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Had the ACA gone further and actually provided a single payer system, I'd consider the block on denials based on preexisting conditions a win. As it is we have

• b3ing 1y ago
  Blame Joe Lieberman for that one.
• matthewdgreen 1y ago
  Health insurance that can discriminate against people based on pre-existing conditions rapidly becomes health insurance you can’t use. Sure, it’ll be cheaper for a few years. Then, with non-negligible probability, you’ll develop a serious condition. At that point the cost becomes anywhere between “high” and “infinite”. If the point is just “private insurance is dumb”, sure, I mostly agree.
  • _heimdall 1y ago
    It isn't insurance if the provider can't consider risk factors for the policy though. If we don't want people's health to be dependent on insurance that's fine, but we should replace it with a system that isn't based on risk at all rather than bastardizing something that still sort of looks like risk-based insurance.
    • ethbr1 1y ago
      > It isn't insurance if the provider can't consider risk factors for the policy though. Insurers are welcome to consider risk factors... for populations in aggregate. It turns their actuarial models into population-subset models instead of individual models. Which is easily the most "fair" (to individuals) option. Allowing insurers to consider individual risk factors (preexisting conditions, genetics, etc.) would make the advertising data mining industry seem quaint. And I don't think any American wants to live in that world. So we can talk about whether insurers should be able to offer lifestyle incentives (yes!), preventative care incentives (yes!), and be backed by catastrophic reinsurers (like mortgages, maybe)... but enrolling people blindly is one of the best things ACA did. (Unless one happens to be young, rich, family-less, healthy, and have no moral compunction about fucking others over for ones own benefit) Also, important unremarked benefit of ACA -- capping maximum insurer "administration" costs. Firsthand from inside the industry as it was implemented, I can tell you that drove efficiency improvements inside insurers, as they couldn't bill for broken, slow, manual processes in additional premiums. Granted, it caused other problems (attempts to self-deal and harvest profits through quasi-related provider / pharmacy entities or Medicare Advantage), but it did focus insurers on being efficient facilitators.
      • mothballed 1y ago
        It's also quite convenient that the contributor group (youngest adults with very little time spent to acquire wealth) are basically subsidizing the richest groups (older adults but still young enough to be on private health care). It's effectively a regressive tax, transfer from the poorer to the richer, due to the way ACA caps the price spread.
      • _heimdall 1y ago
        Where do you draw the line on individual vs population subset risk levels? The insurer must decide what subset (s) of the population a person fits into, preexisting conditions are a factor that would almost certainly weigh heavily on the risk factor for that subset. Are you proposing that it is irrelevant with regards to an individual's risk if they have diabetes, for example? Or are you simply arguing that we aren't comfortable with the costs it would require for an individual with diabetes to get health insurance if that factor is considered? I fall into the latter personally and would prefer a real solution to health care that isn't some form of insurance. As long as it is insurance, though, the former seems impractical.
• lotsofpulp 1y ago
  >Had the ACA gone further and actually provided a single payer system, I'd consider the block on denials based on preexisting conditions a win. Your other option was to continue as things were, with fewer people getting less healthcare. Would that have been more of a win?
  • _heimdall 1y ago
    Yes, either we have a risk-based insurance system or we have a single-payer system that isn't insurance at all. Being stuck in the middle is worse than both extremes in this case.
    • lotsofpulp 1y ago
      How is it worse when more people have received access to more healthcare? Or is that also in contention?
      • mothballed 1y ago
        I'm not sure if it's in contention, but efficiency is also important. Life isn't an optimization for health care. At the middle class and below, people are already spending most their earnings on essentials. Maybe you can alter healthcare so people are paying through the nose (either through highly regulated private entities coupled with incentives/mandates, or through taxes) but more people are covered, and so now they are less able to afford housing, good education, healthy foods, child care, and other stuff. Then they are not necessarily better off.
      • _heimdall 1y ago
        Is your only metric for success the number of people technically covered by a healthcare program? That seems easily gamed and doomed to fail.
• philistine 1y ago
  Wonderful point of view to consider people as akin to cars.
  • abustamam 1y ago
    It's an analogy. They are not comparing the worth of a human being to a car. They're saying that someone else's high risk should not increase your premium.
    • philistine 1y ago
      I stongly disagree with the premise that someone else's high risk should not increase your premium. How do you control your insurer? How do you know who's in their pool?
      • _heimdall 1y ago
        Why should your premium be tied to someone else's risk? There will always be some level of connection, the insurer has to stay in business, but that's very different. Without preexisting conditions your premiums go up only because they can't charge the higher risk individual for that risk. That is no longer insurance at least at the individual level - you're effectively being asked to vouch for, and pay for, someone you never met.
        • philistine 1y ago
          > you're effectively being asked to vouch for, and pay for, someone you never met. That is the basic premise of insurance. Collectivized risk. That you disagree with a specific detail in the implementation and that part, and that part only is vouching for someone else is undermining your point, not reinforcing it. Everyone in the developed world has injected government heavily into healthcare, because its the lynchpin of a healthy and efficient workforce. That's the real solution.
