Yes, and?
Repeal or replace?
- Thread starter Diogenes
- Start date
Yes, and?
Life is Golden
The Sage
If underwriting were removed from homeowners or auto insurance, the results would be disastrous. Underwriting is how insurers assess risk and set prices that match the likelihood of a claim. Without it, everyone would pay roughly the same rate, regardless of risk.
For example, imagine auto insurers couldn’t consider driving records or claim histories. A safe driver with no accidents would pay the same as someone with multiple DUIs and a record of wrecks. The high-risk drivers would flock to buy coverage, while the low-risk drivers would either drop it or go elsewhere. Claims and payouts would surge, but premiums wouldn’t reflect that, quickly draining the insurers’ reserves.
In homeowners insurance, removing underwriting would mean charging the same rate for a home on the Florida coast as for one in Kansas. Properties in hurricane or flood zones would cost insurers far more in claims, yet they couldn’t charge more to cover that risk. Loss ratios would skyrocket, reinsurance costs would spike, and many companies would go bankrupt within a few years.
These examples show why underwriting isn’t about greed, it’s about survival. It’s what allows any insurance system to function without collapsing under its own risk.
We aren't discussing homeowners or auto insurance, are we?
Life is Golden
The Sage
Health insurance used to work the same way as auto or homeowners insurance. Companies assessed risk before issuing coverage. A healthy person paid less, a chronically ill person paid more, or sometimes was denied coverage. When the ACA banned underwriting, insurers lost that ability to balance their risk pool. They could no longer price policies based on health history or deny coverage to high-cost applicants.
The result is like forcing an auto insurer to charge the same premium to a reckless driver as to a safe one. The higher-risk people rush in because it’s a great deal for them, while lower-risk people often leave or opt for cheaper plans. That imbalance drives up overall costs, and insurers would collapse without help.
In health care, the government stepped in with subsidies to cover that gap. Those subsidies are what keep insurers from going bankrupt, just like an artificial support beam holding up a weakened structure. Without them, the system wouldn’t survive.
We aren't discussing auto or homeowners insurance, are we?
Life is Golden
The Sage
Health insurance should function like any other insurance business, where risk determines cost. Obama disrupted that balance, and we’re living with the fallout. You clearly don’t grasp that and prefer empty slogans over facts. I’ve explained it plainly, but if you choose to stay ignorant, that’s on you.
Grok says;
- “Health insurance used to work just like auto or homeowners insurance”
This is nostalgic fan-fiction. Pre-ACA individual health insurance was never a normal “risk-rated” market like car insurance.- Auto insurers can refuse to insure you entirely if you’re too risky, or cancel you after claims. Health insurers could do that too — and they did, constantly. One cancer diagnosis and you were uninsurable for life.
- Homeowners insurance excludes pre-existing conditions (flood, earthquake, “that crack in the foundation you didn’t disclose”). Health insurers excluded pre-existing everything — pregnancy, acne medication, a past knee injury from high-school soccer.
- Car insurance prices go down dramatically with a clean record. Pre-ACA health insurance? A 50-year-old healthy guy paid 5–7× what a 25-year-old paid even if both were perfectly healthy. That’s not “risk rating,” that’s just age discrimination baked in.
- “When ACA banned underwriting, insurers lost the ability to balance their risk pool”
Wrong. The ACA replaced underwriting with three far more powerful risk-balancing tools that the argument completely ignores:- The individual mandate (penalty until 2019, then zeroed out) forced healthy people in.
- 3:1 age rating cap + community rating + guaranteed issue created a predictable, broad pool.
- The three Rs: Risk Adjustment, Reinsurance, and Risk Corridors (especially risk adjustment) transfer billions from plans that enroll healthier people to plans that enroll sicker people. In 2023, risk adjustment moved ~$24 billion around — way more sophisticated than old-school underwriting ever was.
Result? The exchange risk pool is actually healthier than the pre-ACA individual market was. CMS data: average exchange enrollee in 2024 has an actuarial value of ~0.85 vs. ~1.10–1.20 in the old underwritten market. Translation: today’s pool is less sick than the one insurers nostalgically pine for.
