I wrote an overview post on the National Flood Insurance Program (NFIP) that is linked below; read that first. While that program is important in its own right, this week I am writing a series of posts considering what the 43 year old history of the NFIP could mean for health policy, with special emphasis on Medicare.
- Overview of National Flood Insurance Program
- NFIP and Health Policy-1: Why were NFIP and Medicare passed?
- NFIP and Health Policy-2: Distribution of risk in NFIP and Medicare
Today’s post addresses the question: who is responsible for mitigating risk in the NFIP and in health care? Since the inception of the NFIP, three principles have guided this program:
- identification of risk and the development of maps that delineate flood risk (roughly 5 risk bands, with elevation serving as a risk adjuster within bands)
- flood plain management, designed to mitigate risk of flood
- the provision of flood insurance for uninsurable properties
Austin noted yesterday via twitter (@afrakt) that the development of the risk assessment maps necessary for premium setting of federal flood insurance has had other benefits, namely enabling and encouraging mitigation of risk via flood plain management (levees, dams with release capabilities to control watershed water flow, requirements to build dwellings on stilts in some areas, and the like). Mitigating flood risk was an explicit goal when the NFIP was created in 1968. Clear identification of areas at extreme risk have enabled other mitigation efforts, for example local codes requiring that manhole covers/entrances to sanitary sewers be a certain elevation with respect to a predicted flood level (in Durham, N.C. they apparently must be higher than the water level of the 100 year flood; it is possible this is a state regulation). I am not an expert in flood plain mitigation, but it seems clear that the early-1970s identification and classification of areas by risk of flood that was brought about by the passage of the NFIP in 1968 has enabled a great deal of mitigation by federal, state and private entities that has reduced the risk of flood loss.
What about the role of mitigation of harm in health care? This one flummoxed me. There are both many responsible for mitigation of risk and at the same time, no one is actually responsible. This could be a long post, but instead I am just going to sketch some general categories.
- The individual. All of us have responsibility for, and can influence our health, within bounds. There are certain behaviors that are associated with poorer health outcomes, but there is no guarantee of a good outcome if we avoid such behaviors, and no guarantee of a poor outcome if we engage in bad behaviors. And of course everyone eventually dies. Individuals and groups have known barriers to undertaking activities that could be understood as prevention or mitigation of risk, but the individual bears some responsibility to mitigate health risk in our own lives.
- Basic public health from which you cannot opt out. I recall a professor from my school of public health training noting that the most effective preventive measure ever devised was the systematic removal of feces from drinking water. After this, he noted, everything else paled in terms of bang for the buck. Chlorination of water, meat inspection, restaurant and food service sanitation grading and monitoring, are all examples of health risk mitigation that occurs whether you want it or not (public good).
- Health regulations from which you can opt out. Vaccinations are the classic example of a public health function that are delivered or provided through a variety of settings such as local health departments, private physician offices, workplace health fairs, and the like. States have laws requiring vaccination to attend public schools, and going to school often triggers compliance. However, religious exemptions are granted for vaccines, some cannot be vaccinated due to health reasons, and some persons avoid public schools and so are not vaccinated. Also included in this category are broad health information campaigns from government or foundations aimed at encouraging healthy behaviors (don’t smoke, wear a bike helmet, gun safety, etc.) and which may be avoided and which also have uncertain efficacy.
- Excise taxes. Products such as tobacco and alcohol are subject to excise taxes, and the increased cost reduces use. In some cases, a portion of the funds from such taxes may be used to fund programs designed to further mitigate/prevent harm, such as via smoking cessation or prevention campaigns, which are efforts that fall in the category above (regulations from which you can opt out).
- Insurance companies. They have some incentive to invest in health, but at younger ages, the fact that persons tend to change jobs and therefore health insurance lessens this motivation (if company A invests this year, perhaps company B reaps the benefits down the road). Medicare has a clearer incentive, but likely gets involved much too late for some efforts. Still, payment policy for things like vaccines and screenings should be viewed as mitigating risk of disease, however there are a variety of questions about efficacy and cost effectiveness. It is key to identify the goal of such prevention efforts if one wishes to evaluate them: to improve health, decrease costs, or both? Update: Austin’s great post of this morning is relevant here.
Identification of flood risk by the NFIP has clearly enabled and spurred mitigation of flood risk, which is a benefit that was a specific motivation of creating the program. Further, the NFIP can mandate the purchase of flood insurance for certain properties at great risk, forcing financial protection upon the property owner. The boundaries of who identifies risk, and who has responsibility to mitigate risk are fairly clear in flood insurance. Further, success is clear: avoiding flood, and providing for the financial protection against same if it does take place.
The concept of mitigating health harm is inherently more complicated in almost every way. Outside of basic public health services focused on clean drinking water and the food supply, the responsibility for mitigation of health harm is more diffuse, the efficacy is more uncertain, and the goal not as clear (save money, improve health, both?). What constitutes success? The notion of flood invokes images of protecting ones property against an outside force (nature), while mitigation of health risk outside of the broadest public health examples often seems to encompass individuals and other interested parties seeking to motivate a variety of types of change, that often boil down to us being at war with ourselves–knowing there are things we should do, but having trouble doing them.