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.