Hsieh Forbes OpEd: Who Should Control Your Healthcare Spending?

The Forbes website has published my latest OpEd, "Just Who Should Control Your Healthcare Spending?" (5/15/2012)

The theme is that America needs market-based health reforms such as Health Savings Accounts which reduce costs while preserving quality medical care, not government-mandated "bundled payments" which will harm patients and literally set a price on human life.

Here is the opening:

What simple health care reform has reduced medical costs by up to 30%, while preserving quality of care? Hint: It's not government price controls or mandatory health insurance. Rather, it's letting patients decide how to spend their own health care dollars...

(Read the full text of "Just Who Should Control Your Healthcare Spending?")

I'm honored to appear on the Forbes website, and I'd like to thank readers who have shared this piece via Facebook, Twitter, blogging, e-mail, etc.

Heib: ObamaCare and the Road to Serfdom

Dr. Lee Heib of AAPS chats with John Stossel on "ObamaCare and the Road to Serfdom":

Quick Links: Atlas, Herzlinger, Fisher & Gross

Dr. Scott Atlas explains how, "Obamacare imperils America's women" by depriving them of choice.

Harvard health economist Regina Herzlinger, "Predicts ACOs, PCMHs Will Fail".

On the positive side, Dr. Kenneth Fisher and Dr. Lee Gross of D4PC explain the benefits of Health Savings Accounts and patient control of their own health spending in, "Prudence of a patient-centered approach" (Washington Times, 5/3/2012.)

(Note: Eventually, HSA's should be fully privatized without taxpayer support.  Any public funding should be only a transitional step towards a fully private system.)

Roy: How Obamacare Will Make Health Savings Accounts More Costly

In his 4/27/2012 Forbes blog post, Avik Roy explains, "How Obamacare Will Make Health Savings Accounts More Costly".

It hinges on how the Obama administration defines "actuarial value".

Given the nature of HSA's (which are designed to allow consumers to pay larger amounts than in conventional insurance premiums in exchange for greater control over how that money is spent), this will make HSA's "actuarial value" look artificially low via these government yardsticks.

Read the whole piece for more details, including why this moves us in the wrong direction away from free-market reforms.

Quick Links: HSAs, IPAB, Propaganda

Americans for Tax Reform note, "HSAs Increasingly Popular Despite Attacks from Obamacare".

In the 6/20/2011 Washington Times, Dr. Daniel Palmisano notes that the IPAB rationing board is becoming increasingly unpopular with both Democrats and Republicans in Congress. Read his OpEd, "Nailing Obamacare's rationing board".

The 6/20/2011 LA Times reports that our tax dollars will be used to fund another round of pro-ObamaCare commericials. (Via David Catron.)

Armstrong On Third Party Insurance

Ari Armstrong reviewed the film The Business of Being Born recently on his blog. Here's an interesting observation he made about our current mixed system:

...Another thing that struck me about the movie is how much it reinforced my existing political views about modern American medicine and health insurance. One person interviewed for the film claimed that often a C-section surgery is a legal strategy. The idea is that, if a doctor performs a C-section, he or she has made every possible medical intervention, and so cannot be sued. So the problems with American torts certainly show in this area.

I have long argued that third-party insurance payments -- entrenched by decades of federal tax policy and controls -- subvert individual responsibility. One women in the film said, "People in our culture spend more time and effort researching to buy a stereo system, a car, probably a camera, than they do checking out what their choices are for birth." In our third-party system of prepaid health care, most people have no incentive to seek out good value for their health dollars. Moreover, most people get the health care their employer's insurance company tells them to get, rather than the health care that would best serve their needs.

My wife and I, on the other hand, buy low-cost, high-deductible health insurance and pay for routine and expected care through our Health Savings Account. We're going to pay for our delivery by writing a check or running the debit card. We know what care we're getting and how much it costs. It is only if something goes terribly wrong, resulting in higher bills, that our insurance would kick in. ...

(Read the full text of his blog post.)

