Strapped for cash in a lagging economy, Americans still aren't going to the doctor as often as health insurers have been expecting. Higher deductibles, co-pays and other rising out-of-pocket expenses have also depressed health-care utilization. The result? Huge first-quarter profits for some of the country's biggest health insurers, who weren't anticipating such behavior from their customers in 2011, as UnitedHealth Group's CEO explained at an investor conference this week.

But for consumers — along with the health-care system as a whole — the development is a double-edged sword. To a certain extent, insured individuals may be forgoing unnecessary, costly procedures that have contributed to out-of-control health-care spending and rising costs that policymakers have vowed to contain. They'll take a pass on the pricey MRI or dental crowns that they might have gone for without a second thought in earlier years. But Americans may also be forgoing vital preventative medicine and early treatments to nip potentially seriously problems in the bud. While they may save themselves — and other health-care stakeholders — money in the short-term, everyone could end up paying more down the road.

The issue raises big questions about the best way to convince insured Americans to cut back on unnecessary health expenses without forgoing vital treatment. Government cost-cutting provisions like the new Independent Medicare Advisory Board have raised concerns that bureaucrats will end up "rationing" care. But the reality is that someone is going to have to say "no" to excess spending at some point, as I've explained previously. "Rationing is going to go on within the Medicare system. It's a fact of life. … The question's going to be, is that decision going to be made by government and imposed top down under the current system?" the Cato Institute's Michael Tanner told Politico last month.

As Tanner points out, Paul Ryan's Medicare plan intends to empower individuals to make such decisions, giving them a subsidy to purchase insurance on their own rather than having the federal government cover all their expenses. But as the recession may show, if individuals have less to work with up front, they could end up "self-rationing" and forgoing important treatment due to financial hardship or poorly informed decisions.

"You want to be changing habits in a good way. A lot of care was not terribly necessary, but you really want to make sure that people are still getting appropriate care," Kate Sullivan Hare, a long-time health policy observer, tells me in an interview. "Is it 'self-rationing' or rational care?"

If individuals are going to be left on their own to make these tough choices about health spending, they may still need outside support if policymakers really want to improve health outcomes and curb costs in the long run, Sullivan Hare adds. "They'll still need a third party to guide them, either a plan that financially incentivizes them, or a doctor providing them that guidance," she suggests.

To put it another way: If individuals have less available money available to them from the start — whether due to economic hardship, higher deductibles, or increased cost-sharing in government health programs — there's likely to be a drop in their use of both unnecessary and necessary care. The question is how to curb the former without sacrificing the latter.

Suzy Khimm is a staff reporter in the Washington bureau of Mother Jones.