- “It’s like forcing an auto insurer to charge a reckless driver the same as a safe one”
Terrible analogy. In this metaphor:- The “reckless driver” is someone born with cystic fibrosis or who gets breast cancer at 38.
- The “safe driver” is a healthy 27-year-old who can drop coverage the minute they don’t need it.
Auto insurance can say “no” forever. Health insurers under ACA cannot — which is why we have risk adjustment (see above). It’s more like forcing every auto insurer to take every driver, but then making State Farm pay Geico $50,000 every time Geico ends up with the drunk teenager. The system balances itself.
- “Higher-risk people rush in, lower-risk opt out, costs explode”
That’s exactly what happened… in 2014–2016, when risk corridors were gutted by Congress and reinsurance was temporary. Premiums spiked, some insurers lost money and left.
Then the three Rs kicked in fully, the market stabilized, and something hilarious happened:- Insurers started making record profits.
- UnitedHealth, Centene, Molina, Elevance, Cigna — combined underwriting margins 2020–2024 averaged 4–6%, higher than pre-ACA.
- Average benchmark silver premium in 2025 is $482/month before subsidies — but the average subsidy is $522/month. Yes, the subsidy is now larger than the premium because enhanced subsidies (ARP/IRA) turned the exchanges into the best deal in town for middle-class families. That’s not “artificial support beams,” that’s deliberate policy design.
- “Without subsidies the system collapses”
Define “the system.”- If every subsidy vanished tomorrow, yes, millions would drop coverage and premiums would spike — just like if you removed the mortgage-interest deduction, home prices would crash. That’s not evidence the system is fake; it’s evidence the system was built to be subsidized.
- But insurers themselves? They’d be fine. They’re already pricing for a world where CSR payments are gone and risk adjustment is permanent. Remove subsidies and the risk pool gets younger and healthier overnight — insurers would rake in money. The pain would be on consumers, not insurance companies.
- The biggest hole of all: the argument pretends the pre-ACA world was sustainable
It wasn’t.- Medical loss ratios in the individual market were ~65% (insurers kept 35 cents of every dollar). Today they’re 83–88% because ACA mandates 80–85% MLR. Consumers get way more value now.
- 50% of individual market enrollees were in plans that could cancel them retroactively.
- Half the country lived in states where a single $50k claim bankrupted you because lifetime limits were universal.
That world “worked” only if you never got sick.
They’re the price we collectively pay to stop insurance companies from cherry-picking the healthy and dumping the sick in the gutter. And guess what? Insurers are now richer than ever, charging premiums that would’ve been considered obscene in 2009, while delivering better coverage.The argument is nostalgia for a system that never deserved to exist in the first place.
Life is Golden
The Sage
That argument mixes facts with spin. It’s true that pre-ACA insurers could deny coverage or charge more based on health, but that’s exactly what underwriting is for: aligning premiums with risk. Every type of insurance uses it to stay solvent. Removing it didn’t “fix” a broken market, it replaced financial discipline with government subsidies and regulatory mandates.
The so-called “three Rs” and community rating aren’t real substitutes for underwriting. They’re redistribution mechanisms that move billions between companies to offset artificial pricing rules. That may stabilize the books on paper, but it hides the real cost—taxpayers fund the difference. If these tools worked as cleanly as claimed, insurers wouldn’t need massive subsidies to stay in the exchanges, nor would premiums have tripled for many middle-class families who don’t qualify for assistance.
Calling it “nostalgia” ignores that insurance is fundamentally about risk management. A system where companies can’t assess risk independently, and must depend on government transfers to survive, isn’t sustainable—it’s nationalized in all but name. The ACA didn’t create a fair market, it created a subsidized one. And when the subsidies eventually strain federal budgets or get reduced, the only outcome left is a single-payer system, because private insurers won’t operate at a loss once the government stops covering their risk.
Are you laboring under the impression that I think Obamacare is a success?
I don't.
I want it repealed if possible and replaced with NOTHING.
And no, I don't mean private insurance, either.
Does that clear it up?
Life is Golden
The Sage
So, you want to repeal the ACA and eliminate both private insurance and government-backed coverage. That’s not a plan, that’s an absence of one. Without either, you’d have a cash-only system where only the wealthy could afford care and hospitals would absorb billions in unpaid treatment. That would collapse the system faster than any government policy.
