POLICY: Socialized fire departments & trading up

Michael Millenson’s excellent and biting piece on the willingness of Orange Country Republicans to accept socialized fire departments has provoked great response. But of course this being America, even the concept of us “all being in this together” for a devastating disaster isn’t quite true.

Friday’s LA Times has an article about private home insurers running a “concierge-level” fire protection service for those in very expensive homes, and it appears that in some cases the intervention of the private firemen was the difference between saving a $3-5m home and it burning down like the one across the street.

There are obvious comparisons to the privatization of police forces—both the growth in special security companies and the over-staffing of police in tony towns compared to the under-staffing in poorer towns where there’s way more crime. And it does seem unfair that in the midst of the crisis some people got better treatment.

But I don’t think the private firemen completely defeat the concept of social insurance for health care. If you think about it, this is exactly what happens in the UK. Everyone pays into the pool according to their ability to do so. No one is sent a bill for fire protection or health care from the socialized provider, whatever their need. But in the UK and in many universal insurance companies countries, you can trade up to buy supplementary insurance that allows you to jump the queue in certain cases—a little like having the private fire guy come and spray extra retardant on your roof. But the main fire department will still be the ones coming to try to save your house when the fire actually gets into your backyard.

Of course the danger here is that everyone of any means gets the private fire insurance, and then decides that they don’t need to pay for the socialized fire department. Then, if you can’t afford private fire insurance, your house will be left to burn down—while what’s left of the underfunded socialized fire department does its best while overwhelmed by demands from the rest of the poor saps who couldn’t afford private coverage.

And that’s essentially what we have in health care now.

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8 replies »

  1. “Your cherished universal plans are thus destined to fail. Competant physicians will enter concierge practice. Med students will continue to opt for specialization, and government programs will come to depend upon imports from Waziristan and the Central African Republic (as in that shining beacon of medicine on a hill, the UK).”
    I have said this before, Republicans will intentionally design a system to fail. We can’t expect to get docs from the privileged class anyway to make the system work, their expectations and greed are too high. There are a lot of inner city kids who would want to be docs.
    I wonder if Republicans in CA fires were glad to have federal and state government bureaucrats working for them – free of charge? Now wait until the insurance companies start imposing policy contract/loopholes to avoid payment. We’ll see how much Republicans hate trial lawyers then. Maybe we should do away with property insurance litigation and establish property courts to avoid all those expensive trial costs using citizen juries – who we know only fall for trial lawyer tactics against insurance companies.

  2. Has anyone taken a look at the provider community lately. Only masochists choose primary care (or, to a lessor extent, pediatric care). The various ideologically-driven universal health plans will all fail because providers will not accept government reimbursement and won’t venture into sub-specialties dominated by government payment.
    Your cherished universal plans are thus destined to fail. Competant physicians will enter concierge practice. Med students will continue to opt for specialization, and government programs will come to depend upon imports from Waziristan and the Central African Republic (as in that shining beacon of medicine on a hill, the UK).
    Physicians aren’t chess pieces that health care policy wonks can move around the board. Better luck next time.

  3. I pretty much agree with the three processes Steve mentioned above, but I’d add a fourth: end-of-life care.
    Even if the other three processes provide quality care with some cost containment, if there aren’t rational end-of-life decisions being made, all the savings could be lost.

  4. Following up on Kathleen’s post, I suggest that our healthcare system should be built around a patient-centered life-cycle value chain in which there’s an integration of three macro processes: (1) Emergency care through emergency management (including 1st responder and trauma center support), (2) sick-care (acute and subacute care) at the clinical encounter, and (3) well-care (including prevention and self-management of chronic conditions).
    The provision of cost-effective (high-value) care to patients/consumers over their lifetimes in each of these macro processes would be promoted by transforming our clinical and financial sub-processes to enable providers to make better diagnostic and treatment decisions, deliver evidence-based care effectively and efficiently, and rewarding them for doing so with greater profits and competitive advantage.
    In addition, there needs to be infrastructural changes in terms of health information technology use, so that providers and consumers gain rapid access to truly useful information and decision support tools fostering wise choices and responsible actions.
    I’m describing this model in more detail on the Curing Healthcare Blog.

  5. I think we need to change the paradigm and simply claim our health care system dead. And start over. And start over by starting with “What” a health care system is supposed to do. Keep us healthy or cure us regardless of cost? I think if we start with what the goal of a health system should be, then we can begin to build a rational system. We need to re-frame the issue of what people need and want for their families, which might get us out of the realm of partisan politics for a starter.
    And that would be a great start!

  6. I do not see a problem when loss insurers take steps to prevent losses, so long as they do not compete with community-funded fire departments for critical resources like water sources during an emergency. What I WOULD have a real problem with, is if the wealthiest homeowners were allowed to build in the safest, flatest, greenest places – and all others were required to live on steep hillsides among tinder-dry vegetation at the end of narrow, winding roads and substandard water mains. Unfortunately, this is precisely what has happened in our healthcare system: the people least able to deal with a healthcare crisis are often forced to live and work among the greatest health threats and without access to the resources needed to mitigate those threats.

  7. While I don’t see a problem now with two tier fire fighting as it takes a lot less to train a firefighter and any job openings have long lines of applicants. But I do see a relationship problem with two tier medicine. What happens in the case where both fire departments respond and two structures are on fire, one with the concierge service and one without. Who gets use of the fire hydrant first? See in medicane it’s also about the allocation of limited resources. Do you get them because you’re sick or because you pay more?

  8. However whilst you have the opportunity to trade up in the UK to a better insurance deal, you can not opt out of the minimum so irrespective of whether you make £1 billion pounds a year or £1 you have to contribute to the state system, what you do with your income after that is your own business.

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