So, to start with, the ACA lowered the rate of growth in health insurance premiums. If it had done nothing else, you'd ostensibly still be better off with it. But it did more than that: it also provides Americans with guaranteed-issue insurance, which did not exist previously. What people in general seem not to understand about health insurance rates is that they've been skyrocketing since the early 2000s. Employers have been having uncomfortable conversations about health benefits long before the ACA.

More broadly: health insurance isn't expensive because it pays for day-to-day care. Health costs are dominated by chronic illness and inpatient/outpatient procedures, not the overhead of people visiting their GPs.

I'm sorry you had an insurance policy you liked that the ACA killed off. But huge numbers of policies, including from health insurance giants, were abusive: they were marketed (effectively!) as real solutions, but had exclusions and coverage caps that made them worth very little if you actually wound up in a situation where you truly needed insurance. We're better off without those policies.

Nope, health insurance isn't insurance because literally everyone will need access to health care at some point in their lives. 100% of us will die of heart disease, cancer, trauma, etc. It's like if we had a 100% chance of houses burning down, we wouldn't call it fire insurance. It's not insurance because it's intended to be consumed, it's a communal pot.

Further, no matter what there will be more things wrong with us than resources to deal with it so the other goal besides efficient administration of a health system is rationing access to care.

No need to profit here, there's plenty of other ways to make money in the world.

All these "the ACA raised my premiums crap" is just that. You didn't have heath insurance before, you had a program that you thought was health insurance but would have absolutely bankrupted the average person if you ever needed to draw on it.

Do you then also not consider whole life insurance to be real insurance, because everyone dies?

And importantly: once you get to a certain age the premiums start going up significantly, and you can't get it past a certain age IIRC is 65 on my policy.

Why do you say that with certainty? I had a low premium / high deductible plan that was a good fit for me at the time that was both simple and lived up to it's promises, something I have not encountered since.

It's not a real health insurance plan because it doesn't cover the realities of every-day life. You're leveraging (literal) survivorship bias in defense of this plan. You could make the same exact case if you didn't have health coverage at all, and nothing happened to you (that it was a good fit for you and it was both simple and lived up to its promises).

It is clearly false for you to claim Stronico didn’t have insurance.

If something serious had happened they would have paid the $5000 and the rest would have been covered by their plan.

I agree that this might not work for the average American, but that’s the only valid part of your claim.

Their plan would also have worked had they needed to draw on it.

The fact that they didn’t need to draw on it has no bearing on whether their plan would have worked for them.

If you want to use a statistical model to say how many people it would or would not work for, by all means do so, but otherwise this is just an empty definition.

Secondly, you actually argued that it only didn’t work for him because he didn’t make a claim. That has nothing to do with the average American and is simply a false statement.

I agree that it wouldn’t work for everyone. But it would clearly work for many people, including him.

If you want to argue about the average American, then you need numbers and facts, otherwise it’s just an empty opinion.

>The lowest-income households in the U.S. on average spend $412 annually on lottery tickets[1]

>In the U.S., people living below the poverty level and people having lower levels of educational attainment have higher rates of cigarette smoking than the general population[2]

>Among smoking households, the mean quarterly expenditure on cigarettes in constant 2015 dollars was US$458[3]

[1]https://www.bloomberg.com/news/articles/2018-09-12/the-poore...

[2]https://www.cdc.gov/tobacco/disparities/low-ses/index.htm

[3]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009464/

Being poor changes how you think about money. Every time you save a few dollars, something happens - an unexpectedly high electricity bill, an unexpected doctor visit, losing your phone - and that minute bit of savings goes out the door. It's easy to get into the thought pattern that you might as well spend on something fun while you've got it.

As for cigarettes, being as addictive than heroin will do that to ya.

That's not the point. Of course it doesn't - but that unexpected $35 copay for the urgent care visit would've wiped you out, whether you'd bought the $1 lottery ticket or not. At least you had a little burst of "man, if I won, I'd..."

We know from studies that poverty dramatically changes short-term vs. long-term decision making.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641572/

> How are those events handled without savings?

Be hungry the week after, pawn a possession, payday loan.

> How would giving them more money resolve this problem?

How would having money solve money problems? That's really the question?

I have shown that they do have $500 to cover an emergency but they have chosen to spend it on lottery tickets and tobacco products. You claim that this is due to being poor and how they have poor impulse control and that makes them unable to save the money and instead the immediately spend it. If I give them another $500 why wouldn't they just spent that on more lottery tickets and tobacco products?

You have not. You've shown that after a year of not buying lottery tickets they might have that $500, with the caveat of the fact that we know that's not really how that works - any savings gets wiped out by the next unexpected bill long before that.

> If I give them another $500 why wouldn't they just spent that too?

Where was that suggested? That's a silly approach to the problem.

Far more comprehensive solutions are necessary. Better housing policy, living wage, national healthcare, better regulation (or banning) of payday loans, guaranteed access to banking services, etc.

