To get a clearer picture of the competing visions for health-care reform, Americans need look no further than the surgery some in Congress want to perform on patient choice.
The disagreement, in Washington as well as on the campaign trail, is about whether consumers ought to have more or less say in their own health care.
Some pre-op background: As part of the Medicare Modernization Act of 2003, Congress created health-savings accounts, or HSAs. The idea was to give patients an affordable alternative to the high insurance premiums of traditional "first-dollar" coverage.
The HSA option allowed consumers to choose a low-premium insurance option they could couple with a pre-tax savings account to cover "qualified" health costs.
Of course, no serious health-policy analyst believes HSAs are a panacea for all that ails America's health-care system. But the accounts were a welcome step in the direction of patient-centered health reform.
More than 6 million Americans are enrolled in HSA-eligible health plans. And the popularity of these plans is growing, in no small part because patients can determine how much of their money to spend today, or save for tomorrow, for health-care expenses. In short, HSAs allow patients to make prudent decisions for themselves.
Yet some in Congress see HSAs differently. These critics don't trust consumers to manage their own money. For them, patient-centered health care is either "too hot" or "too cold."
Here's how this Goldilocks Theory works: The critics first say account balances are too low to cover the higher deductibles carried by low-premium health plans. They object that patients aren't protected from catastrophic expenses, or might decide to forgo necessary care.
Yet these same critics proceed to argue HSA balances are too high because patients are saving too much. They say the money isn't going toward health care today, and the accounts are merely tax havens for the wealthy.
So are account balances too low or too high? And what amount is "just right?"
HSA detractors in Congress don't know these answers. But for some reason they seem to think politicians, insurance companies and policy nerds are better suited to call the shots on how you spend your money. This reasoning reflects an underlying assumption that patients can't be trusted to effectively control their own health-care decisions.
But the congressional critics know better than to put their cards on the table. So rather than attack HSAs directly, they create a diversion over account balances.
The House of Representatives has passed a measure requiring consumers to "substantiate" in advance that withdrawals from their HSAs are made for "qualified medical expenses." The Senate should recognize the folly of this approach.
Why subject patients to more burdensome government regulation that adds paperwork, drives up administrative expenses and makes the accounts less desirable?
HSA opponents contend patients are under no obligation to use withdrawals - their own money, remember - for health care. This is a distraction, not a real concern. At least 90 percent of account funds go toward qualified medical expenses, according to the Government Accountability Office.
And our friends at the Internal Revenue Service deem misuse of HSA funds to be illegal, meaning account holders are already subject to oversight. There's nothing illegal about a consumer spending money on "unqualified" expenses, either, so long as he pays taxes on that amount.
The real reason HSAs are under the knife of the critics? Some in Congress are at ideological odds with patient-centered health care. The dispute shows, yet again, they want to preserve the worst features of the status quo.
Fortunately, Americans have an alternative. It's a better vision of health reform - one that gives us more direct control over spending, allows us to pick the coverage we want and lets us carry that plan from job to job.
This approach requires Congress to fix a broken, unfair system by reforming the tax treatment of health insurance - not by second-guessing how patients spend their health-care dollars. In other words, a real solution requires the kind of hard work we expect our leaders to do.
Gregory D'Angelo is a policy analyst at the Heritage Foundation's Center for Health Policy Studies, where Ryan Lynch is a graduate fellow.
First appeared in Boston Herald