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Notes -
The auto/medical insurance comparison is a good one to think about. Another distinction between the two is that auto insurance is mostly viewed as an individual thing, where the only real public purpose in getting involved is to make sure people internalize the costs that their decisions may have on others (i.e., basically every jurisdiction requires liability insurance). Whereas in the medical industry, the entire apparatus of the industry and relevant government entities (many of which are entirely captured by the same worldview) is so entirely bound by the view that we must subsidize, that we must transfer incomes via regulation of the medical industry, that they descend into such contorted reasoning along the lines of Everything Not Obligatory Is Forbidden. Those are the only two options once we've decided to implement a system that, instead of being oriented toward individuals internalizing the costs of their choices, is oriented specifically for the purpose of externalizing the cost of every single choice you make, no matter how minor, so long as it pushes around some mathematically-computable risk factor in a PubMed article somewhere. This is why such folks literally think that the only option other than strictly making things with some medical risk forbidden (unless you pay someone with a special government license to give you permission) is to literally put a bullet in the heads of anyone who does anything with computable medical risk. This sort of thing would be unthinkable to even express in the automotive world, because the entire mindset is starting from a completely different frame.
Unsurprisingly, this sort of reasoning is incoherent on its own terms. As mentioned in the other topic in the OP, the vastly dominant risk factor driving obscene amounts of medical spending is obesity. Why doesn't the exact same logic work? Why are we not forced to put a bullet in the head of anyone who uses food irresponsibly (perhaps anyone who attempts to purchase some food that hasn't been prescribed by a government-licensed dietitian)? Why wouldn't we have to put a bullet in the head of anyone who works on or drives their own car, rather than having it serviced by a government-licensed mechanic and be chauffeured around by a government-licensed driver? But this is truly the type of reasoning that has infected anyone who is remotely influential in medical policy. Transferring incomes via medical policy is in their bones, like a sacred value. From this core flows most of the ridiculous policy choices we've made, which have built up hack upon hack, ultimately resulting in messed up incentives for insurance companies. Insurance companies are basically not allowed to be honest and provide an honest product at this point, but that's only one of the many effects of a complete error in mindset.
The more I think about it, the more the auto/medical insurance comparison is driving me up a wall.
I mean, imagine if auto insurance worked like health insurance. For starters, it would be the equivalent of accident insurance plus a maintenance contract. If they had to accept "pre-existing conditions" people would be driving their cars around until fumes were filling the cabin for unknown reasons, get insurance during an open enrollment period, and then dumping their clunker on the nearest garage with entitled demands to "just fix it". Further, imagine car mechanics had some sort of "duty of care" to these cars, and couldn't just turn them away. Imagine of mechanics had to fix cars, regardless of cost, of anyone who could tow them to the garage. And then a bunch of these people just took their cars and drove off into the sunset without paying a dime.
Suddenly car insurance companies would be desperate for anything they could possibly due to stay solvent. And garages would just be making prices up out of thin air to stay solvent. They'd both have virtually uncapped and unavoidable liabilities, and limited means of income. Absolutely every single interaction with a "customer" would be an arms race where they need to either fleece this person as thoroughly as possible, lest they risk getting taken by this person for as much as possible.
Conversely, if health insurance were just like car insurance, they'd pay for traumatic injuries and sudden illness and that would be it. Chronic issues are on you, lifestyle issues are on you. Furthermore, they'd probably calculate your estimated years of life left, versus cost of treatment, to render a decision about whether you are "totaled" or not. They'd probably be a lot more like life insurance too, where they go over you with a fine toothed comb in deciding what the cost to insure you should be. Hospitals and doctors would expect payment for services up front, but hopefully would drop the arms race and just have generally consistent pricing for x-rays, casts, stitches, etc.
