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Comment by yonaguska | Hacker News Reader

My personal take is that it's just hit a breaking point where people have finally decided that it's not worth the money. Im not the only person I know with an uninsured wife, and only coverage for my kids. If it weren't for my kids, I wouldn't have enrolled in insurance either. The math just doesn't work out for someone relatively young and with no major health issues. And with the government cutting back spending, which you can see that hitting big insurers like UNH directly, the market is getting a little tighter.

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> The math just doesn't work out for someone relatively young and with no major health issues.

The thing is, bad and expensive health issues can literally come upon you over night. You can get hit by a vehicle or get beaten up with no perpetrator to be held accountable, you can develop an aneurysm, get food poisoning, get pregnant unexpectedly (with all the risk that comes with, including healthcare not being accessible because of anti-abortion BS), or you can simply fall over a step in your own house.

Seems like something that shouldn't be left up to a consumer market.

"Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

Aneurin Bevan

That's true to an extent, but the majority of US healthcare spending goes to treating chronic conditions caused more by lifestyle choices than misfortune. There's a fundamental issue in public health policy about individual responsibility and whether to charge people more (or potentially even deny care) over factors at least partially under their control. For example, the Affordable Care Act (Obamacare) allows health plans to charge tobacco users higher premiums. Is that fair? Should we also charge higher premiums to alcohol users or those with sedentary lifestyles? There are no clear right or wrong answers here.

> There are no clear right or wrong answers here.

Absolutely, but there are lots of working, existing models that are better than ours in practice, so this isn't much of an excuse.

That's a meaningless statement. You can find many examples of "working" national healthcare systems (for various definitions of working) and they're all different in how they allocate costs to consumers.

For one example there are some positive aspects to the Japanese system in that they achieve good outcomes (on average) at lower costs. But that's partly due to the "Metabo Law" aka "fat tax" which voters in other countries might see as punitive or discriminatory. I'm not necessarily arguing for any particular approach to lifestyle-related health conditions but any choice involves trade-offs.

https://www.telegraph.co.uk/news/2023/12/07/japan-solved-obe...

> That's a meaningless statement

Is it? An existence proof multiple times over actually seems extremely important in debates about the future of healthcare in the US.

That topic should be a non-starter as long as US government policy is to keep shitting in the food bowl. There's way too many communities living under the toxic spill or waste of some unregulated industrial process -- and the country seems perfectly ok with that kind of "lifestyle". I really don't see why we should villify individual lifestyle choices when the entire country is happy with intentionally harmful policy choices.

So, if health insurers want to start charging premiums I suggest they send their bills to Superfund sites first, then to regular toxic cities like Flint, Camden, Hinkley or Picher, then to producers of known-carcinogenic substances (like Chrome-6 or Roundup), and then to advertisers of known-harmful products like alcohol or tobacco. Only when they run out of those targets can we have a discussion on individual lifestyle choices.

OK cute rant but do you have a realistic proposal? I absolutely agree that we should do more to reduce exposure to toxins but there's no legal mechanism for health plans to shift costs that way. Ultimately some of the money spent caring for others with lifestyle-related chronic conditions is going to come out of your pocket through insurance premiums and taxes. This is inevitable. Are you willing to pay more for people who choose to smoke and get lung cancer / emphysema / heart failure / etc? Yes or no?

There's very little tobacco advertising anymore so we're not going to squeeze many dollars out there.

https://www.fda.gov/tobacco-products/products-guidance-regul...

>do you have a realistic proposal?

Realistic in this administration? No. They will keep taking and taking from the working class and pitting them against one another. There's no solution there when the government is actively looking to sabatoge the system.

Arguing over tobacco premiums is pennies on the dollar. Pretty much every other civilized country has figured something out with regards to universal healthcare. I'm sure there's dozens of solutions out there to choose from. The only real steps to take right now is to have Americans stop licking the boot and actually push for something that helps them.

Desk jobs like programming are nearly as bad as smoking based on some of the research I’ve seen. We could just make smokers and programmers pay higher taxes. I guess smokers already do; learned recently that cigarettes are like $10 a pack, a few thousand per year for the average smoker. Not sure how best to tax programmers though.

Socialized healthcare means that the State has a direct financial incentive to reduce or ban consumption of poisonous goods, and crackdown on pollution.

Why do you immediately call charging the worst polluters for the bad health effects of their pollution "unrealistic"? Having a sufficient answer to that question seems like a good basis to start your proposal from.

