At The New Republic, Jonathan Cohn makes some points against the argument Senator Rand Paul made to me about Lasik, namely that because prices have gone down for Lasik surgeries (which aren’t covered by insurance generally), it shows that greater direct consumer responsibility for costs incurred in medicine would lead to lower costs. Cohn notes that Lasik isn’t necessary, isn’t a response to an emergency situation, and finally, its expense is primarily related to the machinery used, not to the doctor’s time.

Now, Lasik wasn’t the only kind of surgery Paul mentioned when arguing that if consumers paid directly for their medical costs (which seems to be Paul’s ideal; he talked about allowing people to put unlimited amounts of money into their Health Savings Accounts) those costs would go down. He also brought up Pterygium surgery, which corrects a condition caused by excessive exposure to sunlight that can be irritating and/or affect sight (although that appears to be a rare effect). He said he’d had cash-paying patients — such as Mennonites or immigrants, neither having insurance — come to see him about doing the surgery.

“It can be done in the hospital, but it’s pretty simple: It can be done in the office,” Paul told medical students at the University of Louisville last week. “I prefer to do it in the hospital because it’s easier and they got better equipment and stuff, but if somebody wants to save, I mean, my fee might be $200 or $300 to do it in the office, but the fee with the hospital might be $3,000.”

Now it’s not clear what the pros and cons were for doing it in the hospital versus Paul’s office, but his point was that when cost was a factor, he did give the patients more than one possible price point. Now if the cost to the patient would have been the same, thanks to insurance, either way, it’s unlikely the consumer would have ever opted to chose Paul’s office, regardless of how minimal the cons were. But if forced to pay that extra $2,700 directly, consumers might have decided that whatever the cons were for an office surgery, they didn’t outweigh the cons of spending an additional $2,700.

Cohn’s other point is that emergency care isn’t susceptible to price factors in the same way, and that seems true — if you’re in the middle of a heart attack, you’re not going to be asking for price points on what doctor is best. But it seems like there are a decent number of treatments (I’m thinking MRIs, check-ups for certain conditions), which are not optional and do need to be done in a set period of time, that could conceivably be done in more than one office/hospital if a patient decided to shop around for prices. It’s just with our current insurance system, there’s virtually no incentive to do that — to consider for instance, if Dr. A will charge less than Dr. B, or if the hospital 40 miles away charges less than the hospital ten miles away.

Cohn’s other argument is that while Paul can help some of the uninsured personally, he can’t help all or even close to all of them — yet he’s comfortable voting against policies that would give them government subsidies for insurance. Well, yes, sure, Paul isn’t going to be able to provide cataract surgery to everyone who needs it. But nor could Paul personally finance cataract surgery for everyone. Just as it’s going to require all American taxpayers to share the pain of subsidizing medical care for some, so it would require a significant chunk of the United States population to either do pro bono surgeries or voluntarily donate for others’ medical costs.

And we know that Americans are willing to help out their neigbhors with medical expenses: According to ThinkProgress (yes, that ThinkProgress), “Last year, ‘Medical, Illness & Healing’ was GoFundMe’s most popular category — and its users raised over $6 million dollars to help people cover their health costs in 2012 alone.” Sounds like not everyone needs the threat of a punishment from Uncle Sam to decide to help out his neighbor.