Unfortunately, those earlier government controls have led to yet further controls, which will further worsen the quality and availability of good medical care. How long will the downward spiral continue? The choice is ours.

Armstrong: Keep Pushing for HSAs

Ari Armstrong explains why Americans who value quality medical care should, "Keep Pushing For Health Savings Accounts".

Here is the opening:

Despite enactment of the Democratic health law, one reform Republicans and market advocates should fight to keep alive is the Health Savings Account (HSA), which allows people to put pre-tax money into an account dedicated to health-related expenses.

Experiences my wife and I have had this week illustrate the power of paying for one's own health care, which an HSA encourages. Rather than pay a hundred plus dollars each to a doctor and an out-of-state testing facility, we each paid King Soopers $20 to test our blood cholesterol. I'm not saying this is a good substitute for seeing a doctor, but we wanted to get a test between regular doctor visits. Our actions illustrate the fallacy of claims that self-payers don't get preventive treatment. We are highly committed to doing what we can to prevent long-term health problems by taking care of ourselves and paying for preventive care.

(Read the rest of "Keep Pushing For Health Savings Accounts".)

Quick Links: Ross, Catron, HSAs

Doug Ross describes "DemCare: a tidal wave of regulations, taxes, fees, bureaucracies, waiting lines, bankruptcies and seniors denied medical care are on the way". (Via Dr. Milton Wolf.)

David Catron reports, "Sebelius to Insurers: Forget the Law, I Make The Rules Now".

IBD hopes that maybe HSAs will still survive ObamaCare.

Quick Links: Protests, HSAs

On March 16, 2010, Tea Party activists from across the country will converge on Washington, DC to rally against ObamaCare.

Dr. Evan Madianos explains, "How to Protest ObamaCare Nationwide in Front of Your Local Hospital".

Jared Rhoads of the Lucidicus Project urges all Americans concerned about their future health care to, "Hold A Sign and Speak Out".

Ron Bachman of the NCPA warns that the proposed ObamaCare legislation could severely limit (or effectively kill) Health Savings Accounts. Read more in his March 5, 2010 paper, "Congress Declares War on HSAs".

Quick Links: Colorado and Indiana

Linda Gorman of the Independence Institute has two new commentaries on Colorado health legislation:

"Bill Summary: HB10-1330, the All-Payer Database: A Transparency Trojan Horse"

Gorman warns that this bill would, "give the Executive Director of Health Care Policy and Financing the power to create a database to collect and store unlimited information on everyone who provides or receives health care in Colorado whether or not the state pays for that health care and whether or not the transaction is a private one."

"Colorado House Bill 1008: Women Pay, But Not Because of Unfair Discrimination"

Gorman notes, "Some people in the Colorado legislature think that everyone should pay the same price for individual health insurance regardless of age, personal habits, or gender. They believe this even though women as a group use more health care than men. They cling tight to the belief that charging someone a lower price for health insurance simply because he uses less health care is, in the language of the bill, 'unfairly discriminatory and shall not be allowed.'"

Ironically she observes, "The Colorado legislature actually helps ensure that women's health insurance premiums cost more."

On a positive note, Indiana governor Mitch Daniels praises health savings accounts in his March 1, 2010 Wall Street Journal essay, "Hoosiers and Health Savings Accounts".

Daniels writes:

Are HSA participants denying themselves needed care in order to save money? The answer, as far as the state of Indiana and Mercer Consulting can find, is no. There is no evidence HSA members are more likely to defer needed care or common-sense preventive measures such as routine physicals or mammograms.

It turns out that, when someone is spending his own money alone for routine expenses, he is far more likely to ask the questions he would ask if purchasing any other good or service: "Is there a generic version of that drug?" "Didn't I take that same test just recently?" "Where can I get the colonoscopy at the best price?"

To the extent that the free market is allowed to operate, patient receive quality care for lower prices. Surprise, surprise!

(Links via PatientPower and JG.)

Will ObamaCare Kill The HSA?

