ObamaCare Implosion

[Jrr85]

I agree that everyone is covered, but take issue with the idea that it will actually be cheaper.

I don't understand what is driving this belief for you. Other countries spend less than us. The GAO study concluded we'd save money too. What are you basing the "it will cost more" statements on?

The GAO study compared the U.S.'s system to Canada's system and basically said if we restricted care like Canada, and paid our doctors less, we'd see similar spending to Canada, which is pretty hard to argue with.  But it's not clear that such a system could feasibly be implemented in the U.S.  One, you'd never be able to outlaw private care.  You'd also have a much more politically difficult time refusing care.  The first time (and every time thereafter) that there was a sympathetic patient with a long shot chance at survival from an expesnive and/or experimental drug/procedure, you'd have TV news involved and crocodile tears and elected representatives pounding podiums at press conferences demanding that our equivalent of NICE or whatever entity makes the decisions on available care change their position. 

I also doubt you'd be able to successfully pay doctors dramatically less in a short time.  I do think we could politically manage to bring our doctor's compensation closer to being in line with other countries' physicians (never actually in line because private sector workers just make more across the board in the U.S.), but I'm not sure how long that would take.  You also couldn't do anything about facilities cost in the short term.  The hospitals are built and politically, we are not going to bankrupt hospitals and/or municipalities (for those municipalities with city owned hospitals) by suddenly reimbursing them as if they had built more spartan facilities over the past twenty years. 

Our political system basically neutered the ability of HMO's to control cost in the 90's after they successfully controlled cost in a way that was much less heavy handed than the typical government run healthcare.  I think you'd see something similar if we tried to have government step into that role.   

[2buttons]

I agree that everyone is covered, but take issue with the idea that it will actually be cheaper.

I don't understand what is driving this belief for you. Other countries spend less than us. The GAO study concluded we'd save money too. What are you basing the "it will cost more" statements on?

In a word. History. Take a look at the Medicare Sustainable Growth Rate - better known as the Doc Fix. 

The GAO report basically said that we could control costs, and curtail spending.  We have not been able to do that in medicare.  See legislation signed by the President last year. 

[Northwestie]

I agree that everyone is covered, but take issue with the idea that it will actually be cheaper.

I don't understand what is driving this belief for you. Other countries spend less than us. The GAO study concluded we'd save money too. What are you basing the "it will cost more" statements on?

The GAO study compared the U.S.'s system to Canada's system and basically said if we restricted care like Canada, and paid our doctors less, we'd see similar spending to Canada, which is pretty hard to argue with.  But it's not clear that such a system could feasibly be implemented in the U.S.  One, you'd never be able to outlaw private care.

You don't have to "outlaw" private care.  Look at say, Germany as one example.  They have multiple insurers, doctors are not employed by the government.  They control costs by having standard reimbursement rates for every procedure, doctor visit, etc.  Everyone charges the same.  Whatever system we come up with can be melded into a structure we already have in place.  We're smart - we can figure this out.  It's not impossible and it is easy to figure out a system that includes everyone and saves us money over the current profit driven hodgepodge we have now.  Politics not withstanding.

[Jrr85]

Yes it is.  Just because it can change over time doesn't mean it's not a fixed amount and if it does then "fixed amount" doesn't apply to government entities rationing care either.  Currently, you get exactly how much healthcare you are able to pay for (fixed by monetary means).  In a government run system it's possible that you may get exactly how much healthcare a government entity decides is necessary (fixed by a government entity).  A government entity could theoretically change what services are available to you at the same rate that your stash changes what services are available to you.  I see no difference between the two scenarios other than how the decision is made on what services are available at any given time.

Also, the bolded part is imprecise.  It doesn't matter how much I'm willing to pay, only how much I currently have available to pay.

You can change the definition of what rationing means and all that accomplishes is to make it a little more wordy when people explain the difference between the government rationing resources versus a pricing mechanism being used to allocate resources. 

Again, whatever you want to call it, there is a big difference between the two and playing semantic games with the definition of rationing doesn't impact the difference.   

[shenlong55]

Yes it is.  Just because it can change over time doesn't mean it's not a fixed amount and if it does then "fixed amount" doesn't apply to government entities rationing care either.  Currently, you get exactly how much healthcare you are able to pay for (fixed by monetary means).  In a government run system it's possible that you may get exactly how much healthcare a government entity decides is necessary (fixed by a government entity).  A government entity could theoretically change what services are available to you at the same rate that your stash changes what services are available to you.  I see no difference between the two scenarios other than how the decision is made on what services are available at any given time.

