Medicare is a monopoly: a central-planning bureaucracy grafted

"Medicare is a monopoly: a central-planning bureaucracy grafted onto American health care. It exercises a stranglehold on the health care of all Americans over 65, and on the medical practices of almost all physicians. Medicare decides what is legitimate and what is not: which prices may be charged and which services may be rendered." These words of Virginia Postrel resonate with a profound warning about the rise of centralized power in the realm of healthcare, a sector that impacts the lives of every citizen. In her critique, Postrel highlights the growing influence of bureaucracy, and how it shapes the access and delivery of medical services, particularly for those over 65. Her words cast a sharp light on a system that, while intended to provide care, has become entangled in its own web of control, limiting freedom and innovation in the very field that demands flexibility, compassion, and respect for individual needs.

In the ancient world, the most revered societies recognized the importance of balance in governance, particularly in matters that directly affect the well-being of the people. Plato, in his writings on the ideal city-state, warned of the dangers of concentrated power. He understood that when any entity—whether a ruler or a bureaucracy—gains absolute control over a critical sector, such as healthcare or governance, it undermines the very essence of human freedom. Plato's ideal society was one in which power was distributed and checks were in place to prevent the dominance of any single force. He knew that a system that grants too much authority to a single body, unchallenged and unchecked, can corrupt its purpose and become oppressive.

Postrel’s words echo this ancient wisdom, cautioning against the dangers of centralization in the context of Medicare. Like the philosopher-king in Plato’s ideal city, Medicare’s administrators wield tremendous power over the lives of individuals. The stranglehold it has on medical decisions, from the prices charged for services to which treatments are deemed legitimate, limits the ability of physicians and patients to make autonomous decisions. This bureaucratic overreach stifles the natural flow of innovation and choice that should be inherent in any healthcare system. Just as kingly power in the hands of one person can lead to tyranny, so too can the concentration of healthcare decision-making in a single entity restrict freedom and personal responsibility.

In history, there are many examples where centralized control over essential services has led to the diminishment of individual freedoms. In ancient Rome, the emperor wielded vast power over the lives of the people, including their access to resources and services. Although the Roman Empire brought many advancements in engineering, law, and culture, it also imposed a system of control that restricted the personal freedoms of its citizens. As emperors grew more powerful, the autonomy of the people diminished. The people’s lives became increasingly regulated by imperial decisions, which determined everything from the allocation of resources to the conduct of daily life. In time, the empire became bloated with bureaucracy and corruption, its citizens bound by a system that, while initially designed to provide stability and security, became a mechanism of oppression.

The story of ancient China during the reign of the Qin Dynasty offers another example. The first emperor, Qin Shi Huang, centralized power to an extreme, uniting China under one rule. While his reign brought unity and construction of great projects like the Great Wall, it also led to heavy taxation, mass labor, and an extensive control over the lives of the people. In such a system, freedom was sacrificed for control, and individual agency was diminished. The people, much like those under Medicare’s grip, became subjects of a larger bureaucracy, their needs and decisions dictated by forces far removed from their personal lives. In the end, the very system designed to maintain order led to widespread discontent and the eventual downfall of the dynasty.

Postrel’s critique of Medicare, then, is a powerful reminder of the need to constantly check the expansion of any bureaucratic system—especially one that controls something as essential as healthcare. While the intention behind Medicare was to ensure that the elderly receive care, it has become, in some ways, a bureaucratic labyrinth that limits the freedom of both patients and healthcare providers. Postrel urges us to recognize that, just as centralized systems in the past have stifled innovation and freedom, so too can modern systems, such as Medicare, prevent the development of a more efficient, compassionate, and personalized approach to healthcare.

From this, we can draw a vital lesson: centralized power, whether in governance, healthcare, or any other sector, often comes with unintended consequences. Choice, autonomy, and innovation are critical to any thriving system, and when those elements are stifled by excessive control, we risk creating a system that, though initially well-meaning, loses its way. As we reflect on the wisdom of Virginia Postrel and the lessons of the ancients, let us strive for a system that balances the need for support and regulation with the need for personal choice and freedom. In healthcare, as in all things, freedom and personal agency must remain paramount. Only through this balance can we create a future where care is not defined by bureaucracy, but by compassion, flexibility, and the empowerment of those it serves.