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DuVal's Axioms

This month's column is dedicated to the memory of Merlin K. "Monte" DuVal, MD, a giant in the field of Arizona health care who passed away recently at the age of 84.

Monte was a friend and mentor who took me under his wing when I arrived in Arizona in late 1995. I knew something about setting up and running foundations, but very little about health policy, the field in which I now spend most of my time. Monte helped to shape my interests and sharpen my thinking. He provided me, in the form of his character and experience, with an ethical and intellectual prism through which to view the complexities of this always interesting, and occasionally disturbing, field. He was a role model for me and many others, and he will be sorely missed.

Monte reminded me of my father, who used to hold court round the dinner table and instruct his children in the finer points of philosophical argumentation. While my mother corrected our grammar, my father would pose a question, seek a reply, and then ask, "What makes you believe that?" So it was that I grew up thinking philosophical discourse was a normal part of family life, and carried on the tradition with my own family and in my professional career. I soon discovered that not everybody enjoys arguing or taking the contrary position just for the sport of it. This includes my wife, who is not shy about telling me to put a lid on it when I go too far and begin to alienate the guests.

But not Monte. He loved to engage in spirited debate and would often call me after reading something we had published and say, "What in the world are you thinking?" We spent many an hour talking about health policy and all sorts of issues, and I always found it challenging, informative and just plain fun. "You're not bad for a young man," Monte would joke. "You'll learn."

A few years ago, I invited Monte to speak to students in a health policy course I was teaching at ASU. He presented his top ten health care axioms and invited the students to poke holes in them. I don't think he would mind if I repeated them here and, in the spirit of open inquiry, invited readers to do the same:

1. If the issues are access, quality and control of costs, you may have any two but not all three of them.
   
   
2. All nations ration health care, whether by price, diagnosis (benefits), eligibility or constraining manpower or facilities.
   
   
3. Once good quality is present, to increase access must necessarily result in increased costs.
   
   
4. Public goods, such as education or medical care, are non-depletable resources -- they are not consumed as a result of their being used.
   
   
5. Public goods cannot be distributed equitably in a marketplace characterized by competition over price.
   
   
6. When one is sick, one wants the best. Only those who are well complain about costs.
   
   
7. We often do things because we can rather than because we should. Use is a function of availability.
   
   
8. If similar health care services are rendered through public and private programs simultaneously, the public programs will always be the victim of adverse selection.
   
   
9. To survive, an insurer must either have a monopoly or must cherry-pick from among its risks.
   
   
10. To profit excessively beyond the actual cost of rendering services to those who are ill is immoral.
    
    

Monte called me the day before he passed away to give me his new address and telephone number in Tucson. "I'm leaving Phoenix, but we'll still get together," he said in parting. "We'll be talking with you about a plan to insure all Arizonans over the next few years."

I can think of no greater goal we could pursue to honor and extend Monte's memory than to do just that.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.