In practice everyone has vastly different preferences, expectations, and desires different levels of care then.

For example Some people want to see a specific doctor they know in a private session to discuss life and family stresses. Others only go to urgent clinics if they need an immediate medication.

What percentage of the market actually pays it this way? IIRC, somewhere north of a third of Americans are already on a form of single payer healthcare. Most of the remainder are getting it through their job, subsidized to varying degrees. The fraction of the population that actually pays the full premiums out of their own pocket is pretty limited, AFAIK.

> What percentage of the market actually pays it this way?

The only way this can make sense mathematically is if you're including children, seniors, and/or the ill—populations who are unable to work. What is your reference?

Pew Research says just under 7% of the population uses the exchanges to buy insurance. Overall, about 36% of the population is on public healthcare, according to Census.gov. KFF says that about 80% of the working population, plus or minus, gets insurance through their employer, with an average of $570/month out-of-pocket for premiums.

Thanks for pulling up data!

These numbers are incommensurate in a way that may not be obvious.

7% of the population doesn't tell you what population fraction is covered by such policies.

36% coverage is even harder—every child in the US is eligible for Medicaid, and such children may not always need it, or may move states after using Medicaid, in a way that makes them doubly counted.

80% of the working population is also less clear; is that 80% of policy-holders get their own policy through their own job? Or 80% of working-age people have a policy through some workplace, even if they are not working?

I think it's also worth considering that taxpayer funded US government spending on health care is about the same as in a typical single-payer European country. Then many tax payers still have to pay for private health care on top, to actually get health care for themselves.

Yeah, doctors get paid way more in the US. There's a number of changes beyond the payment method that we'd have to make if we wanted to have costs on par with a typical European country.

Markets are how our society allocates all its most important resources.

What I think we have now is the most non-market like sector of the economy, with 1/3 of all citizens already receiving government funded healthcare.

All those things could happen but the healthcare provider will mug you once a month.

There has to be SOME point where the constant muggings aren't worth it vs the risk, otherwise they would simply demand all our money, knowing we won't say no with our life on the line.

Agreed and generally insurance would be a value bet between you and the insurance providee with a slight operation overhead. In the US the market is basically circular as the insurance provider also has hands in all related pies so the bet odds are in such awful state that some people take the risk and rely on crazy stuff like gofundme for survival. I'm not an american but this doesn't look like something that can be solved with more market - the odds are just so broken in many cases.

Catastrophic health insurance for most those things is very inexpensive, relatively, but you have to re-buy it every 3 months and then "pre-existing" conditions reset. The expensive insurance is for covering ongoing expenses, as predictable expenses or at least those known 3+ months in advance are the vast vast majority of health care costs.

Realistically catastrophic revolving temporary insurance plus managing what you can in Mexico, plus occasionally paying out of pocket would mitigate the vast majority of yours risks while keeping expense relatively low.

Sure, those things can happen. A lot of younger people will decide to just accept the risk, and then if they get hit by a bad and expensive health issue then they'll go to the ER anyway. Due to EMTALA, most hospitals have to treat them regardless of ability to pay. This is one of the factors causing the US healthcare financing system to collapse.

> Due to EMTALA, most hospitals have to treat them regardless of ability to pay. This is one of the factors causing the US healthcare financing system to collapse.

They'll only treat you until you're stabilized, though. They won't give you chemo or routine care. If you need to be admitted you're also not covered by the EMTALA.

All emergency medicine, not just that triggered by the EMTALA, is 5-6% of all healthcare spending in the US, so while it contributes, it's not collapsing the healthcare system.

The real problems with it are that it's an unfunded mandate by Congress, just adding to the financial tangling of the healthcare system, and that it's way too often used to treat things that could have been much more cheaply treated in a clinic, but then there are no clinics nearby that take Medicaid and are actually open, so instead, like with so much of our health care system, we choose to solve it the stupid way instead.

Hospital costs attributed to EMTALA are relatively low today. My point is we should expect those costs to grow as more consumers become uninsured. This is one of several factors that will eventually wreck the current healthcare financing system.

don't you get a tax penalty if you aren't insured for 100% of the year?

That got remove in Trump's first term.

US voter math: remove penalties/taxes + increase benefits = everything is fine

Thus solving the problem.

The penalties were extremely unpopular and affected poor people the most.

I know the economic idea, but it is not a good mechanism for society.

The expanded Medicaid was supposed to take care of poor people, but several states refused to implement that.

All of that is true. But insurance agains that risk is not worth an infinite amount of money.

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