insurance payments). The other source of all of this free care: the system whereby there are nationally agreed upon wage standards that make sure that residents who have had 4 years of college, 4 years of (usually very expensive) medical school, and often up to 3 or 4 years of residency already are required – if they want to legally train in their field – to work 60-80+ hours a week for $40-50k a year (an hourly salary of less than a fast food worker in many states) during the same years they’re trying to have kids and buy a first house.

I’m sorry this is such a long post – it’s just that this is something I feel very strongly about. When I began working in this field 6 years ago, this wasn’t my viewpoint at all. But, confronted with the reality on the ground, I have become convinced that I was wrong – and that either laws like the Massachusetts law or some sort of single payer system are inevitable.