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@bja While I'm hesitant to get too far into politics in a technical forum, I'm less hesitant if the discussion is purely Machiavellian, rather than partisan. I'd say the Republicans have a bit of a pickle on their hands at this point. Especially after having touched the subject, even without having changed the situation much, they are likely to be held accountable for everything that goes wrong in the future. From a Machiavellian perspetive they likely would have done better in the long-run to have thrown up their hands and said we can't do anything about the PPACA now, so blame any problems on our predecessors.


@bja The basic problem (regardless of whether you like the mandate in principle, or loathe it) is that the penalty for ignoring the mandate is too small to overcome the problem of adverse selection.


@bja If I'm 24, and in good health, and don't have a lot of assets, the mandate is just a bit more tax I have to pay, and is much cheaper than buying health insurance would be, especially given community rating (which pretty much means that I must subsidize the older and sicker if I do buy insurance.) Even if I'm older, but pretty healthy, it probably makes a lot more sense for me to just pay the fine.


@bja Because, if I do become chronically ill, such that I require expensive ongoing health-care, I can just sign up for insurance then.


That's an intentionally overly simplistic take on the subject, but I hope it gets at the heart of the problems with the mandate as it stands.


@bja In some ways the mandate as it stands is not that idfferent from the effects of having no mandate at all, except at the margins.


@bja I'd personally go further and say that we ought to make a distinction between insurance which could be viewed as pooling risk around unforeseen catastrophes, and payment for routine and expected medical expenses. That we conflate the two and that insurance is so tightly tied to employment leads to unfortunate distortions, IMHO, and that is likely true no matter how heavily you think either should be subsidized.


tagore: pretty sure the people who invented insurance inspected the ships they were insuring, and did everything in their power to ensure that the voyages were successful. the distinction you want to make is false.


The point is that the PPACA requires that they insure ships that are leaky. Thta's the point.


Anyway, why PM me?


Oh, I see..


fyi just to respond to this specific msg, nothing personal.


Yeah, I understood after a sec. No worries.


Ben Shapiro has put it quite well - if you have government forcing everyone to buy insurance, insurance companies just become a medium for government-run healthcare, because the risk mitigation factor is gone. In essence, it's a tax, but one generated in such a way that it's not labeled a tax, as weird as that may seem. It will be more blatant once insurance companies collapse entirely, since their business model will have been entirely undermined.


i'm gratified to see that some folks take "off-topic" seriously. 😉


If you remove the fee, the taxation property is lessened. Does that essentially mean ACA vanishes? The pre-existing condition limitation is still concerning, for example.


we all end up paying for the uninsured who wait until a crisis and then go to the emergency room. unless you want to allow ERs to reject people wo insurance.


you can have as many incentives as u want we will stiil always pay the hidden ER tax.


Anyone familiar with -- it's basic view there is: as small a gov as possible, let the free market take care of everything; anytime the gov interferes with free market, it gives people incentive to do weird things


@mobilink Sure, and that's kind of what a low mandate and community rating ensure in the large. We all pay for people who wait until they are chronically ill to buy insurance. The thing is- chronic illness can in the long run be much more expensive than ER visits.


Am saying that by pushing for ACA, we are creating incentives for people to jump onto insurance 'at the last minute'.


And yep - Milton Friedman is one I need to listen more to. Have been digging into Thomas Sowell lately.


It's a bit like, say you're in Florida, and you have a house, and the insurance company can't deny you for pre-existing conditions; so you wait until a hurricane wrecks your home, then you go and buy insurance -- and people wonder why premiums go up


It's like making a bet after the roulette wheel has spun.


The point is that the PPACA requires insurance companies to insure leaky ships.


Understand the basic concept of insurance, and understand that insurance will not exist if its providers cannot make money, and you'll quickly realize 'pre-existing conditions' (or perhaps better termed 'post-purchased coverage') is completely destructive and cannot be acceptable.


At rates not that far from the rates they charge for sound ships.


it's not really "insurance" after all - the originators insured voyages that were not guaranteed to fail. but it's a certainty that we will all get sick, eventually.


It's amazing how relevant Friedman is after all these years. Free market encourages people to buy insurance before shit happens. "Can't deny for pre-existing conditions" makes it so the rational choice for all people to be (1) don't buy insurance until you get sick and (2) buy insurance the day before you need surgery.


it's just a question of when, how badly, and for how long.


And it allows autonomous individuals to choose localized costs that fit them; and if they make poor decisions, they themselves take on the cost of that decision. I have a running theory that the same reasoning we use to make autonomous computing systems, the same reasoning that's led us to microservices and scalability, apply to human systems as well. Autonomous, localized decisions with localized failure ends up being stronger than monolithic decisions.


free narket doesn't encourage anybody to do anything.


It does, by making certain options cheaper and certain options more expensive.


That naturally encourages people to take the cheaper option.


