How would you replace/fix ObamaCare?

[Atlas Has Shrugged]

I'm 18, and the only wisdom I posses is the wisdom to say that I do not know enough to possibly comment in an articulate manner. But I have a general idea of what I would like the healthcare system to look like. I'd want a system similar to the NHS in Britain, paid for by a flat tax that ideally wouldn't be more than an extra 1-2% addition to current income tax rates. Every American pays in, and every American has a chance to benefit from it.

Private insurance would remain legal and private hospitals would still exist. The only caveat that I can see the Atlas left disagreeing with me is that all non-emergency procedures would be barred from illegal immigrants. But that is a whole separate issue.

Another idea, mentioned by SilentCal, is an insurance pool that is open to any American who pays into it like Social Security. But as I noted, I don't know nearly enough to describe any details to this. That's why I hang around here so much, so I can figure these things out .

[🦀🎂🦀🎂]

The way to resist the effect of obesity on healthcosts is to attack its root causes: the overuse of sugar, the promotion of shoddy advice, the lack of time for people in poverty to prepare food for their families etc. Overwraught and moralistic plans (but what if their was a fat tax?) have no real effect at the end of the day, beyond making people feel superior.

Sure, we can go down the 'attack teh FATTIES lol!!!!' route, but it is rather stupid at the end of the day. First it boosts the craven and idiotic ideology of 'fat=unhealthy, skinny=healthy' (which is largely a construct of the insurance industry, rather than medical science). I, for example, have exactly 'correct' BMI but I have no doubt that a lot of people who cross the threshold of BMI are very much healthier than me.

It is very much more efficient to treat people the same, however much you feel they 'did this to themselves'.

[bedstuy]

The way to resist the effect of obesity on healthcosts is to attack its root causes: the overuse of sugar, the promotion of shoddy advice, the lack of time for people in poverty to prepare food for their families etc. Overwraught and moralistic plans (but what if their was a fat tax?) have no real effect at the end of the day, beyond making people feel superior.

Sure, we can go down the 'attack teh FATTIES lol!!!!' route, but it is rather stupid at the end of the day. First it boosts the craven and idiotic ideology of 'fat=unhealthy, skinny=healthy' (which is largely a construct of the insurance industry, rather than medical science). I, for example, have exactly 'correct' BMI but I have no doubt that a lot of people who cross the threshold of BMI are very much healthier than me.

It is very much more efficient to treat people the same, however much you feel they 'did this to themselves'.

I'm inclined to agree.  But, you're wrong on the medical issue of obesity.  1.  Obesity is not strictly BMI, because BMI does not account for body composition.  2.  Having a lot of body fat is never healthy.    It's not fatal, but being 30% body fat or more isn't healthy.  3.  The fact that obesity is not the only factor in overall health is a banal fact.  You can be a healthy heroin addict who uses dirty needles, doesn't make as healthy as not being a heroin addict who uses dirty needles.

That said, it seems fairly pointless to turn insurance into this punishment/reward system.  It would ultimately punish sick people and unfairly reward people with a few positive data points on their medical chart.  And, would it really be worth it, the cost of gathering all that data might just outweigh the benefit.

Instead, we ought to look at how we incentivize diet and lifestyle through our government policy.  Just think about the fact that we have huge corn and wheat subsidy programs, when those products in the form of processed foods are leading to obesity.

[7,052,770]

Maybe the government could start paying people to exercise. That would probably be positive cash flow for the government in the long run, not to mention the economic benefits of having a healthier populace.

[🦀🎂🦀🎂]

Of course, we all cost a lot in the end. Perhaps we should be paying people to get fat and smoke so they die prematurely and won't burden the NHS and social care with their elderly frail bodies?

[Deus Naturae]

The way to resist the effect of obesity on healthcosts is to attack its root causes: the overuse of sugar, the promotion of shoddy advice, the lack of time for people in poverty to prepare food for their families etc. Overwraught and moralistic plans (but what if their was a fat tax?) have no real effect at the end of the day, beyond making people feel superior.

