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Fire Burns Away the Fog of Ideology: Can Humane Health Care Reform Rise from the Ashes? – Michael Millenson

THCB welcomes back our solid pal, the erudite Michael Millenson, for whom the sun doesn’t shine if there’s no wisecrack in the wings. Now leading a consulting firm specializing in health care quality projects, Michael is a former Chicago Trib reporter with 3 Pulitzer nominations to his credit. Michael’s groundbreaking 1997 book Demanding Medical Excellence was one of the first to call attention to the problems addressed by the Quality and Safety movements. Enjoy.

As wildfires sweep Southern California, I have been surprised that homeowners in some of the most affluent and staunchly Republican enclaves in the state have not protested the widespread deployment of government workers bearing fire hoses and driving ambulances. The pain of watching one’s life possessions burn to a crisp must almost be matched by the pain of watching tax dollars wasted on a task that private, for-profit firefighters could surely perform more cheaply and more effectively. Yet not even the richest of the fire-torn refugees has expressed regret over government intervention in their rescue.

It’s important to remember that wildfires in California are a
foreseeable event, just like hurricanes in the Southeast, blizzards in
the Upper Midwest or – to switch from the cosmic to the quotidian –
illness or accidents befalling individuals. In bumper sticker terms,
stuff happens. If one believes in the marketplace, then it should be up
to individuals knowingly facing risk, not the government, to either
take prudent steps to protect themselves or face the consequences.

If, after all, one believes that Medicare should be privatized, then
one also implicitly believes that the old, frail and infirm should be
left to their fate if they chose a health plan adequate to finance the
flu but with coverage too meager for multiple myeloma. Economists call
this a “market signal,” meaning that it’s supposed to scare everyone
else into acting like Rational Economic Man rather than like actual
human beings. Similarly, if your health savings account is exhausted
before your medical needs, that should teach the guy in the next
cubicle to quit wasting money on a big mortgage and sock away something
for a possible stroke.

Given the Republican allegiance to the marketplace, should not
California taxpayers send fire engines to rescue only those whose home
insurance covers full replacement cost – Rational Economic Man — and
the “deserving poor” who, clutching tax returns in hand, can prove they
couldn’t afford the premiums? The question answers itself.

Firmly held convictions about the importance of individual
responsibility seem to melt away when the flames approach our house,
the winds howl outside our window, the snow drifts trap our car or
disease strikes our family. The marketplace does some things very well,
but responding swiftly to rescue those who cannot rescue themselves is
not one of them.

Fire, wind, rain, snow and illness can strike any of us, regardless of
political beliefs. Paying taxes to protect the vulnerable from
devastation is not a step down the slippery slope of socialism but a
reaffirmation of a basic human commitment. As our nation tries to build
a consensus for sweeping health care reform, perhaps the California
fires can reignite a recognition that Rational Economic Man is a straw
figure and that community and compassion are the values that truly
define us.

Michael Millenson (mm@healthqualityadvisors.com) is the President of Health Quality Advisors LLC in Highland Park, IL.

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AlanRobSophie JensenLynnPolly Recent comment authors
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Alan
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Rearranging the chairs isn’t going to save the ship. The key problem facing our health care system is the cost of medical care. Whether the system is market driven or government run there’s only four sources to pay health care costs: taxes; premiums; the consumer’s wallet; or charity (someone else’s wallet). That’s it. And the drivers of increasing health care costs aren’t tied to how the system is financed. This is the issue that deserves attention from policy makers, but it’s not an easy challenge. So we’re unlikely to see much progrss in that directin.

Rob
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Rob

Wow, you know, the whole part of using analogies is there’s always someone who will analyze the individual electrons used to transmit same, and find them not at all equivalent. What public-good project should we use instead? Free voting booths? All are social projects for the common good. The nub of the argument is that people don’t have to prove their worth when they call the fire department. Nor do they have to prove they’re insured to vote. The value of a doctor’s attention is infinite when one is sick. The price shouldn’t be. The price should be borne by… Read more »

Sophie Jensen
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Sophie Jensen

The analogy doesn’t work for me, because insurance companies often refuse coverage to people with pre-existing conditions.
Building in a remote area surrounded by brush could be considered a pre-existing condition for the homeowner.
Of course, the building and planning departments which allow developments in such vulnerable areas are equally to blame with the homeowners.
Rebuilding after a disaster, whether it’s in the tinder-dry areas of California, or on the Atlantic coast’s barrier islands and beaches should not be supported by the government or private insurance.

