Covering the uninsured and the costs to society

by Lucas Restrepo, MD

Recently, the fire department of a small town in Tennessee called South Fulton ignored the call of a man who needed help quelling a fire near his house.

The firefighters declined lending a hand because the caller neglected to pay a $75 bill, the prerequisite for deserving assistance. The caller tried to put down the fire with a garden hose, but after two hours, his house caught on fire. When the property of a neighbor who had paid the $75 became threatened by the flames, the gallant firemen promptly answered the call of duty. The brave public servants prevented the flames from spreading to the property of their responsible contributor, carefully avoiding to suppress the conflagration’s source. Someone has to teach a lesson to the free-loaders in our society, explains a high-minded commentator.

Our health care system works exactly like South Fulton’s worthy fire department: we are entitled to health care only if we have money or qualify for Medicare or Medicaid. If you don’t have money, your health entirely depends on the charity of health care providers, who, as our admirable firefighters, may refuse to help.

I wish to argue that, besides being cruel and inhumane, the “South Fulton health care model” is a latent threat to society. The cost and effort of preventive medicine and basic primary care (fire prevention, putting down a small fire) is less than dealing with instances of end-organ failure (a house in flames). Moreover, having uninsured people (not aiming water to the fire source) creates a constant economic liability to responsible costumers (the neighborhood). On the other hand, why should someone become a doctor, nurse, or health insurance company founder (a firefighter) without being an altruist? Do firefighters dream of wealth and leisure?

The costs of not doing anything about a burning house are always paid in full by society ― and some costs are not immediately apparent. Who loves the sight and smell of a charred landscape? Where will the man live now that he has no house? Will he react violently to the inaction of the firemen? Will the reputation of the fire department (and the city’s) go up in smoke?

A single dispossessed is a liability to an entire society.

The Patient Protection and Affordable Care Act (PPACA) aims at controlling the “fire hazard” of the uninsured. But PPACA is being sued on behalf of a crowd of demagogues. They argue that, while Congress can regulate commercial activity, it “can’t regulate inactivity.” The pompous frivolity of such musings is not particularly persuasive. In fact, the inaction of someone who doesn’t purchase insurance generates a flurry of commercial activity elsewhere: health care companies losing money on the uninsured increase costs to their “active” costumers to make up for the loss. It’s like setting houses on fire, while asking firefighters to contain the flames without aiming their hoses to the fire source.

From a biological standpoint, if you’re “merely alive,” you are “active.” Cells proliferate beyond the reach of our volition, sustain physiological stress, micro-injury and repair; infections ensue and are fought off, while passers-by are in turn infected; some engage in unhealthy behaviors, many unbeknownst to themselves or their neighbors; heredity works its way silently toward phenotypes; furtive cells become antisocial; people grow old and forget. In other words, we are getting sick regardless of our economic activity or inactivity.

Folks suing PPACA ail from the worst kind of irresponsibility: that exhibited by those who lack solutions.

Good health is requisite for life, liberty and the pursuit of happiness. This is true for individuals, but also for societies, which are successful if their members are healthy and fair-minded.

PPACA tells us that we all have to pay the $75, but also that firefighters can’t just sit and play the lyre while our neighbor’s house burns.

Lucas Restrepo is a neurologist who blogs at Progress Notes.

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  • guest

    The problem is that if everything is free there will be less incentive to work hard in order to have enough money to pay doctors directly or pay for health insurance.

    Its a question of whether we want equity (everybody receives care at a likely high cost) or maximum value (unequal amounts of care or quality of care but less cost) for our health care. Perhaps a balanced view is needed. Everything can’t just be free.

    • anonymous

      In order for this discussion to be worthwhile, we should clarify between equality (where everyone gets the same care) vs equity (where people get care proportional to the money they put into the system) vs socialism (where people put the same amount into the system and get the same care) vs communism (where people contribute “what they can” into the system and get “what they need”. I put these last phrases in quotes because they are often defined in different ways to further various political agendas.

  • Jeff

    Apparently, the author has never heard of EMTALA, the federal law which requires healthcare providers to deliver necessary services in the true event of an emergency. While I do support the PPACA, I do not support the use of false analogies or misleading comparisons. Granted, the neglectful decision of firefighters in South Fulton was atrocious, but comparing this to the healthcare sector is disingenuous, since the law of the land already requires providers to deliver necessary healthcare services regardless of ability to pay.

    • Lucas Restrepo

      Thanks for your comment. I actually have heard of EMTALA. However, the issue here is not emergency situations. The point of my piece is that putting down small fires is easier than dealing with large ones, and that people have reasonable expectations that fire fighters (and physicians) will help them, regardless of their personal failings or insurance status. William Osler suggested that medicine is a “calling,” and I suspect that most fire fighters would say the same about their profession. Hence, not answering the plea of someone in need seems uncharacteristic of fire fighters or doctors. Finally, I whole-heartedly agree that, like all metaphors, the South Fulton FD isn’t fully satisfactory. However, I feel that there are compelling parallels between the South Fulton model and our health care system. Thanks again for reading my piece and sharing your thoughts.

  • Bladedoc

    Every person in this country has emergency access to medical care. Period. Any discussion of the health care system that eludes this fact is on it’s face dishonest. So to make your comparison to the fire situation apt you would have to admit that the actual situation would be the fire truck pulls up to the uninsured victims house, is mandated by law to put out the fire, and then is allowed to charge for the service. Not only that, if the fireman felt bad for the victim and wanted to do it for free he WOULD NOT BE ALLOWED to do so (by Medicare law you are not allowed to charge any less than your Medicare fee to ANYONE).

