To the Editor:

How do we encourage – or force – people to take responsibility for their own health? This is one of the pervasive, vexing questions our society faces as we struggle to achieve a balance between personal and societal responsibility for health.

Now arguments are appearing for the defined-contribution approach to health insurance [see “The Future of Health Care Financing,” January 2001, page 31] that would allegedly save money and provide strong incentives for a healthy lifestyle and appropriate utilization of health care. The dreamers who designed this program don't seem to have done their homework: Where's the evidence that individual control of health care resources leads to appropriate utilization without jeopardizing health? On one end of the scale, the more affluent will continue to get whatever they want and can afford (I seldom hear my colleagues complain about frivolous utilization of their services in exchange for cash on the counter). On the other end, there's ample documented evidence that when there are restraints on access to care, people tend to forgo or delay seeking help until treatment is more difficult and expensive.

Defined-contribution insurance or medical savings accounts would be a boon for the relatively affluent, educated, motivated and healthy segments of our population since the cost of their insurance and health care would be substantially lower. However, sicker, poorer and less educated individuals would be forced into a much more expensive risk pool, which would effectively deny them health care or make them a tax burden on society. The two-tiered health system would be further promoted.

Defined-contribution insurance and medical savings accounts are a ploy to re-institute fee-for-service health care. They're a giant step backward and must be resisted.