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PubMedDate not supplied

Health insurance for the "uninsurable".

State-sponsored health insurance plans for people labeled "uninsurable" by commercial carriers provide financial lifelines for those who qualify. In 28 states, individuals suffering from cancer, AIDS, multiple sclerosis, emotional disorders, cystic fibrosis, para- or quadriplegia and other chronic or recurrent health problems receive benefits--for reasonable premiums--from innovative programs that can literally make the difference between life and death, solvency or indigence. Medical practices and other health care facilities can play a pivotal role in informing patients of these coverage options--and by doing so, increase their revenue, as well.

Health Insurance Portability and Accountability Ac↗
PubMedDate not supplied

Genetics and the moral mission of health insurance.

Deciding whether genetic differences among individuals are morally relevant to health insurance requires us to ask, What kind of good is health care? and, What principles should govern its distribution? There are good reasons to doubt that "actuarial fairness" is an adequate description of genuine fairness in health insurance.

Actuarial Analysis↗
PubMedDate not supplied

Insurance for the insurers. The use of genetic tests.

Genetic testing raises concerns that individuals will be denied health insurance (and thus, effectively, access to health care), or that employers will screen to eliminate potentially costly workers. Although we as a society do not yet concur on the degree to which private businesses have a responsibility to promote social justice, several different policy alternatives might allow us to weigh the interests of insurers, as businesses, against the interests of citizens in a responsible manner.

Eligibility Determination↗
PubMed1991

Health access America--strengthening the US health care system.

Although Americans remain generally satisfied with the health care provided to them, sufficient access to high-quality, affordable health care for citizens without health care insurance has become an increasing problem in the last decade. Using the policy development process of the American Medical Association, Health Access America was conceived by the Association to improve access to affordable, high-quality health care. The proposal consists of six fundamental principles and 16 key points. This article specifically focuses on the five points that, if enacted into law, would improve access to health care for Americans who are, for various reasons, without health insurance.

Aged↗
PubMed1990

Insurability and the HIV epidemic: ethical issues in underwriting.

The HIV epidemic has focused criticism on standard underwriting practices that exclude people with AIDS or at high risk for it from insurance coverage. Insurers have denied the charge that these practices are unfair, claiming instead that whatever is actuarially fair is fair or just. This defense will not work unless we assume that individuals are entitled to gain advantages and deserve losses merely as a result of their health status. That assumption is highly controversial at the level of theory and is inconsistent with many of our moral beliefs and practices, including our insurance practices. We should reject the insurers' argument. Justice in health care requires that we protect equality of opportunity, and that implies sharing the burden of protecting people against health risks. In a just healthcare system, whether mixed or purely public, the insurance scheme is in systematic terms actuarially unfair, for its overall social function must be to guarantee access to appropriate care. This does not mean that in our system insurers are ignoring their obligation to provide access to coverage. The obligation to assure access is primarily a social one, and the failures of access in our system are the result of public failures to meet those obligations. In a just but mixed system, there would be an explicit division of responsibility among public and private insurance schemes. In our mixed but unjust system, both legislators and insurers cynically pretend that the uninsured are the responsibility of the other. The attempt to treat actuarial fairness as a moral notion thus disguises what is really at issue, namely, the risk to insurers of adverse selection and the economic advantages of standard underwriting practices. Standard underwriting practices will be fair only if they are part of a just system, not if they simply are actuarially fair. The failure of the argument from actuarial fairness means that we must face an issue private insurers had hoped to avoid if we are to defend standard underwriting practices at all. In view of the clear risk that a mixed system will fail to assure access to care, the burden falls on defenders of a mixed system. They must show us that its social benefits outweigh its social costs, and that it is possible to have a mixed system that is not only just, but also is superior to a compulsory, universal insurance scheme.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Universal health insurance and high-risk groups in West Germany: implications for U.S. health policy.

Access to West Germany's broad-based health-insurance system is geared to the country's occupational structure. People who qualify, however, may seek coverage from alternative sources, including local "sickness funds." The changing nature of the German job market is leading to concentration of high-risk groups in the local funds, some of which could in turn face serious financial problems. Proponents of a universal health-insurance program for the United States need to take account of the growing segmentation of risk groups in the current German experience, which may ultimately threaten the concept of solidarity on which the system is founded.

Economic Competition↗
PubMed1988

The erosion of purchased health insurance.

In this paper, we trace the decline of purchased health insurance and examine the reasons for the rapid growth of self-insurance between 1981 and 1985. Then, using nationally representative data on benefits in larger private sector firms, we examine the changing content of self-insured plans and compare them with fully insured conventional plans from commercial insurers and Blue Cross and Blue Shield Plans. Between 1981 and 1985, the percentage of employees in mid- to large-sized firms covered by self-insurance grew from 21% to 42%. Self-insured plans cost more than purchased plans in 1981, and continued to cost more in 1985. Their higher premiums were not due to richer benefit packages. Indeed, they less often covered "fringe" services and required greater cost sharing via higher deductibles and coinsurance. Upon considering both the efficiency and the equity issues of self-insurance, we sound a cautionary note on this growing trend.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Making fair decisions about financing care for persons with AIDS.

