Not long ago, a relative called us for advice about a hospital bill. A public interest lawyer in New York, he had developed chest pain when exercising and consulted his internist, who ordered a stress test with an echocardiogram. To his relief, no abnormalities were found. Distress came later, when he saw that the hospital had charged some $8,000 for this test. Despite having excellent insurance, he was informed that he was responsible for $2,000 of the total.

The bill seemed exorbitant to us, and we suggested that he contact other medical centers in the city to find out what they would charge for the same examination. To his surprise, he discovered that prices ranged from about $1,200 to $6,000. When he called the billing office at the hospital where his test was performed and asked why the echocardiogram was priced at such a high level, he did not receive a clear answer. Frustrated, he informed the hospital that he declined to pay. This resulted in several veiled threats, but he countered that he would contact the attorney general of New York about what he believed was abusive pricing without justification. After much back-and-forth, his internist intervened on his behalf, and the hospital dropped the demand for the $2,000 difference.

This story points to the extraordinary predicament of our current health care system. Since the implementation of President Obama’s Affordable Care Act (ACA)—and the mandatory coverage it brought—most patients needing a procedure such as an echocardiogram can count on some form of insurance. But Obamacare put no controls on the pricing of drugs or clinical care, leaving the profit-driven health industry mostly intact.1 As a result, patients are too often required to pay large out-of-pocket costs while insurance premiums have continued to rise. Most patients navigating the financial shoals of our health care system do not have relatives who are doctors to advise them, nor are they lawyers; and many do not have insurance policies as generous as our relative’s.

Now, if the Trump administration and a Republican-led Congress are successful in their efforts to replace the ACA with “a free market solution,” largely stripped of regulatory restraints, the situation could get much worse. In May, the House of Representatives passed its version of a bill (called the American Health Care Act or “Trumpcare”) aimed at dismantling Obamacare, and the Senate has been crafting its own bill. The Congressional Budget Office has estimated that the House bill, if enacted, would leave 14 million people uninsured as soon as next year, and 23 million by 2026. Furthermore, this plan would make it even more costly for the neediest patients to access care.

At the center of both our flawed current system and its disastrous proposed replacement is a more fundamental reality: health care in the United States is enormously costly, often in ways that are baffling not only to patients but to doctors…