Lynn
Guest
Lynn

We’re still missing one critical piece–the fire’s administrative overhead. Surely we must account for the marketing, profit and claims administration. Are we certain that all that fire fighting was truly necessary? I’m certain a number of homeowners will find that their claims will be rejected because fire fighting wasn’t necessary or they didn’t receive prior authorization to have a fire fought. What is the 800 number for prior approval? Some homeowner will certainly find their insurance retroactively canceled. I’m sure they will be referred to the California high risk fire insurance pool. It takes a lot of adjusters, claims processors,… Read more »

Polly
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Polly

Great post, and a great analogy. It’s devastating to hear about what’s happening in California with all of the fires. Unexpected, but as you say, all disasters are inevitable. At some point, you will get sick. Unfortunately, the current healthcare system leaves those unable to pay for care, or just barely getting by with their measely, yet slightly affordable coverage, not many options. Living on a fixed budget is difficult, especially when you have to pay for higher and higher premiums, and the funding keeps getting cut. I know that we’re all looking for some meaningful health care reform that… Read more »

Chris
Guest
Chris

If, after all, one believes that Medicare should be privatized, then one also implicitly believes that the old, frail and infirm should be left to their fate if they chose a health plan adequate to finance the flu but with coverage too meager for multiple myeloma. I guess a “core” question would be: “Given a large deficit in health care resources to meet health care demands, who should have the greater say in how dollars will be spent, the individual or the governmental agency?” I know we don’t believe that “good intentions” balance budgets. I assume we’ll have very large… Read more »

RW
Guest
RW

But Michael, how do we know we are getting “quality” fire fighting? But seriously, what about the requirements in fire prone areas (both for insurance and by local ordinance) that homeowners take appropriate precautions, including landscaping, building materials (e.g. no shake roofs, etc.)? If your analogy works for healthcare shouldn’t specific requirements for health behavior be built into the system? Does public funding lead to regulations regarding weight/diet/caloric intake/exercise etc.? Certainly if we are all going to pay for it we should expect that certain “precautions” be taken. You can’t take personal responsibility out of the equation. The latest example… Read more »

Peter
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Peter

“its largely because the fires threaten to spread to other areas– its the contagion that makes it in everyone’s interest to put them out quickly.” Actually firefighters had to abandon fighting the fire and concentrate on protecting million $$$ homes. They were just as much protecting insurance companies loss as that of the owners, who by the way get subsidized fire insurance rates due to publically funded fire departments. And who pays for all the other services needed to manage these fires such as police, works departments and power crews. If people think that the rest of us not in… Read more »

George Goldstein
Guest
George Goldstein

Michael, give ’em hell! This is really good, befitting Jon Stewart. I have only one disagreement. Re: “Given the Republican allegiance to the marketplace, should not California taxpayers send fire engines to rescue only those whose home insurance covers full replacement cost – Rational Economic Man” Should not these rational men have entered into contracts either directly with companies of fire-fighting doctors , or purchased fire insurance from companies that then contract with doctors of fire-fighting? I propose the following market based subrogation of costs. The amount of money a home owner with insurance will be the net of the… Read more »

jd
Guest
jd

Vijay, I think the analogy is stronger than you suggest. You write, “I don’t see significant public dollars being used to deploy high-priced contractors to rebuild the houses (that’s for private insurance).” There may not be much govt. money going directly to deploy contractors, but there is disaster relief funding. What is this for if not to help people financially beyond what private insurance would provide? Don’t forget that there is more than one way for govt. to reduce the financial risk that people face, whether it is from fire, disease or plunging investments. When Medicare pays for the treatment… Read more »

Andrew Sotirokos DPT, CSCS
Guest
Andrew Sotirokos DPT, CSCS

Paying taxes to protect the vulnerable from devastation is a far cry from subsidizing treatment for medical conditions that can be prevented by self discipline and personal repsonsibility. A great example is low back pain. Billions of dollars are spent each year are on treating low back pain in indiividuals of all ages, most of which can be prevented through exercise throughout the life span. Don’t we also know that regular exercise can help control diabetes, prevent obesity and other medical conditions? Maybe if we shifted our focus to subsidizing preventative measures we wouldn’t have to pay for expensive medical… Read more »

Vijay Goel, M.D.
Guest

Michael, I’m not sure the analogy works as extensively as you would make it. While we’re providing public resources to fight the fires, its largely because the fires threaten to spread to other areas– its the contagion that makes it in everyone’s interest to put them out quickly. While I think you’ve made a terrific analogy to the public health system (vaccines, water testing, CDC), I don’t see significant public dollars being used to deploy high-priced contractors to rebuild the houses (that’s for private insurance). If you extended your analogy to today’s health system, we would then have a centralized… Read more »

Peter
Guest
Peter

What a geat analogy. Well done and timely. I might add that 60 Minutes did a piece on these fires last Sunday. Years of fire suppression have led to large quantities of underbrush dried by drought caused by global warming which also melts less available snow faster at elevation that also helps the drying of the underbrush. Firefighters interviewed said that years ago a 100K acre fire was rare, now it’s just another day at the office with 400K and 500K fires common. The pines that normally are fire resistant can’t survive these hot fires. All you hear from our… Read more »