That’s the case with drug co-pay coupons.

Let me explain. A drug has a patent for twenty years, during which the pharmaceutical company that developed it has exclusive rights to produce and sell it. After that, it has to compete with other companies that can now produce the same drug.

Profits on the brand-name drug obviously fall as a result. But recently drug companies are trying a new way to keep those profits up: helping consumers with their co-pays.

You’ve seen the ads, I’m sure. “Stay with Lipitor for as little as $4 a month.” For many people with private insurance, $4 a month would make Lipitor more affordable than the new generic version, atorvastatin.

Generic drugs are usually far, far cheaper than the brand-name version, with (by law) no difference in the active ingredients. So insurance companies encourage both physicians and patients to choose the generic versions to keep health costs down for everyone. That’s why generic drugs often have a lower—or no—co-pay.

But drug companies circumvent this cost safeguard by subsidizing co-pays with coupons. It actually doesn’t cost them that much, since most of the cost of a drug is covered by insurance, not the patient. If patients keep asking for Lipitor (for example), and doctors keep prescribing it, Pfizer will still rake in the profits, minus the small amount it has to pay consumers to cooperate.

The co-pay coupon scheme depends on the fact that consumers don’t realize their insurer still has to pay more for medicine than it needs to—or that, as long as they get it cheaply, they don’t care. But the more insurers (or self-funded employers, or governments) have to pay for drugs, the more expensive pharmacy benefits, and health insurance, become. Using brand-name drugs when generics are available may cost individuals less, but it costs society much more.

Drug companies that offer coupons to battle generics are betting on ignorance and self-interest. Here’s hoping they lose.

In this country we have a powerful tradition against taking cost into account when we make medical decisions. The only people who worry about money are the ones who have to write the checks—generally employers and governments.

But now the ACP has put it in writing: Doctors should think about cost. Indeed, it is their ethical responsibility to use resources carefully.

Of course, as with all resolutions, this one is easier to make than it is to keep. Will being “parsimonious” with care mean that doctors will start to think twice about prescribing treatments they think might not be necessary? According to a Kaiser Family Foundation report, as much as 30 percent of all treatment is unnecessary.

These are not easy questions, and the ACP’s manual doesn’t try to answer them. But the statement on “parsimonious care” is an acknowledgment by the medical community that physicians play a part in health care costs.

Writing down a resolution doesn’t make it happen, as we all know, but judging from that statistic about unnecessary care, I hope it does.

In mid-December, HHS issued a bulletin explaining how it will accomplish this, and the short answer is . . . it won’t.

The Department has decided that instead of specifying the benefits that every American can expect to have covered, it will let states decide. Every state will select a “benchmark” plan from one of the largest ones currently offered within its borders. The benefits offered in that plan will become the “essential health benefits” in that state.

Yes, those benefits will have to cover those ten different categories of care I just mentioned. But how—and how thoroughly—will be up to each state, and I think that’s a problem. It’s a problem in the states that don’t require their insurers to provide much coverage, because their residents will still be at risk of buying inadequate coverage.

And it’s a problem in the states with mandates and requirements far beyond the national average, too, where spending and health care costs will go unchecked.

When the Institute of Medicine issued its report on this question in October, it was very clear: In order to control health care costs in this country while making coverage universal, we have to figure out what exactly is essential. In letting the states decide on benefits, HHS is ignoring the question of affordability—even though the federal government will be helping to subsidize these plans.

It’s popular in Washington today to complain about policymakers delaying decisions, aka “kicking the can down the road.” In this case, perhaps spooked by the looming elections, they have kicked that can into someone else’s yard. But asking the states to make these decisions for them, as the administration has done, wastes a singular opportunity to make our health care system more rational and more cost effective.

That’s the point of the individual mandate: to require everyone, even the young and the healthy, to buy health insurance, under threat of financial penalty.

Many people are wondering: Is that constitutional? And the Supreme Court is gearing up to answer that very question this spring.

But I’m wondering:  Will it even work? You see, the mandate is just too weak. The penalty for not buying health insurance is simply too low. In the first year, it’s only $95 or 1 percent of an adult’s income, whichever’s greater. Far, far less than health insurance costs. Even in 2016, when fully phased in, the penalty is only $695, or 2.5 percent of income.

David Nather at Politico has done the math:  “A family making $55,125 a year . . . would face a $1,378 fine if it didn’t have health insurance . . . But it could pay up to $4,438 in premiums if it bought health insurance. And that’s after the tax credits the law would give it to make the insurance cheaper.”

For a family making $55,000 a year, that $3,000 difference could be a pretty convincing argument against buying into the system.

