[thomasthomas]

Thanks to the ACA, a larger share of Americans have health insurance than ever before

because its compulsory. this shouldn't an argument for the ACAs effectiveness. I have to buy car insurance if i choose to drive a car on public roads. i have to pay income tax if i have income. now, by birth, i automatically owe the state. i'd like my freedom and right to choose back please.

the fact this isn't the main argument from GOP shows their incompetence.

[burkaman]

You actually don't owe the state anything if you can't afford health insurance. So similar to income tax, you can choose not to work and you won't have to pay the penalty.

And of course, it's not by birth, you owe nothing if you're dependent on someone else.

[felipellrocha]

If, you chose to gamble with your life, and end up not being able to afford medical treatment in the future one of two things ends up happening. You actually notify your doctors before hand that you don't have money, and will elect to not receive any treatment and follow through with your gamble, or someone else will pay for your treatment for you. Most likely every other person who can afford to pay for their treatment via raised prices (which will, in turn, remove more people from the market, more people will gamble, raising prices further in a spiral).

Which option do you think is more likely to happen?

[rrock]

Which is, of course, exactly what happens: those with insurance subsidize those without. Why do you think a simple bandage or ibuprofen costs so much on insurance? To cover those that walk into hospital ERs, uninsured. It's a hidden tax, highly inefficient, but quite real.

[dlp211]

You pay for private insurance or you pay for public insurance via taxes. Any other solution is unworkable and you are a free rider.

[DougN7]

The fact that we have to buy such expensive insurance is what burns me. Before ACA my family had good options for an individual plan (I'm self employed). Now we must pay $20K/year, and don't even get much benefit until we've spent another $5K out of pocket. The scope is what I don't like.

[thomasthomas]

i'd like the choice to not have any insurance

[nyxtom]

That's not a sustainable choice for our economy, it leads to too many people living like nothing could possibly go wrong until they need a doctor. The point of insurance is to distribute risk, not participating in that effectively negates the effectiveness of the industry.

[lend000]

The whole idea of health insurance is backwards and inconsistent with a free market in my opinion (fraudulent). The problem is that the government has enshrined it as the gateway to healthcare.

Insurance is a useful product for mitigating risk, so accident insurance could be a very constructive concept (protecting against accidental injuries, broken arms, falls, car crashes, etc.). However, health problems are not a risk; they are a guarantee with probability approaching one as you age. The whole point of insurance is that you mitigate risk by paying more than you take out on average, but that doesn't make sense for healthcare, where almost everyone ends up going over their limit near the end of their lives.

If we didn't have all of these subsidies everywhere and inflated demand from Medicare/Medicaid/restrictive occupational licensing/FDA-granted monopolies/ACA, then perhaps we could pay everything out of pocket, which would make a lot more sense.

[mikeash]

The basic concept of health insurance works fine. Yes, your probability of dying approaches 1 as you age, but the costs you incur along the way can vary enormously. Somebody who's wonderfully healthy until they instantly die in bed of a heart attack will cost the insurer basically nothing, while somebody with a chronic condition can easily cost millions of dollars over decades. Costs can vary enormously depending on your luck, which is just the sort of thing insurance is good for.

There are big problems with running the whole system using insurance, of course. It's fairly easy to predict future costs for a lot of people. Given free reign, insurers will charge completely unaffordable premiums to those people, effectively excluding them from the system. You see the same thing with other types of insurance: if you have a horrible driving record, or if your house is in an area that gets a devastating hurricane every ten years, your premiums will be huge. The difference is that those are optional activities, and if you can't afford the premiums then you can walk, bike, hitch a ride, buy a different house, etc. A sick person can't switch to a healthy body.

That's why the ACA has the mandate. If you require everyone to pay in, then you can also require insurers to ignore certain predictors of future risk when determining premiums.

Fundamentally, there are only two choices. One choice is to have lots of people dying of easily treated conditions because they can't afford the treatment, and the other choice is to have government step in and socialize the system to some extent. The system was already socialized before the ACA with the Emergency Medical Treatment and Labor Act, which requires hospital emergency rooms to treat all patients regardless of ability to pay. This was horribly inefficient, of course, but that's how it was.

So: choose your poison. If you think the advantages of going full free market in health care outweigh having poor people die of easily treatable diseases, then that's a valid opinion, but you should acknowledge the negative consequences. If you want poor people to be able to obtain treatment, then you'll need to accept some interference, the only question is how you'd like to have it be structured.

Edit: rather than "poor people," I really should say "people whom the hospital thinks are poor." If you get beaten up and mugged and left for dead, the ER won't know if you have money, and might decide not to take the risk. There are good reasons for even a selfish wealthy person to want some form of universal treatment.

[lend000]

> If you think the advantages of going full free market in health care outweigh having poor people die of easily treatable diseases, then that's a valid opinion, but you should acknowledge the negative consequences.