Now, things get thorny, in both directions, when you consider the state requiring you to have car or health insurance. Many states do currently require car insurance, and many states are also experiencing the effects of society shifting towards low trust defect-bots where illegal immigrants without insurance are crashing left, right and center ruining things for everyone, and despite breaking all the laws, nobody does jack or shit about it. Likewise when the ACA attempted to make having health insurance mandatory, the cost of plans was so ruinous many people just ate the penalty, and the whole scheme was so unpopular Trump got the mandate revoked.
But maybe we could pretend we still lived in a functional high trust society where everyone bought health insurance and the prices were reasonable, with all of the above. I still don't think people would accept the tradeoffs of health insurance being "just like" car insurance.
Yeah… ultimately, a lot of Americans view health insurance as a general paypig for health-related expenditures, in a way they don’t when it comes to car or home insurance (not yet, at least, as they’re getting there with regard to uninsured motorists [a Noticer might ask: and who are these "uninsured motorists"?]). From their point of view, health insurance companies exist just to approve claims and send money.
They’re not entirely blameworthy in that view, descriptively-speaking. Where the US government does its usual subsidization of demand and restriction of supply, and turning intrapersonal reallocation of risk into stealth interpersonal redistribution of wealth (another example would be Social Security).
However, prescriptively, it’s also an ought for many Americans—not just an is—that Someone Else should pay for their healthcare (especially if they’re frequent flyers due to some meme “diseases”/”disabilities”), that Someone Else should pay for their parents’ end-of-life care to eke out a few more months (lest they have to do a cost-benefit analysis using their parents’ estate—or heaven forbid—their own net-worth), that Someone Else should pay for the healthcare of Vulnerable Communities such as women, non-Asian minorities, and Persons of Under-documented Citizenship.
The notion that health insurance companies might perform actuarial risk/reward assessments is out of their personal Overton Windows. On DataSecretsLox (where I’m but a humble, occasional lurker), there were two back-to-back comments that I thought summarized the situation nicely:
Lumifer:
EchoChaos:
Illegals, who everyone just bluntly refers to as illegals or ‘Venezuelans’ when they’re around them. It’s not some big secret; when I went to driving school they straight up told us it was a good idea to have uninsured motorist protection in case you got into an accident with an illegal.
This isn’t some kind of politically incorrect knowledge that everyone pretends not to have like 13/52 or drunk driving rates by ethnicity.
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I don't buy this. Everyone dies of something. The efficient way to reduce medical expenses is to die of something that kills you relatively fast. Any claim that people's actions "cause them to have medical expenses" has to be seen in this light. It's by no means clear that some activities cause medical expenses at all just because they lead to early illness and death (I believe cigarette smoking reduces medical expenses for this reason). And even if they do, are they really something we wish to discourage? (do we want to blame people for being nonsmokers because that increases their medical expenses for old age care?)
Why it would even work?
I expect that smokers are more likely to die due to prolonged lung-related diseases rather than something acting quickly. And therefore increase costs.
But they also die much earlier and without elderly care, which is on a totally different level of cost. Also significant savings on social security: the state loves a man who dies on his 65th birthday and covers payments for a lawyer who lives to 98.
the claim was
which seem very unlikely to be true. Pension is surely not a medical expense?
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Fair enough. I was definitely being too strong in my language. If anything, it sort of highlights how difficult it is to even know how to compute it. Upon further reflection, I'd say that it's probably highly nonlinear and complicated, perhaps somewhat resistant to traditional methods (let's be honest; it's going to be a variant on OLS). For example, suppose two people use very similar amounts of fentanyl (to hit another topic in the OP), but just different enough or the people being just different enough in size or whatever that one of them dies and the other one is left alive, but with major organ issues or whatever. Maybe they're scared straight or are physically unable to go out and get drugs anymore, but their life just drags on for a long time, with ever-increasing medical bills. How, then, does one account for this risk factor in the calculus?
I think this actually brings me back to my initial position, though. I don't want to have to solve these wicked estimation problems in order to do public policy. I shouldn't have to. It should be mostly a meaningless question, at least for the purposes of public policy, if we were focused on setting things up so that folks internalized the costs of their choices rather than doing everything we can to externalize everything and transfer incomes.
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