Socialism is dead, though many of its academic proponents take no notice of its demise. With its death, private property in the means of production is not generally in dispute, and the action in political philosophy centers on the justification of the welfare state. The heart of the welfare state is social insurance programs, such as government managed and subsidized health insurance, retirement pensions, and unemployment insurance. The arguments about health insurance will arguably be (...) among the most ferocious, difficult, and important of the welfare-state debates: Ferocious, because proposals to alter government managed or subsidized health care strike at people's fears and concerns in a way matched by few other proposals. Difficult, because people can often not even conceive of a market alternative to the status quo in health insurance, and there is no real existing alternative to hold up as a model. Important, because if an intellectually solid case for market health insurance can be established, then supporters of the welfare state should be on the defensive, since social health insurance is an institution central to their vision of the just or good society. (shrink)

This volume is an exploration of the ethical issues raised by health insurance, which is particularly timely in the light of recent advances in medical research and political economy. Focusing on a wide range of areas, such as AIDS, genetic engineering, screening and underwriting, new disability legislation and the ethics of private and public health insurance, this comprehensive and sometimes controversial book provides an essential survey of the key issues in health insurance. Divided into (...) two parts, the first considers the ethics of underwriting, risk assessment and the acceptance and refusal of insurance risk by insurers. Discussing the unjust treatment of high-risk applicants, the authors identify sources of unfairness to both parties of the insurance contract, indicating how reasonable trade-offs can be made. The second part considers the argument for a mix of public and private insurance for acute and long-term care, offering recommendations for changes in the balance of social insurance, and discussing the shift toward long-term contracts in private health care and pension insurance. (shrink)

This volume is an exploration of the ethical issues raised by health insurance, which is particularly timely in the light of recent advances in medical research and political economy. Focusing on a wide range of areas, such as AIDS, genetic engineering, screening and underwriting, new disability legislation and the ethics of private and public health insurance, this comprehensive and sometimes controversial book provides an essential survey of the key issues in health insurance. Divided into (...) two parts, the first considers the ethics of underwriting, risk assessment and the acceptance and refusal of insurance risk by insurers. Discussing the unjust treatment of high-risk applicants, the authors identify sources of unfairness to both parties of the insurance contract, indicating how reasonable trade-offs can be made. The second part considers the argument for a mix of public and private insurance for acute and long-term care, offering recommendations for changes in the balance of social insurance, and discussing the shift toward long-term contracts in private health care and pension insurance. (shrink)

We may create a catch-22 so that only people who are unlikely to need health insurance can afford it.... Genetic risk testing is important because it exposes the logic of a system that provides access to health insurance to those least likely to need it.

We may create a catch-22 so that only people who are unlikely to need health insurance can afford it.... Genetic risk testing is important because it exposes the logic of a system that provides access to health insurance to those least likely to need it.

Public insurance is both everywhere and nowhere. It is everywhere in the sense that it is omnipresent in industrialised societies: public health insurance, unemployment benefits and pensions. It is a sizeable part of modern nations’ public budget . It has permeated our understanding of societal institutions to the extent that now access to public insurance coverage is understood as being a struggle for equality and equal citizenship .Public insurance is only one aspect of a broader (...) phenomenon: the transformation of modern societies into insurance societies, i.e. societies that are orientated toward risk-management . Nevertheless, public insurance is at the core of the welfare state as insurance system. Paul Krugman once said of the modern state that it is ‘an insurance company with an army’ while David Moss argues that government is the ultimate risk manager ( .. (shrink)

According to US law, insurance companies can lawfully differentiate individual health insurance premiums on the basis of non-genetic medical information, but not on the basis of genetic information. The article reviews the case for such genetic exceptionalism. First, I critically assess some standard justifications. Next, I scrutinize an argument appealing to the view that genetically based premium differentiation expresses that persons do not all merit equal concern and respect. In the final section, I argue that even if (...) genetic exceptionalism is unjustified, there is a forceful luck egalitarian argument against basing premiums on genetic risks, to wit, that this tends to make some individuals worse off than others as a result of the bad brute luck involved in having a genetically determined, above-average risk of developing health problems. (shrink)

