There was a house in Tennessee that made the news because it was allowed to burn down by the firefighters on the scene due to non-payment of the fire protection fee. Interestingly, it turns out it was more than just a house burning, it was a metaphor for the healthcare system as well. The  pro Affordable Care Act folks point out that

Fire protection is usually compulsory. You pay for it with your taxes, just like you pay for police protection, a national defense, and Social Security. But in rural areas, apparently, some people who could pay for fire protection don’t–in the same way that some people who could buy health insurance today don’t. The trouble with this arrangement is that some people who decline protection will need it. 

How does this metaphor extend to healthcare policy?

To me this is a classic case for requiring payment up front–that is, an individual mandate. People shouldn’t have the option to decline fire protection if protection is available. If they refuse to pay the fees, assuming they are reasonable relative to their means, they should be subject to financial penalties. The same goes for health insurance. Don’t let people go without basic coverage, but make them pay for it, to whatever extent their income allows.

The anti-Obamacare group (seems we can’t even agree on how to refer to it) point out that the real hazard was the threat to the neighbors of the unfortunate homeowner who were paid up so the firefighters did their duty by spraying down the yard while the house burned. The homeowner had made his choice and thus was made to suffer the consequences.  Apparently in healthcare the state should be involved as it affects others, such as by treating syphilis and other communicable diseases but as it relates to individuals Dan Foster at the National Review points out

“This is essentially the same as an insurance company refusing to pay for someone’s essential medical care because that person never bought insurance in the first place.” And I don’t mind living in that kind of society at all.

Over at Reason. to go a step further, it

 begs the question who does pay in the hypothetical medical care situation above. If the patient doesn’t have insurance and can’t pay, his costs are spread to other (paying) patients, or to charities or to taxpayers eventually. Is any of that just? Moral? If it’s charity paying, certainly so. If it’s other folks, there’s a lot more to debate.

But according to the essayist it is really a straw man because

 There is very little denial of “essential medical care” in the United States if we’re talking about emergency room visits and the like. The real question in this variation is the definition of essential. Does it mean basic medical care (of the sort provided by any number of free and low-cost programs) or does it mean the level of care one presumes a Nobel laureate, tenured professor, and NYT columnist gets? I know very few people – even libertarians – who are against the provision of free and reduced-price medical care (the libs will rightly suggest that philanthropy rather than state bureaucracy is more cost-effective and efficient).

As someone who works in a “safety net” hospital I can report that being expected to put out fires on people who aren’t paid up is very expensive, especially when your competition takes all of the paid up folks. Despite what people believe in theory, in practice to treat really sick people you have to purchase medications, nursing care, physician time and other infrastructure. Try treating someone who comes to the emergency department in diabetic ketoacidosis with prayer and a stethoscope instead of a $20,000 a day ICU. In addition, rebuilding a house is easily accomplished as opposed to dealing with the sequelae of preventable illness such as a stroke. I hear repeatedly that almost everyone is for “emergency care.” I would like to see those who favor emergency care provided by well-intentioned good Samaritans come forward with proposals for how to pay for it.  In addition, what do we do with the people who because they have made some poor choices (food and shelter in lieu of medication, for example) are rendered unable to function because of disability. What is the healthcare equivalent of sleeping in a tent or moving to an apartment?

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