Hoffman Sharona
Case Western Reserve University School of Law, USA.
Indiana Law J. 2003 Summer;78(2):659-721.
Health insurers are generally guided by the principle of "actuarial fairness," according to which they distinguish among various risks on the basis of cost-related factors. Thus, insurers often limit or deny coverage for vision care, hearing aids, mental health care, and even AIDS treatment based on actuarial justifications. Furthermore, approximately forty-two million Americans have no health insurance at all, because most of these individuals cannot afford the cost of insurance. This Article argues that Americans have come to demand more than actuarial fairness from health insurers and are increasingly concerned by what I call "moral fairness." This is evidenced by the hundreds of laws that have been passed to constrain insurers' discretion with respect to particular coverage decisions. Legislative mandates are frequent, but seemingly haphazard, following no systematic methodology. This Article suggests an analytical framework that can be utilized to determine which interventions are appropriate and evaluates a variety of means by which moral fairness could be promoted in the arena of health care coverage.
健康保险公司通常遵循“精算公平”原则，据此，它们根据与成本相关的因素区分各种风险。因此，保险公司常常基于精算理由限制或拒绝承保视力保健、助听器、心理健康护理乃至艾滋病治疗。此外，约有4200万美国人根本没有医疗保险，因为这些人大多负担不起保险费用。本文认为，美国人对健康保险公司的要求已不止于精算公平，且越来越关注我所称的“道德公平”。这一点从为限制保险公司在特定承保决策方面的自由裁量权而通过的数百项法律中可见一斑。立法授权很常见，但似乎是随意的，没有遵循系统的方法。本文提出了一个分析框架，可用于确定哪些干预措施是适当的，并评估在医疗保险领域促进道德公平的各种手段。