How does one lead to the other? Social safety nets are not mutually exclusive with removing a lot of other market barriers. See my prior comment on this thread -- our healthcare market is the most distorted in the world (even when compared to 'universal healthcare' countries). Freer market means 'easily treatable' conditions are cheap, as opposed to our current system where they are expensed behind oppressively occupationally licensed practitioners selling monopolized medical products, where a 10 minute checkup with a dermatologist out-of-pocket is nearly $500. But regardless, it is certainly an interesting, quantifiable argument (albeit hypothetical) that a 20% speed increase medical innovation in a free market could be measured against lives saved with today's medicine in a socialized system, assuming that system makes services as affordable/accessible as intended.

Here's the reason health insurance as an industry can be considered fraudulent, especially when it's generally the gateway to all healthcare access -- and why ACA fails to fix it. Pre-existing conditions and re-adjusted contract rates.

If there was one company and one client, they could certainly craft a perfectly sound insurance contract to pay a set rate with steady increases over X years in exchange for coverage in the event of future, currently unascertainable medical services. But if you are responsible and get insurance BEFORE you get sick (by the way, not much sympathy for those who do not and demand that insurers take them, since that's the whole point of insurance), you are effectively tied to this contract and can never again negotiate another of equal value after you have been diagnosed with a condition, even though your initial/current contract already priced in the risk of getting those conditions. In fact, the rates to cover your risk, which need to be higher on average than the amount of healthcare you actually use, become ridiculous quite quickly. This problem is amplified by the fact that the government thought it was a good idea to tie healthcare to employers, so people switch very frequently and therefore are forced to renegotiate contracts frequently, robbing them of lost value that would be acquired if they were able to ride out the original contract.

So to say health insurance is inherently fraudulent is hyperbole, but in the current setup, it functionally is, because it is non-transferrable. ACA attempts to address this problem by subsidizing those who do not make much money and forces insurers to take everyone, but this just adds artificial demand (due to the subsidies especially) up to the amount of the maximum subsidy and raises everyone's rates (although those who are subsidized will see somewhat lower rates), and does nothing to address risk renegotiation, especially since it includes people who never had a contract. Similar economic effect as student loans/student aid. Each dollar increase in student aid raises tuition by over 40 cents... the rest is probably distributed across student housing, amenities, textbook prices, concert prices in college towns, etc.

A better way to eliminate the fraud, while still limiting ourselves to an insurance-dominated system, would be to legally codify standards for contract negotiations, which would allow contracts to be traded/transferred between companies, effectively locking in your risk at the time you first get uninterrupted insurance (and perhaps some protections for temporary uninsured periods).

[dllthomas]

I agree that we far too often conflate "health insurance" and "health care".

That said, while in some sense "health problems" are guaranteed, the range of costs involved is huge.

[MR4D]

That's not quite true. For instance, life insurance takes a varying times for it to kick in (varies depending on type and amount, as well as which state's laws apply.)

It's quite possible that your health insurance could be limited at first, and grows to cover more things and higher dollar amounts.

And before anyone says you can't do this, go look at your dental insurance. Odds are that your coverage increases each year so long as you have two checkups annually and don't let a lapse of insurance occur.

Note that as the ACA is __currently__ written, the situation the OP states probably exists.

[dlp211]

And what happens when you're 18 and get cancer? Building up may work for dental because even in the most catastrophic case, the costs have a ceiling, but your overall health doesn't have these kinds of ceilings. Also, every dental plan I have ever had has lifetime maximums, something else that doesn't work with health insurance.

[mikeash]

I've never heard of anyone getting hit with a million-dollar bill for dental work, so I don't think that's quite the existence proof you want it to be.

[antisthenes]

Actually that's not what makes it expensive. It leads to too many people making very poor health choices and becoming obese or engaging in palliative care to eek out 2 more miserable weeks of existence at enormous costs to healthcare providers.

Young people, and especially young, healthy people are the ones subsidizing the elderly and the unhealthy, including most of those who are unhealthy by choice through poor decisions.

> The point of insurance is to distribute risk

Perverse incentives. Insurance needs to be structured in such a way as to incentivize people to take part in preventive care, which costs a fraction of treatment and palliative care.

[db48x]

You're making the assumption that nobody could possibly pay for their health care out of pocket. That's just not true, even with health care as expensive as it is these days.

[dlp211]

With the exception of the most wealthy (ie, Bill Gates), I guarantee that there is a health issue that would bankrupt you. Also, if you are that wealthy, why wouldn't you insure your health? It would be a pittance compared to your overall wealth and just simply a prudent thing to do. I bet you that Bill Gates and Warren Buffet have health insurance.

[d_e_solomon]

Just to be sure - if you show up at the hospital w/o means of payment - even if in coma - are you going to be treated? If yes, then you have insurance and you're free-riding on the system. If no, then you're more barbaric than Reagan.

[mikeash]

How will you ensure that paramedics won't take you to the hospital if you have a sudden event in the street?

[rrock]

I'd like for you, along with everyone else, to pay an increased income tax to cover health care for everyone (the way every other industrialized country does it).

And before you reject that notion, try asking someone from one of those other industrialized countries if they'd like to swap their system for ours.

[toodlebunions]

You have that choice right now.

