THE HARDEST PART OF PARTISAN POLITICS IS ACCEPTING THAT YOU WON:

The conservative thesis holds that the demand for health care is unlimited because it has been, historically, a free good for many patients. Moreover, the argument runs, much illness is driven by bad personal health choices -- for example, smoking and obesity, and the heart disease and diabetes that follows. Thus, much of our cost problem is actually the patient's fault.

Since patients have historically paid a relatively small fraction of health costs, the conservative remedy is that patients must have more "skin in the game," that is, pay more of the cost themselves. If we do this, people will exercise more discipline in their personal health habits, and also "shop" for care when they need to use it, and costs will go down.

Adherents to this explanation point to Joseph Newhouse's nearly forty-year-old RAND health insurance study which showed that patients who shared some of the cost used a lot less care and were, apparently, no sicker at the end of the study period. The oft-ignored coda to the Rand study was that patients were incapable to distinguishing high-value from no-value care, a finding echoed just last week by a study of patient behavior in a high-deductible health plan.

This thesis--that lifestyle and indiscriminate use of care are the main drivers of heath spending--has led to multiple remedies: health savings accounts; higher cost sharing; higher patient front-end cash payments to doctors and hospitals; and also "price transparency" -- attempting to clarify in advance of care what something will cost, so patients can use their own money to shop for care.

The conservative narrative had an influential role in shaping the structure of private coverage under the Affordable Care Act, where very high deductibles and annual out-of-pocket limits are the norm, as well as the Cadillac Tax on so-called "high value" health plans, designed to discourage first dollar coverage. It has led to a quintupling of patients with high deductible plans since 2007. According to the 2015 Kaiser Family Foundation Health Benefits Survey, patient cost sharing has grown six times as fast as wages since 2010.

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