The article presents two main arguments. First, we claim that in contemporary societies, insurance enacts peculiar kinds of solidarities as well as inequality and exclusion. Especially important in this respect are life, health, disability and old age pension insurance, both in compulsory and voluntary forms. Second, the article maintains that the ideas of solidarity, inequality and exclusion are transformed by the machinery of insurance. In other words, the concrete ways in which insurance relations are (...) practically arranged have an effect on the ways in which the related moral and political concepts are perceived. We elaborate on three different forms of insurance solidarity, which we call chance, risk and income solidarity. The existence of multiple forms of solidarity relevant to insurance is significant because practices of insurance require decisions concerning what kind of solidarity is emphasised, when it is emphasised, and on what grounds. Moreover, what is solidarity for some can entail exclusion and inequality for others. Showing these internal tensions within insurance practice underlines the inherently political and moral nature of insurance. (shrink)

This paper examines the role that population vulnerabilities play in insurance coverage for a representative sample of Latinos and Asians in the United States. Using data from the National Latino and Asian American Study (NLAAS), these analyses compare coverage differences among and within ethnic subgroups, across states and regions, among types of occupations, and among those with or without English language proficiency. Extensive differences exist in coverage between Latinos and Asians, with Latinos more likely to be uninsured. Potential explanations (...) include the type of occupations available to Latinos and Asians, reforms in immigration laws, length of time in the United States, and regional differences in safety-net coverage. Policy implications are discussed. (shrink)

While in America most people think of “welfare” as means-tested programs such as Aid to Families with Dependent Children, in reality in the United States and other affluent democracies the heart of the welfare state is social insurance programs, such as health insurance, old-age or retirement pensions, and unemployment insurance. They are insurance programs in the sense that they protect against common risks of a loss of income if and/or when certain events come to pass (...) ; they are “social” because unlike market insurance they are not run on a sound actuarial basis, the premiums are not voluntarily incurred but compulsory, and there is very limited choice or flexibility concerning the type of policy one can purchase. Why have social insurance rather than market insurance? In this essay, I take up this question with regard to old-age or retirement pensions, which at present absorb around 9 percent of the gross domestic product and 25 percent of government spending of the affluent industrial countries comprising the Organization for Economic Cooperation and Development. My aim is to show that old-age or retirement social insurance is worse in virtually every relevant normative respect than its alternative, some form of market or private pensions. By relevant normative respect, I mean those values or principles which are used by contemporary political philosophers in their discussions and justifications of welfare-state policies, and which are applicable to assessments of different systems of old-age or retirement pensions. (shrink)

By 2014, each of the fifty states and the District of Columbia will have a new health insurance exchange, or marketplace, established under the Patient Protection and Affordable Care Act. These exchanges are the centerpiece of the reform law: they will be the main portals where people who do not have health insurance coverage through their jobs and small businesses will go, either in person or online, to find a health plan and to learn about (...) and apply for federal subsidies. The most immediate challenge facing all fifty‐one exchanges is fulfilling their most basic role: ensuring that all who are eligible to enroll in qualified health plans and to receive federal subsidies in fact enroll. (shrink)

As Big Data, the Internet of Things and insurance collide, so too, do the best and the worst of our futures. Insurance is summoned as an example of the interference in our private lives that is already underway everywhere. In this paper, we pause to reflect on this argument. Can changes in the way insurance measures the value of behaviour really serve as an example of the individual and social harms of datafication? How do we know? (...) class='Hi'>Insurance is a mathematical relationship staged between individuals and groups, between risk and uncertainty, between distribution and assessment, between the value of sharing and the sharing of value. We use the case study of Discovery International, owner of Vitality, the market leading brand in behavioural insurance to consider how behaviour is being branded and how the brand behaves. (shrink)

ABSTRACTThe health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance . In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee education (...) and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives. (shrink)

This project focuses on the extent to which disability insurers should be allowed to use genetic information in underwriting and rate-setting, but this subject cannot be completely isolated from the related questions of whether life and health insurers should also have this discretion. Federal and state laws place significant restrictions on insurers’ use of genetic information in health insurance, but regulation of such use in life and disability insurance is considerably more modest. This essay examines the (...) reasons for this disparity and discusses the implications for future proposals to regulate disability insurers’ use of genetic information in underwriting and rate-setting. The thesis is relatively simple: Communitarian values are stronger in health insurance than in life and disability insurance. Accordingly, the public is likely to acquiesce to insurers’ insistence that they be allowed to make distinctions among insureds in disability insurance that would not be tolerated in health insurance. (shrink)