Sure, we can go down the 'attack teh FATTIES lol!!!!' route, but it is rather stupid at the end of the day. First it boosts the craven and idiotic ideology of 'fat=unhealthy, skinny=healthy' (which is largely a construct of the insurance industry, rather than medical science). I, for example, have exactly 'correct' BMI but I have no doubt that a lot of people who cross the threshold of BMI are very much healthier than me.

It is very much more efficient to treat people the same, however much you feel they 'did this to themselves'.

It isn't more efficient to treat everyone the same, anymore than it's more efficient for a rental car service to charge the same fee to everybody regardless of how long they're actually going to use the car. If you are going to be incurring more costs to the insurer/medical system, it makes sense for you to pay more into the pool/system.

[bedstuy]

The way to resist the effect of obesity on healthcosts is to attack its root causes: the overuse of sugar, the promotion of shoddy advice, the lack of time for people in poverty to prepare food for their families etc. Overwraught and moralistic plans (but what if their was a fat tax?) have no real effect at the end of the day, beyond making people feel superior.

Sure, we can go down the 'attack teh FATTIES lol!!!!' route, but it is rather stupid at the end of the day. First it boosts the craven and idiotic ideology of 'fat=unhealthy, skinny=healthy' (which is largely a construct of the insurance industry, rather than medical science). I, for example, have exactly 'correct' BMI but I have no doubt that a lot of people who cross the threshold of BMI are very much healthier than me.

It is very much more efficient to treat people the same, however much you feel they 'did this to themselves'.

It isn't more efficient to treat everyone the same, anymore than it's more efficient for a store to sell all of its goods for the same price. If you are going to be incurring more costs to the insurer/medical system, it makes sense for you to pay more into the pool/system.

Not necessarily.  This is one of those libertarian teenager fantasies, that everyone gets what they deserve.  Fat people get sick, skinny people don't.  That's not true.  Some thin people are going to get leukemia or crohn's disease or break their pevlis in a car crash.  There's often no rhyme or reason to it.  And, there's nothing that person could have done to avoid that outcome.

I think if someone has a childhood cancer, that shouldn't permanently disqualify them from private health insurance like it did before Obamacare.  If someone has a chronic illness, that shouldn't bankrupt them or keep them paying $4000 a month just to stay alive.  Being a decent society means that we take care of people who get sick and help chip in to pay for them.  And, if you're paying a higher premium without ever taking advantage of your coverage, you're lucky.  Being healthy is immeasurably more important than saving $60 a month in health insurance premiums. 

However, you are right to think about how we incentivize people towards a healthy lifestyle.  But, insurance seems like a bad way to create those incentives.  We ought to look at farm subsidies, city planning, and a number of other things first.

[Deus Naturae]

It's true that since we're discussing insurance, we're dealing with hypothetical probabilities rather than predetermined outcomes. But, it still makes sense to charge higher premiums to those who have a higher probability of incurring costs, since that approach is more likely to be cost-efficient than not.

The alternative (charging everyone the same) might work out, but it's still more likely that people with unhealthy lifestyles would incur greater costs and the flat rate would essentially subsidize the fat and irresponsible at the expense of the fit and healthy.

Also, I 100% agree with you on farm subsidies. Government subsidies to grain (particularly corn) producers as well as tariffs on cane and beet sugar which promote HFCS usage are a big part of obesity in this country. Sadly the grain industry has so much influence that's it's even ingrained (no pun intended) in the USDA food pyramid which is taught to kids.

[bedstuy]

Here's my take. 

If charging someone more causes them to change their behavior in a way that reduces costs, it's something to consider.  Like with smoking, smokers pay a cost for the habit which hopefully covers some of the negative externality that they create.  Although for other health data points, you have to consider whether collecting all the data is worth the effort or actually fair.  For example, it's wouldn't be fair to judge whether someone is fat based on their weight or their BMI.  What if someone has an athletic frame and a lot of lean muscle, should they pay more for the health insurance?  I don't think so.  So, does everyone in America get an annual body fat composition test?  It could be way more trouble and administrative cost than its worth.