    What your cri du cour actually demands has nothing to do with emergency care. It is more akin to a system where a homeowner could demand that his neighbor pay into fund to pay the fire department to come to his house three times a year and check the alarms (well-patient visits), pay for the most expensive paint for yearly touchups (Medicare part d for everyone), and to resod his lawn once a year because he can’t be bothered to take care of it regularly.

    Access to insurance is not the same as access to health care.

  • skeptikus

    Where to start? The “pompous frivolity” of those who challenge the constitutionality PPACA? Oh, I thought they were arguing for federalism and the Constitution. Principles of government that have served us well for over two centuries are “frivolous”?

    “The cost and effort of preventive medicine and basic primary care (fire prevention, putting down a small fire) is less than dealing with instances of end-organ failure (a house in flames).”

    Nonsense. Preventative medicine is not a solution. As every healthcare economist knows, three conditions consume most of our healthcare dollars: diabetes, heart disease, and cancer. Making a dent in these conditions involve mass life style changes. Doctors can appear every year or so and tell patients to stop smoking, but that won’t change much.

    “Good health is requisite for life, liberty and the pursuit of happiness. This is true for individuals, but also for societies, which are successful if their members are healthy and fair-minded.”
    Maybe. But, the truth is that healthcare, from a statistical perspective, is not related to “good health.” The drivers of good health outcomes in a nation have little to do with healthcare availability. Genetics, diet, and lifestyle are determinant.

    Healthcare is, in the end, a private concern. People have the right to decide what resources to expend upon this service of little value. Not governments or bromide spouting doctors.

  • Vox Rusticus

    The South Fulton Fire Department story involved the willingness of a town’s fire department, paid for by that town’s residence respond to calls in areas outside of the town where the residents did not support the fire services by their taxes, their own fire department, which they had none, nor any other fire department. As an option, the fire department of South Fulton was willing to enroll households in the areas outside the town of South Fulton to subscribe for fire department services by annual prepaid subscription. Enrollment was entirely optional, not required. Evidently the residents outside the town were happy enough with that arrangement, at least happy enough to not make fire protection a mandatory service imposed by a property or use tax. The good citizens did as they chose, and so did the property owners. Some evidently chose to subscribe; others did not, obviously taking the chance that they wouldn’t need a fire department to respond or could adequately fight a fire with their own resources.

    One property owner chose not to subscribe. His house caught fire, but the South Fulton Fire Department, responding to a neighbor who was a subscriber responded to protect the subscriber’s property but not the homeowner’s property that had not subscribed.

    Tough break, but everyone knew ahead of time that you only got fire services from outside the community if you subscribed ahead of time. If someone living outside of town didn’t like not having fire services as a tax-paid service, they could move into South Fulton or gripe and pay the subscription fee. They had choices.

    Fire services cost money. Most communities levy taxes on their property owners to pay for them and all that is involved with maintaining a fire department, same with police and and animal control and roadway repair services.

    That is the South Fulton story. It is not like medicine in the USA.

    Unlike the South Fulton story, doctors are frequently required to provide services to people who don’t pay into the subscriber fund. EMTALA and hospital staff bylaws require that they do. The doctors get stuck with the costs unless the patients choose to pay, and many don’t.

  • anonymous

    Another interesting aspect of this story:
    My understanding is that the unsubscribed homeowner offered to pay his $75 fee on the spot but was not allowed to. (Someone please post a correction if I am wrong.) Can you imagine if we could all pay for our insurance-type expenses after the fact, only in the years we needed it? No one would buy life insurance, health insurance, malpractice insurance, or auto insurance! They would just expect they could pay something similar to their annual premium after a claim was made!

    • Marcy

      And the reason the fire department told him “no” this time was that the last time this happened with him, they did allow him to pay the $75 after-the-fact. You’d think he’d learn his lesson then – he didn’t, he expected to save that money each year until/if he needed the service again.

      • anonymous

        I didn’t know about this. Thanks for posting it.

    • gzuckier

      In fact, this signing up for medical plan when you’re already being admitted is seen quite a bit; the big winner is, of course, pregnancy, which has a pretty predictable time course and lends itself well to gaming the system to snag cutrate maternity care thusly.

  • Muddy Waters

    The author of this post is a prime example of the ideology that is eroding the fabric of our society. Like the far left of the federal government, he would rather enable people to continue their never-ending dependence on the tax-paying producers of our country rather than forcing them take responsibility for their own lives. Very sad.

  • Michael F. Mirochna, MD

    I think the point is that there is a cost to society as a whole for letting things go and getting worse and being forced to treat them at end stage emergencies. We already pay for it through loss of tax revenue due to tax write-offs etc… for free care.

    The big question is how do we deal with them? They are getting some care already now for free, but would it be cheaper to change that system?

    Maybe everyone takes umbrage with the political slant.

  • guest

    How about personal responsibility? How about leading a healthier lifestyle to decrease one’s use of health care. Health care does not automatically lead to greater health. Doctors can’t do much when people are stuffing their mouths with Big Macs, smoking, drinking, and haven’t exercised since the first Bush administration.

    • gzuckier

      Yes, if people would only take more care to choose parents with better quality genomes, and stay indoors all the time to avoid being hit by lower quality drivers, then they wouldn’t need healthcare.

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