This past weekend has seen a lot of DOC heat over Type 2 Diabetic and former Arkansas Governor Mike Huckabee's analogizing signing up for medical insurance with a pre-existing condition to trying to insure a home after it has been completely burned to the ground, or a car that has been completely totaled. Our peers have been enraged at the idea that Governor Huckabee is discounting productive lives to the point that, if the analogy were allowed to be continued, we should be completely culled from society (read: euthanized) -- either at the point of diagnosis, or at the point at which we can no longer pay the cost of our medical upkeep ourselves.

Traditional insurance is a sort of parimutuel betting against risk, and the insurance company is the betting agent. Consider the (statistical) risk of Russian Roulette. With six participants, one spin, and a six-shooter, there is a 1/6 chance that any one participant will die. Let's make it non-lethal: instead of pointing the gun at their head, the players agree to shoot the gas tanks of their cars. The live bullet will cause an explosion. If each car cost $6000, and each person participating paid $1000 to play (with the loser receiving the entire pool of money), then the cost of replacing the destroyed car would be completely covered by the entrance fees and (except for the damaged car and the risk to firefighters), no harm would have been done. This is the way insurance works.

Today's health insurance is something different. We pay into a combined bargaining and risk pool to get lower prices on routine care, as long as we use the providers who have agreed to these lower prices, and as long as we agree with the pool's limitations on what it will provide for us (for example, syringes and insulin, but not pens or pumps). It's as if they shopped at Sam's World or COSTCO:  bargain prices on bulk-compatible items, but retail price for everything else. We also accept the pool's limitations on what services it will provide, at what rates, for various acute medical issues. And because the pool covers risk, it promises us a certain degree of rate-reduction for the chronic medical issues it discovers, since our caring for the chronic issues may lower its down-the-road costs for related acute issues.

The key to making this all work is understanding and managing costs and managing risk.

Let's start with the idea that a person who has no diagnosed illnesses (acute or chronic), fits the "healthy" metabolic profile for his (or her) height, age, and gender, and has no known genetic risk factors in his family tree out to, say, 200 years, is "physically perfect". Let's also say that this person is "lifestyle perfect" (eats a healthy and calorie-appropriate diet, exercises regularly, etc.). By these criteria, this person should be of very low risk for developing any chronic conditions (such as heart disease, diabetes, or cancer) and therefore, barring an unfortunate accident or a new, highly-destructive disease (e.g. Legionnaire's Disease, AIDS, West Nile Virus, etc. which have all popped up in the last 30 years), should have very low medical costs through most of his life. This person will very likely be paying into the system, but requiring very little from it other than the bargained-for rates for health maintenance. Using Governor Huckabee's "car" analogy, this would be like buying a new car direct from the manufacturer, complete with all its warranties, dealer-service package, and so on, and only driving it within the parameters of a standard lease.

Once a person has a chronic medical condition, the costs of care rise. This is kind of like driving 20,000 miles a year in a car that is only warranteed for 10,000 miles a year -- or a car that had already been in a "fender-bender". There will be more wear on the body, the engine, and/or the tires, and you'll have to change the fluids more frequently. In short, it will cost you more to ride that car -- and if you wished to trade it in two years down the road, that wear would give it a lower value than the "cream puff" that had only been driven 10,000 miles throughout its life.

If you were buying a used car, you would expect that the car with 50,000 miles on it (or had been in an accident) would cost you more in maintenance than an identical model with only 20,000 miles on it and no accident history. If someone were going to reimburse you for the costs of driving that car, you would require that person to pay you more money to cover those higher costs.

Going back to insurance, you would expect an insurance company to charge higher rates to someone who lived in an area where his car was more likely to be stolen, or a driver who has a track record (pardon the pun) of car crashes, because that greater risk implies a greater likelihood that the pool will have to pay out to that particular person.

And so it used to be with medical insurance for people with chronic illnesses, and so it should be. We may not be completely-burned-down houses, or totaled cars -- both of those analogies suggest that we are already dead -- but we are, in effect, damaged. We have much greater wear-and-tear on our bodies' basic systems than someone without these conditions. Without proper maintenance, the damage will increase until it does kill us. But just as we have to pay our mechanics more to service our well-worn-but-beloved cars, we should have to pay our healthcare providers (or their agents, our insurance companies) higher rates based on our relative risk and our higher demand for goods and services.