But, it doesn't really do any good to charge someone who had cancer 10 years ago more, even though they're a higher insurance risk.  I don't care how much you incentivize someone, they can't just force themselves to not be a cancer survivor. 

You need to think about what health insurance is.  It's not an optional thing like car insurance or personal liability insurance.  Someone can say, hey, I can't pay xyz rate, I better get a cheaper car or I better not operate a skydiving business because I can't afford the liability insurance, or I better not build a house on that 2 year flood plain.  That doesn't work with your health.  It would be nice if you paid, hmmm, I can't afford colon cancer, I better opt for a head cold.  But, it doesn't work that way.  Health insurance covers the costs of being alive and being alive is not an optional thing, in fact, it's mandatory at least for alive people.

[The_Doctor]

To answer Crabcake categorically:

1. Overuse of sugar - end corn subsidies. That instantly would help, as well as perhaps taxing fast food and pastry shops. But really, we need to incentivize people to stay in shape. This generation's grandparents did fine, and we were fine up to the 1960s. Really, they were healthy without government incentive, but since we have a crisis, we're going to have to take some harsh measures.
2. Shoddy advice - everyone wants a quick fix. There isn't one. Proper diet and exercise is it. The shoddy advice exists because people don't want to apply themselves.
3. People in poverty have more access to food than those in the Third World. They also can prepare  cheap good food that is healthy. I don't buy that poor people can't buy cheap good food. Here, I can give you examples, if you want, that you can find in any supermarket.
4. Fat = unhealthy. That is 100% correct. The BMI test is only inaccurate in the sense that it doesn't measure body fat as accurately as a true body fat test (and the BMI test actually underestimates the body fat by a slight margin). Thin people are not necessarily always healthy but they're on balance, if they're not abusing and are eating well and exercising, they're much healthier than fat people in the long run. And they cost the system much less.

Fat people should pay more for health care and thin people less because frankly, the fat people are going to be using the system far more.

[7,052,770]

Fat people should pay more for health care and thin people less because frankly, the fat people are going to be using the system far more.

Theoretically, you're on to something, but it would be very difficult to define "fat," "thin," etc. Which scale do you use to measure someone's weight? Weight varies day to day and hour to hour, so when the measurement was taken. You would also have to consider that amputees are going to have lower weights and adjust accordingly, and take into account that cancer patients often lose a lot of weight, but are much less healthy and higher-cost than they were before they had cancer.

You're talking about adding on a lot of administrative costs and leaving yourself open to litigation as people disagree with their given weight. It's just not worth it. Another thing to consider as far as smokers go is that insurance companies have no real way to verify if someone is truly a non-smoker if they claim to be. Insurance companies can't spy on you to know if you really smoke, or check receipts or anything, it's all honor system. You'd run into this same issue with your proposed weight rating system.

Also, Obamacare prohibits changing someone's rate (as long as they don't change coverage or move) during the year, so people would be locked in for the whole year based on their weight in January, whether that goes up or down. That could lead to further problems.

[🦀🎂🦀🎂]

At the end of the day, we all use the system a lot when we, err, age and die. I'm very uneasy about the idea of carving everybody up into high-risk and low-risk categories - to me it rather betrays the entire point of public insurance, that pools everybody in a collective net.

The reason I oppose targeting the overweight in particular is its crudeness. The obesity crisis is a societal problem and not an indivividual one, and attempts to attack obesity through shame based tactics is doomed to fail. It only helps the hacks and spivs that run bulls*** programs like Weighteatchers, cosmetic surgeons and the fad diet industry. Targeting the individual in a world where people are literally encouraged to be overeat fructose products and sit in offices all day (and then constantly yo-yo in weight, and get stuck in desperation trying to get out of the cycle) is foolishness.

(And of course then the merely 'overweight' get lumped in with the obese, a blurring which is fantastically appalling.)

[Snowstalker Mk. II]

Create a National Health Service, ban private insurance.

