**4.4 Unreliability: exiting less profitable markets**

Despite receiving long-term subsidies from the federal government, private health insurers leave their market, often with little advance notice, whenever their profits fall below expectations of their CEOs and shareholders. As just one example, at least 1.4 million people in 32 states lost their ACA coverage at the end of 2016, leaving them fewer choices than before [28].

#### **Figure 3.**

*Insurance overhead in 6 countries (CAF Figure 11.2, 151).*

#### **Figure 4.** *(CAF Figure 4.2, 45)*

### **4.5 Segmented risk pools**

To be effective nationally, health insurance must be compulsory in order to eliminate segmentation of risk pools, as Dr. Henry Sigerist, then Director of the History of Medicine at the Johns Hopkins University, recognized as far back as 1944:

*Illness is an unpredictable risk for the individual family, but we know fairly accurately how much illness a large group of people will have, how much medical care they will require, and how many days they will have to spend in hospitals. In other*  *words, we cannot budget the cost of illness for the individual family but we can budget it for the nation. The principle must be to spread the risk among as many people as possible … The experience of the last 15 years in the United States [since 1931] has, in my opinion, demonstrated that voluntary health insurance does not solve the problem of the nation. It reaches only certain groups and is always at the mercy of economic fluctuations … Hence, if we decide to finance medical services through insurance, the insurance system must be compulsory [29].*
