> The ACA introduced no cost controls and just shifted the costs around from 1 demographic to another (mostly to the lower-middle and middle class healthy peopl

> The ACA introduced no cost controls and just shifted the costs around from 1 demographic to another (mostly to the lower-middle and middle class healthy people, who don't actually use much health care). In a lot of ways that's exactly what insurance is. It's pooling resources to cover expenses for the people who need it. In any given time period most people won't need it, or won't need it to an extent higher than their contributions, but it's there just in case. There's variation in premium amounts to account for the difference in likelihood of need (so those younger generally-healthier people pay lower premiums), but a very important part of making it work is having a large enough pool that only a limited percentage needs to use it each year. There are also measures that were taken to try to reduce costs, but how effective they were may be up in the air. The only one I can name offhand was the requirement that insurance companies spend at least 80-85% of revenue on medical expenses. At least one person noted that might also lead to higher costs (via overpaying to let that overhead grow), though I think that that's the kind of problem that market factors would actually address - if you're overpaying, that money has to come from somewhere so you're also charging higher premiums and will shed customers as they seek cheaper insurance. Other cost-cutting measures have been killed off through effective lobbying (e.g. Medicare being barred by law from negotiating drug prices, introduced back with Medicare Part D and the Donut Hole). And yes, the general fitness level of Americans is pretty poor. Unfortunately, addressing that is more of a public health matter, and since the onset of modern medicine public health has been more and more relegated to a secondary role. Interestingly, some insurance companies seem to be trying to revive non-medical measures to improve the health of their customers through things like discounts for fitness assessments, fitness programs, etc. The assessments and advice resulting from them may make a difference, but even just the embarrassment factor of being unfit and going for one may help change behaviors. I'll just note that in general, obesity is different from anorexia - fat people realize they're fat, are often concerned or embarrassed about it, and a large percentage of them would like to be be if not thin at least a lot less fat.