[7,052,770]

Why single out the overweight anyway? There are other "high-risk" activities you could charge more for:

• driving on deadlier roads, or just by total miles driven
• dangerous behavior while driving - eating, texting, etc.
• consumption of alcohol and unhealthy foods, even if not overweight
• living in high crime areas
• living in areas with high air pollution
• owning guns
• listening to music with headphones at high volumes
• using a keyboard and mouse all day at work - CTS and other conditions
• number of limbs (can't get skin cancer on a leg you don't have)
• whether or not you get enough vitamins and minerals in your diet
• working around asbestos before we knew it caused cancer
• irresponsible sexual behavior
• having religious beliefs that discourage medical attention
• low-IQ and low-income people tend to have higher claims costs
• certain conditions pop up more common in some racial/ethnic groups than others
• having ancestors with certain genetic conditions, even if you yourself haven't shown the signs
• etc.

If you really want to design a health insurance rate that reflects a person's projected claims cost, you'd have to take all of these factors into account, plus hundreds more. The administrative costs of determining a value for all of these stats for all 300,000,000 Americans would be astronomical, though, and it would still be easy to hide some of these from an insurance company.

Personally, I think it's even more unfair to arbitrarily pick a couple of easy target, low-hanging fruit "bad risks" like obesity and smoking and ignoring everything else, than it is to just charge everyone the same rate* and be done with it.



* - except age - you gotta rate to some extent on that in the individual market, although I strongly support the Obamacare system of your portion of your bill being based on your income, regardless of age, and the government picking up the rest of the tab, irrespective of what it is.

[Deus Naturae]

At the end of the day, we all use the system a lot when we, err, age and die. I'm very uneasy about the idea of carving everybody up into high-risk and low-risk categories - to me it rather betrays the entire point of public insurance, that pools everybody in a collective net.

The reason I oppose targeting the overweight in particular is its crudeness. The obesity crisis is a societal problem and not an indivividual one, and attempts to attack obesity through shame based tactics is doomed to fail. It only helps the hacks and spivs that run bulls*** programs like Weighteatchers, cosmetic surgeons and the fad diet industry. Targeting the individual in a world where people are literally encouraged to be overeat fructose products and sit in offices all day (and then constantly yo-yo in weight, and get stuck in desperation trying to get out of the cycle) is foolishness.

I don't really care about obesity as a "social problem", if people want to maintain a lifestyle that will lead to them being obese, that's a personal decision on their part and it's none of my business to interfere. What I take issue with is government regulations which effectively require insurers to subsidize the obese at my expense.

Also, what "fad diets" are you referring to? I've been eating mostly Paleo for several years now and I'm in great health. Low-carb diets are generally the most effective. There are some bad fad diets but the real scam is the mainstream nonsense about red meat and cholesterol being bad for you and carbs being good. That's a whole different subject though.

[🦀🎂🦀🎂]

Yeah well of course you don't care about doing anything useful, you're a libertarian.

[Small Business Owner of Any Repute]

Also, Obamacare prohibits changing someone's rate (as long as they don't change coverage or move) during the year, so people would be locked in for the whole year based on their weight in January, whether that goes up or down. That could lead to further problems.

Weight is not an accurate way to determine someone's health nor body fat percentage. I am between 10-15% body fat, and yet due to the amount of muscle I have on my body, I am in the "overweight" category.

In any case, there is a legal basis for charging more for smokers than those who are overweight. In 1987, the Department of Health and Human Services was asked by a group representing the nation's health insurers to review whether it would be appropriate and lawful to create special community rating classes for smokers, the obese and those suffering from hypertension.

To qualify for this government approval, a risk factor must meet all three of the following criterion:

1. The risk factor must cause substantially increased health care costs
2. The risk factor must be easily and objectively verifiable
3. The risk factor must be subject to change by the insured and, if changed, result in lower health care costs.

On July 6, 1987, Dan Kollmorgen, Director, Division of Compliance, Office of Prepaid Health Care, Health Care Financing Administration, wrote:

You must be logged in to read this quote.

The issue of charging the obese more was revisited more recently during Tommy Thompson's tenure at HHS. In short, a key distinction was made between smoking -- a behavior -- and a person's weight, which is classified as a health status.

