Recently Ezra Klein pointed out (“What liberals get wrong about single payer,” Washington Post, January 13) that single-payer healthcare wouldn’t solve the problem of America having the most expensive healthcare system in the world. American health insurance premiums aren’t so high because of the overhead cost or profit of insurance companies, but because of the price of service delivery itself. The private insurance industry is an uncompetitive cartel, to be sure. But next to the almost 300% price markup on an MRI in the U.S. compared to France, or the 2000% markup on a drug under patent, the cost of insurance is almost nothing.

In response, Professor Uwe Reinhardt of Princeton added that a single-payer system wouldn’t work in the U.S. because it would be controlled by the corrupt culture of the service deliverers (“Is the U.S. too corrupt for single-payer healthcare?” Washington Post, January 16). “Medicare is a large insurance company whose board of directors (Ways and Means and Senate Finance) accept payments from vendors to the company. In the private market, that would get you into trouble.” Basically, the prices Medicare-for-all paid for healthcare services would be set by the healthcare providers and reflect their institutionalized monopoly culture.

All too often, when well-meaning people say a particular need should be a “basic human right,” what that means is that the average person gets that need for “free” — but they get it as defined by the authoritarian institutions and professional priesthoods that deliver that service. The nationalization and public financing serve mainly to lock in that institutional culture permanently, and make it difficult at best for the individual to escape that institutional model of service whether they actually want it or not.

A common theme in the work of Ivan Illich was the provision of services in all aspects of life by bureaucratic, hierarchical institutions with high overhead business models and the delivery of actual services by authoritarian professional priesthoods.

“Many students … intuitively know what the schools do for them. They school them to confuse process and substance …. [T]he more treatment there is, the better are the results …. The student is thereby ‘schooled’ to confuse teaching with learning, grade advancement with education, a diploma with competence, and fluency with the ability to say something new …. Health, learning, dignity, independence, and creative endeavor are defined as little more than the performance of the institutions which claim to serve these ends, and their improvement is made to depend on allocating more resources to the management of hospitals, schools, and other agencies in question.”

If you want an illustration of the total gestalt of the kinds of services delivered by such institutions, with their mission statements, Weberian work rules and accounting systems which define the consumption of resources as “value,” just compare the proprietary, institutionally designed “office productivity software” the IT department makes you use at work with platforms and utilities like Open Office that people willingly choose for themselves at home.

I once saw an activist critic of agribusiness on C-SPAN describing the process by which the USDA created the “Food Pyramid”; it was basically negotiated by a committee made up of representatives of Big Cereal Grains, Big Meat, Big Dairy, ad nauseam.

We have “free” education through grade 12 as a basic human right in the U.S. And what is it? A system set up for processing, grading and sorting human raw material into an input for corporate HR departments. The first statewide public school systems were set up in New England because mill owners needed hands who’d been taught to be punctual, line up on command, eat and pee at the sound of a bell, and cheerfully obey instructions from an authority figure behind a desk. As a majority of people moved into white collar jobs, this basic function persisted — with the additional task of schooling students to prioritize tasks set for them by an authority figure over their own self-directed interests, and to regard as a trivial “hobby” anything not assigned by a boss.

The proper solution to the crisis resulting from enormously expensive healthcare is not to leave the expensive business model in place and then finance it with tax money, but to cause its price to implode to affordable levels by removing all the state-enforced monopolies and institutional frameworks that make it so expensive. Imagine a society where one of Pfizer’s $10 pills cost fifty cents, an MRI was $250, outpatient treatments and tests were covered by $70/month dues at a cooperative clinic, and catastrophic insurance was $50/month. That’s what we’d have if corporate-state collusion and monopoly were replaced by competitive markets and horizontal cooperation.

Before you make something “free,” think long and hard; you may also be making it compulsory.