Health insurance, for all its flaws, exists because modern medicine is expensive. You can’t run a country of 330 million people on a “pay out of pocket” fantasy. The choice isn’t between government or nothing, it’s between managed structure and chaos. Removing both would turn every ER into a bankruptcy line and every serious illness into financial ruin.
No, I want what I said I want.
If people want to purchase private insurance, that's NOMB.
It's not a binary world.
Life is Golden
The Sage
I get that you want “nothing,” but that’s not realistic. Without private or public coverage, costs would skyrocket, hospitals would fail, and millions would go without care. Saying it’s “not binary” doesn’t change the fact that a system with no safety net only works for the wealthy.
It's perfectly realistic.
I distinctly recall stating that if people want to buy private insurance, that's none of my business. I don't mean this unkindly, but are you OK?
I didn't say I wanted to eliminate private coverage, did I? As for taxpayer-funded, yes, get rid of it.
Before modern welfare states, the indigent had options.
- Charity hospitals (religious or civic): free.
- Private charity from doctors who treated poor gratis (“pro bono” literally means “for the good”).
- Family and friends.
- Savings.
The poor you will always have with you, I hear. I'm not wealthy, but I stay healthy, without taxpayer-funded aid. Don't ask me again "what if", I already told you in this thread. Scroll back and read if you've forgotten.
- Only 44% of the global population (3.5 billion people) live in countries where ≥80% of health costs are covered by public/pre-paid pools with no major copayments—i.e. what people mean by “free” care.
- That means 56% (4.5 billion people) do NOT have publicly funded care that is effectively free at point of use.
If you're poor, lock in Medicaid before you get sick (the #1 move)
- 2025 Medicaid income limits by state (use this exact site on your phone): https://www.healthcare.gov/lower-costs/
Pick your state → “See if I can enroll” → it tells you the exact dollar amount for your household size.
Example: single person in Texas = $21,087/year; in California = $42,627. - Pro tip: If you earn $1 over the limit, spend it down on purpose in December (pre-pay rent, buy a cheap used car, pay off debt) so January 1st you qualify. People do this legally every year.
IL, NY, CA, OR, WA, CO, NM, AZ, NV, MT, ID, UT, HI, AK, MN, WI, MI, OH, KY, WV, VA, MD, DE, PA, NJ, CT, RI, MA, VT, NH, ME, LA, AR, OK, MO, IN, IA, NE, ND + DC.
Go there for 31 days → establish residency → enroll. Greyhound one-way tickets are $49–$179.3.
Free hospital care that 99% of poor people never claim (even if they have no insurance)
- Every non-profit hospital must give you free care if you earn <400% of poverty line ($60,280 for a single person in 2025).
- Here’s the master list of every hospital’s exact policy + application: https://www.dolthcis.com/
Search your hospital name → download the 2-page form → mail it.
Real example: In 2024 a guy in Tulsa got a $117,000 heart surgery written off to $0 because he mailed the form.
- Broken arm? Ask for the “self-pay cash price” before treatment.
Average prices 2025:
– ER visit + X-ray + sling = $380 cash (vs $4,200 billed to insurance)
– MRI = $450 cash (vs $4,500 insured)
– Childbirth = $2,500 cash at a birthing center (vs $35,000 insured) - Site that lists every hospital’s cash prices: https://turquoise.health (type your zip code)
- $0 insulin: Lilly, Novo Nordisk, Sanofi all have programs → $35/month max, often $0 with one form.
- Any expensive drug: go to the drug company website → “patient assistance program” → 2-page form = free meds shipped to your door.
2025 example: Ozempic = free if income < $75k for family of 4 (Novo Nordisk program).
- Dental schools: root canal $250 instead of $1,800. Find one: https://www.ada.org/resources/careers/dental-student-resources/dental-schools
- Free clinics list (updated weekly): https://nafcclinics.org/find-clinic
"The first Trump Administration actually produced a very thoughtful healthcare plan. I thought the section below was especially compelling.