But the law and its math are complicated—and human beings are even more complicated—and you can certainly find arguments that conclude the penalties are strong enough and the mandate will work. The Congressional Budget Office estimates that as a result of health care reform, 94 percent of Americans will end up with health insurance, compared to 83 percent now (although that takes into account the expansion of Medicaid).

Still, to me the individual mandate seems woefully weak. If the Supreme Court rules that it is constitutional, the question remains:  Will all Americans jump in the pool in 2014 or will a crippling number decide the water isn’t to their liking and choose to pay a small fine in order to stay out?

The Court will hear just one of these: Florida v. Department of Health and Human Services, which was brought by 26 states and the National Federation of Independent Business. Most of their arguments—in fact, much of the opposition to the law in general—revolve around the individual mandate, the requirement that (almost) every American purchase health insurance or face a penalty. Is that constitutional or not?

The first ruling in that case, by U.S. District Judge Roger Vinson, found that the individual mandate was not constitutional, and was not what judges and lawyers call “severable” from the rest of the law, meaning, as he put it, “the entire Act must be declared void.”

The Obama administration appealed to the United States Court of Appeals for the 11th Circuit, in Atlanta, where, in August, a three-judge panel agreed that the mandate was unconstitutional, but said that it was severable—the rest of the law could stand.

The problem is that it can’t. Maybe it can legally, but practically, there is simply no way insurance companies can cover everybody unless everybody buys insurance. And everybody won’t buy unless they have to. If health insurers have to cover everyone regardless of health status or preexisting conditions (and they will in 2014), then young, healthy people could wait until they get sick to buy insurance. But health plans cannot survive if they cover only the sick. As I’ve said before, “The simple fact is that health insurance works best by spreading the cost of health care among a broad cross-section of the community—from the most healthy to the most ill—that is, when everybody pays for health insurance, but not everybody uses it.”

You can read my full post on the topic from back in February. The upshot is that when it comes to the health reform law, “severability” is possible in the courtroom, not in real life. If the individual mandate falls, the whole thing falls apart.

The Supreme Court is likely to rule in June.

And that’s the oversimplified version. There are people who are very good at math—actuaries—who do this job. Then, when the health plan files its premium rates with the state, government actuaries analyze and certify the data.

Starting this year, New York’s Department of Financial Services wants to make all that data and all the calculations for every health plan available to the public. I say, good. Transparency is almost always in the public’s interest.

Of course, the public isn’t composed entirely of actuaries. They may not be able to make sense of the numbers they see. Or they may not care to. Or they may be tempted to take a figure out of context to prove a point.

But that’s the risk we take any time we make information freely available. I’m confident that those who look closely at the data will find something significant there, something they might not have just taken my word for: the fact that rapidly increasing health care costs generally drive increased premiums.

It’s true that sometimes, as I explained in an earlier post, a big increase can come from a change in the coverage pool. If the covered population changes drastically, the change in its health care usage—and therefore its premiums—can be drastic too.

But if health care usage stays the same and premiums go up anyway, the culprit is obvious: rising health care costs. That’s what the data show. And once people understand that, they might even want to see the math behind those costs. Why do hospitals (and doctors and pharmaceutical companies and so on) charge what they charge?

If insurance premium transparency is a public good, shouldn’t we have provider transparency too?

Hard to believe, from our current anti-smoking perspective, but half a century ago, cigarette ads featured such family-friendly spokespeople as doctors, dentists, Mickey Mantle, and even Santa. Ho-ho-[cough].

You don’t see that anymore. And you don’t see cute, cartoony Joe Camel. Today, smoking in movies and TV is relegated to Bad Guys, smokers are relegated to their homes and designated smoking areas, and ads are . . . where are the ads?

Fewer than 20 percent of U.S. adults now smoke, down from a peak of 45% in the 1950s. That decline has saved and extended countless lives. And it shows what a concerted, cooperative effort by advocacy groups and government can do to change the culture and affect public health.

I’m wondering if the same large-scale social change can occur with obesity. Right now our numbers are bad and getting worse, and the cost to the country is staggering. Is it possible that we could look back in a few decades with wonder at a time when so many of us were overweight and ads for cheese pizza in a cheese-stuffed crust were the norm—just as we look back now with wonder at a time when it was OK to use Santa to sell cigarettes?

As a public health issue, obesity is different from smoking. For one thing, you can’t quit food. And even quitting junk food won’t solve the obesity problem; it’s just more complicated. We need not just less bad food, but also more access to good, healthy foods, and greater opportunity for physical activity.

Although we suffer as a society from the health costs associated with obesity, it doesn’t pose the kind of immediate threat that second-hand smoke does—the sort of threat that spurs people to pass local laws and give up personal freedoms.

