Daniels N
Tufts Univesity.
Milbank Q. 1990;68(4):497-525.
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.
艾滋病疫情使人们对标准承保做法提出了批评，这些做法将艾滋病患者或高危人群排除在保险范围之外。保险公司否认这些做法不公平的指控，反而声称从精算角度看公平的就是公平或公正的。除非我们假定个人仅仅因为健康状况就有权获得利益并应承受损失，否则这种辩护是站不住脚的。这一假定在理论层面极具争议，并且与我们许多道德信念和做法不一致，包括我们的保险做法。我们应当驳回保险公司的论点。医疗保健中的正义要求我们保护机会平等，这意味着分担保护人们免受健康风险的负担。在一个公正的医疗保健系统中，无论是混合系统还是纯粹的公共系统，保险计划从系统角度看在精算上都是不公平的，因为其总体社会功能必须是保证获得适当的医疗服务。这并不意味着在我们的系统中保险公司忽视了提供保险范围的义务。确保获得保险的义务主要是一项社会义务，而我们系统中无法获得保险是公共部门未能履行这些义务的结果。在一个公正但混合的系统中，公共和私人保险计划之间会有明确的责任划分。在我们这个混合但不公正的系统中，立法者和保险公司都 cynically 假装未参保者是对方的责任。将精算公平视为一种道德观念的企图因此掩盖了真正的问题，即逆向选择给保险公司带来的风险以及标准承保做法的经济优势。只有当标准承保做法是公正系统的一部分时才是公平的，而不仅仅是在精算上公平。精算公平论点的失败意味着，如果我们要为标准承保做法辩护，就必须面对私营保险公司原本希望避免的一个问题。鉴于混合系统明显存在无法确保获得医疗服务的风险，捍卫混合系统的责任就落在了他们身上。他们必须向我们表明其社会效益超过其社会成本，并且有可能建立一个不仅公正而且优于强制性全民保险计划的混合系统。 （注：“cynically”原英文拼写有误，可能是“cynically”，意为“冷嘲热讽地、愤世嫉俗地” ，这里按推测翻译）
