From the New York Times on Sunday March 14, this article states the obvious; that avoiding change in the health care system is not an option and that payers will exercise some decision-making and control over what is paid for and permitted. An inherent challenge in any system where the payers are not the consumers is that usual marketplace controls are not present. When we pay ourselves, we generally exercise restraint. In health care it is the rare service that is paid for by the patient. The patient has no particular motivation to not consume, or to shop for price, and the providers have motivation to treat and sell services to the degree that they can be medically justified. An interesting thought experiment would be to imagine a patient seeking or being advised to obtain a given treatment, and then instead of being given the treatment, they are given the money that the treatment would cost at the place they were considering, and told that they have a choice of getting the treatment, keeping the money and foregoing the treatment, shopping for the treatment at a lower cost and keeping the difference, or changing the type and extent of the treatment (for example switching from a brand name to generic drug). Obviously the complex nature of diagnosis and treatment would make decision-making a challenge for many. Furthermore, irresponsible behavior combined with the perverse incentive of keeping the cash would mean that many would take the money and not vaccinate their kids, and generally be more resistant to preventive care where they are not currently suffering or in pain. Health reform proposals as best we can tell, are not meaningfully addressing the excess utilization trends that occur regularly.