Also, the bolded part is imprecise.  It doesn't matter how much I'm willing to pay, only how much I currently have available to pay.

You can change the definition of what rationing means and all that accomplishes is to make it a little more wordy when people explain the difference between the government rationing resources versus a pricing mechanism being used to allocate resources. 

Again, whatever you want to call it, there is a big difference between the two and playing semantic games with the definition of rationing doesn't impact the difference.

I understand why people feel like semantic arguments are distractions, but I disagree.  Often I find that figuring out the differences in semantics between me and a rhetorical opponent can lead to a better understanding of our differences.  To that effect, can you explain to me the difference since I'm not seeing it?

[BTDretire]

A plan that sorta approximates my employer subsidized plan is
$2251     Gold Compass 500
Deductible $500.00/Person/Year    Max $6850/Person/Year

OK, sounds like you have an upper tier program.
I never looked into any high end policies, so can't comment.

The exchange will show you an estimated subsidy for a given income level.
I iterated thru the ones below, mid to upper 80s is either a sweet spot
or a calculation bug.


Income   Subsidy
-------  -------
 50000     1056
 60000      949
 75000      765
 80000      698
 82000      670
 85000     1045
 87000     1017
 90000      975
 95000      902
100000      842
110000      761
120000      681
130000      600
140000        0

Something weird going on, I don't think there is supposed to be a sweet spot.
 I see the cutoff is $94,200 for a family of four. 
Maybe you went higher because (ISTR) you have a family of 6?
 I ran the numbers for my family of four and got a straight line decrease of subsidy.

Income     Subsidy
50000     1,217
55,000    1,155
60000      1088
65000      1021
70000       949
75000      889
80000      849
85000      808   
90000      768
95000      728
100000    000 

None of this is accurate, because it is based on income not MAGI (Modified Adjusted Gross Income)
which is how the subsidy is calculated, when the IRS is done telling you what your subsidy really is.

 
 

[Jrr85]

Yes it is.  Just because it can change over time doesn't mean it's not a fixed amount and if it does then "fixed amount" doesn't apply to government entities rationing care either.  Currently, you get exactly how much healthcare you are able to pay for (fixed by monetary means).  In a government run system it's possible that you may get exactly how much healthcare a government entity decides is necessary (fixed by a government entity).  A government entity could theoretically change what services are available to you at the same rate that your stash changes what services are available to you.  I see no difference between the two scenarios other than how the decision is made on what services are available at any given time.

Also, the bolded part is imprecise.  It doesn't matter how much I'm willing to pay, only how much I currently have available to pay.

You can change the definition of what rationing means and all that accomplishes is to make it a little more wordy when people explain the difference between the government rationing resources versus a pricing mechanism being used to allocate resources. 

Again, whatever you want to call it, there is a big difference between the two and playing semantic games with the definition of rationing doesn't impact the difference.

I understand why people feel like semantic arguments are distractions, but I disagree.  Often I find that figuring out the differences in semantics between me and a rhetorical opponent can lead to a better understanding of our differences.  To that effect, can you explain to me the difference since I'm not seeing it?

I'm not sure what you're asking here?  If you asking why the verb "ration" is not properly used to describe the voluntary exchange of goods and services, it's simply because "ration" has a meaning and connotation and neither of them lend themselves to describe the voluntary exchange of goods and services.  I would be that you virtually never see the verb "ration" used to describe the manner of allowing a price mechanism to allocate resources.  I also would be that at virtually all times, rationing is used in a manner where there is some authority performing the action.  If you use the word "ration" as a synonym for "allocate", you might be able to fit that in the technical definition, but people would not understand what you are saying.  If you say resources are rationed based on the choices of individual consumers and suppliers in the economy, most people would assume you had inadvertently chosen the wrong word.   

If you are asking what's the difference between rationing goods and services by government fiat versus allowing a price mechanism to be used to allocate those goods and services, it's basically the difference between Venezuela and Switzerland.  It's the difference between pulling into a gas station and quickly filling up and paying for your gas versus sitting in a line for two hours to get a quarter of a tank.  It's the difference between emergent order and top down planning.  There may be some results some individuals don't like, but all in all, it's proven to be a good system. 