National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the (...) structure and characteristics of health insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform. (shrink)

This is a volatile time for health insurance policy. Medicare and Medicaid are in turmoil, as is the private health insurance market. Public and private health insurance costs constitute eighty percent of healthcare spending in the United States. Public health professionals depend on the insurance system to behave in ways that are responsive to public health in prevention and crisis management.Seventy-five percent of the American population, excluding the elderly, has coverage through (...) the private health insurance system. Ninety percent of this group receives their insurance through employer-sponsored programs, and the remaining ten percent buy their own coverage. Approximately ten percent of the non-elderly population has insurance through a government program, and fifteen percent of the non-elderly population, almost forty-one million Americans, is uninsured. (shrink)

Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons – who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly (...) describe blacklisting in the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced. (shrink)

BackgroundTo prevent the planet from catastrophic global warming a reduction of greenhouse gas emissions to net zero is required. Thus, divestment from fossil fuels must be a strategic interest for health insurers. The aim of this study was to analyse the implementation of environmental, social and governance criteria in German private health insurers’ investments.MethodsIn 2019 a survey about ESG strategies was sent to German private health insurance companies. The survey evaluated investment strategies and thresholds for the (...) exclusion of sectors and business practices, as well as company strategies for sustainable business development.FindingsGiven their business reports, German private health insurers manage assets of more than €350 billion. 11 of 40 insurance companies provided quantitative data, 10 refused to answer. According to quantitative data, €66 billion of assets is managed according to any ESG criteria; this equals an average of 76% of each company’s bonds. None of these insurers excluded the production and sale of fossil fuels. All excluded coal mining but only at high thresholds. For €226 billion, no data were provided.InterpretationThe findings are in contrast to the expected intrinsic economic interest of the insurers to stop global warming and improve public health. The majority of assets are managed in a highly problematic manner, especially the absence of capital allocated in fields contrary to medical ethics cannot be presumed. Lack of transparency is a major problem that limits clients in choosing the insurer who has the most advanced ESG criteria. (shrink)

Communitarian values are stronger in health insurance than in life or disability insurance. This correlates with increased tolerance for insurers' use of genetic information in disability insurance underwriting, which, in turn, is relevant to the scope and content of proposals to regulate such use.

Current research on the human genome holds enormous long-term promise for improvements in health care, but it poses an immediate ethical challenge in the area of health insurance, by raising the question of whether insurers should be allowed to take genetic information about customers into account in the setting of premiums. It is widely held that such discrimination is immoral and ought to be illegal, and the prevalence of this view is understandable, given the widespread belief, which (...) I endorse, that every individual in a society as affluent as ours has a basic right to affordable health care. But prohibiting genetic discrimination in health insurance is not an effective way to protect this right. On the contrary, I argue that because of the nature of insurance as a product sold in a competitive market, such a prohibition is misguided, and its worthy aims must, instead, be pursued through reforms in our country’s system of publicly provided health care. (shrink)

Lack of health insurance coverage is a large and growing problem for millions of American families. Rising health care costs and economic insecurity continue to threaten the bedrock of the health insurance system - employer-sponsored coverage - while states’ fiscal situations and the escalating federal deficit complicate any efforts at reform. Providing health insurance coverage to the millions of uninsured remains a major health care challenge for the nation and understanding the current (...) health insurance environment, who the uninsured are, and why they are uninsured is critical when considering health care reform. This paper aims to define the problem of the uninsured, providing an overview of the uninsured in America and the roles and limits of private and public insurance. Following this discussion, the paper describes the current health insurance environment and examines the prospects for improving coverage. (shrink)

Lack of health insurance coverage is a large and growing problem for millions of American families. Rising health care costs and economic insecurity continue to threaten the bedrock of the health insurance system - employer-sponsored coverage - while states’ fiscal situations and the escalating federal deficit complicate any efforts at reform. Providing health insurance coverage to the millions of uninsured remains a major health care challenge for the nation and understanding the current (...) health insurance environment, who the uninsured are, and why they are uninsured is critical when considering health care reform. This paper aims to define the problem of the uninsured, providing an overview of the uninsured in America and the roles and limits of private and public insurance. Following this discussion, the paper describes the current health insurance environment and examines the prospects for improving coverage. (shrink)

Genetic information may be used by health and disability insurance companies to deny or restrict coverage. How health insurance companies use genetic information, and how public policy has limited that use, can be illustrative for genetics and disability insurance policy.