@mobilelink: some of us will die, in our sleep, in good health. Others will require decades of expensive care. I'm not taking a position here about how the latter should be paid for, just noting that there is a difference,


that's not encouragement.


Then... what is it?


I suspect we're not sharing the same definition.


On the other hand, people use lots of routine and expensive health-care that is not at all unforeseen. It seems odd to treat that as something that should be 'insured.'


it's just options. free asparagus at the local restaurant does not encoursge me to become a vegan. it's just another possibility.


Subsidized- well that's a different question. But insured against?


Hmm. Maybe it could be insured, but at long-term greater cost to the person putting a strain on that resource?


Sure, but that will encourage other folks with lesser means to partake of that more freely.


@tagore: I don't understand the question you're proposing.


It won't encourage everyone to partake of it, for sure. But the desirability is greater for some than others. That's still an encouragement, an attractor or incentive of sorts.


@qqq: what I mean is that I think it's silly to call payment for, for instance, a yearly checkup, or prostate exam, or whatever, a matter of insurance.


it comes down to what kind of society we want to live in. if you blow your money in vegas, i'm content to watch you live in penury. but if you work hard at a crappy job all your life and then you catch cancer - and, this is a ctitical point: thru no fault of your own - i am disinclined to watch you die in the gutter and say "bad luck, poor guy".


That is the role of family and/or community, the next autonomous unit of society above the individual.


@qqq You planned on getting that- you're not insuring against anything, and there is no pooling of risk involved.


@tagore - Perhaps, but paying smaller quantities out of that pool to prevent extensive downstream costs may be acceptable to the insurance company.


To add to @fellshard 's point, it's rather unfortuante that we have moved from a society of "I'm GRATEFUL that family/friends/neighbors did XYZ for me" to a society of "the government OWES me XYZ; I'm ENTITLED to it"


@fellshard I'd say that it's still important to make the distinction. Note that that distinction is independent of subsidy. It's a matter of decoupling.


For sure. There might be room for that. But the insurance company, in the end, can make that decision, and if its rates are influenced because of that, people may leave for another company.


Nowadays, we have loosened the constraints of community and family - some ways intentionally, some ways unintentionally. We're starting to see some restructuring of it, based less on locale and travel and more on groups of interest across the Internet. Hence the popularity of services like 'GoFundMe', where virtual communities can assist one another.


I think that absent enforced incentives no insurance company would actually cover preventative care, for instance.


The numbers on it are not very good.


And that could be the case. I'm not the one with actuarials. 🙂


They can do the math for themselves, and I think they should be permitted to.


sure, local control, you're a gay black lesbian in a .. well you get my point. this is why we have central govt's, so the locals cannot torture the kinds they don't like.


At least from the perspective of an insurance company's bottom line.


Maybe they could instead reduce the rates of those who voluntarily - and with their own money - pursue preventive care?


@fellshard Why should they? Preventive care does not seem to reduce health-care costs.


Does it not? That would surprise me greatly. What do you mean by preventive care, specifically? Could be we're just not on the same page.


The world is rather unintuitive in its behavior....


I'll post some cites in a minute, but I'll first propose an explanation (which might or not be correct)


Let's say you have to insure people for the rest of their lives. You have two prospective insurees, one a smoker, and one a non-smoker.


Who should get the lower premium? I'm inclined to think the smoker should.


Because they'll die more quickly, and with less care able to sustain them in the long term?


Lung cancer kills you quickly (my Mom and my Grandmother died of it, so I've seen it in effect.)


Healthy people, on the other hand, take forever to die.


That's presuming the insurance company would insure them at all.


There are other economic effects involved here, of course, and they should not be ignored.


Well my Mom was still pretty productive when she got sick. She was still turning out a couple of books a year.


And there are other things that are hard to measure....


For instance I loved my Mom, and would have preferred she die a little later.


But tbh thre's really nothing that could have been done for her.


I'm sure preventative medicine saves some lives, but I think it is likely very overrated in that respect.


There's a difference, I think, between weighing individuals who make personal decisions consistently that lead towards unhealthiness, and individuals who are striving to remain healthy.


I'm thinking more in cases of, for example, early cancer detection, blood pressure monitoring and weight management, etc.


Conditions that can be detected but are outside the person's direct control.


That is what insurance is primarily for, as well.


Well, we can ask questions about that sort of thing, based on data, I think.


The data I've seen says that preventative care does not reduce the long-term cost of health-care.


I would be surprised if it did, tbh. If anything it ought to raise it.


My mom, for instance, did not die expensively.


Across all people, perhaps


For individuals?


Well, when we talk about insurance, or government subsidy, we are talking about 'across some large population,' right?


Correct. Hence why it makes sense for the cost to be tunable autonomously, which does indeed argue against insurance companies handling it.


Well that's outside the domain of what I was arguing- I was simply arguing that we ought to distinguish between unforseen events that need to be insured against and foreseen routine expenses, as conflating the two makes setting policy around them unnecessarily complicated.


Ah, alright. 🙂