But that's the very definition of insurance: spread the risk over the entire pool.

US health insurance does not work this way, and it's part of the reason that system is so messed up and super expensive.

But the devil is in the details, specifically in the definition of the "pool". To keep it fair (and subscription voluntary) generally requires pooling similar risk levels. Which is why for car insurance your driving record is important; for term life, your age and smoking status; etc.

But at least in the US, health insurance is not really an insurance (as in your definition of spreading the risk of rare but expensive events); it is a complex monster touching negotiated pricing, access to care, etc.

You are implicitly arguing that it should be the entire population, but lots of people see it as a chosen group with identifiably similar levels of risks.

Medicaid is intentionally handicapped since it’s a poor person program and poor people don’t have good political representation.

“For hospitals” is just Part A. And, “over 65 or disabled”.

For a lot of types of insurance I don't think it is clear cut at all.

(Note that the law in the article is about other types of insurance, not healthcare)

Everyone gets ill, everyone dies, smokers in most countries pay additional taxes on every packet of cigarettes they buy. But, even if they didn't, having a national insurance scheme (as we have in the UK), is the best way of spreading the risk of costly healthcare.

When you buy insurance you're not subsidising anybody, you're joining a pot of individuals who are trying to lower the overall risk of high medical bills. The more people, the easier it is to absorb exceptional costs.

You already do, when that guy gets cancer, dies and has no money left over, your taxes pay for his care. You're just cutting out the middle man at that point.

   How old is the smoker?  And you? What type of care does the plan for the pool you could both be in cover? There are risk pools of less than ten to over one million to choose from in private hc market currently... But the best argument is cost.  

   A single payor system would likely cost you much less overall for the same level of hc coverage as current options.   If you have to subsidize *more* smokers than you currently for a plan (risk pool) to be economically feasible but the cost of care is lowered enough that your overall cost is reduced it would save you money.  


  The reduced cost of care would increase the social and community improvement we see from a baseline level of charitable healthcare we as a nation have already agreed to subsidize. 


  A functional single payor system will likely require larger risk pools but greatly reduce cost by mitigating the current market forces that drive our ever inflating cost of care. Providing better charitable care for our sick is a noble and ethical goal to target as a society and you *being open to the idea* of subsidizing *more* smokers healthcare helps us achieve that so thanks for asking the question.

You insure against risk, you pay for care, just as you pay for gas in your car and oil changes, but your insurance covers accidents (which goes so far as to charge people of different genders and ages differently because of the risk demonstrated by the data). Should I be offended that my auto insurance charged me a crazy high premium for driving a high performance sports car at 18 years old as a single male? No! I was a high risk based on the data (which distilled down to my own risk management as then owner of an 18 year old male brain). And if the data (even genetic data) shows someone to be higher risk for an insurance product (again, we’re not talking health insurance or healthcare), they should be exposed to that cost.

Life isn’t fair, and this is a poor attempt at tilting the scales if your goal is to make it more fair (considering the size of your risk pools at typical private insurers offering these products). It’s an unfunded mandate.

You can always take any existing regime of discrimination and make it more fine grained, but at some point that has to stop or there is no insurance. If discrimination has to stop somewhere, then there's no principled reason why the discrimination you like is necessary, or natural. Even apart from the existence of protected classes in society.

If an insurance company can discriminate arbitrarily, why not do it in real time? Your car could have a monitor that would tell if you are tired or drunk. Would it make sense to allow them to charge you extra minute by minute? The ultimate would be to have the decelerometer that sets off your airbag signal the insurance company, and charge you based on the projected average repair cost before you come to a stop.

Sometimes people say car insurance is like health insurance and sometimes they say it's not, but both have extensive regulation that prevents the insurance company from maximizing returns, because insurance is extremely susceptible to devolving into taking in money and paying 0% out. It seems fundamentally wrong headed to me to have in your mind an ideal of an untrammeled insurance market of any type, when it has to be heavily regulated to be of any use.

Insurance is not socialism. If my risk of getting into a car accident is low, shouldn't I pay low premiums? Why should I subsidize bad drivers?

I think we already have precedents which go further. With ADA you have to provide reasonable accommodation for disabled people. Some of them are disabled purely by chance, but some are disabled because they are dumb (they dived head on and are now on a wheelchair). No difference under that law.

