TJ: Supporters believe that when consumers have to spend their own money, they will think twice before running off to the doctor. And when they do, they will shop for the doctor who will offer the best price and quality, much the way they shop for a TV set. They also argue that the high deductibles will cause the price of care to come down because these policies will offer skimpier coverage and consumers will use fewer services which, of course, keeps premiums down.

TL: Has that happened?

TJ: Insurers say yes, but we really don’t know. There is evidence that people with HSAs from their employers are more likely to participate in exercise, stress management, and nutrition programs. They are also more likely to seek out health information and keep track of their health care expenses. They are healthier and use fewer medical services. Advocates of these plans believe that people in consumer-driven plans spend less money, and their employers save money. But an employer’s insurance premium may just be lower because employers are simply shifting costs to their workers. One study showed that, on the surface, these plans saved employers a lot of money. But when you look harder at the data, you see that the savings were largely attributable to healthier workers signing up for the consumer-driven plans, leaving the less healthy workers in more traditional plans.

TL: Can consumers really bargain with doctors for cheaper services?

TJ: It’s silly to believe that consumers bargaining with doctors and hospitals can bring down costs. It makes no sense. Even the insurers don’t believe that. It’s not going to happen. Consumers aren’t going to the hospital to drive a hard bargain. Medicare and insurance companies will always get a better deal.

TL: Is it reasonable to expect that consumers can bring down health care costs?

TJ: Relying on consumers to put the brakes on costs is problematic. The information is not there to allow them to do that, and if it were, consumers often would not be in a position to rationally process information. Successful cost control is much more likely to come from the government, or private payers saying that they are not going to pay for medical products and services that don’t work.

TL: Have consumer-driven policies hurt people’s health?

TJ: People in high deductible plans have a harder time getting care. They are more likely not to fill prescriptions or go to the doctor, and less likely to get the health care they need. A study by the RAND Corp. showed that consumers could not discriminate between non-essential care and necessary care, and they basically saved money by not going to the doctor.

TL: Do HSAs further health care equity?

TJ: No. HSAs definitely favor wealthier people. There’s pretty good evidence that where people have an option of an HSA plan, HSA plans are chosen more by wealthier employees. A significant number of these people are using them as a tax shelter for retirement. These plans protect neither the health nor financial security of people who are poor.

TL: Do they further a two-tier health care system?

TJ: More wealthy people use these plans; they get tax benefits and generous contributions to their HSAs. Lower income workers get high deductibles. That means health insurance may be affordable, but when you get sick, health care is not. Just because insurance is affordable doesn’t mean that someone can get affordable care. Consumer-driven plans just postpone the question of affordability. The wealthy can always afford their care. Poor people can’t.

TL: How do these plans affect the doctor-patient relationship?

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.