In rural Obion County, TN, residents have to pay $75/year to buy into the fire protection service. But the fee is not mandatory. There’s no automated system for collecting it (like payroll taxes) and residents can choose to pay or not, or they can simply forget to pay. But if they don’t pay the fee, firefighters will not respond if their house is on fire. Gene Cranick learned that lesson the hard way when his house burned to the ground last week because he had not paid his $75 fee. The fire department came to the scene when a neighbor (who had paid the fee) called because he was concerned that the fire was threatening his property. They protected the neighbor’s property, but did not attempt to fight the fire that destroyed Cranick’s home.
I imagine that it must have been extremely difficult for the firefighters to ignore the fire, but they were operating under orders to do so. If the fire department had put out the fire despite the fact that Cranick hadn’t paid his fee, their ability to collect the fee in the future would be hampered. As it stands now, my guess is that most of the rural residents in that area are now current on their fire protection fees, if they weren’t as of last week. The fire department sent a strong message, and did exactly what they had said they would do. But they have been roundly criticized for doing so, and most Americans seem to find it very objectionable that the fire department carried through on their promise that people who didn’t pay the fee would not have access to fire department services.
I wonder how things would have been different if the $75 fee had been mandatory, collected via the tax system, and passed on to the fire department on behalf of everyone in the county?
For me, the parallel to health care is obvious in this situation.
Although the PPACA was signed into law six months ago, there are ballot initiates, lawsuits, and political campaigns all over the country right now that are based on repealing the individual mandate portion of the reform law (although people don’t seem to have any problem with the portions of the law that require insurers to accept everyone without medical underwriting starting in 2014). Those who are opposed to the mandate claim that people should be free to decide whether they want to have health insurance or not, and that if people choose to pay out of pocket for their health care (instead of having health insurance), they should be allowed to do so.
In our current health care system, ambulances are dispatched to help sick and injured people without the dispatcher having any knowledge of whether the person is insured, or whether the person has the means to pay for the ambulance fees. In addition, emergency rooms cannot turn away a critically ill patient because of payment issues. They have to stabilize the patient regardless of whether the person is insured or has the means to pay for care. Beyond that, payment is definitely an issue. Doctors and hospitals can refuse to provide on-going care (even for life threatening conditions) for patients without the ability to pay, and this does often come up in the news. But the initial ambulance ride and treatment to prevent an imminent death in the emergency room are available to everyone in this country, regardless of financial situations.
What if this were not the case? What if ambulance dispatchers had to check to see if a person was insured before sending an ambulance, or else collect payment from the patient (or the patient’s family) before the paramedics could begin working on the person? What if emergency rooms started securing payment before beginning treatment on critically ill patients? I imagine that there would be a public outcry similar to what we’re seeing in reaction to the house fire situation. But instead, emergency rooms continue to have to write off bills every day because their patients don’t always have insurance or any way to realistically pay for the care they have received.
People who are opposed to the individual mandate say that we should all be able to choose whether we want health insurance or not, and opt instead to pay out of pocket for health care if and when we need it. But the problem with health care is that even a healthy person can rack up huge medical bills without much warning. Yes, we can plan for things like a new car or a college eduction for our children. We can save money each month to cover predictable expenses, and we can save relatively large amounts of money if our time frame is long enough. But realistically, very few Americans have the means to pay for several days in the ICU, or even a single major surgery, without health insurance.
When people choose to not have health insurance (I’m not talking about people who can’t afford it, since there are programs like Medicaid and the subsidies included in the PPACA to help make health insurance affordable), what guarantee do health care providers have that they will be paid for treating those individuals? Are we comfortable with allowing emergency services providers to turn away patients who are uninsured and cannot pay upfront for their care? If we are not, then the rest of us are paying for their care (indirectly, through higher health insurance premiums). And if we are, we find ourselves right back in the debate about whether it’s ok for firefighters to watch a house burn to the ground because the homeowner didn’t pay his fire protection fee. It seems that we all like having choices until we make the wrong choice one day.