The Human Genome Project has allowed researchers to gain new insights into the genetic causes of health and disease. With this knowledge comes the potential to develop new genetic tests that are capable of predicting the risk of disease or disability among presently healthy individuals. This information is potentially beneficial in that it may allow individuals to develop strategies to reduce their risk of illness and may allow health providers to recognize and treat the early stages of disease (...) more effectively. As knowledge about genetic contributions to disease continues to grow and genetic testing technology becomes more widespread, there is a risk that personal genetic information could be used in ways potentially concerning to consumers. Genetic testing technology could potentially be used to discriminate against individuals in terms of their ability to obtain health, life, and disability insurance. Decreased access to insurance, in turn, significantly hinders access to health care and income for oneself and/or for one's dependent. (shrink)

Health insurance exchanges can organize the market for health insurance by connecting small businesses and individuals into larger insurance pools. HIEs have been proposed as a possible means of making insurance more accessible, increasing competition among health plans, and promoting choice of insurer. President Obama's campaign proposal and various congressional leaders have proposed establishing insurance exchanges through federal legislation. However, whether the federal or state government, or even a private entity, can organize (...) an insurance exchange to connect health insurance sellers and buyers under the law is the question explored in this paper. Specifically, the paper addresses legal restraints or limitations to such an exchange at the federal, state or private entity level, and offers solutions. Although exchanges implicate many design and policy issues regardless of whether they are implemented at a federal, state, or private entity level, the paper concludes that are no absolute legal bars to the establishment of health insurance exchanges. (shrink)

This paper explores the consequences of the oft ignored fact that public health insurance must actually be supplied by the state. Depending how the state is modeled, different health insurance outcomes are expected. The benevolent model of the state does not account for many actual features of public health insurance systems. One alternative is to use a standard public choice model, where state action is determined by interaction between self-interested actors. Another alternative—related to a (...) strand in public choice theory—is to model the state as Leviathan. Interestingly, some proponents of public health insurance use an implicit Leviathan model, but not consistently. The Leviathan model of the state explains many features of public health insurance: its uncontrolled growth, its tendency toward monopoly, its capacity to buy trust and loyalty from the common people, its surveillance ability, its controlling nature, and even the persistence of its inefficiencies and waiting lines. (shrink)

National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the (...) structure and characteristics of health insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform. (shrink)

National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the (...) structure and characteristics of health insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform. (shrink)

This paper examines the lack of health insurance coverage in the US as a public policy issue. It first compares the problem of health insurance coverage to the problem of unemployment to show that in terms of the numbers of individuals affected lack of health insurance is a problem comparable in importance to the problem of unemployment. Secondly, the paper discusses the methodology involved in measuring health insurance coverage, and argues that the (...) current method of estimation of the uninsured underestimates the extent that individuals go without health insurance. Third, the paper briefly introduces Amartya Sen's functionings and capabilities framework to suggest away of representing the extent to which individuals are uninsured. Fourth, the paper sketches a means of operationalizing the Sen representation of the uninsured in terms of the disability-adjusted life-year (DALY) measure. (shrink)

In The Ethics of Universal Health Insurance, Alex Rajczi shows how defenders of universal health insurance can address the ethical issues raised by these objections and make the moral case for an American universal health insurance system that improves on the gains made in the Affordable Care Act.

This “Legal Solutions in Health Reform” paper identifies and analyzes the legal issues raised by health insurance exchanges. Like all Legal Solutions papers, it does not purport to provide a concrete proposal as to how health insurance exchanges should be organized or even whether they should play a role in health care reform. Rather, it attempts simply to describe the legal issues that health insurance exchanges raise, and to propose alternative solutions to (...) legal problems where useful. More specifically, it analyzes and offers alternative solutions to the legal problems raised by proposals to establish insurance exchanges by the federal government, by state governments, and by private entities or associations. Because the focus of this project and paper is on legal issues, discussion of policy and design issues is attenuated. Nevertheless, some attention to policy issues is unavoidable because law is the realization of policy. (shrink)