In reading their paper on creating a better health care system (Nov/Dec 05), I was disappointed that my Stanford University friends and colleagues, John Cogan and Daniel Kessler, did not include the principle that all consumers should have a financially responsible choice among alternative health care financing and delivery plans - as we have here at Stanford. Perhaps they took it for granted that most people have this kind of choice, although, in fact, barely 10 percent of the employed insured do. It is important for people to have such a choice because premium differences (risk-adjusted) reflect the total annual per capita cost in each delivery system. The financially responsible choice of health plans puts market pressure on each delivery system or network to be innovative in reducing total cost - and not just costs in the first $1,500 below the deductible.

Adding to our excessive tax preferences to cover out-of-pocket health care spending is not wise, especially when we do not know how the federal government will be able to pay for obligations it has already assumed.

National health spending has doubled its share of gross domestic product (GDP) in the past twenty-five years. Absent some quite fundamental change, this will double again in the next twenty-five, seriously straining public finances. We need to look for policy changes that are far more ambitious than a 6.2 percent reduction in private health spending.

We need to close the gap between spending growth and GDP growth. That will require a fundamental change in financial incentives for consumers (making a cost-conscious choice of a full health plan instead of selecting a low-priced doctor) and providers (replacing fee-for-service with per capita prepayment and salaries). Perhaps when things get bad enough, such fundamental change will become politically feasible.