I don't see how this math works. Lets say my total annual income is $5000 to keep the math easy. My spending looks like this:

get $5000 paycheck (for the sake of ease of math)

spend $3000 on rent

spend $500 on lottery tickets

spend $1000 on food

spend $500 on tobacco

Now I have a $500 bill that I don't have the money for.

Conversely I could:

get $5000 paycheck

spend $3000 on rent

spend $1000 on food

Now I have a $500 bill that I can cover because I did not buy all those lottery tickets.

Your car breaks down. You get a parking ticket. Your kid gets sick. You get evicted and some of your stuff gets ruined by the rainstorm because the landlord put it on the lawn.

If saving money causes more bills to appear as you suggest the solutions seems to be to give the poor less money so they will have less bills.

Sigh. I'm not sure if this is a comprehension issue or if you're deliberately misrepresenting what I'm saying.

Saving doesn't cause bills to appear. The bills are already there. They've likely been piling up for years, and continue to do so.

If you're $20k in debt, and it keeps growing, and every time you've tried to save up a few dollars to pay it down you've had to spend the couple bucks you managed to accrue on yet another critical bill you can't put off any longer, it starts to feel pointless to save.

> you suggest the solutions seems to be to give the poor less money

What?

I laid out specific, systemic interventions that are necessary, none of which require giving the poor less money.

>If you're $20k in debt, and it keeps growing, and every time you've tried to save up a few dollars to pay it down you've had to spend the couple bucks you managed to accrue on yet another critical bill you can't put off any longer, it starts to feel pointless to save.

If they have so much debt buying so many lottery tickets? Seems like a bad idea. What if they never bought lottery tickets to begin with? Who keeps extending them credit when they clearly never pay any bills?

Do you extend this same logic to firms like Amazon? Amazon spends virtually every dollar they make, does that mean they are poor? Should the government step in a give them money because of how poor they are?

I don't see why, "You have to stop buying lottery tickets" is a non-starter when talking about Americas poor. First stop buying lottery tickets, then we can talk about money problems you may have.

Predatory lenders, utilities and hospitals that may not be legally permitted to deny service but can still attempt to collect, etc. They're certainly not getting a 2% cash-back credit line from Chase.

They're also not never paying bills. They're juggling them, so the latest and most critical get paid. Squeaky wheel gets the grease - you'll probably pay to get your car out of impound before you'll pay your kid's school lunch debt.

> Do you extend this same logic to firms like Amazon? Amazon spends virtually every dollar they make, does that mean they are poor?

My "I'm being argued with in bad faith" senses are beginning to tingle.

> I don't see why, "You have to stop buying lottery tickets" is a non-starter when talking about Americas poor.

Again, systemic solutions are required here.

Add "get rid of lotteries" to my systemic fixes list, if you like.

Single-payer tax-funded health insurance means that each person contributes based on their capacity, and nobody has to pay when they receive services. Then the tax collector has an incentive to increase effectiveness of health services by educating and encouraging the population to eat well and exercise daily.

(emphasis mine)

Strongly disagree. What you refer to is a health benefits plan. Insurance should cover only unlikely events, not routine events. Just like your car insurance doesn't pay for new tyres or burnt bulbs.

As someone who does my best to stay healthy, I don't think my lifetime health bill will come to anything close to what I pay for insurance. But I want the insurance for the random stuff I can't control.

Especially when it comes to preventable diseases, good health insurance companies are doing some really interesting work on effective behavioral change and early intervention. My insurance for instance pays me to walk every day.

The ACA requires insurers to spend at least 80% of premiums on direct patient care. To grow profits, they must grow premiums.

But then the population doesn't have an incentive to follow that education and encouragement—at least not a monetary one. As a comedian said, "You see, I don't have to exercise, because I have health insurance."

Currently the largest medical payer in the US is medicare, a government program. It is also one of the most expensive programs the government runs. The government already has this "incentive" and yet we don't seem to be getting healthier nor do people seem to eat better and exercise more. People seem to be getting more obese, not less [1].

I don't know of a single organization or program that has managed to have long-lasting reductions in obesity. Diets routinely fail because people can't maintain them, and exercise by definition is hard so again it's hard to stick to. One fundamental issue is we don't quite understand why people get fat. It's not clear how the basal "fat" set point that everyone has gets set, but it is clear that deviating substantially from that set point is very difficult and that it might shift over time.

[1] https://www.stateofobesity.org/obesity-rates-trends-overview...

isn't that the point of insuring uninsured people and ending preexisting condition coverage. if the agreement is "hey we need to cover riskier people because its the right human thing to do" costs are going to go up. thats the trade off. in this case, you being angry that costs went up shouldnt be directed towards government inefficiency. costs ballooned because coverage expanded (and age banding aka community rating, which is similar, agreeing to cap elderly costs and having young people pay. and everyone under 26 being a child, consuming but not paying in.)

anyone paying attention going into the aca, knew that costs would go up for healthy people over 26 but not yet retired. (democrats did do _a bit_ of lying about costs going down for everyone and being able to keep existing plans, to get it passed, a fib they admit.) if you are a part of that range, and you voted for the law knowing all this, you were either being compassionate, or hedging that someday you might fall into an uninsured condition situation, or both.