Somewhere along the way, the entire healthcare sector veered off course. Insurance no longer means what the word means. We don’t mandate car insurance to cover oil changes or tire replacements. We insure against accidents. Healthcare should work the same way, covering unforeseen catastrophes, not predictable, routine care.
Maybe someone, somewhere, can dust off this report and take another look."
Somewhere along the way, the entire healthcare sector veered off course. Insurance no longer means what the word means. We don’t mandate car insurance to cover oil changes or tire replacements. We insure against accidents. Healthcare should work the same way, covering unforeseen catastrophes, not predictable, routine care.
Maybe someone, somewhere, can dust off this report and take another look."
Life is Golden
The Sage
1. “It’s perfectly realistic” / “I don’t want government coverage”
You’re conflating what’s possible for an individual with what works at scale. Sure, you personally can go without public coverage. But not everyone is healthy, disciplined, or wealthy enough to navigate the system of charity, savings, and pro bono care. A country of 330 million cannot function if the majority rely on these ad hoc, unreliable options. Individual anecdotes do not scale.
2. “Before modern welfare states, the indigent had options”
Yes, charity hospitals, family, and friends existed, but they were inconsistent, underfunded, and often limited by geography or capacity. Millions went without care, and preventable deaths were common. That’s why the modern system developed, to make access universal and predictable. Suggesting we return to a patchwork of charity ignores historical outcomes.
3. “44% of the global population has public coverage” / “Medicaid/Medicare exists”
You’re citing global statistics and selective state programs to justify a policy choice. That doesn’t change the fact that in most of the U.S., millions of people still fall into coverage gaps without ACA protections. Saying “Medicare exists at 65” doesn’t address those under 65 who have chronic conditions, sudden injuries, or no family safety net.
4. “Free hospital care / cash pricing / patient assistance programs”
These programs exist, but they’re reactive, not preventive. ER visits and catastrophic illnesses are unpredictable. Relying on forms, approvals, and charity creates delays, rationing, and inequity. The ACA’s subsidies and guaranteed coverage exist to prevent people from falling into that gap in the first place. The fact that some individuals navigate these systems successfully doesn’t make them a replacement for insurance.
5. “You can move states, enroll in zero-premium Medicaid, or use charity care”
Yes, mobility and paperwork are technically options—but they are not practical for the majority. Not everyone can afford to relocate, establish residency, or navigate complex applications while sick or poor. The ACA provides coverage automatically based on residence and income, creating a stable baseline for the population.
6. “Cash prices are cheaper than insurance”
Those are isolated examples, not the norm. Insurance spreads risk across many people; it protects against catastrophic events. A single heart surgery or childbirth may cost thousands even with charity programs, and smaller unexpected illnesses can accumulate quickly. Without pooled coverage, anyone with chronic or major illness faces financial ruin.
Paying cash for a broken arm or an urgent care visit is one thing. But what happens when you spend two months in the ICU, need multiple specialists, or require rehab after discharge? Charity programs and “cash pay” rates don’t cover that. They don’t negotiate your $500,000 hospital bill or lost wages. Insurance isn’t about convenience, it’s about protection from financial ruin. The ACA’s structure exists for that reason. It isn’t a luxury or a handout—it’s a safeguard for when life stops going according to plan.
You’re conflating what’s possible for an individual with what works at scale. Sure, you personally can go without public coverage. But not everyone is healthy, disciplined, or wealthy enough to navigate the system of charity, savings, and pro bono care. A country of 330 million cannot function if the majority rely on these ad hoc, unreliable options. Individual anecdotes do not scale.
2. “Before modern welfare states, the indigent had options”
Yes, charity hospitals, family, and friends existed, but they were inconsistent, underfunded, and often limited by geography or capacity. Millions went without care, and preventable deaths were common. That’s why the modern system developed, to make access universal and predictable. Suggesting we return to a patchwork of charity ignores historical outcomes.
3. “44% of the global population has public coverage” / “Medicaid/Medicare exists”
You’re citing global statistics and selective state programs to justify a policy choice. That doesn’t change the fact that in most of the U.S., millions of people still fall into coverage gaps without ACA protections. Saying “Medicare exists at 65” doesn’t address those under 65 who have chronic conditions, sudden injuries, or no family safety net.
