David Leonhardt of the NY Times is a great fan of evidence based medicine which is a system where doctors are guided by controlled studies of medical outcomes and supervised and advised by their peers. The theory here is that doctors' individual intuition, however well trained by years of education and practice, can be improved by science.

Wonks Anonymous works for a medical group that practically invented evidence based medicine. Wonks Anonymous shares his enthusiasm.

David Leonhardt is also a big fan of consumer driven health plans, that would be health plans where the consumer pays out of pocket for all medical care up to a deductible that is a substantial fraction - say 25% - of most families incomes. The theory here is that if you subject the average lay person to substantial financial risk whenever they get sick that person will make optimal, cost effective medical decisions despite their notable lack of medical training and experience.

David Leonhardt sees no contradiction between the two positions. Wonks Anonymous will attempt to illuminate the contradiction with a simple example. Which would be the disgraceful US record on premature births reported by Denise Grady in the NY Times.

It turns out that there are certain conditions - pregnancy induced diabetes and pregnancy induced high blood pressure - that have been shown to lead to premature births. It also turns out that these conditions can be managed with medical care and attention. These strategies turn out to be more effective and less costly that a premature birth and an extended stay in Neonatal Intensive Care.

Doctors and ordinary folks might think that the care required to manage these conditions qualifies as preventative care. Which care is usually covered free of charge in our consumer driven health plans.

We would be showing our ignorance of the subtleties of health insurance. Preventative care is for the healthy. Once you have a diagnosis you have to pay.

Which presents a serious problem for a doctor trying to practice evidence based medicine. She will know from evidence based medicine that a working class pregnant woman with one of these problems needs regular visits and coaching to have a successful and cost effective outcome. She will also have a hard time persuading this same woman to spend $75 to $150 per week for regular visits.

Maybe after the woman receives the first bill she stops showing up and goes out to find a curandera to fix the problem. Because the woman, with so much skin in the game, will do her best to save money and direct her own care. Who wouldn't?

In cases like this what often happens, if there is good communication between doctor and patient, is that the doctor provides the care that she thinks is needed for free because doctors have just not mastered the higher morality of the financial sector. But of course this means that the health insurer gets to collect premiums and pay nothing out.

And then there are the cases where there is not good communication.

Memo to David Leonhardt: If you think that Doctors are not able to make optimal health care decisions on their own, what makes you think that untrained consumers can or should?