[Northwestie]

It's very commonly used in this manner:

https://en.wikipedia.org/wiki/Healthcare_rationing_in_the_United_States

https://www.verywell.com/what-is-healthcare-rationing-2615389

http://www.rwjf.org/en/library/articles-and-news/2012/10/rwjf-scholar--u-s--rations-health-care--too.html

[stoaX]

Oh - we ration health care in the US.  By financial ability.  Don't kid yourself.

If you are on the lower rungs of the financial ladder and have a near-minimum wage job with no benefits you likely are not going to spend money on preventive care rather than food for the kids.  Meanwhile - a typical middle class person has benefits along with a better paying job and can manage to take the kids to the doc for checkups, etc., and can manage the co-pay.
 

One of the provisions of the ACA that went into effect several years ago mandated that all ACA compliant plans pay for preventive care visits in full - no copays, deductibles or coinsurance apply to visits coded as preventive.

http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/

[Jrr85]

It's very commonly used in this manner:

https://en.wikipedia.org/wiki/Healthcare_rationing_in_the_United_States

https://www.verywell.com/what-is-healthcare-rationing-2615389

http://www.rwjf.org/en/library/articles-and-news/2012/10/rwjf-scholar--u-s--rations-health-care--too.html

Any examples outside of healthcare, where it's part of a political argument?

[shenlong55]

I'm not sure what you're asking here?  If you asking why the verb "ration" is not properly used to describe the voluntary exchange of goods and services, it's simply because "ration" has a meaning and connotation and neither of them lend themselves to describe the voluntary exchange of goods and services.  I would be that you virtually never see the verb "ration" used to describe the manner of allowing a price mechanism to allocate resources.

I'm asking what difference you see between a private healthcare system and a government run healthcare system, besides the authority that gets to make the rationing decisions.  Also, just because a word is not currently used in a particular context does not mean that it does not fit that context.

I also would be that at virtually all times, rationing is used in a manner where there is some authority performing the action.

Correct.  In the case of free market policies, that authority is the "invisible hand" of the market.  Personally, I'm not convinced that the market is best authority in this instance.

If you use the word "ration" as a synonym for "allocate", you might be able to fit that in the technical definition, but people would not understand what you are saying.  If you say resources are rationed based on the choices of individual consumers and suppliers in the economy, most people would assume you had inadvertently chosen the wrong word.

If you are asking what's the difference between rationing goods and services by government fiat versus allowing a price mechanism to be used to allocate those goods and services, it's basically the difference between Venezuela and Switzerland.  It's the difference between pulling into a gas station and quickly filling up and paying for your gas versus sitting in a line for two hours to get a quarter of a tank.

That doesn't follow.  Nothing about rationing inherently implies that you would have to wait around for anything.  You may believe that that is a difference, but it's not a given.  If low wait times are a priority for us, then we can design around that.

It's the difference between emergent order and top down planning.  There may be some results some individuals don't like, but all in all, it's proven to be a good system.

Again it comes back to which authority you think can better make rationing decisions in regards to healthcare, the market or the government.  Can you make a case for why emergent order is inherently better that top-down planning in this instance?

[Northwestie]

Ummm, you don't think there is major cost shifting going on in the current, non-Medicare insurance business??   Hospitals are charging you and me and folks with insurance quite a bit more to deal with the uninsured.    If we went to some Medicare for all system we also would need some cost containment. 

Right now the cost of say, a hip replacement, varies widely for no apparent reason.   In other countries, even those that depend on a network of private insurers such as Germany, there are standards applied for procedure costs.   You, as a consumer, can't even find out how much most procedures will cost you prior to going into the hospital for crying out loud.  We have the crappiest health care system around - unless you have money if you are poor/under or unemployed.

Exactly my point in your first paragraph.

Germany covers 89% of the population - 11% (the super rich) opt out of the crappy   supplement the state insurance scheme and pay for private insurance.

Actually this is wrong.  The higher income folks don't "opt out" they merely purchase supplemental insurance, just as one can do with Medicare.   Fixed that for you.

[CanuckExpat]

IN fairness, usually when I see these types of comments, people are trying to look at a program that works in a relatively small, homogeneous country like a nordic country and claim that it will work in the U.S., which is certainly a suspect claim.

Can you explain this to me please?  What about being a large, non-homogeneous country means that universal healthcare won't work?

Don't say it too loud because it riles people up, but the US already has socialized medicine, it just breaks down like this:
If you are 65 or older and the government provides healthcare, it's as America as apple pie.
If you are 64 or younger and the government provides healthcare, it's godless communism.

[Northwestie]

I don't know - maybe an aging boomer population will put some pressure on the system for some kind of change - maybe not though as they will be covered by Medicare.  Seems that expanding Medicare is the most logical start though.

