Our health care system, with or without the ACA, is a mess. People disagree about the reasons it is a mess or what specific aspects of it are most problematic, but anyone can see this isn't working. The fundamental flaw is one thing that nobody in the Republican Party has the balls (being as male-heavy as it is in Congress, the gendered euphemism is appropriate here) to address.

On the surface it seems like the choice between a pure free market and a pure single payer system for health care would give us two options that both work as self-contained entities with very different consequences. A free market system would cost less for many individuals, cost more for others, and leave some people unable to afford health care at all. A single payer system would guarantee service to everyone but raise issues of overall cost (depending on how it were run) and how efficiently service could be provided. The problem in the U.S. is not that we have picked the wrong one of these options, but that we have neither of them.

The loophole that makes our system the enormous clusterbang that it is results from Republicans not having the courage to back up their tough talk on people who can't afford health care. As long as the law requires Emergency Rooms to take people irrespective of ability to pay, the system we use today is guaranteed to be an expensive mess. A system that requires people to buy insurance from a for-profit insurance industry or face a penalty is going to leave some people uncovered. Those people are going to get sick and get in car accidents just like everyone else. When they do, they end up getting services they have no intention of or ability to pay for. The costs get passed on to everyone else. This is why health care in the U.S. has been such a disaster – because we treat it like an industry rather than a social service.

The logical solution is to have a single-payer system in which people don't have to go to the ER when they have the flu because it's the only service provider they have access to that can't reject them for being uninsured and poor. The alternative, though, is for the Republicans to sack up and change the law that requires ERs to take uninsured patients. If they really are committed to the idea of health care as a product, the provision of which is governed by the invisible hand, then go all the way. Tell people, "If you don't have insurance, the ER will leave you outside on the sidewalk and lock the door. Hospitals don't have to treat you anymore, even if you're comatose, until they determine what you can afford."

That's abhorrent, of course, but they don't seem to have any problem being abhorrent as long as they know that their poorest constituents can get into a hospital somehow (and then suffer under a mountain of medical debt they can't begin to pay back, which is a win for the debt collection industry). Nonsense. Take away the safety net. If you want a market in which health care is treated the same as any other product or service, then stand behind your ideology and let's do this for real. See how it looks in practice. Let people experience it. See how they like it.

It's the only way for Americans to make an informed choice, after all, on the merits of treating access to medical care as an issue of personal responsibility and a privilege one must earn.