4. “Free hospital care / cash pricing / patient assistance programs”
These programs exist, but they’re reactive, not preventive. ER visits and catastrophic illnesses are unpredictable. Relying on forms, approvals, and charity creates delays, rationing, and inequity. The ACA’s subsidies and guaranteed coverage exist to prevent people from falling into that gap in the first place. The fact that some individuals navigate these systems successfully doesn’t make them a replacement for insurance.
5. “You can move states, enroll in zero-premium Medicaid, or use charity care”
Yes, mobility and paperwork are technically options—but they are not practical for the majority. Not everyone can afford to relocate, establish residency, or navigate complex applications while sick or poor. The ACA provides coverage automatically based on residence and income, creating a stable baseline for the population.
6. “Cash prices are cheaper than insurance”
Those are isolated examples, not the norm. Insurance spreads risk across many people; it protects against catastrophic events. A single heart surgery or childbirth may cost thousands even with charity programs, and smaller unexpected illnesses can accumulate quickly. Without pooled coverage, anyone with chronic or major illness faces financial ruin.
Paying cash for a broken arm or an urgent care visit is one thing. But what happens when you spend two months in the ICU, need multiple specialists, or require rehab after discharge? Charity programs and “cash pay” rates don’t cover that. They don’t negotiate your $500,000 hospital bill or lost wages. Insurance isn’t about convenience, it’s about protection from financial ruin. The ACA’s structure exists for that reason. It isn’t a luxury or a handout—it’s a safeguard for when life stops going according to plan.
Life is Golden
The Sage
This is a dumb idea. As if the unwashed masses can be trusted with free money. He is seriously about to lose my support.
Think so?
Wow. Elitist much?
Think he wants it?
I'm not "at scale". I am one person. You’re the one conflating mandates with necessity. Nobody’s saying charity and savings cover every edge case flawlessly, but forcing 330 million into a one-size-fits-all government plan because some people make bad choices is the ultimate nanny-state overreach. The ACA isn’t a “safeguard”; it’s a trillion-dollar middleman that jacks up premiums for the healthy to subsidize the sick, while bureaucrats decide what “essential” means. If you’re healthy and disciplined, why should Uncle Sam confiscate your money to pay for someone else’s insulin? Anecdotes don’t scale? Neither does a federal program that can’t even keep its own exchanges from crashing every open enrollment.
It's not my responsibility to pay anyone's else's' bills.
Romanticizing the pre-ACA past is your strawman. Nobody’s advocating a full rollback to 19th-century poorhouses. The point is that decentralized, voluntary systems—church hospitals, mutual aid societies, lodges—handled far more than you admit before Medicare/Medicaid crowded them out with red tape and taxes. Life expectancy has risen despite government bloat, not because of it; antibiotics, sanitation, and vaccines did the heavy lifting. Pretending the ACA invented “universal access” ignores that ERs were already required to stabilize anyone under EMTALA since 1986. Your “historical outcomes” conveniently omit the millions bankrupted today by ACA-compliant plans with $8,000 deductibles.
Cherry-picking global stats while ignoring that most “public coverage” countries have shorter wait times for elective care only because they ration it outright—ask a Canadian about their 25-week orthopedic backlog. Medicare starts at 65? Great, so the 54-year-old cancer patient should just cross their fingers for 11 years? That’s your idea of compassion? The ACA’s “no gaps” promise is a joke: 28 million uninsured in 2023, bronze plans with 40% coinsurance, and networks so narrow you need a GPS to find an in-network oncologist. Medicaid expansion? A fiscal time bomb that’s already bankrupting states like Illinois, where able-bodied adults now outnumber the disabled on the rolls.
“Reactive, not preventive”? Preventive care was free at community clinics long before Obamacare. The ACA’s “guaranteed issue” just incentivized people to wait until they’re sick to buy insurance, driving premiums skyward—adverse selection 101. Charity care write-offs hit $41 billion in 2022; hospitals aren’t turning away the uninsured, they’re eating the cost and passing it to the insured via $3,000 MRI “facility fees.” Patient assistance programs from pharma cover 95% of brand-name scripts for low-income patients if they bother to apply—something ACA navigators were supposed to help with but mostly just collect salaries.