[2buttons]

Ummm, you don't think there is major cost shifting going on in the current, non-Medicare insurance business??   Hospitals are charging you and me and folks with insurance quite a bit more to deal with the uninsured.    If we went to some Medicare for all system we also would need some cost containment. 

Right now the cost of say, a hip replacement, varies widely for no apparent reason.   In other countries, even those that depend on a network of private insurers such as Germany, there are standards applied for procedure costs.   You, as a consumer, can't even find out how much most procedures will cost you prior to going into the hospital for crying out loud.  We have the crappiest health care system around - unless you have money if you are poor/under or unemployed.

Exactly my point in your first paragraph.

Germany covers 89% of the population - 11% (the super rich) opt out of the crappy   supplement the state insurance scheme and pay for private insurance.

Actually this is wrong.  The higher income folks don't "opt out" they merely purchase supplemental insurance, just as one can do with Medicare.   Fixed that for you.

Nope, you are wrong. They opt out of the social health insurance funds. Go read about it. Its actually a big deal, because you cannot get back into the public option very easily once you are out.

[Northwestie]

Thanks -- I did read about it - but misread it -- you are correct - about 11% use a private insurer INSTEAD of the government system.  My mistake.

[2buttons]

Yeah, I was a little surprised that 50k euros a year was the threshold. You would think it would be higher. But there is a forced health savings through the premium that is government mandated.

I think the Japanese have done a better job with our system than we have, US style system with compulsory insurance.

Had Democrats and Republicans come together on ACA, I wondered if we would have ended up with something closer to that. Coulda woulda shoulda.

[JetBlast]

I thought some in this discussion might find this link interesting regarding fixing Obamacare.

http://fivethirtyeight.com/features/insurers-can-make-obamacare-work-but-they-need-help-from-congress/

[MustachianAccountant]

Yeah, I was a little surprised that 50k euros a year was the threshold. You would think it would be higher. But there is a forced health savings through the premium that is government mandated.

I think the Japanese have done a better job with our system than we have, US style system with compulsory insurance.

Had Democrats and Republicans come together on ACA, I wondered if we would have ended up with something closer to that. Coulda woulda shoulda.

This really bothers me too.
I was thinking about it this morning. The whole ACA thing turned into a huge partisan political fight, instead of the politicians working across the aisle for the good of all the American people. They were literally playing a political game using people's healthcare as a pawn. And for what? I don't even know what the end game was. It certainly wasn't a good healthcare system.

[deadlymonkey]

Yeah, I was a little surprised that 50k euros a year was the threshold. You would think it would be higher. But there is a forced health savings through the premium that is government mandated.

I think the Japanese have done a better job with our system than we have, US style system with compulsory insurance.

Had Democrats and Republicans come together on ACA, I wondered if we would have ended up with something closer to that. Coulda woulda shoulda.

I would second this.  As someone who lived in japan for years (although not in the Japanese system, although lots of friends were), costs were low, people had no issue going to the doctor for issues or preventive care.  They tended to have a healthier lifestyle (except for smoking), but that is likely cultural. 

[Jrr85]

Yeah, I was a little surprised that 50k euros a year was the threshold. You would think it would be higher. But there is a forced health savings through the premium that is government mandated.

I think the Japanese have done a better job with our system than we have, US style system with compulsory insurance.

Had Democrats and Republicans come together on ACA, I wondered if we would have ended up with something closer to that. Coulda woulda shoulda.

This really bothers me too.
I was thinking about it this morning. The whole ACA thing turned into a huge partisan political fight, instead of the politicians working across the aisle for the good of all the American people. They were literally playing a political game using people's healthcare as a pawn. And for what? I don't even know what the end game was. It certainly wasn't a good healthcare system.

It didn't really even have anything to do with reaching across the aisle, as they didn't have to reach across the aisle.  The problem is that there wasn't even agreement among democrats at what they wanted to do, other than say they passed healthcare reform.  You had some heavily involved people looking to make Obamacare a trojan horse for single payer.  You had some heavily involved people actually trying to reduce third party payments and sever the link between health insurance and employment (which would be more republican/conservative/libertarian ideas if included in a coherent package).  You had some that just wanted to use it to get redistribution done that wouldn't be politically feasible outside of the context of healthcare.  And again, most of them just wanted to pass it so they could say they passed healthcare reform (the "we have to pass it to find out what's in it caucus").  So we ended up with an incoherent mess.  Even for people that want to move in more of a market oriented direction (which includes me), what we ended up with is probably worse than if Democrats had just committed to moving to a statist direction and dropped the sham market stuff.   

