Life expectancy rise in rich countries slows down: took 30 years to prove

The free market aspect is the insurance marketplace.

If you’re poor, you’re fucked. If you’re old you’re ok. If you work for the government or certain companies, you have access to world class care. Everyone else is on a spectrum from high quality PPO to the shittiest Cigna plan.

There is nothing free about the health insurance market. It is regulated to hell to the point where a common complaint of actuaries I know is that they are not allowed to price your health risk.

^ When the grossly overweight 60yo smoker pays the same amount as a health-conscious 30yo, we have a problem.

Maybe but I'm more concerned about a) easily demonstrable and measurable risks not being addressed and b) separating people from the consequences of their own choices.

Ignoring risk and consequences doesn't make them go away.

What about the 60 year old with autoimmune issues? That have expensive drugs but it wasn’t “their actions” that led to this?

The entire system only works if healthy 30 year olds are putting in somewhat similarly (it will be cheaper regardless). Insurance is based on the idea of spreading risk. Without it insurance cannot function.

Even the insurance side isn't really a free market. I've only ever gotten like two choices of insurance provider at any job I've had. More than two plans, but very limited provider choices. You can't get a job offer and then during onboarding say, "sorry, this insurer is unreliable, can we use this other provider instead?"

It's usually not the same amount. The Affordable Care Act (Obamacare) explicitly allows health plans to set premiums based on age and smoking status. However, this might not capture the full risk differential for some members.

https://www.cms.gov/marketplace/private-health-insurance/mar...

There's a deeper philosophical question here about how we should spread risks and costs across society. Like should some plan members pay more because they have a history of cancer, or because they engage in risky activities like flying light airplanes?

But what's the point of a health care system where only those that don't need it can afford it?

On the subject of (b), shouldn't tobacco companies be paying the risk premium for their customers? Why does the buck stop at the individual consumers and not those making money from their misery?

To put it into more technical, economic terms: why should the individual tobacco consumer bear the full cost of their externalities while the tobacco company does not?

> ^ When the grossly overweight 60yo smoker pays the same amount as a health-conscious 30yo, we have a problem.

It depends on what your goals are. The reasoning behind why the ACA ("Obamacare") is the way it is:

> Suppose you want to make health coverage available to everyone, including people with pre-existing conditions. Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.

> For one thing, the insurance industry would not take kindly to being eliminated, and has a lot of clout. Also, a switch to single-payer would require a large tax increase. Most people would gain more from the elimination of insurance premiums than they would lose from the tax hike, but that would be a hard case to make in an election campaign.

> Beyond that, most Americans under 65 are covered by their employers, and are reasonably happy with that coverage. They would understandably be nervous about any proposal to replace that coverage with something else, no matter how truthfully you assured them that the replacement would be better.

> So the Affordable Care Act went for incrementalism — the so-called three-legged stool.

> It starts by requiring that insurers offer the same plans, at the same prices, to everyone, regardless of medical history. This deals with the problem of pre-existing conditions. On its own, however, this would lead to a “death spiral”: healthy people would wait until they got sick to sign up, so those who did sign up would be relatively unhealthy, driving up premiums, which would in turn drive out more healthy people, and so on.

> So insurance regulation has to be accompanied by the individual mandate, a requirement that people sign up for insurance, even if they’re currently healthy. And the insurance must meet minimum standards: Buying a cheap policy that barely covers anything is functionally the same as not buying insurance at all.

> But what if people can’t afford insurance? The third leg of the stool is subsidies that limit the cost for those with lower incomes. For those with the lowest incomes, the subsidy is 100 percent, and takes the form of an expansion of Medicaid.

* https://archive.is/HzS1G / https://www.nytimes.com/2017/07/10/opinion/obamacare-repeal....

* https://thehealthcareblog.com/blog/2023/02/15/all-three-legs...

The goal of the ACA in the US was getting closer to universal coverage, and that means 'subsidizing' bad behaviour to a certain extant.

Certainly smokers and such should practice more (so-called) 'personal responsibility', but there are a lot of situation where the pre-existing condition is not smoking or other lifestyle choice, but something genetic / congenital. So unless we want to get into (social) Darwinism and leave those folks on the sidelines, the lifestyle folks can end up coming along for the ride when society decides to protect other non-lifestyle pre-existing people.

> why should the individual tobacco consumer bear the full cost of their externalities while the tobacco company does not?

Because people are well aware that smoking is dangerous and can freely choose to smoke or not.

> The goal of the ACA in the US was getting closer to universal coverage, and that means 'subsidizing' bad behaviour to a certain extant.

Yes, therefore separating people's lifestyle choices from the plainly obvious risk and consequences involved.

But if you can socialize your losses (banks) or bad decisions (people) and avoid some of the consequences, I get it.

It is incredibly frustrating to have only one option for insurance provider, and then discover that a solid majority of the health care providers in your area don't take that insurance because they have such a bad reputation.

Then you get into the wonderful world of getting receipts for every procedure and manually submitting them, only for them to be rejected so you have to call and tell them to provide the service they promised you. The insurance isn't even cheap! My monthly deduction would be close to the same price as an Obamacare plan, and that doesn't include the employer contribution. Healthcare is such a racket.

The problem with your outlook is you can’t follow through unless you’re a sociopath. Are you willing watch your parent/child/friend/spouse reap the consequences of their “lifestyle choices” and suffer and/or die? I have watched that happen - i guarantee you that you wouldn’t.

Last year, my wife died from a recurrence of metastatic melanoma. By your standard, that suffering was her “fault”, because she failed to use sunscreen as a teenager. If insurance was rated like general liability insurance, she would have been dropped 8 years ago when the original cancerous lesion was removed. Fuck that noise.

I would have bankrupted the entire family to fight for the 60% survival rate in a few months, and she would have suffered even more without adequate care at the end.

We have Medicare “socialism” because social security was allowing the elderly to support themselves and live longer. Many were neglected and dying in inhumane ways, or saddling families with the burden of being a full time caretaker. It’s gross that we live in a society drowning in riches, but we take a principled stance to avoid taxation for rich people, at an incalculable human cost.

Definitely disagree with at least the ‘can freely choose to not smoke’ Nicotine is highly addictive much more so than many illegal drugs.

Don't use quotation marks if you're going to rephrase what I said.

Ironically, two of his three factors are still able to be priced in: age and smoking status. Weight, gender, and many other risk factors are not, though.

The point of insurance is to cover unforeseen costs. Not to foist bills you know you're going to have onto other people.

Yes, those bills should be paid out by the state such as happens in developed countries like Brazil.

Choose two from: Good/fast/free.

Those "civilized" countries universally have very long wait lists that make health outcomes worse.

The tobacco company (also composed of people) is well aware of the health consequence of smoking to its customers yet freely chooses to continues to sell tobacco products. Where's the difference?

Actually it's much worse than that. The tobacco company is not just selling tobacco products, it's marketing them and actively encouraging their use!

But the point of healthcare is to help people not die, regardless of if they can pay or not. We have a problem then, because outcomes don't line up.

If anything, healthcare and insurance have almost completely perpendicular incentives. No wonder then we have the world's most inefficient system.

> shouldn't tobacco companies be paying the risk premium for their customers

How would that even work? Any such tax would be priced in into the price of the product. It doesn’t really matter if the government is collecting it directly or through the tobacco companies.

Or if we wanted tobacco companies to pay for all the damage they did retroactively they would just go bankrupt, since they don’t have even remotely enough cash/assets to cover it.