For instance, in the case of lifesaving treatments, the demand is essentially infinite, and this is a fact which Pharmaceutical companies use to raise the cost of treatment to astronomical levels. When the alternative to expensive treatment is death, there is simply no countervailing market force to bring costs down.

The same goes for pre-existing conditions. It may have been fine for you and your wife to pay for a reasonably-priced high deductible plan, but without the ACA, that simply would not be an option for a huge number of people. Without government regulation, there is absolutely no incentive for an insurance company to cover a chronically ill or high-risk individual. The rational way to operate that type of business in order to maximize profit would be to cover healthy people only, and remove anyone from your coverage who is likely to file a large claim, and we have seen this come to pass.

This is precisely because there is no health "insurance" middlemen for purchasing those services. The market drives those costs down.

If - like in pre-ww2 America - instead people saved up for the inevitable doctors visits and paid out of pocket directly to the doctors and hospitals, costs would be FAR lower both due to competition and price sensitivity. This is the fundamental problem with using health "insurance" for expected costs, rather than just unpredictable emergencies.

So like, real question here... How does would that work if you're poor, chronically ill, have cancer, need an organ replacement, have HIV, etc? How do I know if I'm getting my money's worth, given I do not have medical education? What happens if I can't make a choice of what services I consent to because I've been rendered incapacitated due to a medical emergency?

For a counterexample, look at dental surgery. This is also often not covered by insurance, but it's much more expensive, and low-income individuals often take on debt and risk their financial security to undergo these procedures because the alternative is often a severely degraded quality of life. The difference is that the demand is much less flexible, so providers can get away with higher prices. Many healthcare procedures fall into this category.

Pre-WW2 America isn't a place most people would want to return to in terms of healthcare. It was far far less advanced, people died much more easily and you may recall a certain Great Depression which made it so those savings weren't quite as reliable as people hoped.

Oh and when you go to the ER after getting hit by a bus, are you going to call around for the best deal?

You might argue that's what insurance is for, but now you end up back where we are today, with a middle-man paying for things. Things that are essentially guaranteed to happen but unpredictable in their magnitude.

I'm not saying we shouldn't have more market information, but it's just incorrect to say the market will solve this. Serious medical problems are a, "your money or your life" situation, pure unregulated markets are going to really struggle in this area.

I dunno, the differences weren't huge, and at least people didn't go bankrupt (data not from the US, but close).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2625386/

"Life expectancy of mature women taken from Hollingsworth8 and OPCS data for England and Wales

Date Life expectancy of women at 15 years (years)

1480–1679 48.2

1680–1779 56.6

1780–1879 64.6

1891 61.6

1901 62.6

1911 66.4

1921 68.1

1951 73.4

1961 75.7

1971 76.8

1981 78.0"

1989 79.2

As a specific and personal data point, I have chronic kidney disease, which developed rapidly when I was 25. With pre-WW2 medicine (no transplants, no dialysis), I might have lived to 26, maaaaybe, and even then only if I'd been able to control my blood pressure long enough for renal failure to set in instead of a stroke or heart attack.

Thanks to modern medicine, I'm now nearing 40 with a good prognosis; there's no reason to believe it will impact my life expectancy, and the impact on my quality of life is relatively minimal. Compared to dying in my mid-20s, that's a vast world of difference. I will not willingly go back to pre-WW2 medicine, thank you very much.

To take a contrived and simplified example, imagine a hypothetical world in which everybody dies on their 90th birthday by default, but a handful of diseases cause 25% of the population to die on their 30th birthday instead. That brings the average life expectancy to 73.75y.

Now imagine a bunch of medical breakthroughs bring the 30-year-old mortality rate down from 25% to 7%. That enormous difference brings the average life expectancy to 85.45y.

That's in increase in life expectancy just shy of 16%, despite the fact that it comes from a 72% reduction in 30-year-old mortality rates.

That's obviously a massive oversimplification, and real distributions look different, but it illustrates the problem with just looking at average life expectancies; it makes it look like everyone's life span has just been scaled up by 16%, which is not the case. If you look at it from the perspective of, "what are the chances my life will be cut short by some preventable disease?", the magnitude of the change is much greater. Some of that change is due to very cheap innovations like bread-mold-as-antibiotic, and some of it is due to very expensive innovations like organ transplants. Either way, I for one am glad those days are over, despite the appealing economic simplicity.

With that in mind, from a consumer point of view I prefer to look at it as buying peace of mind rather than betting against the insurer (because in the long term the insurer will always win).

We can have third-party "evaluators" that anonymously evaluate and guarantee the reality of the medical claim, and let the network approve or reject the claim based on those evaluations.

This is extremely hard to do. It isn't at all clear that it's even possible. Merely suggesting it isn't enough; to add something valuable to the discourse, you really need to describe the scheme itself, and that scheme needs to have a credible chance of success.

There's always one...