          • _heimdall 1y ago
• NeutralCrane 1y ago
  > All that means is the companies charge everyone else more to subsidize the cost of those who are more at risk. Literally the purpose of insurance
  • Ancapistani 1y ago
    Huh? The purpose of insurance is to mitigate the risk of a very costly but unlikely outcome by paying a smaller amount over time, thereby spreading that risk among those of similar risk. Not being able to consider individual risk means that insurance makes no sense for those with a low risk profiles, because they’re in the same cohort as those who will _definitely_ file claims.
    • array_key_first 1y ago
      Cohorts are based off of your employer, because we, inexplicably, tied health insurance to your employer. If you work for a very young and hip company then no, your cohort might not file claims. There's levels of broken-ness to healthcare in the US. Even if you allow health insurance to discriminate based on health conditions, it will still be broken in other ways.
      • _heimdall 1y ago
        That's one way, true. I've mostly been considering the ACA here and those getting coverage that can't get it through an employer. Employer health insurance rates fan still get wonky for small businesses though. It probably can't happen today, but I was at a small business where everyone's rates went up shortly after one person was diagnosed with cancer and another one or two with diabetes. That is an example of it not really being individual insurance though. The insurance company is just lumping the employees together and setting rates based on the relative risk of the whole group, not dissimilar from getting an individual policy where the rates are based on a group of one.
    • laterium 1y ago
      How do you propose we address adverse selection in insurance markets then? That's the part you're overlooking and making you go "Huh?". It's clear to everyone else.
• SilasX 1y ago
  >As it is we have a system of private "insurance" that can't consider the risk level of those being insured. All that means is the companies charge everyone else more to subsidize the cost of those who are more at risk. That's what social insurance/welfare systems do throughout the developed world -- make sure everyone's covered at some minimal level even if it wouldn't be profitable when evaluated individually; it's just using insurance companies as an arm of the state to pull it off. If, as it seems, your only objection is to labeling it "insurance", that's not a substantive objection to the merit of the policy, only how it's marketed.
  • _heimdall 1y ago
    What you're describing isn't insurance. There's nothing wrong with that and maybe (probably) its better than what the US has today, but if it claims to be insurance than it must be allowing the insurer to consider the risk of each policy it writes.
    • SilasX 1y ago
      I don’t see where I was disputing that point.
• randerson 1y ago
  Your neighbor buying a Porsche was a choice they made. Nobody chooses to have a pre-existing condition. We're also talking about a luxury vs simple survival. I am not sure how you can compare them. What insurers in some countries do is charge higher premiums for people who engage in high-risk behaviors, like smoking, drinking, or extreme sports. Those are all choices so it seems fair to charge a sin tax for them. Higher premiums would discourage risky behavior and improve the health of the country as a whole.
  • _heimdall 1y ago
    > Nobody chooses to have a pre-existing condition Are you sure about that? Plenty of medical conditions are the result, at least in part, of decisions a person makes. A person with lung cancer seeking health care could very well have smokes for decades. A person with type 2 diabetes may very well have eaten poorly for decades. Obviously those aren't always directly linked to life choices, but they often can be.
    • randerson 1y ago
      Nobody _intentionally_ signs up for a pre-existing condition. Whether a past action caused a condition, sure, but where do you draw the line? If you become disabled in a car accident, despite knowing full well that accidents can happen, should you be denied insurance in future because you did something risky? What if you were a smoker for the decades when cigarette companies suppressed the research about how bad it was? Also, how would you even prove that a condition was self-inflicted? My old dog had lung cancer despite (to my knowledge) never smoking (and nor did anyone else in the household). I lost a close family member to liver cancer despite being a lifelong teetotaller, but how would anyone even prove that? The moment you start means-testing people, you're adding a whole lot of extra cost to taxpayers and stress for patients. Denying healthcare to the most vulnerable members of society is simply cruel. It is kicking them when they're down. Having the condition is punishment enough. We can do better than that.
      • _heimdall 1y ago
        That's simple though. For insurance the line is drawn at how expensive it will likely be for a private company to insure you over the course of your policy. It doesn't matter if someone intended for a decision to lead to higher risk, the only question at the point of signing an insurance policy is how risky that private company views the policy. The whole insurance debate often feels misplaced. Many people simply don't want healthcare to depend on an insurance system. And I get that, I also would rather people be able to get the care they need regardless of their individual risk. As long as we have anything claiming to be insurance that simply isn't how the system works. If the game is insurance the insurer should be able to consider individual risk. If we don't want that, build a system that isn't dependent on an insurance scheme at all.
• laterium 1y ago
  How do you address adverse selection then? There's no private insurance where you don't address adverse selection. Either you force everyone to have coverage: ie car insurance in US or universal health insurance systems or you force them to get insured in groups (US employer based insurance), or you accept outrageously expensive rates for it. Healthcare already being expensive doesn't make it amenable to that last option unlike insuring your laptop where you might be okay paying 2-5x the expected loss for peace of mind. Criticizing the method of addressing adverse selection is fine, but not the existence of it. You need something. There's no such thing as completely free market of health insurance. Any economist can easily explain this to you.