Brian Schwartz at PatientPowerNow.org alerts us to this recent analysis on whether ObamaCare will kill the HSA (Health Savings Account).

From Roy Ramthun's piece, "Status of HSAs and Consumer-Driven Health Care in Health Reform":

...[T]he changes proposed to all health insurance policies could have potentially adverse affects on high deductible health plans (HDHPs) that currently make people eligible to contribute to HSAs. Some of the impact may not be known until regulations implementing the final provisions are written.

...Another new requirement for all insurance policies is that they provide a minimum actuarial value for the benefits covered.

Under the House bill, the minimum actuarial value must be at least 70 percent. Under the Senate bill, the minimum actuarial value must be at least 60 percent. Given the higher deductibles that most HDHPs have (compared to traditional HMO and PPO plans), the lower minimum actuarial value requirement in the Senate bill would make it easier for more HDHPs to meet the standard.

...It is also not clear whether a plan's actuarial value would include employer or individual contributions made to the individual's HSA.

The House bill is completely silent on this matter which would leave it up to the Secretary of HHS to define in regulations. The Senate bill requires the Secretary of HHS to issue regulations on this matter.

Including the contributions in the calculation of a plans actuarial value would make it easier for more HDHPs to meet the minimum actuarial value requirement. If contributions are not included, HDHPs, many of which have actuarial values below 60 percent (or whatever the final standard becomes) based on the insurance coverage alone, could no longer be sold.

(I highly recommend reading the full text of "Status of HSAs and Consumer-Driven Health Care in Health Reform" for additional details of the proposed new regulations.)

In essence, the Secretary of Health will have the discretion to determine whether you are allowed to use a Health Savings Account to take care of your insurance needs. Instead of a "rule of law", we'll have "rule by men" with enormous latitude to decide whether you can spend your own money as you see fit to protect your own life and health.

Given the increasing popularity of HSA's, these new laws could affect millions of Americans

This is just an application of the basic principle that we've already seen in Massachusetts. When government makes health insurance mandatory, the government must also necessarily determine what constitutes an "acceptable" policy. This means depriving individuals of the ability to choose plans (such as HSA's) that they might consider in their best interest. Instead, government will force Americans to spend their money as the government sees fit.

The End Of HSAs?

The November 23, 2009 Wall Street Journal warns that the Senate health care bill could destroy Health Savings Accounts for many Americans.

Here are some excerpts:

Liberals claim people who choose these options aren't helping as much to finance a common pool and may encourage adverse selection if too many young or healthy people opt out. While all insurance involves some degree of risk-sharing, Democrats want to impose true social insurance a la Europe by obliterating the flexibility of insurers to design products that are tailored to suit different individual needs.

In other words, the government wants to prevent you from spending your own money for your own health based on your judgment, on the grounds that you are failing to live up to your obligation to pay for everyone else's health care.

The Wall Street Journal also notes:

...David Goldhill, a media executive, recently wrote in the Atlantic Monthly that if a 22-year-old starts at his company today earning $30,000 and health costs grow at 3%, by the time he retires he'll have paid out $1.77 million in premiums, lower wages, out-of-pocket costs and both sides of the Medicare payroll tax.

If all that money were instead available via an HSA, including by borrowing against future contributions, "wouldn't you be able to afford your own care?" Mr. Goldhill asks. "And wouldn't you consume health care differently if you and your family didn't have to spend that money only on care?"

This is precisely the future liberals fear because it would make health care less susceptible to political control. The Reid bill makes it impossible for people to choose better reform alternatives, the ones that can only be discovered through innovation and competition in a dynamic marketplace.

The politicians don't want you to control your own money. Instead, they want to do your spending (and your thinking) for you.

Will we let them?

(Read the full text of "The End of HSAs". Article link via Brian Schwartz.)

