"They aren't assuming anything. They know that healthcare in the US is hit-or-miss, that it is normally for people to move between having and not having healthcare throughout a lifetime."

That's a general complaint that has nothing to do with insurance being a cost you pay out of your take-home salary in the US.

Your anecdote seemed to be predicated on an accounting difference between the US and Canada, that the Chinese supposedly didn't know about. I'm saying that doesn't really exist. The sort of people who adopt would have a job with insurance, but the price of the insurance would not be included in their salary.

In my lifetime, I have been uninsured, insured by my employer, on an ACA (Obamacare) plan, etc. But never been in the situation where I was making a good salary and paying full price out of it for a health insurance policy, like people do with car insurance. Nor have I ever known anyone who did. Of course, somebody probably has, somehow, but it's not common, let alone a norm that some government would assume.

I never said my friend had a job. Part of the problem, in the US, is the link between employment and insurance. My friend earned reasonable money as a moderately-sucessful artist but did not have an employer. In the US that would mean paying out of pocket. In canada he didn't have to pay a dime.

Also the self-employed in the USA have to pay over the odds for rubbish schemes. Large employers can be assumed to employ mostly healthy people, but an individual is more likely to want health insurance if they already know they are a bad risk. This "moral hazard" means that selling health insurance to the self-employed is a money-losing proposition unless you screw them at every opportunity.

I’m no fan of health insurance as currently instantiated, but I don’t see it as screwing them at every opportunity if they are actuarially unprofitable otherwise.

Depends on framing. If you divide the population by an arbitrary standard with a very high health bias (employed, in big co), and adjust payments accordingly, then those on the wrong side of your arbitrary standard get shafted.

The second group may be unprofitable with lower payments, but the insurer doesn't even want the second group, the profits are from decreased expenditures on the first group.

Absent an individual mandate with actual teeth (or outright government providing of healthcare), do you have a solution that seems workable on a voluntary arms-length basis for all actors involved?

I’m not arguing those other conditions shouldn’t exist, but rather making the weaker, more limited argument considering “given the arrangement of the insurance market as it exists today, what should the price for that insurance offer be?” In other words, “What should a for-profit insurance company do, acting on their own and immediately?” because I think that’s pretty close to the question they’re facing when setting pricing for individual plans.

Ah, yes, the good old supply and demand theory of health: if you can‘t pay for your healthcare, you obviously have no need for it, because needs are only things you are willing and able to pay for.

It’s more like “if the cost to serve a broad population P is $X, I don’t think it’s screwing them to say ‘the price cannot be lower than $X’ because we are a health insurance company, not a charity.”

I think you’re arguing that perhaps health outcomes should not be funded by private for-profit insurance companies and I’d agree, but while it is, this outcome seems grounded in actuarially sound math.

How is charging X more for Y's behavior not screwing X?

I’m genuinely not understanding the X and Y category or behavior you’re contemplating here.

Is Y’s behavior being on average healthier and therefore less costly to insure?

Well, if I was the Chinese government, it sure wouldn't make sense to me to let him adopt in either country regardless.

  5.5% of children under the age of 19 were uninsured

Bear in mind that this paper is a survey, not a study that looks at actual coverage records, and the survey population is not consistent year to year.