to what most Americans believe, access to health care is not a right, but a good whose value should be determined by the free market. In his view, government has no business in the delivery of health care. When government becomes involved, he says, costs rise and quality of care falls. Paul calls for the eventual elimination of Medicare (federally funded health care for the elderly and disabled) and Medicaid (health care for the poor, jointly funded by the federal and state governments), and he has been a staunch opponent of the Affordable Care Act health insurance reform law that was enacted in 2010. He says that federally funded healthcare is "unconstitutional" and that the costs of the programs are unsustainable and are bankrupting the government. Paul says that when he entered medical practice in the early 1960s, before the Medicare and Medicaid programs were established, the poor and the elderly were hospitalized at about the same rates as they have been under Medicare and Medicaid in the 2000s, and that they received good care. He says further that in those days, doctors and hospitals provided cut-rate or free care to people who did not have health insurance – "every physician understood that he or she had a responsibility toward the less fortunate, and free medical care for the poor was the norm" – and that this was possible because healthcare costs were much lower. At a church charity hospital where he worked in his early years of practice, "nobody was turned away" for lack of ability to pay. Paul claims that government meddling in health care delivery is to blame for healthcare costs having skyrocketed over the past few decades. He recalls that in the early 1960s, patients typically paid for basic medical services with cash, as there was almost no government payment for care, and as those Americans who had private insurance were typically only covered for hospitalization and emergency care. In that setting, he says, providers almost always charged minimal fees for services in order to improve the chance of being paid. He argues that the emergence of government as a payer for healthcare services in the form of Medicare and Medicaid, along with government policies of the 1970s that led to the expansion of private insurance to cover routine medical services in addition to hospitalization and emergency care, and which required most employers to provide health