Why single out the overweight anyway? There are other "high-risk" activities you could charge more for:

• driving on deadlier roads, or just by total miles driven
• dangerous behavior while driving - eating, texting, etc.
• consumption of alcohol and unhealthy foods, even if not overweight
• living in high crime areas
• living in areas with high air pollution
• owning guns
• listening to music with headphones at high volumes
• using a keyboard and mouse all day at work - CTS and other conditions
• number of limbs (can't get skin cancer on a leg you don't have)
• whether or not you get enough vitamins and minerals in your diet
• working around asbestos before we knew it caused cancer
• irresponsible sexual behavior
• having religious beliefs that discourage medical attention
• low-IQ and low-income people tend to have higher claims costs
• certain conditions pop up more common in some racial/ethnic groups than others
• having ancestors with certain genetic conditions, even if you yourself haven't shown the signs
• etc.

None of these meet the three requirements set out above.

[stegosaurus]

I would abolish Obamacare and nationalize the health insurance industry, either under "Medicare for all" or some new universal public option entirely. It would be funded by a slight increase in payroll taxes across the board and savings from the abolition of Medicaid. Finally, the new Medicare/Public Option would have a fixed fee schedule to stabilze the price of procedures.

[The_Doctor]

To respond to various people in this thread.

1. Yes, weight is a measurable sign of health or ill health. The medical community is pretty clear about it - which is why they tell the obese and the overweight to lose weight. It is an accurate way of measuring most people's health in many instances and is a perfectly valid medical measurement.

2. We don't need to change ObamaCare for this. One aspect of this is that we need to see people keep the weight off. That means if you lose weight and you keep it off, eventually, you'll get that break. We don't need to worry about the fact that rate changes are annually for this particular problem.

3. Weight fluctuates but it only fluctuates five pounds. Most people are at a weight that is within 5 pounds, unless they're gaining or losing. Avoiding litigation could be easy, by limiting it legally. Simple - you spell out a procedure, where everyone (we're all required to have insurance now, right?) has to have an annual weigh in and verified by one or more doctors. That data is given to your insurer who would make the rate changes accordingly.

4. I object as a thin person that I have to subsidize the obesity crisis in America, and have no recourse. I rarely use insurance but I know that my rates will be higher because of fat people continually using it. I shouldn't have to be punished by subsidizing the behavior of others.
a. Smoking and obesity are the two most identifiable behaviors we can punish. It's also frankly the two most common behaviors, and taking them out would allow our insurance, overall, to go down. So it's legitimate to single them out. These are two high risk behaviors that we can and should definitely target. Not only that, these are the two conditions resulting from poor behavior. If you have a past history of hard drug use, I would be fine with you paying higher premiums as well.

5. Overweight people are slightly less at risk for health complications than the obese. But they're still at risk.

[Torie]

In other news, the Pubs have finally come up with with fix for Obamacare, to be put in place if SCOTUS cuts off subsidies to federal exchanges run by the Feds rather than the states who refused to set one up.

[Small Business Owner of Any Repute]

To respond to various people in this thread.

1. Yes, weight is a measurable sign of health or ill health.

Here's a picture of a person who is classified as obese per BMI:

[AggregateDemand]

In other news, the Pubs have finally come up with with fix for Obamacare, to be put in place if SCOTUS cuts off subsidies to federal exchanges run by the Feds rather than the states who refused to set one up.

The new plan is actually a reversal of the fix. The beginning, middle, and end of our healthcare problems are caused by the foolhardy gross exclusion from income for employe health insurance premiums.

The original fix taxed most healthcare benefits like regular compensation, which stops the frivolous misuse of health insurance by corporations. The new "improved" plan restores the exclusion from gross income. Stupid. We'd be better off letting the Cadillac tax vest in 2018.

[The_Doctor]

To respond to various people in this thread.

1. Yes, weight is a measurable sign of health or ill health.

Here's a picture of a person who is classified as obese per BMI:

In my first post and subsequent posts I acknowledged body fat percentages as a better measure. Weight, however, for the vast majority of Americans will suffice as a measure.

By body fat percentages Arnold Schwarzenegger is perfectly healthy. Most Americans if they were at his weight would probably look very different