In some respects, the ideal world is one in which everyone’s premiums are tied to a free and easy Apple Watch-like device that silently tracks exercise, blood sugar at a frequency that can tell when you ate a big dessert, air quality (and the presence of smoke or pollution), blood alcohol content, whether you are in speeding cars, whether you are participating in dangerous sports, etc. Such a system would directly confront individuals with the cost of their behaviors in an economic way, probably leading many or even most people to improve their habits in the aggregate.

But such a system comes at other costs that most people intuitively feel infringes on core values they have.

Edit to add: this system would actually have some great advantages over an “existing conditions” tax in that now you pay low rates until you have diabetes, all during the time you are leading the unhealthy lifestyle. But once you have it you are not rewarded for starting to exercise and eat healthy and get it under control. In the hypothetical scenario above, you’d be punished economically during the period you were building bad habits and you would be able to restore sane costs after course correction

It also fails to take into account the fact that eating clean and exercising daily doesn't eliminate your risk of getting cancer at age 40 or having your car's brakes fail randomly.

Is the obvious retort to this:

I don't think we should play arbiter for who has and hasn't lived a healthy enough life to still believe they should get healthcare?

The entire purpose of health insurance is spreading risk across a wide and diverse risk pool.

> why should I also be subsidizing Billy "video-games-are-my-exercise" fatass's chronic health conditions?"

Nobody is asking you to: enrolling in insurance is a choice in the USA.

Also, replace "chronic health conditions" with "unavoidable inherited genetic risk factors". We don't want Billy to be screwed for life just because he was born to a suboptimal combination of parents.

> "If I focused on my health, ate clean and exercised daily, why should I also be subsidizing Billy "video-games-are-my-exercise" fatass's chronic health conditions?"

Then why are you not asking your insurer why they cover a lot less preventative health or other options. For example, Kaiser flat out refuses to prescribe GLP-1s for weight loss, others insurers are the same with gym subsidies or not covering nutritionists.

But they'll happily pay for your gastric bypass.

There are plenty of health insurers that are not publicly traded, and in fact are non profit, and yet they have the same premiums as the publicly traded ones. See Kaiser, Providence, Cambia, Regence, and the dozens of other BCBS affiliated plans.

If your claims were true, then the publicly traded businesses would have no customers.

> Insurance premiums have only gone up as far as I can remember, though there's a ton of variables at play here.

An interesting thing about rising health costs is that it has happened at roughly similar rates in most first world countries for the last 50+ years.

For example in 1990 the UK, FR, and US were paying 2.0, 2.2, and 2.6 times their 1980 costs per capita. By 2000 that was 4.1, 4.1, and 4.2. By 2018 (the last year I had data for when I calculated this a few years ago) it was 10.6, 7.5, and 10.2.

Here's the 2000 to 2018 increase for those and some others: DE, FR, CA, IT, JP, UK, US were 2.1, 1.8, 2.0, 1.7, 2.6, 2.6, 2.3.

When politicians in the US talk about rising health care costs they usually put the blame on recent policies from opposing politicians. That so many first world countries with so many different health care systems all have seen similar increases for the last 50+ years suggests that it is due to something they all have in common and that government policy doesn't affect it much.

The individual mandate part of the ACA was the part designed to reduce premiums. You need healthy participants in any health insurance scheme to subsidize unhealthy people.

That was eliminated by a Republican bill, the Tax Cuts and Jobs Act of 2017.

In 2010, it was already known the proportion of old to young was increasing, and the proportion of doctors was decreasing.

Prices were always going to increase.

Aetna has their own scumminess. Want the convenience of 90 day refills? Have to use their mail order service. They'll refuse to authorize >30 day supplies of medication through any other pharmacy.

> The insurance business in general is very competitive and not very profitable...

Knowing several Americans, and how much they pay for health insurance (and are still required to pay for some things "out of pocket"), this is incredible to me. And that's before you even get to the process of making a claim.

Such a broken system.

The ACA doesn't prevent some magical fairy-dust AI from pricing premiums, though, which is currently all the rage amongst insurers. (Not because AI will be accurate or anything, but because it offers a completely opaque pricing process.)