I had a coffee mug with “In the good old days a husband brought home the bacon and his wife cooked it up in the pan” written on one side and “You can kiss that s-t goodbye!” on the other. If I designed that coffee mug it would say “In the good old days your employer or the government gave you your health insurance and got nothing extra from you in return” on one side. The other side would not change.

The financial exhaust pipe of unaffordable health care cost increases is something that governments and employers are not going to be able suck on and survive much longer, because the costs are killing their budgets. Something will have to give; we, as the insured, are either going to cost our health insurance providers less over the long haul or we are going to get much more – or all – of our health care costs dumped in our laps and we will be sucking on the exhaust pipe.

The alternative may be a model in which costs rise less because we become healthier, so fewer of those higher costs would then have to be passed on to us. However, it has been easier to send Americans to the moon, Alice, than it has been to get them healthy. Barring some additional motivation to do so, it seems unlikely Americans will become healthier and thereby less expensive to insure anytime soon.

It is unfortunately time to give us all that motivation by making health insurance a social contract in which the employer or the government provides your health insurance, and, in return, you provide your best possible health. The closer you are to your best possible health – allowing for whatever illnesses you have – the less you would pay for your share of your health insurance premiums. The less healthy you are than you could be, the more you will pay. A diabetic with heart disease would not pay more than a world class athlete with an ankle sprain as long as both were as healthy as they could be within the limits of their conditions. A couch potato with a cholesterol and weight of 320, blood pressure of 180/120, who never goes to the doctor and chews tobacco by the ton would pay through the nose.

In that scenario your insurance policy would look a bit like a menu. Want to ride around without your seat belt? No problem, but it will cost you an extra $300 per year for your policy. Want to exercise and keep fit? Great – that will save you $600 a year on your share of your premium. Extra pounds overweight will cost you extra bucks. If you want to rock climb or swim with sharks for hobbies, you pay a high-risk activity premium. Are you diabetic and your blood sugars are so high your diabetes will cost you your kidneys in 20 years? Well, in the meantime it will cost you an extra $200 year for every HbA1c point (measures average blood sugar) you are over the goal of 7.

A key component in such a contract would be that all preventive care – pap smears, annual physicals, vaccinations, visits to your health care providers, etc. – would be completely covered whether you are a saintly marathoner or a pot-smoking hang glider with a death wish. So would all medications, because we cannot expect people to be as healthy as they can be and then make it difficult for them to afford their medications. There would be no penalty for getting a disease such as cancer, only for doing things such as smoking that clearly increased your cancer risk.

The whole idea is deeply flawed, of course, riddled with potential and actual problems. How do you measure how hard someone is working to keep themselves healthy within a given disease, for example, and who knows if someone exercises regularly? Many details would have to be worked out, and there would be limits to how intrusive we could be in measuring a person’s efforts to remain as healthy as possible. Then again, what solution to our problems is perfect?

The idea of using insurance as a motivator for better health is not new; many employers now are cutting employee insurance premiums for employees who participate in limited employer-sponsored efforts to improve the employee’s health. MaineCare and some other state Medicaid plans are using financial incentives to induce Medicaid enrollees to stop smoking, keep appointments, take their medications, etc. What we need, however, is to supercharge the idea; make it the norm in all health insurance, and ratchet up the differential between what you pay for your insurance if you are doing the best job possible staying as healthy as you can be, and if you are doing bupkiss or worse, then fine-tune the idea to allow for access problems due to poverty, etc.

Truth be told, I hate the whole idea, but I am a desperate man, desperately seeking solutions. We – individually and nationally – are hellbent on the road to economic ruin unless we do something dramatically different to control our health care costs. Radical changes in the equation are required. Health insurance as a social contract, trading health insurance premiums for our best possible health, is just such a change.

It could get all of us invested in the game of getting healthier, something we have got to do on our own, or kicking and screaming under contract.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.