David Brooks is concerned about the future of the Republic which is threatened by out of control health care costs and new entitlements. Only a noble few, the Senate moderates and the health insurance companies, stand ready to defend it.

And he and his friends have good reason to be concerned. Health insurance used to be a wonderful business. People fear sickness, people fear helplessness, sickness combined with poverty gives us the worst of all possible worlds. In the 1930's health insurers discovered that people would pay large amounts of money for the feeling that they were secure from poverty even is they could not avoid illness.

Which was just grand, particularly when even the most extreme treatments were relatively inexpensive and sick people tended to die more quickly, thus reducing the surplus population. What with modern technology, an aging population and rising expectations, things have gotten out of hand. We don't like to talk about this but people get sick, they expect treatment and they live for a long time, spending valuable resources on medical care. It is the Rhino in the room.

Indeed the recent years have been bad for health costs and for insurance companies. Valid methods of cost control - for example subjecting medical decisions to review by highly qualified accountants and statisticians - have been rejected by an ungrateful public.

At the same time discontent over normal profits and administrative expenses - how could we think that 15% even 20% of total premiums was unreasonable - has risen and calls for regulation have increased.

But not to worry Davis Brooks and his friends in the insurance industry have a solution which will save us and restore normal business conditions:

Besides, you’ve got a bunch of big, evil rhinos stomping around! You want more than some promising ideas to pinpoint waste, fraud and abuse. You want some big heavy hammers to clock those suckers in the head.

Now that the first wave of legislation is bogging down, you want to take the seeds of cost control and you want to do more. You want to eliminate or cap the tax exemption on employee health benefits. This is a big way to crush one of the core drivers of health care inflation. You’re willing to give MedPAC-style technocrats a chance to take control of Medicare spending away from Congressional spendthrifts.

You want to loosen federal regulations so that states have more room to experiment — not tighten them, as the current legislation does, so that states have less. You want reforms throughout the system that will cut down on first-dollar reimbursement in exchange for catastrophic protection. You want to tie Medicare subsidies to income. You want to look at anything that will move us away from a fee-for-service model, the core perversion in the system.

Because the problem is those sick people. They take advantage of tax breaks to bargain with their employers for comprehensive coverage. Then they get sick and use that coverage to go to doctors and buy medications without even once considering the costs that they impose on their insurers and society. This is abetted by regulations that restrict insurers ability to experiment.

And this is all happening now, just as insurers have come up with a sure fire solution for all our problems. We can all get cheap health insurance right now and this health insurance will offer sufficient profits to support a strong health insurance sector.

All we need to do is accept the idea that, after we pay our premiums, we will need to pay $5,000 to $10,000 additional for medical care before insurance kicks in.

Which will surely give the large number of us who are healthy ample incentives to avoid doctors and hospitals until we develop some serious health problems. But as Wonks Anonymous has pointed out earlier, this still does not cover the medical costs of the sickest 20% of the population who account for over 90% of medical costs.

Well, Wonks Anonymous was wrong, as the prophet of high cost sharing, Jason Furman points out:

Much of the expenditure of this high-spending 20 percent may still be subject to cost sharing. The typical high-deductible health plan includes cost sharing up to about $7,000 of total health-care expenditures for individuals and $14,000 for families. In total, 86 percent of non elderly households, representing 41 percent of total expenditures, fell under these limits and thus were subjected to cost sharing throughout the year. Moreover, even for people who eventually go above the limit, cost sharing might affect their initial spending, potentially affecting as much as the 61 percent of total health spending falling in the cost-sharing range.

Meaning that health insurers could charge us for insurance while paying for less than half of total health spending. Which would reduce the price of insurance and dramatically lower the amount of subsidies that any scheme for universal coverage would require. The healthy and the government would both be relived of the burden of paying for sick people.

Of course there is still the problem of those elderly households who account for a great many sick people and a great deal of medical expenditure. But Brooks sees a way around this. If we apply means testing to Medicare then the elderly who are not in poverty will need to buy private insurance. The savings produced by high cost shares will extend to even more of the population.

And ultimately we might just do away with Medicare and offer subsidies for the purchase of private insurance. Everyone would get the character building advantages of high cost shares.

In this situation it might be expected that some unhealthy people would avoid care and worsen their conditions. Many of these might present themselves at Emergency Departments for expensive, life saving treatments.

But this would not be an expense borne by the government or the insurance companies or the healthy. Patients would still be obligated to pay for care up to their deductible or cost share and if this rendered them bankrupt doctors and hospitals could be relied to take on the expense out of the goodness of their hearts.

We need to act before sick people destroy our way of life. We need to recognize that using resources for their care only enables their sick way of life. We need to make them, and the medical profession that helps them to continue their lifestyles, pay!