[Scandium]

That's it. That's the entire reason the US is such an outlier.
I can't even.
EVEN IF that were true, countries with "socialized" health care spend more money on PREVENTION than we do, because when you spend money on prevention, the costs are less down the road - and since the taxpayers are footing the bill, there is an incentive to spend less on preventable issues. There is no incentive for prevention in our current system.

I often  wonder about this oft-cited number. What does "medical spending" mean? Is that government outlays, or insurance payments? Both? Does it include private spending on electrives, or insurance premiums? Frankly, as a taxpayer the only number I care about is government spending. How much insurance companies or hospitals spend don't bother me.

So, does the US government spend more or less than the UK government per capita?

One problem I have comes exactly from your last sentences. Once the government pays everything, it can justify any and all forms for control over your personal lifestyle (even more than now); eating, exercise, risk-taking etc etc. Every once of sugar of fat you eat is now something the government can justify controlling, "for the common good". "It's a direct cost!" Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc. But if we all pay the same into the system how do we do that? AFAIK other countries don't, instead the have stupid things like high sugar/fat/beer tax, banning soda and invasive nanny state nonsense.

[Jrr85]

Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc.

Actually, I don't think it's legal to risk rate for anything other than smoking.  They can also do limited risk rating for age, but way less than what would actuarily be required.  That's why it's so important to get young and healthy people into the exchange.  They pay rates that are much more than if they were risk rated to make up for the artificially low rates for people that are not young or not healthy. 

[Scandium]

Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc.

Actually, I don't think it's legal to risk rate for anything other than smoking.  They can also do limited risk rating for age, but way less than what would actuarily be required.  That's why it's so important to get young and healthy people into the exchange.  They pay rates that are much more than if they were risk rated to make up for the artificially low rates for people that are not young or not healthy.

Exactly, and that's the problem. Smoking is a choice, being fat is a choice, doing extreme sports is a choice. If you do these things you should pay more. Getting cancer is not (except if from aforementioned smoking). Maybe there should be some $/BMI premium system, or something. BMI would cause extremely fit, muscular people to look fat, so maybe bodyfat %? But something. I'm young, eat healthy and work out. I have no interest (or IMO moral obligation) to pay for fat, lazy people. I will however gladly pay for people who just get cancer through no fault of their own.

[GuitarStv]

Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc.

Actually, I don't think it's legal to risk rate for anything other than smoking.  They can also do limited risk rating for age, but way less than what would actuarily be required.  That's why it's so important to get young and healthy people into the exchange.  They pay rates that are much more than if they were risk rated to make up for the artificially low rates for people that are not young or not healthy.

Exactly, and that's the problem. Smoking is a choice, being fat is a choice, doing extreme sports is a choice. If you do these things you should pay more. Getting cancer is not (except if from aforementioned smoking). Maybe there should be some $/BMI premium system, or something. BMI would cause extremely fit, muscular people to look fat, so maybe bodyfat %? But something. I'm young, eat healthy and work out. I have no interest (or IMO moral obligation) to pay for fat, lazy people. I will however gladly pay for people who just get cancer through no fault of their own.

It's very hard to filter out / charge more for unhealthy people.  You can be wildly unhealthy and skinny.  You can be carrying an extra 30 - 40 lbs and be in pretty great health.  Some smokers live well into their 90s.  Generally public health care systems don't even bother to try to address this.

Imperfect ways to charge people who use the system more:
- mandatory body fat percentage and aerobic capacity measurements.  (extremely expensive to measure and complicated to enforce)
- Sin taxes on cigarettes, junk food, soda, etc. to cover the costs of increased hospitalization rates (not entirely fair, you could be in great shape and want a coke)

[Jrr85]

Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc.

Actually, I don't think it's legal to risk rate for anything other than smoking.  They can also do limited risk rating for age, but way less than what would actuarily be required.  That's why it's so important to get young and healthy people into the exchange.  They pay rates that are much more than if they were risk rated to make up for the artificially low rates for people that are not young or not healthy.

Exactly, and that's the problem. Smoking is a choice, being fat is a choice, doing extreme sports is a choice. If you do these things you should pay more. Getting cancer is not (except if from aforementioned smoking). Maybe there should be some $/BMI premium system, or something. BMI would cause extremely fit, muscular people to look fat, so maybe bodyfat %? But something. I'm young, eat healthy and work out. I have no interest (or IMO moral obligation) to pay for fat, lazy people. I will however gladly pay for people who just get cancer through no fault of their own.

