For a real world view of consumer-directed health care, we can turn to the recent report by the Kaiser Family Foundation which indicates "Twenty-seven percent of women under age 65 delayed or went without needed medical care in the last year because they did not think they could afford it". And these weren't just the uninsured. In fact, "17% of women with private insurance delayed or went without care because of cost concerns."

While I don't mean to sound like a strident opponent of consumer education or deny the importance of involving individuals in the economic consequences of their health behaviors, it does strike me that when one out of six insured women delay care or skip it entirely due to cost we have a pretty good sense of the real effect of so-called "consumer-directed" health care - economic rationing.

It will be interesting to see if other studies of actual plans that are based on these ideas have different outcomes.