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That's the essence of where Republicans want to go. And why Democrats aren't making that a lot more clear is a very good question without any good answers. The problem is that you go to the doctor and agree to take the tests the doctor recommends. Shadegg and Hoekstra want a system where if your doctor suggests a biopsy for a suspicious lump you think about the pros and cons. Is it worth the money? Do you have the money? How suspicious is the lump anyway? Maybe you get the first one. But not necessarily the follow up scan six months later.

This is the essence of the Republican plan: the fact that you're insured and aren't directly feeling the cost of individual tests and procedures is the problem and getting rid of the insurance concept is the solution. Give you a structure where you can save money for future procedures and medications (the more money you have the better) and you decide how much medical care you think you can afford. That's what HSAs are about (google it). That's the gist of the column and it's not surprising because that's what most conservative policy ideas are about.

To be clear, such an approach probably would cut costs because most people just couldn't afford to get a lot of care, which is a great way of cutting costs. But remember, the problem according to most Republicans in Congress isn't that there's not enough insurance or that it's not good enough. It's that there's too much. The problem is that you have insurance. And good policy will take it away from you.

Late Update: TPM Reader CL notes this earlier TPM post from January 2006 on President Bush's effort to push this same approach to reforming health care. In other words, yes, the 'new' proposals are the Bush proposals all over again.

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Josh Marshall is editor and publisher of TalkingPointsMemo.com.