It's very hard to filter out / charge more for unhealthy people.  You can be wildly unhealthy and skinny.  You can be carrying an extra 30 - 40 lbs and be in pretty great health.  Some smokers live well into their 90s.  Generally public health care systems don't even bother to try to address this.

Imperfect ways to charge people who use the system more:
- mandatory body fat percentage and aerobic capacity measurements.  (extremely expensive to measure and complicated to enforce)
- Sin taxes on cigarettes, junk food, soda, etc. to cover the costs of increased hospitalization rates (not entirely fair, you could be in great shape and want a coke)

Not really that hard.  You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information (and once everyone starts doing it, be as good as it as other insurance companies).  Pretty sure just an age, height, weight, body fat%, cholesterol test, medical history, and how often do you smoke, how often do you use illegal drugs, and how often do you drink would get you decent mileage. 

[GuitarStv]

Now we can (and should) just jack up the premiums for smokers, fat people, bungee enthusiast etc.

Actually, I don't think it's legal to risk rate for anything other than smoking.  They can also do limited risk rating for age, but way less than what would actuarily be required.  That's why it's so important to get young and healthy people into the exchange.  They pay rates that are much more than if they were risk rated to make up for the artificially low rates for people that are not young or not healthy.

Exactly, and that's the problem. Smoking is a choice, being fat is a choice, doing extreme sports is a choice. If you do these things you should pay more. Getting cancer is not (except if from aforementioned smoking). Maybe there should be some $/BMI premium system, or something. BMI would cause extremely fit, muscular people to look fat, so maybe bodyfat %? But something. I'm young, eat healthy and work out. I have no interest (or IMO moral obligation) to pay for fat, lazy people. I will however gladly pay for people who just get cancer through no fault of their own.

It's very hard to filter out / charge more for unhealthy people.  You can be wildly unhealthy and skinny.  You can be carrying an extra 30 - 40 lbs and be in pretty great health.  Some smokers live well into their 90s.  Generally public health care systems don't even bother to try to address this.

Imperfect ways to charge people who use the system more:
- mandatory body fat percentage and aerobic capacity measurements.  (extremely expensive to measure and complicated to enforce)
- Sin taxes on cigarettes, junk food, soda, etc. to cover the costs of increased hospitalization rates (not entirely fair, you could be in great shape and want a coke)

Not really that hard.  You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information (and once everyone starts doing it, be as good as it as other insurance companies).  Pretty sure just an age, height, weight, body fat%, cholesterol test, medical history, and how often do you smoke, how often do you use illegal drugs, and how often do you drink would get you decent mileage.

You and I have a very different idea about what constitutes hard then (also you are much more comfortable with government intrusion into your personal life than I am).  What you're proposing is that each person in a country be subjected to:
- a lengthy visit with a doctor or technician
- body fat measurement (unspecified if this is via calipers - which are quite unreliable, or full body immersion and density calculations - which is expensive)
- blood work for a cholesterol test
- blood work and lung biopsy to determine amount of smoking
- blood work for every illegal drug on the market (pot, cocaine, heroin, lsd, etc.)
- liver biopsy and blood work to determine amount of drinking

This of course would have to be administered on a regular basis because people change behaviors regularly . . . so what, every three months or so?

It's also ignoring many other things people do that greatly increase risk of injury.  The further that you live from your work the higher premium you should pay.  The same is true of your distance from a hospital.  If your job involves interaction with chemicals (too many jobs to list), radiation (some lab techs, people who work in nuclear plants), disease (medical work, farm work), breathing in fine dust (mining, wood working), etc. you are a greater risk and certainly should pay more.  Your hobbies (if you have a motorcycle license you should pay more, if you go skiing regularly you should pay more, if you enjoy boxing you should pay more, if you own a gun you should pay more).


At some point you have to really ask yourself:
- is this worth the cost?
- is it really going to be fair in the end anyway?

[Jrr85]

Not really that hard.  You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information (and once everyone starts doing it, be as good as it as other insurance companies).  Pretty sure just an age, height, weight, body fat%, cholesterol test, medical history, and how often do you smoke, how often do you use illegal drugs, and how often do you drink would get you decent mileage.

You and I have a very different idea about what constitutes hard then (also you are much more comfortable with government intrusion into your personal life than I am).

