Imagine a country where a homeless person is guaranteed a free room in any five-star hotel -- where a shabby beggar can demand a free coat from the most expensive clothier -- a place where anyone without money can walk into a fine restaurant and order the most expensive item on the menu.  Sound like an impossible business model?  Try multiplying those costs by 45.8 million, and you have an accurate picture of the American medical system.

We tend to put medical care in a different category from housing, clothing and food -- although most medical care is often far less essential, and always costs far more.  America is often criticized as offering inadequate access to medical care, but emergency rooms and hospitals are clogged with uninsured patients getting Cadillac care -- for free.  Sad to say, many patients who don't pay for their service -- especially those patients with insurance -- treat it as though it was worthless by gluttonously consuming as much as possible.  This is made possible by a payment system that involves a triangle of provider, patient and insurer -- each passing costs around the loop in a way that defeats personal responsibility for expense.

In a recent article in the New Yorker, Dr. Atul Gawande pointed out disparities in health costs between the Texas towns of McAllen and El Paso, suggesting that ballooning health costs were caused by the irresponsible spending of physicians.  This unproven assumption has become one of the mantras of health care reform, with critics recommending that doctors should be paid salaries along the model of the Mayo Clinic.  It's true that most patient expenses must pass through the pen of the ordering physician, but changing reimbursement won't help contain costs if the real problem is the greedy medical expectations of an American public that is already consuming too much of everything else -- including soft drinks, french fries and gasoline.

A better solution is to make each patient personally responsible for their medical spending.  Dr. Sardonicus suggests issuing an income-adjusted supply of annual "Medi-credits," exchangeable for health-care services -- modeled after the food stamp program.   Extra credits could be issued for people who comply with public heath recommendations -- safe driving, cutting back on cigarettes and alcohol and getting plenty of exercise.  Parents could transfer credits to their children or relatives.  Once those credits are gone, patients unable to afford care would resort to federally funded clinics and public hospitals -- bare-bones services we have traditionally offered the homeless and destitute.

When patients realize they are spending their own money, we will see market forces shaping a new age of lower medical costs -- and a new golden era of personal responsibility.

PS - Oh yeah, and one other thing -- ban those annoying pharmaceutical ads!