The 2020 election season on the horizon, and one of the most important issues will be how candidates define the future of healthcare. On one side, we have the Republicans, who at all costs aim to repeal the Affordable Care Act (ACA) with no explicit plan on how to replace it. The Republicans fail to acknowledge that the unregulated and uncontrolled healthcare system that existed prior to the ACA was troubled by shameful access to affordable healthcare and that the cost to deliver sub-optimal care was rising at a rate that threatened our economy. Although the ACA has not stopped healthcare from becoming more expensive, it has undoubtedly slowed the rate at which those costs are rising.

On the other hand, we have the Democrats, who are mostly pushing universal healthcare or what many call “Medicare-for-all,” which moves beyond the ACA towards a national health plan. While this may be the direction that as a nation we need to take,, the Democrats need to do a better job of selling it. Individuals must realize that a universal healthcare system is not free healthcare. Republicans and opponents of a universal healthcare system often argue that the government is inefficient and wasteful when managing funds for social services. Moreover, they promote letting free market economics govern healthcare as if unrestricted capitalism is the only answer to any problem. The fault in this reasoning is that, unlike other markets, patients often do not get to make decisions about the healthcare they ultimately receive. Nothing illustrates this better than a basic emergency department (ED) visit. The interventions and diagnostic testing are rarely, if ever, within the patient’s control and often the tests selected are for the benefit the ED physician (eg, defensive medicine) or the facility (ie, profit driven).

Patients cannot shop around for a better deal, and they are almost never presented with the cost of care prior to receiving it. Rather, patients find out after the fact, when they get the bill.

So, imagine that your air conditioner (AC) stops working and no one is willing to give you an estimate to repair it. In fact, the AC repairman does whatever he feels is appropriate, at whatever cost, and you get stuck with the bill. No one in their right mind would say that this is free and fair competition; that is not free market capitalism. Yet, that’s exactly what opponents of universal healthcare are arguing in favor of.

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National Public Radio (NPR)’s Terry Gross interviewed Sarah Kliff, senior health policy correspondent on Vox.com, about the unexpected costs that arise from an ED visit.1 Ms. Cliff has looked at ED bills from thousands of patients and found some astonishing practices. For example, some individuals were being charged $76 for bacitracin ointment, which costs $4.99 at CVS. In other cases individuals were charged $5000 for an ice pack, and $629 for a Band-Aid®. In each of these situations, an individual presented to an ED for fairly straightforward care that was provided at an astronomical cost. Probably one of the most eye-opening discussions was that of the $629 Band-Aid. In this example, a young girl was taken to the ED by her parents for a minor finger injury requiring only a simple Band-Aid, which typically costs 20 cents. The parents got a bill for $629. Of the $629, $7 went towards the Band-Aid, which is in and of itself a 3500% markup. The remaining $622 went towards the hospital’s “facility fees.”

This article originally appeared on Medical Bag