There are three basic ways to provide healthcare: (1) the state can provide it, as the NHS does in the UK (with very good results), (2) individuals can buy individual services (i.e. a chiropractic treatment, a dental cleaning, an immunization, a checkup) and insurance for emergencies and chronic conditions (broken bones, cancer, burst appendix), or (3) one’s employer can be required to purchase insurance for all treatments, however routine, as well as more serious health emergencies and chronic conditions. The US has (1) for veterans (the VA), the elderly (Medicare), and the very poor (Medicaid), (3) for those employed by large employers, and (2) for everyone else. In light of the Hobby Lobby decision, I think it’s clear we need to take a good hard look at Obamacare and how we can live with it and, at the state level, improve it.

I talk herein about why employer-based healthcare is fundamentally a terrible idea, how we can harness the free market to make healthcare costs more transparent and subject to the downward pressure of competition, and finally three crucial roles the government may be best poised to play: emergency insurance provider, keeper of records, and wellspring of preventative care.

The Hobby Lobby decision was essentially caught up in two quibbles. On the one side, Ruth Bader Ginsburg was saying that if a corporation has religious conscience, it could decide that blood transfusions, mental health services, or in principle any other procedure were impermissible for its employees. Her point was slippery slope: Alito’s opinion carves out an exemption for contraception-that-the-corporation-thinks-is-abortion-esque without explaining why all these other things cannot qualify for that same exemption—that there is no legal grounds to separate one category of religious beliefs as “to be taken seriously” and another to be dismissed as silly or insincere. Alito counters that those questions were not before the court, and that because the Obama Administration had already conceded that churches (which are corporations—artificial persons—albeit nonprofits) are entitled to the exemptions which attend possession of religious conscience, granting that conscience to another class of corporation was really a very small legal jump. I agree with both of the Justices, but think more broadly that no corporation should be entitled to religious conscience at all—that paying someone’s healthcare bills is like paying a form of their wages, and that you ought not to be entitled to dictate how one’s wages are spent without conjuring images of Company Stores in the post-Reconstruction South.

All of this is to say that tying healthcare to employment creates a totally unnecessary layer of opacity between medical services and end user that invites obscurity and price inflation only seen by end users in the form of less and less of their total wages coming to them in real money—rather than ever-rising healthcare insurance costs that their employer must pay. If we gave people their full wages, and let them buy insurance on the open market for the degree of coverage they felt they needed, perhaps requiring the usual emergency and chronic issues be covered or the individual forfeit a tax incentive, the market would be far more responsive and individuals would get far closer to what they actually need. However, I think insurance is largely unnecessary, because most medical visits would benefit from being paid for out of pocket and transparently rather than through inflated premiums on the back end.

Earlier this year, I got a TB test from a CVS Minute Clinic. The experience wasn’t Apple Store-good (nothing at CVS ever has been) but the concept is brilliant: put a nurse practitioner where many people are likely to go anyway and, if they have a routine medical issue, let them seek medical opinion without having to pay an M.D. or involve the bureaucracy of a huge medical center. The test was something like $40, and I have no way of knowing whether that was a good price (they didn’t accept my insurance), but I think the point is that there ought to be classes of routinized services that insurance doesn’t cover. If insurance only has to cover emergencies and serious, unforeseen health crises, and routine services are paid for up front, insurance will drop precipitously in price. The more that individuals can see the prices for various medical services transparently, the more those services will invariably feel the pressure of the market to become efficiently produced and affordably offered.

