The Bush administration, like all before it, shies away from urging that health insurance premiums be taxable -- voters would hate that -- and instead is trying to level the field by making all premiums deductible. There's an argument that this is regressive, because the tax deduction is worth more to high-income taxpayers. But that's true of all tax deductions, and can be compensated for by giving lower-income people deductible tax credits.

Will health savings accounts be an entering wedge to produce a more market-oriented health care sector? Democrats fear that, and Republicans hope so. I confess that I am not sure. What is clear is that health savings account-type policies have been rapidly growing since passage of the 2003 act. There are now 3 million people with health savings accounts, and big employers in increasing numbers are offering high-deductible policies. The employee gets to choose whether to pay more for more coverage or to pay less and be able to keep what he doesn't spend.

Of course, the health care sector will never be entirely market-oriented. Emergency patients on gurneys can't make cost-conscious decisions, and the poor will receive care that will in some way be subsidized by others. But health savings accounts have been spreading more rapidly since the 2003 Medicare act than defined-contribution pensions did after the 1978 tax act.

The New Deal and the World War II years produced policies that left people dependent on large organizations -- organizations that, we now learn when we contemplate the problems of steel pensioners or Social Security recipients, don't always deliver. Public policies like Section 401(k) and, perhaps, health savings accounts give more control to individuals and more flexibility to society.

The Clinton health care plan failed in part because we do not have one health care finance system, but many -- and it is impossible for even very smart people to design a one-size-fits-all model that will be politically acceptable. The Bush administration's push for health savings accounts is an attempt to change things not by government mandate, but by opening the way for private actors -- employers, employees, insurers, individuals -- to make decisions that will increase the power of market forces. Not a headline issue, but an important one.