Automatically based on residence and income” sounds seamless until you hit the ACA’s income cliffs: earn $1 over 400% FPL and your subsidy vanishes, sticker-shocking you with a $15,000 premium. Moving states? People already do—look at the net exodus from California and New York to Florida and Texas, where Medicaid hasn’t expanded but healthcare costs are lower thanks to certificate-of-need repeal and cash-practice growth. The ACA’s “stable baseline” is a mirage; 40% of exchange enrollees churn off plans annually because they can’t afford the next year’s hike.
Isolated examples? Try Surgery Center of Oklahoma posting transparent $5,800 cash joint replacements versus $55,000 hospital bills—same outcomes, no insurance paperwork. Insurance “spreads risk” the way a casino spreads house odds: you pay $800/month for a $9,000 deductible, then discover your “covered” ICU stay still leaves you with $80,000 in balance billing because the anesthesiologist was out-of-network. A $500,000 bill? Good luck getting that from a cash-only surgical center; they quote upfront and compete. The ACA outlawed affordable catastrophic plans for anyone over 30, forcing 27-year-olds to buy maternity coverage they’ll never use. Financial ruin? Try the 650,000 medical bankruptcies after ACA—mostly people with insurance who couldn’t meet deductibles.The ACA isn’t a safeguard; it’s a protection racket. It mandates coverage, inflates costs, narrows networks, and still leaves millions exposed—then calls anyone who notices a monster. If your plan requires coercing the healthy to fund the sick while insurers and pharma rake in record profits, maybe the problem isn’t the free market—it’s the cronies who rigged it.
Please scroll back and read what I said about "what ifs: again
You’re waving the $500,000 ICU bill like it’s Excalibur, but that sword is made of cardboard once you look closer. Two months in the ICU? That’s a vented, multi-organ failure case, rare, and the kind hospitals already write off under charity policies or negotiate down to pennies on the dollar for the uninsured. MD Anderson, Cleveland Clinic, and every major system have indigent-care funds that eat six-figure bills yearly; they just don’t advertise it because ACA subsidies keep the revenue flowing. Cash-pay surgery centers won’t touch that patient?
Correct, they transfer to the safety-net hospital that will, and EMTALA guarantees stabilization regardless of wallet.
Your $500k sticker price is pre-negotiation theater; the uninsured routinely settle for 10–20% via hardship programs, while insured patients with “coverage” still drown in $50k deductibles and 40% coinsurance.Lost wages?
Neither ACA nor any private plan replaces income unless you separately bought disability insurance—another product Obamacare didn’t invent.
The ACA’s “essential health benefits” don’t include paycheck protection; they mandate acupuncture and fertility treatments instead. Rehab? Skilled nursing facilities take charity cases post-discharge if Medicaid kicks in retroactively (which it does in every state for catastrophic spend-down). The system you worship already funnels the truly broke into the very Medicaid you pretend only exists because of Obamacare.And the cruelest joke: the ACA created the narrow-network, high-deductible bronze plans that leave insured families bankrupt.
A 2023 KFF study found 41% of ACA marketplace enrollees skipped care due to cost, with insurance.
Meanwhile, direct primary care (DPC) practices charge $75/month for unlimited visits, labs, and generics. No claims, no networks, no $9,000 deductible surprises. They’re illegal to count as ACA-compliant coverage, because God forbid people opt out of the subsidized casino.
Your “safeguard” is a leaky raft that charges $1,500/month for the privilege of sinking slowly. The real protection from ruin? Price transparency laws (thanks, Trump EO 13877) now force hospitals to post cash rates, $1,200 cash colonoscopies vs. $5,600 insured.
Surgery Center of Oklahoma’s $1,800 cash hernia repair vs. $18,000 in-network.
The market works when government stops outlawing affordable options.
So no, the ACA isn’t a lifeline—it’s a choke chain. It bans the cheap catastrophic plans young people want, forces insurers to cover pre-existing conditions without risk-rating (hello, death spiral), and subsidizes the outcome with taxes on the healthy.
If your plan requires holding a gun to my paycheck to “protect” me from a bill I’ll never pay anyway, maybe the ruinous one here is the law itself.