How To Protect Yourself Against ObamaCare

Dr. Steve Knope gives some good advice on how patients can partially protect themselves from ObamaCare and the inevitable rationing. Here's an excerpt:

My advice: Maintain your private medical care if at all possible. If you are relatively healthy, look into a high-deductible health insurance plan linked to a Health Savings Account (HSA). Start putting money away in that HSA for a rainy day. Find a "concierge physician" or doctor with whom you can establish a direct financial relationship; someone who will act as your medical advocate in a system that is broken and will only get worse. You get what you pay for and medicine today is no different.

All indications are that there will be attempts to ram a national healthcare program through Congress early in the Obama administration. They will create a false sense of urgency, just as they did with the "financial bailout" of our economy. No time to study the issue; this must be done or the society will collapse! Tom Daschle has studied Hillary Clinton's failed national healthcare attempt and he does not want to make the same mistakes she made. He was just quoted in the WSJ as saying that the new Congress needs to act quickly. "We need to be on the offense. This time around, lawmakers cannot try to address every detail when it comes to legislation. Details kill." [Secretary-nominee of Health and Human Services Tom]Daschle said.

"Details kill?" "Lawmakers cannot try to address every detail?" We are just going to guarantee medical coverage for every American on the backs of the American taxpayer and we don't have time to discuss the details of how it will work or how it will be paid for? Every good lawyer I've ever retained has reminded me that the devil is in the details! It looks like we are in for a devil-of-a-new program.

Read the whole thing.

Of course the best way to protect yourself from the dangers of government-run universal health care is to stop it in the first place. So let your friends, family members, co-workers, and elected officials know that you don't want it! After all, it's your life that's at stake...

Business Week on HSAs

The October 13, 2008 Business Week has a detailed discussion of Health Savings Accounts (HSAs), covering the pros and cons for individuals.

The positives far outweigh the negatives for the responsible consumer. And as more patients adopt these sorts of plans (thus achieving a critical market share), I anticipate that the hassles HSA clients experience with insurance companies and providers' offices will start to decline.

(Via Gary Takahashi.)

United HealthCare Analysis of HSAs

United HealthCare is completed a year-long analysis of Health Savings Accounts (HSAs) and drawn some interesting positive conclusions. In particular, they note the following:

"Health Savings Accounts: A year-long look at adoption, usage and funding patterns"

* HSAs have application across income groups, consumer life stages and varied employer environments.

* To encourage participation and make plans as useful as possible, employers should consider making contributions to the accounts. Even in their early years, HSAs show evidence of flexing to the specific needs of savers versus spenders.

* Positive balances at year-end are an encouraging indicator of HSAs ability to help make health care more affordable.

As one would expect, giving patient control over their medical spending decisions works!

Scandlen Defends HSAs

Greg Scandlen of Consumers for Health Care Choices set the record straight on Health Savings Accounts (HSA's) in his recent May 14, 2008 testimony to the Health Subcommittee of the Ways and Means Committee of the US House of Representatives. Given that this is the very committee trying to destroy HSA's for honest Americans, his remarks are especially timely. Here's an excerpt from his testimony:

...Most of what you have been told in the testimony to date is either mistaken, based on suppositions or surveys of uninformed people, or simply irrelevant to CDHC (Consumer Driven Health Care). For example –

* You were told that lower-income people cannot afford the out-of-pocket responsibility that comes with an HSA. You were not told how those same people could afford the higher premiums that are required to avoid that cost. In fact, money that is paid to an insurance company for first-dollar coverage is money that is lost forever. Lowering the premium and using that saving to pay directly for services gives the low-income consumer a chance to save money that would otherwise be lost.

* You were told that the tax break associated with HSAs is unprecedented and a boon to the "wealthy." In fact, the tax treatment of HSAs is precisely the same tax treatment afforded to employer-sponsored health insurance. Premiums are untaxed and benefits are untaxed. It is true that the "wealthy" get a larger tax benefits than the unwealthy, but that is the case for employer-sponsored comprehensive coverage as well as for HSAs. Further, the opportunity to save, say, $2,000 a year that would otherwise go to an insurance company is of far greater benefit to the low-income worker who earns $20,000 a year than to the wealthy executive who makes $200,000, regardless of the tax treatment.

