Disappointed has more to say on the brave new world of consumer driven health plans:

It seems to me that with respect to this matter, as with many others, a more appropriate approach first takes into account sound economic theory and then limits the application of that economic theory to produce a greater social justice. That middle (or hybrid) ground could be that the health care policy should encourage deductibles and co-pays,but only to an extent commensurate with one’s income. For example, a person at the lower end of the income scale would be expected to contribute a lower amount (or percentage) of income to deductibles and co-pays than a person at the higher end. This approach would combine the best economic theory to contain costs with the commendable social value that everyone should have affordable access to healthcare.

Which sounds just grand and doubtless will help Disappointed and others sleep better at night

Disappointed is in good company in his fantasies. He shares them with Matthew Yglesias and Brad DeLong. Wonks Anonymous - in his role as bureaucrat - sees things differently.

Right now about 20% of the people who Wonks Anonymous' Accountable Care Organization treats are on these wonderful new High Deductible plans. Here's how it works.

Low income workers are more likely to have a deductible than well paid workers. Their deductibles are likely to be higher as well. Workers who have a higher value to their employers get higher pay and better benefits. A person at the lower end of the income scale is likely to pay moreout of pocket than a person at the upper end of the scale.

In Wonks Anonymous world this is mitigated to a certain extent by means tested aid. When poor person with a high deductible plan shows up at the doctor's office or the ED - usually sicker than they would have been if the plan had not discouraged wasteful check ups - they are treated without demand for prior payment. No one is refused service because of their inability to pay.

After treatment the patient talks to a financial counselor who tries to figure out a way to help them pay the bills, which may amount to over 20% of their annual income. Often this involves application for government aid. One of the larger items in the MedicAid budget is supplementary payments that cover cost shares for the working poor.

After that providers go on to try to figure out a payment plan for the balance of their bills which could amount to a small monthly payment for the next few years. After that providers write off the rest of the cost of their care as a bad debt if the provider is a for profit concern or as charity care if the provider is not for profit.

All of this costs real resources which are part of the overhead charges for health care providers.

For Wonks Anonymous organization unpaid care currently comes in at over $1 million dollars per year. He is sure that other care providers are in the same general world.

Economists have great imaginations and have almost never worked in administration. They live in a frictionless world where mere thought and will generate costless social changes that produce the intended results.

Welcome to the real world.