  It only involves government intrusion if you have a crazy system where government for some reason is the health insurance provider. 

What you're proposing is that each person in a country be subjected to:
- a lengthy visit with a doctor or technician

   Probably about 30 minutes.  If you can do it for life insurance, seems like you could do it for health insurance. 

- body fat measurement (unspecified if this is via calipers - which are quite unreliable, or full body immersion and density calculations - which is expensive)

  Again, you don't have to be perfect, you just have to be better than doing nothing.  If calipers are worse than BMI, then you use BMI, unless BMI is worse than nothing. 

- blood work for a cholesterol test

     Pretty easy to do.

- blood work and lung biopsy to determine amount of smoking
- blood work for every illegal drug on the market (pot, cocaine, heroin, lsd, etc.)
- liver biopsy and blood work to determine amount of drinking

       Why in the hell would you think any of this?  You just do a questionnaire as part of the 30 minute visit with a technician (or more likely, as part of the application).  You lie about smoking and end up with lung cancer or another cancer with higher risk due to smoking, and you've screwed yourself.  Lie about drinking and end up with alcohol caused cirrhosis of the liver, you've screwed yourself.   

This of course would have to be administered on a regular basis because people change behaviors regularly . . . so what, every three months or so?

   People don't change behaviors that regularly.  How many people do you know that started smoking after age 22?  Started drinking after age 30?  Doing illegal drugs after age 30?  But regardless, 3 mos is way too often.  Behavioral issues that you survey could be asked once a year at renewal.  The bloodwork would ideally be one time, and once you're covered and stay covered, you can't be rerisk rated for anything other than age.  That's actually somewhat complicated to work out in a way that allows people the flexibility to change plans while also preventing gaming the system where people move to more comprehensive coverage when they start to think they are going to have more need for healthcare.  And of course a lot of the stuff like cholesterol and blood pressure can be complicated because it can be behavior related or not. 

It's also ignoring many other things people do that greatly increase risk of injury.  The further that you live from your work the higher premium you should pay.  The same is true of your distance from a hospital.  If your job involves interaction with chemicals (too many jobs to list), radiation (some lab techs, people who work in nuclear plants), disease (medical work, farm work), breathing in fine dust (mining, wood working), etc. you are a greater risk and certainly should pay more.  Your hobbies (if you have a motorcycle license you should pay more, if you go skiing regularly you should pay more, if you enjoy boxing you should pay more, if you own a gun you should pay more).


At some point you have to really ask yourself:
- is this worth the cost?

  Or maybe phrase it something along the lines of saying " You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information "

- is it really going to be fair in the end anyway?

  The goal is not to be fair.  Why would health insurance be the one place the government tries to make things fair.  We don't go around trying make things fair between tall people and short people or between good looking people and ugly people or between people with good social skills and people without good social skills or between people with high intelligence and low intelligence.  If you're worried about things being fair, you should look for an end result as a proxy.  It's sort of ridiculous to take a good looking, high IQ white guy, making $500k as a sole proprietor and say "oh my gosh; he's got high blood pressure and it's not his fault.  Are we really going to make him pay an extra $100 per month on health insurance?"  The guy will survive. 

But if you do want to give a nod to fairness, a doable way to do it would be to give everyone the opportunity to acquire non-risk rated insurance when they are 22 (or 25 or whatever young age).  As long as they get insured and stay insured, nothing matters except age (or you could add some obvious behavioral things like smoking if you'd like).  If you drop insurance, you are subject to risk rating if you try to get insurance again.  Keep medicaid so everybody can always have the option of being insured, and then you could have a barebones safety net for people that voluntarily choose to run the risk of being uninsured (as we're not going to let them die in the street) with clawback provisions where somebody with an income that gets treated for a heart attack is on the hook to pay for a long time) and also a high risk pool that allows people to get insurance if they become uninsurable after dropping insurance.  It would take some tweaking to design a high risk pool and safety net that would maximize the incentive for people to stay insured and to get in the high risk pool if they become uninsured after dropping their insurance.  You don't want it to look like a good bet to drop insurance and know that you can just rely on the bare bones safety net if you ever run into anything you can't pay out of pocket. 
 

[Gin1984]

Again, you don't have to be perfect, you just have to be better than doing nothing.  If calipers are worse than BMI, then you use BMI, unless BMI is worse than nothing. 

BMI is not an accurate measure for a large percent of the population.  Then again, neither is calipers.  Someone did tell you what was accurate, but it is extremely expensive (which you were also told).

