Hillary Clinton and John Edwards promise to deliver “universal coverage,” through some combination of government and private health insurance. Many on the left would prefer government coverage for everyone. Dennis Kucinich and New York Times columnist Paul Krugman advocate “Medicare for all,” and even Clinton proposes to open Medicare or a similar program to all comers.

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Among the dangers of universal coverage is that when the system fails, patients may find they no longer have freedom to spend their own money to get the medical care they need. This threat to patient autonomy exists right here at home in the U.S. Medicare program.

Most would agree that patients should always be free to spend their own money on the medical services they desire. Over the past 20 years, however, the Medicare bureaucracy — and to a lesser extent Congress itself — has limited the freedom of beneficiaries to purchase medical services with their own money.

Medicare beneficiaries have complete freedom to spend their money on medical services not covered under the Medicare program. However, the federal government effectively prohibits them from purchasing Medicare-covered services themselves.

The restrictions work by prohibiting physicians who engage in such arrangements from seeing any Medicare patients for two years. Since 97 percent of physicians participate in Medicare, and being cut off from Medicare patients would devastate a physician’s practice, that prohibition effectively precludes most Medicare beneficiaries from ever paying for covered services themselves.

At present, that prohibition seldom denies care to beneficiaries — but only because Medicare generally pays providers enough to guarantee their participation. As Medicare’s fiscal pressures mount, however, Congress will have to reduce payments, which will reduce beneficiaries’ access to care. When that occurs, the ban on private contracting will deny care to beneficiaries, because it will prevent them from going outside Medicare to purchase those services themselves.