How would you replace/fix ObamaCare?

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(These figures are approximate and won't be exact in every county and state, but they should be in the ballpark everywhere.) When maternity is "optional," a maternity contract costs about twice as much as a non-maternity contract. When maternity is just an included benefit, it only raises the price for everyone by about 5%.

Do you really think the former option is preferable? And why single out maternity? Women don't get discounts because they can't get testicular cancer. Whites don't get discounts because they can't get sickle cell anemia. Shorter people don't get discounts because their skin has less surface area to have problems on.

Just cover everything and have everyone pay a composite rate (well, you've got to age rate because New York demonstrated that illegalizing age rating kills the market). It's so much easier (cheaper) to do it that way. No, you may never need maternity, but you will probably need something at some point that most people never need, and you'll be glad no one ever carved out your particular condition as an exclusion.

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A few things that could be fixed:

• Get rid of tobacco rating and only rate on age and geographic location. I'm as anti-tobacco as it comes, but it's awfully arbitrary to single out smokers when there's so many bad habits out there for people to choose. Smokers under the age of 65 generally only have around 10% higher claim costs anyway, and yet the ACA allows insurers to charge smokers up to 150% more. It's not until people reach Medicare age that smokers really pull away on costs
• Allow subsidies for people who make above 400% of FPL and buy insurance on the Exchanges. The people at 401% are the biggest losers of the ACA. I believe a person making 400% of FPL has their premiums capped at 9% of their income. Just do that for everyone who buys it on the Exchanges. The subsidies won't be extended too much further than that anyway, just because the rates aren't so high that a person making 800% of FPL will have to spend more than 9% for a silver plan. But if he does somehow, he should get a subsidy too.
• Somehow require all states to accept the Medicaid Expansion. Maybe as a compromise, the Feds could cover at 100% permanently (then you could legally justify forcing states to accept, probably), although that will cost more.
• Maybe get rid of the employer mandate and funnel more people onto the Exchanges. Or change accounting laws to make it so that large businesses can just help people pay for individual insurance on the Exchanges (post-subsidy) and come out ahead or equal money-wise.

Interesting fact: Before the ACA, the U.S. was only ranked a few spots behind Canada in the WHO list of best health care systems. I imagine we'll pass Canada pretty soon. Single payer, at least in the Canadian sense, is not the answer for the USA, and while the British system is objectively superior, there's just no way it's ever going to happen here.

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How many people at >400% of poverty don't receive subsidized insurance through their jobs? I make less than that and I get my insurance through my employer.

It would be a salary just over $60,000 for a single-person household, and higher for any more people than that, so I doubt it's very common. Still, though, a plumber in business for himself who makes $61,500 a year may have to spend well over 9% of his income to buy insurance on the Exchange, especially if he's older.

The fact that it's (presumably?) pretty rare is a good argument of why we need to do it -- it won't be expensive, and there's leftover money anyway since Obamacare is cheaper than originally thought.

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As said, it's currently illegal to kind of make smokers and fat people pay more

No it's not. Smokers can be charged up to 150% of the rate that an otherwise identical non-smoker would be.

And while I agree that theoretically, it would be nice to make people pay more for conditions that are their own "fault," while not charging more for people's pre-existing conditions that aren't their fault, that would be really hard administratively to do.

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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.

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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.

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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.