[GuitarStv]

Not really that hard.  You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information (and once everyone starts doing it, be as good as it as other insurance companies).  Pretty sure just an age, height, weight, body fat%, cholesterol test, medical history, and how often do you smoke, how often do you use illegal drugs, and how often do you drink would get you decent mileage.

You and I have a very different idea about what constitutes hard then (also you are much more comfortable with intrusion into your personal life than I am).

  It only involves government intrusion if you have a crazy system where government for some reason is the health insurance provider.

I'm against doing this for both the government and private companies . . . as I don't think the intrusion into your personal life from the proposed ideas yields benefits to make it worth it.  I've fixed the quote above to clarify for you.

[Jrr85]

Again, you don't have to be perfect, you just have to be better than doing nothing.  If calipers are worse than BMI, then you use BMI, unless BMI is worse than nothing. 

BMI is not an accurate measure for a large percent of the population.  Then again, neither is calipers.  Someone did tell you what was accurate, but it is extremely expensive (which you were also told).

Blood Pressure and Cholesterol are not accurate measures of future healthcare expenses for a large percent of the population.  But that's not the standard.  The standard is whether they are accurate enough they allow you to more accurately price insurance, and that the savings from more accurately pricing insurance would cover the costs of doing the screening.  If they are not accurate enough to allow you to cost effectively more accurately price insurance, then you just don't do it, hence the sentence:  "If calipers are worse than BMI, then you use BMI, unless BMI is worse than nothing."

[Jrr85]

Not really that hard.  You don't have to be perfect, just better than doing nothing by enough to justify the cost of gathering the information (and once everyone starts doing it, be as good as it as other insurance companies).  Pretty sure just an age, height, weight, body fat%, cholesterol test, medical history, and how often do you smoke, how often do you use illegal drugs, and how often do you drink would get you decent mileage.

You and I have a very different idea about what constitutes hard then (also you are much more comfortable with intrusion into your personal life than I am).

  It only involves government intrusion if you have a crazy system where government for some reason is the health insurance provider.

I'm against doing this for both the government and private companies . . . as I don't think the intrusion into your personal life from the proposed ideas yields benefits to make it worth it.  I've fixed the quote above to clarify for you.

It's pretty much what you do for life insurance unless you get it through group coverage, which will typically be more expensive and have a relatively low cap on the insurance you can get before getting individually risk rated (at least in my experience).  And I'd be find doing away with it for people that get insured as soon as they are an adult and stay insured.  But if you give people the freedom to make their own decisions as to whether and when to drop and add insurance, I don't see how you can prevent insurance companies from doing risk rating without seriously jeopardizing the ability to have an insurance market at all (as allowing people to acquire insurance after they've discovered or have reason to suspect there is a problem means it's no longer insurance). 

[Metric Mouse]

It's very hard to filter out / charge more for unhealthy people.  You can be wildly unhealthy and skinny.  You can be carrying an extra 30 - 40 lbs and be in pretty great health.  Some smokers live well into their 90s.  Generally public health care systems don't even bother to try to address this.

Why wouldn't healthcare be charged the same way as auto insurance, for example? A baseline risk based on how 'healthy' one might be, and then increase the premiums as the individual makes more claims against that insurance.  That would be a way to make sure unhealthy people are charged more (as they'd use more healthcare, which is the issue, I guess?). Sounds much better than charging a smoker who doesn't use any healthcare more than a crossfitter who has regular injuries, for example.

[Jrr85]

It's very hard to filter out / charge more for unhealthy people.  You can be wildly unhealthy and skinny.  You can be carrying an extra 30 - 40 lbs and be in pretty great health.  Some smokers live well into their 90s.  Generally public health care systems don't even bother to try to address this.

Why wouldn't healthcare be charged the same way as auto insurance, for example? A baseline risk based on how 'healthy' one might be, and then increase the premiums as the individual makes more claims against that insurance.  That would be a way to make sure unhealthy people are charged more (as they'd use more healthcare, which is the issue, I guess?). Sounds much better than charging a smoker who doesn't use any healthcare more than a crossfitter who has regular injuries, for example.

The problem with that is that you are then not really insuring against long term illness.  If you get cancer and survive doing treatments off and on for ten years, but your insurance company gets to rate risk you during that time, you're not really insured anymore.  It starts to look more like a prepayment plan with a lag period.  It's sort of the opposite problem of not allowing any risk rating.  Your upfront premiums would probably be dirt cheap for this though.