Now, Minute Clinics aren’t necessarily the best model, though I think they are a good one. My preference is to move medical issues out of the medical centers and into individual private practices with an M.D. and several nurses—or even a mere nurse practitioner. Dentists’ offices are a good model, here, though so too in a sense are law firms, where the reputation is more than a single doctor but less than UCLA Medical Center, or Cedars-Sinani, which are so huge that reputations are aggregates of data points that may or may not relate to your precise need. If we left non-emergency care to these smaller practices, patients could call around for price quotes as they do to contractors for retiling their shower or plumbers to replace their hot water heater—or lawyers to draw up their estate planning documents. Reputations would be far more relevant than in the haze of the huge medical center, and prices would reflect quality of care. In this sense, I think Republicans’ hand-wringing about buying insurance across state lines misses the point: we should be transitioning out of insurance as much as possible, giving back the inflated cost of that insurance in real money to individuals, so that no longer will we be fighting with a customer service representative about why or why not our plan ought to cover Thing X, but rather will be able to go out and buy it for ourselves. Insurance is fundamentally limiting. Buying goods and services at market cost is fundamentally freeing. Purchasing insurance does not magically make a dental exam or flu shot cost less—it merely hides the cost in a monthly recurring bill or in wages that you do not see. Except where absolutely necessary—in unforeseen emergency or hugely expensive chronic situations—I think healthcare reform should be all about removing insurance to the extent possible.

The role of government seems to me to be at most threefold. Britain’s NHS has been consistently ranked among the best ways to get medical treatment in the world, and although Canada’s scheme is less lauded, the results would not appear to condemn socialized healthcare absolutely. For our purposes, however, I will assume that socialized care will not extend past Medicare, Medicaid, and the VA. Despite this, the Government might well find that providing emergency insurance coverage (Medicare+? Medicare Part E For Everyone? I’m not a branding expert) and insurance coverage for long-term conditions like cancer and Alzheimer’s could work, leaving the vast majority of medical expenses to the free-market model described above. If society concludes (as Obamacare has done clumsily, with an employer-based framework) that some basic safety net for calamitous health crises is necessary, we could avoid the whole question of premiums and merely have a tax (probably on income) for catastrophic circumstances like heart attacks, strokes, and cancer.

The second thing to which the government may be best suited to is records keeping. Because records are things people ought to be able to access anywhere, at any medical office they enter, they might be attached to Social Security or Draft Card information and maintained centrally. I am certainly attracted to Apple and Google’s ideas about Silicon Valleying our way out of our current bureaucratic problems, but am inclined to think that no institution except one with a governmental like monopoly will be able to offer the kind of ubiquity and breadth necessary for supplying records everywhere and always. Fragmentation of differing systems would appear to be significant, though if tech companies can overcome this to develop platform-agnostic methods, I would be absolutely delighted. (The only thing the US Government can do that I’m not sure Apple could is defeat Hitler. Apple would never have gone into Afghanistan. “It’s a shithole!” they would have said. “The Soviets got their snouts whacked!” they would have said. But no.)

The final thing I would grant the government is, as I put it in my introduction, the “wellspring of preventative care.” What does this mean? I have been scrupulously careful in my listing of chronic conditions not to mention metabolic syndrome, the cluster of diseases that tend to travel with obesity—type 2 diabetes, hypertension, lipid problems, alcoholic and non-alcoholic fatty liver disease, certain forms of cancer. These diseases, as Robert Lustig notes, constitute fully 75% of US healthcare dollars spent, and are therefore the eight hundred pound gorilla in the room. Metabolic syndrome, an almost entirely avoidable set of diseases, is caused by processed food in general and chronic consumption of more than 6-9 teaspoons per day of sugar in particular (we consume something on the order of three times that threshold). Only the government can tax this substance of abuse as it taxes alcohol, and decreasing its availability is the only realistic way of preventing its abuse. It must tax sugar as it taxes these other substances that cause expensive illness if it has any hope of (1) stemming the tide of chronic disease that continues to balloon or (2) paying for it. The damage caused by sugar is far in excess of the cost we pay for it at market. We pay the extraction cost, not the use cost. The cost of consuming sugar in the quantities we do—as with alcohol, as with tobacco, as with illicit drugs—is far in excess of the cost to bring them to market, and in these cases, it is the duty of any government with an interest in (a) the health of its people or (b) its own solvency to regulate and tax these substances such that their consumption falls to safe levels.

So there it is. Take insurance out of the hands of employers. Limit it to only expensive, urgent, or long-term conditions. Perhaps let the government organize this miniaturized version of insurance and/or health records. And above all, tax things that are killing us extremely aggressively. It’s not rocket science.