[67726e]

Or you pay a hefty tax penalty. Hardly "free"

[runamok]

They definitely did push back against the mandate and that was one of the arguments that went to the supreme court. http://www.nytimes.com/2012/06/29/us/supreme-court-lets-heal...

Furthermore all of us are consumers of health care at one time or another. I admit I am resentful against the many people that take terrible care of themselves but the fact is 40% of americans will get cancer. http://www.upi.com/Health_News/2010/05/06/41-percent-of-Amer...

Due to laws like this: https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an... and of course for ethical reasons hospitals can't turn you away when you can't pay.

I do feel it all needs urgent reform but I do feel the ACA was an attempt to expand competition and fairness while not leaving it completely unfunded like so many government plans seem to.

[nyxtom]

Choosing to not be insured is unsustainable for our economy the moment you have an issue and need a doctor.

[thomasthomas]

so i shouldnt have the right to choose?

[CamperBob2]

As long as the rest of us don't have the right to let you die on the sidewalk outside the ER, no, I'm afraid you shouldn't have the right to choose not to participate.

If you want to go off the grid, you need to go ALL the way off the grid. Otherwise you're just another moocher.

[Turing_Machine]

This is a false dichotomy, which assumes that the only possible alternatives are Obamacare and no insurance at all.

Not to mention that the majority of people who do have Obamacare are getting subsidized by the government (i.e., they're "moochers", in your terminology).

How does making this public subsidy pass through more sets of pockets before it gets to the doctor make it any less "mooching"? Please be specific.

Also, what about the people with expensive preexisting conditions? Virtually all of those people are consuming far more resources than they will ever pay in. Are they also "moochers"?

Note that I'm not saying that those people shouldn't have health care. I'm just objecting to calling it "insurance", because it isn't. Insurance is a bet.

[dlp211]

> This is a false dichotomy, which assumes that the only possible alternatives are Obamacare and no insurance at all.

No it isn't, the parent poster made no judgement about the system available, just that one must participate. What that system looks like is an entirely different debate to the "I should be able to not have insurance" debate.

> Also, what about the people with expensive preexisting conditions? Virtually all of those people are consuming far more resources than they will ever pay in. Are they also "moochers"?

That is the entire point of insurance. Some will pay more than they take and others will take more than they pay, but in the end, both sides of the ledger for the collective is balanced and both individuals had the same* access. *for some loose definition of same.

[Turing_Machine]

"That is the entire point of insurance"

If you are allowed to buy "health insurance" after you are already sick, it's not "insurance" at all. Sorry, it just isn't.

Do you also think that you should be able to buy fire insurance after your house is already on fire, or car insurance after you've already had the accident?

Note again, and note well, that I'm not saying that people who are already sick should be abandoned. That is a real problem and one which should be addressed. I'm saying that bundling them into an "insurance" program makes no sense whatsoever.

It makes even less sense when you bundle them into Obamacare, the other users of which tend to be poor. I mean, they weren't able to afford insurance before... and now they're expected to not only cover their own costs, but the costs of all those with preexisting conditions? How did anyone expect that to work?

If you insist on funding the preexisting folks by charges on another risk pool, it probably should be done across the board (i.e., by charging the costs of the preexisting folks to all recipients of health insurance, not just the ones unfortunate enough to be stuck with Obamacare). That, at least, would have spread those costs over a much larger pool.

[nyxtom]

No, because at some point you will inevitable need care. We build care systems in place and pay into them to mitigate and distribute risk. You are effectively free-riding on everyone else's participation.

[MR4D]

So by choosing not to work, you can effectively choose, but by choosing not to have insurance you cannot?!?

Your logic makes no sense in the current environment. If I'm unemployed and can't afford it, I'm free riding.

So yes, you should be able to choose. If for no other reason than you already can (by not working).

[maxxxxx]

You should have the right. But you also should not get any kind of treatment under any circumstances if you don't pay upfront.

[dlp211]

While I don't disagree in principle, this is impossible to enact. Consider the case where this person who has chosen not to have insurance is in a car accident and render incapable of communicating. Responders and those at the hospital must act under the assumption that the victim has insurance and do everything in their power to save them.

In this situation the person in the accident can later claim that they didn't want to be saved and thus owe nothing. We, that is the rest of us who participate, are then forced to carry this cost and they free ride.

[maxxxxx]

I guess he needs a tattoo?

[seanmcdirmid]

In a country in china where they ask for insurance and/or payment at the hospital door, sure! You have the right to pay or die.

In western countries where we have deemed that immoral, you will be treated, and we would like not to pay for you.

[grzm]

You've now made this same point three times in this thread without expanding your argument. Please make each comment each add substantively to the discussion.

[thomasthomas]

because i recognize the futility in expanding my argument which a philosophical one thats been going on for centuries. no ones going to change their minds. if you'd like my expanded argument you should start with 'the road to serfdom' by hayek but i wont attempt to summarize it for you here on HN.

[grzm]

It sounds like you do have something useful to contribute if you chose to do so. If you feel it's futile to contribute substantively, please refrain from doing so. Otherwise it's just noise and distracts from potentially useful discussion.