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Editor's Correspondence
October 26, 2009

When History Really Is Not Applicable or Relevant

Arch Intern Med. 2009;169(19):1806-1818. doi:10.1001/archinternmed.2009.364

We wish to respond to the Commentary “A 300-Year-Old Solution to the Health Care Crisis,”1 in which the authors present an interesting analogy between fire insurance in London in the late 1600s and today's health care system in the United States, particularly between the incentives for insurers in both cases.

The Commentary is thought provoking but the analogy and arguments fail to provide any fresh insights into how we might solve the current health care crisis. The analogy fails in 2 critical aspects. First, the incentives stated (reduced risk exposure and cost control and increased profits) for prevention and for effective and efficient fire fighting that property/casualty insurers had in London are absent for US private health insurers. This is because private health insurance companies and insurers can reduce their exposure to risk, control costs, and increase profits by other means such as “cherry picking,” denying claims (as the authors note), or by reducing reimbursements. Second, a medical emergency (eg, myocardial infarction or stroke) does not lead to another in the same manner as one house on fire can burn down the neighboring house. In cases where such an event can happen (ie, epidemic, natural disasters), governments are acceptably better equipped to deal with it than independent private insurers.