* You were told that "the sick" do not benefit from HSAs because of the higher out-of-pocket responsibility. In fact, both the healthy and the sick have less out-of-pocket exposure with an HSA, a point that was well documented in a recent Health Affairs article. In fact, HSAs limit a patient's out-of-pocket exposure, something that is not true for the Medicare program, for instance.

* You were told that most health care spending takes place above the deductible associated with an HSA, so they will not have "a significant effect on overall spending." This is probably true, but irrelevant. HSAs are having a profound effect on lower-cost routine spending and that is significant by itself. Other strategies are needed for high-cost services with or without an HSA.

* You were told that many people with a high-deductible health plan do not open up an HSA. That, too, is true but irrelevant. The HSA itself is attractive for those people who are able to get a tax benefit from passing their direct payments through the account. Other people, especially those who pay no income taxes, may find it more suitable to simply pay cash at the time of services or to keep their funds in some other, non-HSA, account. Further, there is likely to be a lag time between the point of enrollment and opening up that account. This is not a problem.

* You were told that some people who have to pay directly for care or for prescription drugs may fail to do so to save the money. That also may sometimes be true. But there is never any guarantee that people will always fill their prescriptions and take their medications regardless of the financing scheme. In fact, we know that many health conditions are caused or aggravated by patient behavior under all health insurance systems. But, to the extent that people with CDHC are more knowledgeable and more invested in their own care, their compliance will be better than it is for other benefit programs. And that is precisely what we are seeing in the market.

Given that HSA's are becoming increasingly popular (with over 6 million Americans currently enrolled, an increase of 35% from last year), it's important that lawmakers understand the tremendous benefits they offer for Americans seeking the best value for the health care dollar.

Ralston LTE in Wall Street Journal

The April 25, 2008 Wall Street Journal printed several good LTE's supporting Health Savings Accounts, in response to their recent article warning about Congressional plans to regulate these plans to death ("Health Savings Sabotage"). The following LTE was by Richard Ralston, executive director of Americans for Free Choice in Medicine:

Don't Kill Health Savings Accounts With Regulation

Why would a group of politicians want to do anything possible to deny most Americans the means to provide themselves with affordable medical care? Why would those who maintain that most Americans cannot afford their own medical care insist that they can afford to first pay taxes on the money they use to pay for it? ("Health Savings Sabotage," Review & Outlook, April 19). The proposals you describe in the House Ways and Means Committee to require government bureaucratic review and approval of each individual expense funded by a Health Savings Account are a transparent attempt to destroy such accounts.

Perhaps what is really intolerable to these congressmen is the idea of Americans depending on their own choices and resources, rather than being forced to depend on politicians as their only source of medical care. That requires them to relentlessly oppose anything that makes health care affordable for most Americans as an obstacle to implementing politically-controlled medicine. Americans must decide if they want to control the medical care of their own bodies, or if medical and most other decisions of our daily lives must pass through the hands of those whose priority is maintaining a political spoils system.

Richard E. Ralston
Executive Director
Americans for Free Choice in Medicine
Newport Beach, CA

The Plot to Kill the HSA

The April 19, 2008 Wall Street Journal reports on moves by the current Congress to add more burdensome regulations onto Health Savings Accounts:

Health Savings Sabotage

...This week, the House passed legislation that included a provision to require every HSA transaction be reviewed and verified as a legitimate medical expense. Democrats say this is to ensure that consumers are using their tax-free withdrawals for a knee replacement, rather than a new iPod. In reality it adds a layer of bureaucracy that could sharply reduce the appeal and cost savings of HSAs.

But what is the real reason behind this new proposal?

...A key player here is Ways and Means Health Subcommittee Chairman Pete Stark, whose main purpose in politics is to give the U.S. a government-run health-care system. He is a known opponent of HSAs – once comparing them to "weapons of mass destruction" – because they introduce more individual choice into the health-care marketplace.

