[alpinisme]

Insurance that is maximally responsive to patient health changes in terms of cost (ie making healthier people pay less) ends up being an inefficient way of just having people pay for their healthcare directly.

And it naturally means the people with highest premiums are the least likely to be able to afford it (the elderly, the disabled, those with chronic conditions that make them less likely to maintain high earning jobs steadily, etc)

[Workaccount2]

The obvious retort to this is:

"If I focused on my health, ate clean and exercised daily, why should I also be subsidizing Billy "video-games-are-my-exercise" fatass's chronic health conditions?"

This is why there is a hyperfixation on shifting blame away from (failing) individuals. The logic breaks when Billy has to admit he just hates exercising.

And yes, before you comment, I know "maybe Billy has (condition outside all control) so it's not on him". Please, see what I just said in the previous statement.

[ImPostingOnHN]

The entire purpose of health insurance is spreading risk across a wide and diverse risk pool.

> why should I also be subsidizing Billy "video-games-are-my-exercise" fatass's chronic health conditions?"

Nobody is asking you to: enrolling in insurance is a choice in the USA.

Also, replace "chronic health conditions" with "unavoidable inherited genetic risk factors". We don't want Billy to be screwed for life just because he was born to a suboptimal combination of parents.

[Workaccount2]

The most cataclysmic thing that could happen to healthcare would be chronically healthy individuals creating their own health insurance.

[ImPostingOnHN]

Not really (in fact that doesn't even make sense), but in any case, I think you replied to the wrong post. Your reply doesn't seem to have anything to do with the post it replied to

[Workaccount2]

You said enrolling in insurance was a choice. If everyone with a BMI under 22 who did at least an hour of cardio a week had their own health insurance club, they would be doing excellent with cheap premiums and great care, while everyone else drowned in medical debt as their plans collapsed.

The choice right now is all or nothing. There is no choice for healthy people to only share a plan with other healthy people. If there was, everyone else, especially the least healthy, would be totally screwed.

[ImPostingOnHN]

I am still having trouble understand how that pertains to the post to which it replied. Here are those 2 points again:

1. In the US, enrolling in health insurance is currently a choice (I'm can't tell whether your hypothesis about healthy people is agreeing or disagreeing with this point).

2. We don't want Billy to be screwed for life just because he was born to a suboptimal combination of parents.

Would you mind clarifying the connection here, please?

[alpinisme]

In some respects, the ideal world is one in which everyone’s premiums are tied to a free and easy Apple Watch-like device that silently tracks exercise, blood sugar at a frequency that can tell when you ate a big dessert, air quality (and the presence of smoke or pollution), blood alcohol content, whether you are in speeding cars, whether you are participating in dangerous sports, etc. Such a system would directly confront individuals with the cost of their behaviors in an economic way, probably leading many or even most people to improve their habits in the aggregate.

But such a system comes at other costs that most people intuitively feel infringes on core values they have.

Edit to add: this system would actually have some great advantages over an “existing conditions” tax in that now you pay low rates until you have diabetes, all during the time you are leading the unhealthy lifestyle. But once you have it you are not rewarded for starting to exercise and eat healthy and get it under control. In the hypothetical scenario above, you’d be punished economically during the period you were building bad habits and you would be able to restore sane costs after course correction

[Terr_]

There's a similar phenomenon when people grouse about paying taxes for "roads I don't even use." Even if we assume zero indirect benefits, the billing infrastructure necessary to truly achieve that goal would create a creepy panopticon of constant surveillance.

This is difficult to convey to certain brands of self-styled libertarians.

[tonyedgecombe]

> creepy panopticon of constant surveillance

Which we have anyway. We might as well get some benefits from it.

[xigoi]

The government already knows whether you have a car. What more information would they need?

[duskdozer]

It also fails to take into account the fact that eating clean and exercising daily doesn't eliminate your risk of getting cancer at age 40 or having your car's brakes fail randomly.

[Workaccount2]

Its dumb to create an insurance program using anecdotes.

The system can accommodate (and frankly is the ideal many people strive for) some health nut getting long drawn out cancer battle at 41. Its rare enough to be noise in the giant money payout pool.

Obesity and it's litany of health effects are not rare, and next to age, are a dominating signal drawing money from the pool.

[OverTheTetons]

Is the obvious retort to this:

I don't think we should play arbiter for who has and hasn't lived a healthy enough life to still believe they should get healthcare?

[Analemma_]

Yeah, I think what Workaccount2 is not realizing is that there's no bottom to "you have higher risk factors, why should I pay for you?", and so once you start down that way you may not like where it ends up. Some hobbies have higher injury rates, why should I pay for your health care if you choose to play those? Some parts of the country have lower life expectancies, why should I pay for your health care if you choose to live there?

[Workaccount2]

The actual realization, which usually comes years after the realization that there is no bottom, is that there is no top either.

The battle along the spectrum of privatizing gains (lower healthcare premiums for a healthy lifestyle - high premiums for unhealthy lifestyle) vs socializing losses (paying $20/mo to get $1200/mo of care - paying $1200/mo for $0/mo of care) is constant and boundless in either direction.

[ben_w]

But there is a bound in both directions?

On end, it's "national insurance", functionally equivalent to fully-tax-funded healthcare like the NHS or the German system with several providers competing but regulated to near identical results, but moreso as the UK and Germany also has private care; on the other, it's the absence of insurance.

[Workaccount2]

This is a macro problem larger than health insurance, and exists everywhere from employee bonuses, high school group project grades, handicap parking, gas prices, Everest summits, to gas prices.

Those might all seem wildly disconnected, but they all have systems of unfair allocation to compensate for unequal outcomes.

Generally national healthcare programs are entirely dependent on young healthy people paying into the system despite rarely needing it, and then hopefully enough dieing quick deaths or having multiple children to cover their costs. These rebalancing systems are artificial and humans are generally terrible at managing them.

[FireBeyond]

> "If I focused on my health, ate clean and exercised daily, why should I also be subsidizing Billy "video-games-are-my-exercise" fatass's chronic health conditions?"

Then why are you not asking your insurer why they cover a lot less preventative health or other options. For example, Kaiser flat out refuses to prescribe GLP-1s for weight loss, others insurers are the same with gym subsidies or not covering nutritionists.

But they'll happily pay for your gastric bypass.

[IanCal]

> Insurance that is maximally responsive to patient health changes in terms of cost (ie making healthier people pay less) ends up being an inefficient way of just having people pay for their healthcare directly.

That's true for predictable costs, but not true for unpredictable ones - which is the point of most insurance (housing, car, etc). The point and use of insurance is to move risk to entities that can bear it.

Utility is non-linear with money, and so you easily have situations where spending X times more on something "costs" you more than X times if measured in how useful the money is to you.

Typically, as you have more money, each further dollar doesn't provide as much benefit as the last (sometimes things are lumpy, the difference between "not quite enough to pay rent" and "just enough to pay rent" is huge, but broadly this is true). Going from $1000 to $10000 is more impactful than $1001000 to $1010000.

That means that moving the other way, each additional dollar spent has a greater personal cost to you.

Therefore, sharing unlikely but high expenses can mean that your expected cost is the same (if there's no profit/middleman) or a bit higher, but your expected personal cost is lower.