I once had a doctor – I no longer remember who – that shared with me a little joke about medicine that comes to mind every year as I get older and more susceptible to life’s little ailments.  Doctors, he said, don’t really cure anything.  They just let you trade in one malady in for another.

I know he was talking about the side effects of medicines and treatments we take for our weak hearts and faltering knees.  But I keep thinking that it applies equally well to the situation of health care financing as well.  Employers, governments, and individuals are being crushed by the mushrooming costs of health care goods and services, and most are not happy about it.   Yet the cures to these problems – if anything can be said to truly cure them – are things we won’t like either, at least at first.

Of course, to even get started on this discussion we need to agree on what the problem with health care financing is.  And that’s not easy.  Many people think that the problem is high costs, and the only way they know to solve it is to shift the cost for what they consume to someone else. 

There is a lot of that going on in health care.  Medicare cuts reimbursement rates and effectively shifts hospital costs to private payers.  Cash strapped Medicaid programs in states tighten eligibility and push more people out of the program, pushing costs to community hospitals that care for those who can’t pay.

But the problem isn’t really high costs, by themselves.  With our affluent, aging population, in an era of rapid advancement in medical science, it would be surprising if health care did not consume an ever larger proportion of our total spending.

It’s what we’re getting for that spending that is the problem.  The United States spends at least 50 percent more per capita on health care than other industrialized countries, yet on fundamental measures like average life expectancy and infant mortality we rank no better than average, and often worse.  We practice expensive medicine, largely because we are shielded from seeing the true costs, with little, if any, improvement in outcomes.

Enter the idea of “consumer-driven” health care.  It’s a very simple, appealing idea.  Put consumers in charge of decisions on what services and drugs they use, and they will force providers to be more responsive and efficient.  Leave insurance, the third-party payer, there to step in only for the catastrophic events that overwhelm our ability to pay.

But as everyone who has investigated the high-deductible/health savings account (HSA) insurance plans offered by many employers these days knows, there is a big catch.  The only way you, the consumer, can be said to be truly in charge of your health care spending is to spend your own money.  That means money out of your own pocket.

When you’re spending the money you’ve taken out of your paycheck and put into your HSA on things like physical therapy, pain medication, or even followup doctor’s office visits, you will ask the question – do I really need to do this?  For all of us who have never known anything but third-party payer systems, it is an utterly foreign concept.  We have lived our entire lives having someone else – usually a medical professional – tell us what we need.

And maybe we’d like to go on that way.  From the point of view of those of us with employer-provided health care, consumer-driven health care replaces one problem with another.  We now need a lot of information – on the price, the quality, and the effectiveness of care and treatment options – we didn’t need before.  And worst of all, we’ve actually got to spend our own money.  More of it, in fact, than we would have under our old plans, unless we ratchet down our use of routine drugs and services.

Those facts probably explain why those who have opted for HSA’s and high-deductible plans thus far tend to be younger, less obese, more likely to exercise, and generally less likely to consume health care.  Look for that to change in the near future, as cost differentials widen.