The WSJ correctly praises HSA's:

...This is health insurance many Americans can afford, and it doesn't force those who have better use for their scarce dollars to buy gold-plated insurance with special-interest mandates (cover the chiropractors!) that Democrats want to force on everyone. HSAs also give consumers more reason to care about prices, bringing much-needed market discipline.

Finally, it concludes that the proposed new rules are a dishonest way of trying to destroy HSA's:

...Having lost the policy argument when HSAs were created, Democrats are now trying to kill them with regulatory subterfuge. The new scheme purports to ensure that money saved tax-free in an HSA is actually used for health expenses. But this is a nonproblem: Any withdrawal from an HSA is already subject to a federal tax audit, just as individual tax returns are. In any case if people cheat on their HSAs, they are only cheating themselves. When a medical expense arises below the insurance deductible, they will be the ones paying for it, whether from their HSA or another bank account.

(Via Kevin MD.)

The Truth About Health Care Costs

The January 10, 2008 edition of Investor's Business Daily has the following excellent analysis of why health care costs so much in the US. The short answer -- government interference in the free market:

The Truth About Health Costs
By INVESTOR'S BUSINESS DAILY | Posted Thursday, January 10, 2008

Health Care Reform: Democrats claim high medical costs are a "failure of the free market," and they demand a government takeover. But a new study says government's to blame.

Public health programs account for almost half of the $2 trillion spent on U.S. health care, a Hoover Institution report says. An astonishing 80% or more of all medical-care pricing is based on government reimbursement rates set by Medicare.

As for private costs, they would be lower if government didn't interfere in the market. Regulations imposed on the industry cost more than $330 billion a year, Hoover says.

Perverse tax policies have created a third-party payer system. Patients no longer have first-dollar responsibility for medical bills thanks to employer insurance.

Someone else is paying, so inflation goes unchecked and unabated.

"Patients have no idea what their doctor visits, surgeries, diagnostic studies or other medical services — whether urgent or elective — will cost until the bill comes weeks later," said Dr. Scott W. Atlas, a senior Hoover fellow and chief of neuroradiology at Stanford University Medical School.

Even then, they seldom flyspeck the bill. Why bother, when they're responsible for just 10% to 20% of it?

Meanwhile, demand climbs higher and higher, and insurance premiums along with it, taking a bigger bite out of employer paychecks and putting health care completely out of reach for a growing number of Americans.

So if Uncle Sam made health care so unaffordable, why do so many voters like Democrats' plans to expand government control of health care? Because they've bought into the myth that the private sector has failed and begs for government rescue.

Democrats' solution to this failed government-heavy system is more government in the form of mandatory health coverage. Public plans offered by Hillary Clinton, John Edwards and Barack Obama all boast of "using government to lower costs and ensure affordability for all."

But if you think health care is expensive now, just wait until government makes it "free."

Hillary calls for expanding coverage through public health plans like Medicare or the Federal Employees Health Benefit Program. Yet Medicare already costs more per capita than any other industrial nation's public medical program.

The way to control costs isn't to expand a health care bureaucracy that already is divorcing patients from market-price decisions. The answer is letting them choose between health care and money.

Most of the Republican plans would help patients make that choice by expanding health savings accounts with high-deductible insurance plans. HSAs are tax-deferred accounts that patients set up to pay for routine medical care and to save for future unexpected medical expenses.

The key, however, is making the accounts attractive enough to shift incentives from the current employer-based system of insurance to the individual market.

Right now only about 17 million Americans buy their own health insurance. If 50 million did so through HSAs, we'd see at least a 30% reduction in medical costs, studies show, thanks to increased competition in the market.

By putting the patient back in charge of health care, making him a buyer as well as a user of care, a nationwide HSA rollout would create a large enough consumer-driven market to control costs.

Then the health care market would work more like a real market.

The medical costs Americans complain about were caused by government, not the private sector. This is a little recognized fact.

More government will not only ramp up costs, but deteriorate the one thing American patients seldom complain about — the quality of their health care.