This isn’t about race or sex (and the discrimination argument made), but the underlying genetics that present as those traits (and any risks, such as premature death or the need for extended assisted care, that come along for the ride).

Using systems like social security and universal healthcare are better models if the desire is to ignore identifying and pricing risk (as insurance does) and spread the costs across the population with less admin overhead.

You realize you still share the same roads with bad drivers, right? Insurance pool is the wrong level of abstraction to isolate bad driving. If anything, it puts our skin in the game to advocate for better education, prevention, licensing and enforcement on bad driving.

This is almost the same for healthcare. Covid demonstrated one more time, state of public health is tightly connected to your individual health. There is no rugged individualism as far as the virus is concerned.

This is basically how it works in Europe and it's fine. I see the concept of punishing people for how their body behaves deeply unethical. We can't control this, things happen randomly to many of us.

Obviously you could sell cheap health insurances to people that you know will be healthy, but isn't this essentially a scam?

But, in general, I'm not sure health insurance would work without risk pooling. A large part of the problem is that health insurance isn't exactly insurance: paying for medication that someone takes everyday doesn't really fit the definition.

If we could start over from a clean slate, I don't see any reason why a health care system without insurance wouldn't work (it works it many other countries). But, as it stands, I fear that the only way we can fix our Healthcare problem is to implement single payer.

There's arguments against it, cost (not a good one, it would reduce costs) and 'quality' (not a good one, there's lots of great potential doctors not getting trained).

There's no forcing anybody to do anything (just removing restrictions on educating people and providing funding for training). It wouldn't even cost all that much (a few trillion over a decade vs $4 trillion annually on medical care).

Your ethics is a bit roundabout. Nature is the one introducing unfairness and "punishment" to the world. In a sense you are blaming companies for treating them equally rather than taking it upon themselves to correct the unfairness of nature.

Really what we have here is a situation where insurance is an appropriate solution for some people, while others need charity. You are presuming that there is no charity for some reason, and that those people who need it are the insurance systems responsibility too.

And 20 years ago healthy young people could get insurance very cheap (Less than what people spend on phones today). It wasn't a scam. Sooner or later you might get food poisoning or fall off your bike and break your leg or something. And there's always a small chance something really horrible would happen.

Yes, nature gave one person cancer and not another person, or nature makes a young person on average healthier than an old person.

But what we do with the hand nature has dealt us is on us not nature. Saying "Hey it's nature that made that guy require so much resources, there's nothing we can do about that, they simply cost more and so they should have to pay more, or die more." Is both unethical and a lie, because, there IS something we can do about it.

We are not unthinking animals with no capacity to bend nature to our will, or at least compensate for nature we can't bend.

And the people who cost more among us are not objects with no other factors in their equations than what they cost vs what they produce.

When you say "Nature is the one introducing the unfairness." You actually make the very point you think you are arguing against.

You say "It's Nature's fault", which is true, but then you, with very swiss cheese ethics, select only 2 out of the 3 implications from that to care about. You only talk about how that means it's not your fault or any insurance companies fault, and you don't account for the equally true fact that it's also not the cancer victims fault.

If something is "introduced by Nature" your own words remember, then you yourself are acknowledging that it's no one's fault, and therefor no one's responsibility.

Your inventively kinked ethics interprets that to mean only that therefor it's not your responsibility to do anything about it, completely neglecting the perfectly valid opposite option that if it's no single persons responsibility, then it's everyone's responsibility equally.

It doesn't matter what arguments you manage to muster in defense of the selfish and frankly sociopathic response to the given facts of life and "nature", it's all the damning it needs to be merely that you try, other than in a devil's advocate role.

Yes, provide them charity. I think perhaps your emotions interfered with your concentration and you you didn't read my post quite carefully enough. Particularly this part: "Really what we have here is a situation where insurance is an appropriate solution for some people, while others need charity. You are presuming that there is no charity for some reason, and that those people who need it are the insurance systems responsibility too."

Insurance companies aren't healthcare providers nor are they charities. Insurance is a product to manage risk. A certain and chronic need for health maintenance is not a risk anymore.

So long term care insurance is for people that want to preserve their assets and/or receive care beyond what Medicaid will fund.

The problem is that the logical extreme is eugenics (and DNA testing is making that a practical reality), except we have a weird carve out for people in the US that have a “proper” job.

That’s why many (most?) people think it’s time to abolish private, for-profit health insurance.