In his State of the Union address last week, President Bush blessed the latest thing in American health policy: “consumer directed health care,” also widely and inaccurately known by the acronym HSAs, which stands for “health savings accounts.”1 The idea is to “empower” “consumers” (formerly “patients”) to function as agents of both quality control and cost control in health care, through two instruments.

Americans would be enticed into private health insurance with very high annual “deductibles”—out of pocket payments before insurance kicks in, from $2100 to $10 000 or more per family. In the words of Alan B Hubbard, director of the White House National Economic Council, the idea is to provide “people an opportunity… to have more skin in the game.”2 And Americans would be empowered with user friendly information on the cost and quality of the health services offered by individual doctors and hospitals—an ambitious vision that, so far, remains largely on the drawing board.

Not ever …