As health economist David Catron so eloquently puts it:

The plight of the uninsured is a SYMPTOM. It is NOT the disease. If our attempts at health care reform do not recognize this fact, the real disease will continue to metastasize. What is the real disease? Perverse incentives caused by a series of government interventions in the health care market, not the least of which being misguided tax breaks for employer-provided insurance.

Avner on Health Savings Accounts

The January 9, 2008 Denver Post published the following opinion piece by Jackie Avner on personal responsibility and Health Savings Accounts:

Inventions of prudence
By Jackie Avner

To what degree are we, as individuals, personally responsible for the health care crisis?

Americans blame insurance and pharmaceutical companies, doctors and the government — and perhaps rightly so. But curiously missing from the list of culprits is us. Are we to blame for skyrocketing costs, as well?

Some Americans choose to buy things other than health insurance. Nearly 40 percent of the uninsured reside in households with earnings greater than $50,000. Their health care costs are spread among everyone else.

Most Americans choose to overeat. According to the World Health Organization, 74 percent of U.S. adults are overweight or obese. Obesity contributes to expensive, chronic conditions such as diabetes, hypertension and heart disease.

Americans over-consume pharmaceutical drugs, tests and procedures from the buffet of health care options, including those our doctors think will be marginally effective. Our reasoning is, "If it doesn't cost me anything extra, why not try it?"

We over-consume emergency room services. One extensive study showed 74 percent of patients who sign themselves into the ER have health issues that could be treated by a primary care doctor. Most ER visits occur during hours when less expensive alternatives for care are available. When surveyed, patients explain their preference for the ER by citing easy access to diagnostic testing, higher quality of care, access to specialists, and convenience. There's little incentive to take overall cost into consideration.

Annual U.S. health care expenditures are $5,711 per person, far greater than in any other country. But spending the most money doesn't give us the longest lifespan. We rank 38th in life expectancy. Cuba ranks 37th — and has a per capita health care expenditure of $229.

All of us should be more responsible. We should acknowledge that death, pain and illness are a part of life and can't be avoided through copious consumption of health care services. We should have a living will so we won't be subject to treatments we consider inappropriate. We should show a greater willingness to care for our elderly parents at home, rather than placing them in expensive assisted living or nursing care facilities.

But we're all spoiled, and pointing it out isn't likely to transform our "health care consumer" mind-frame into a "good citizen" mind-frame.

Don't fight human nature

Our own history may offer a solution. America's founding fathers designed the Constitution around an ingenious concept: Don't fight human nature; work with it. Harness our selfishness with "inventions of prudence" such as checks, balances, and wide dispersal of power, and make self-interest work for the public good. Why not apply the same principle to health care reform?

In 1993, Congress introduced Health Savings Accounts, which provide financial incentives for people to make responsible, cost-effective health care decisions. My family signed up for an HSA last year. We now have a health insurance policy with a high deductible, and use our HSA to pay for all medical expenses we incur before meeting that deductible. Our annual costs and health benefits are exactly the same as before. However, each year we get to keep whatever money we contributed to the HSA but didn't spend. These savings will grow, tax-deferred, for us to use in retirement.

I now shop for the best prices in dental and eye care. I buy generic drugs, and consider costs as well as benefits when choosing among treatment options presented by my doctors. My behavior is entirely different, and entirely more responsible as a result of a simple incentive from the government.

America's founding fathers would applaud the way the HSA plan can change individual attitudes and behavior without reducing individual liberty. Why can't the government offer similar financial incentives to Medicare and Medicaid patients, and to doctors and insurance companies?

Human nature may never change, but the right incentives can change human behavior for the better. That's health care reform.

Jackie Avner of Highlands Ranch (Jackie.Avner@gmail.com) worked in the U.S. Senate and is now a full-time mom. Her husband is a physician.

I liked her piece quite a bit. My only major comment is that I don't believe one has to justify encouraging rational self-interest in the name of fostering "the public good". Instead I would say that it is morally good for individuals seek their rational self-interest (which includes respecting the rights of others), and that this is justification enough, without having to also invoke any further collective good.