An estimated 40 percent of the nation's 55,000 persons with acquired immunodeficiency syndrome (AIDS) have received care under the Medicaid Program, which is administered by the Health Care Financing Administration (HCFA) and funded jointly by the Federal Government and the States. In fiscal year 1988, Medicaid will spend between $700 and $750 million for AIDS care and treatment. Medicaid spending on AIDS is likely to reach $2.4 billion by fiscal year 1992, an estimate that does not include costs of treatment with zidovudine (AZT). Four policy principles are proposed for meeting this new cost burden in a way that is fair, responsive, efficient, and in harmony with our current joint public-private system of health care financing. The four guidelines are to (a) treat AIDS as any other serious disease, without the creation of a disease-specific entitlement program; (b) bring AIDS treatment financing into the mainstream of the health care financing system, making it a shared responsibility and promoting initiatives such as high-risk insurance pools: (c) give States the flexibility to meet local needs, including Medicaid home care and community-based care services waivers; (d) encourage health care professionals to meet their obligation to care for AIDS patients.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Potential methods to reduce risk selection and its effects.

Risk differences are inherent with voluntary enrollment or choice of health plans. If these desirable features are to be maintained, risk differences must be assessed and payments to plans adjusted. Perfect prediction of individual level costs is impossible, but it is feasible to approximate costs for large groups of employees joining a purchasing cooperative. When people within an employee group or cooperative can choose among different health plans, there is much more opportunity for risk selection. A fair but powerful referee to determine adjustment methods within the cooperative's zero-sum setting may reduce markedly the potential for selection problems.

Actuarial Analysis↗
PubMed1997

Operation start-up.

When Mount Carmel Health System sized up the Medicare market in Columbus, Ohio, executives liked what they saw: Seniors trusted them more than insurers to run a managed care plan. Only six months later, their provider-sponsored plan opened for business under a HCFA pilot project. Here's how Mount Carmel pulled it off.

Aged↗
PubMed1996

Health insurance: the tradeoff between risk pooling and moral hazard.

Choosing optimal health insurance coverage involves a trade-off between the gain from risk reduction and the deadweight loss from moral hazard. This paper examines this trade-off empirically by estimating both the demand for health insurance and the demand for health services. It relies on data from a randomized controlled trial of cost-sharing's effects on the use of health services and on the health status for a general, non-elderly population.

Actuarial Analysis↗
PubMed1992

Reform of financing for health coverage: what can reinsurance accomplish?

Reinsurance is one way that insurance companies pool risk, in this case, across insurance companies. Under conventional private practice, primary health insurers, including self-insured groups and HMOs, voluntarily contract with reinsurers to share some risk and some premiums. Because the primary carrier mainly wants to protect its solvency against unpredictable variation in claims experience, it normally reinsures only the "high end" of claims risk. This retrospective coverage of unusually high losses helps primary insurers take on more risk than they otherwise could. But it does not help secure affordable coverage for people with prospectively known high risks. Some plans for reforming private health insurance also invoke reinsurance-like mechanisms, especially in the markets for individual and small group coverage. There, reinsurance serves as part of a strategy for requiring that primary insurance be made available to all applicants, regardless of risk. Reinsurance or similar rules for allocating the burden of unusually high risks can help keep any one private insurer from having to bear a disproportionate share of high risks, and thus extend the reach of private insurance markets through regulation. But reinsurance alone does not reduce the underlying high cost of providing such primary coverage. Nor can reinsurance alone provide the resources to cover the uninsured, ensure that insurers will want to cover them, or make them voluntarily buy private coverage. Only some combination of new subsidies and mandates can do that.

Economic Competition↗
PubMed1992

Private insurance reform in the 1990s: can it solve the health care crisis?

A number of health insurance reform proposals have surfaced at the state governmental level in the United States. These include Medicaid expansion for the below-poverty or near-poverty uninsured, state subsidy to individuals and/or businesses for the purchases of health insurance, risk pools for the medically uninsurable, insurance industry-initiated reforms within the small group market, the promotion of "stripped down" insurance plans that reduce premium cost, and state mandating of employer-sponsored health insurance for the employed uninsured. All of these insurance reform proposals have serious limitations: (1) they fail to address the inequities of the underwriting principle by which older and sicker people pay more for health insurance than the young and healthy population; (2) they extend the illogical linkage of employment and health insurance; and (3) they do not slow the rate of health cost inflation nor do they contain a mechanism to finance broader health coverage through savings within the health sector. An alternative to insurance reform is the establishment of a social insurance program that brings the entire population into a single risk pool.

Adult↗