When medical care was a lot less effective, and therefore a lot less expensive, as recently as the last century, photographs taken then show beer-belly bulldozer operators, smoking movie stars, and drug-sniffing dissolutes in San Francisco basements. Back then, cigarette ads included doctor endorsements, and health insurance, rarely sold, didn't exclude tobacco users or fat folks, although there was a cigarette ad suggesting that the latter "reach for a Lucky instead of a sweet". Car insurance wasn't yet mandatory, but the companies' actuaries were beginning to raise rates for multiple-crash customers.
You couldn't get insurance for a pre-existing condition like a wrecked car or a crushed pedestrian, but, if you chose to create more of the same after policy-purchase, you paid more for the post-incurred protection. It says a lot abut the mind-set behind federal flood insurance that, actuarial reality notwithstanding, floodplain dwellers are enabled to pay less than they'll most likely cost, and (with a very few rare exceptions) they're encouraged to stay because their rates don't rise when they choose to stay after repeated flood events.
So much for actual actuarial science in governmental practice; I can bring to mind only two Midwestern cities which have relocated to high ground after repeated floods.
What I can't bring to mind is an understanding of the reason for governmental hostility to a health-savings plan, the tax-incentive device whereby consumers set aside dollars for "ordinary" medical services, while relying on risk-spreading insurance against the possibility of "catastrophic" needs. That's what car owners do when they opt for high-deductible coverage.
Nor can I understand why consumers who freely indulge in health-risking behaviors, some of which can't be described in this family newspaper, shouldn't pay higher premiums for the higher health-service costs they are actuarially predicted to generate. I can accept the notion that, for the U.S. as a First World nation, having sidewalks lined with the dying uninsured is a Third World tourist attraction not acceptable here, and that, therefore, actuarial science is trumped by governance standards for consumers with involuntary pre-existing conditions, their higher risk being covered in some part by general fund revenues, but I'll admit to being unable to comprehend why those whose pre-existing conditions are voluntary -twinkie (or worse) based-shouldn't pay more than those whose body-mass index meets a recognized standard. Nor should taxpayers who subsidize the involuntary pre-existing condition be required to subsidize the voluntary-action miscreants: employers increasingly won't do it for smokers and the military already won't do it for fatties, both of these qualities, twinkie legal defense construct notwithstanding, being really quite voluntary.