There’s also the question of discrimination and political correctness. How do we battle obesity without blaming and ostracizing the obese? In a culture that preaches acceptance but worships attractiveness, what exactly is the right way to tell people they should lose weight?

Maybe there isn’t one. Maybe instead we have to focus on children. To make people aware of our responsibility—as parents, as teachers, as communities—to keep kids from going down that unhealthy road.

If we fully accept and aggressively act on that responsibility, we can change the culture that promotes obesity just like we changed the culture that promoted smoking. In the future, maybe Santa Claus will put down that Coca-Cola and lose a few pounds.

Both health care and education are widely seen as troubled in this country. They are both enormous systems that affect everyone and they both enjoy (or endure, depending on your point of view) a combination of federal, state, and local input.

But the most important common element—the one that Swiss health outcomes pointed me toward—is this: you get out of both of them more or less what you put in.

And I’m not talking about money. I’m talking about people, and how healthy and intellectually prepared they are before they even enter these systems. Our test scores—both blood sugar and SAT—depend to a great extent on our home life. Are we eating right and exercising? Are we reading and talking to our kids?

Two big federal programs are involved in education reform. One of them, No Child Left Behind, requires statewide standardized testing and holds schools responsible for the results of those tests. The other, Head Start, gives underprivileged children access to early education programs.

No Child Left Behind is all about standards and accountability. And those are appealing concepts. But I don’t think they really get to the root of the problem. It’s unproductive—not to say unfair—to hold to the same standards kids with vastly different home preparation and resources. Kids who have trouble learning to read don’t need to be tested more; they need to be read to more. If everyone had the early support that our better-off families have, the nation’s reading scores would ultimately improve.

Could the same be true for health care? When we think about reforming our health care system, should we worry less about whether everyone has the same benefit plan and more about whether everyone has access to good prenatal care, healthy food, preventive medicine—in short, the knowledge and resources to raise a healthy family?

If more Americans entered the health care system with a head start on health, all the U.S. health numbers would get better, from BMI to the budget.

That’s clear. But who’s responsible for that head start? Clearly, I’m responsible for my own family, but what if my neighbors can’t or won’t take responsibility for theirs?  To what extent is that government’s job?

One popular flavor is Swiss, because the Swiss system, like ours, is market-oriented. The Swiss have to buy insurance, but the government kicks in a subsidy if the premium exceeds 10% of one’s income. All insurance is private, but all the companies have to offer the same basic benefits package, on which they are not allowed to make a profit. (They can profit on supplemental insurance, though.) Competition among insurance companies helps keep costs down, as do price controls on hospitals, doctors, and especially pharmaceutical companies.

The Swiss report being happy with their system, and they should be. Although they spend less of their GDP on health care than we do, their outcomes are better. Their life expectancy is higher than ours, and their infant mortality rate is far lower.

So why don’t we go the Swiss route? Well, for starters, the population of Switzerland is 8 million; the population of the U.S. is about 300 million. But it’s not just a question of size: by every metric, Switzerland’s population is wealthier and healthier. They’re more active and less overweight.

Switzerland’s great health outcomes, in other words, seem to have more to do with its population and less to do with health insurance or health care.

The simple truth is, no matter how much we’d like to find the answer ready and waiting in another country’s health care system, we’re not going to.

But we may find good questions. What do these places do well? What are they doing that we’re not? What are we missing?

In this case, we might ask ourselves: If starting with a healthier population improves outcomes, should we be putting less money and time into health insurance reforms and more into prevention of disease and promotion of healthy lifestyles? And are we prepared as a nation to address poverty and economic disparity—issues that have an enormous impact on population health?

Since then, New York has redesigned Medicaid. By-and-large, the Medicaid Redesign Team that Governor Cuomo assigned to the task has done a good job. They took various elements of the system apart and analyzed them. They looked for areas where costs appeared out of line and made changes. For example, they moved prescription drugs out of a free-standing, State-run program and into Medicaid Managed Care plans.

All-in-all a good effort, but not enough to produce any meaningful reductions in the average annual cost per New York Medicaid enrollee that the Kaiser Family Foundation estimates to be $6,910.  Redesign won’t bring that cost per enrollee anywhere near the $3,686 that California pays. That’s because redesign trims costs around the edges, while leaving intact New York’s rich benefit plan. 

Benefit reductions that would put Medicaid on par with comprehensive private health insurance will take action by the State Legislature. It will mean confronting the various interest groups that have lobbied for years for their pet services to be covered benefits. 

The simple fact is that New York will keep paying more than any other state on a per-enrollee basis as long as the Legislature and the Governor choose to continue to provide health care benefits under Medicaid that are way out of line with the health insurance most New Yorkers have.