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PubMed2006

Insurability and mitigation of flood losses in private households in Germany.

In Germany, flood insurance is provided by private insurers as a supplement to building or contents insurance. This article presents the results of a survey of insurance companies with regard to eligibility conditions for flood insurance changes after August 2002, when a severe flood caused 1.8 billion euro of insured losses in the Elbe and the Danube catchment areas, and the general role of insurance in flood risk management in Germany. Besides insurance coverage, governmental funding and public donations played an important role in loss compensation after the August 2002 flood. Therefore, this article also analyzes flood loss compensation, risk awareness, and mitigation in insured and uninsured private households. Insured households received loss compensation earlier. They also showed slightly better risk awareness and mitigation strategies. Appropriate incentives should be combined with flood insurance in order to strengthen future private flood loss mitigation. However, there is some evidence that the surveyed insurance companies do little to encourage precautionary measures. To overcome this problem, flood hazards and mitigation strategies should be better communicated to both insurance companies and property owners.

Journal Article↗
PubMed2005

Restructuring primary health care markets in New Zealand: from welfare benefits to insurance markets.

BACKGROUND: New Zealand's Primary Health Care Strategy (NZPHCS) was introduced in 2002. Its features are substantial increases in government funding delivered as capitation payments, and newly-created service-purchasing agencies. The objectives are to reduce health disparities and to improve health outcomes. ANALYSIS: The NZPHCS changes New Zealand's publicly-funded primary health care payments from targeted welfare benefits to universal, risk-rated insurance premium subsidies. Patient contributions change from fee-for-service top-ups to insurance premium top-ups, and are collected by service providers who, depending upon their contracts with purchasers, may also be either insurance agents or risk-bearing insurance companies. The change invokes the tensions associated with allocating risk-bearing amongst providers, patients and insurance companies that accompany all insurance-based funding instruments. These include increases in existing incentives for over-consumption and new incentives for insurers to limit their exposure to variations in patient health states by engaging in active patient pool selection. The New Zealand scheme is complex, but closely resembles United States insurance-based, risk-rated managed care schemes. The key difference is that unlike classic managed care models, where provider remuneration is determined by the insurer, the historic right for general practitioners to autonomously set patient charges alters the fiscal incentives normally available to managed care organisations. Consequently, the insurance role is being devolved to individual service providers with very small patient pools, who must recoup the premium top-ups from insured individuals. Premium top-ups are being collected only from those individuals consuming care, in proportion to the number of times care is sought. Co-payments thus constitute perfectly risk-rated premium levies set by inefficiently small insurers, raising questions about the efficiency and equity of a 'universal' insurance system pooling total population demands and costs. The efficacy of using financial incentives to constrain costs and encourage innovation when providers retain the right to arbitrarily recoup costs directly from patients, is also questioned. RESULTS: Initial evidence suggests that total costs are higher than initially expected, and prices to some patients have risen substantially under the NZPHCS. Limited competition and NZPHCS governance requirements mean current institutional arrangements are unlikely to facilitate efficiency improvements. System design changes therefore appear indicated.

Journal Article↗
PubMed1998

Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature.

CONTEXT: There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care. OBJECTIVE: To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians. DESIGN AND PARTICIPANTS: Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy. MAIN OUTCOME MEASURES: Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists. RESULTS: Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01). CONCLUSIONS: Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.

Body Height↗
PubMed2006

Health insurance coverage and cost barriers to needed medical care among U.S. adult cancer survivors age<65 years.

BACKGROUND: The health insurance and cost barriers to care among cancer survivors age <65 years were examined. METHODS: Using the 1998 and 2000 National Health Interview Survey, survivors ages 18 to 64 years (n=1718) were compared with similarly aged adults without cancer (n=50,276) to examine health insurance and reported delayed/missed needed medical care within the previous year because of cost. Findings were initially adjusted for age, sex, race, and ethnicity, and further adjusted for employment, income, health status, marital status, and region. RESULTS: Before adjustment, survivors were less likely to be uninsured (12.4% vs. 18.0%) and more likely to have public insurance (11.2% vs. 6.2%). After initial adjustment, survivors were as likely to lack insurance, less likely to have private insurance, and more likely to have public insurance. After further adjusting, differences in being uninsured were found to be small, differences in having private insurance were eliminated, and differences in having public insurance were reduced. Survivors most likely to lack insurance were younger, female, African-American, or lower income. Survivors, particularly uninsured or publicly insured survivors, were more likely to delay/miss care because of cost. Overall, 20.9% of survivors, including 68% of uninsured survivors, reported delaying/missing needed care. CONCLUSIONS: Health insurance coverage among cancer survivors age<65 years appears to be comparable to that of adults of similar age, sex, race, and ethnicity, but survivors may more likely be publicly insured. Differences are attributable in part to employment, income, and health status, factors potentially influenced by cancer. Unmet medical care needs because of cost were common among survivors, particularly uninsured survivors.

Adult↗
PubMed2000

Ovarian cancer. an institutional review of patterns of care, health insurance and prognosis.

The purpose of this study was to investigate the prognostic importance of the health insurance status in 145 consecutive patients with ovarian cancer diagnosed between 1984 and 1996. All patients had basic (Type III) insurance to cover outpatient treatment and hospital expenses for a per diem flat fee; some patients had one of two types of supplemental private insurance (Type I and Type II) to cover the treatment by physicians of their choice and fee-for-service hospital treatment. The prognostic impact of health insurance was evaluated by multivariate statistical methods. The median follow-up was 81.9 months (range: 21-181); the 5-year probability of survival was 72% (standard error of the mean (SEM) 9.8%) for stage I, 53% (SEM 16.2%) for stage II, 17% (SEM 5. 9%) for stage III and 11% (SEM 5.5%) for stage IV cancer. Age, stage, histological grade and debulking surgery were independent predictors of survival in multivariate proportional hazards regression analysis. Patients with private insurance were younger and received more chemotherapy than patients with basic insurance. In multivariate analysis, insurance was an independent predictor of survival: patients with Type II insurance had a hazard ratio of 2.31 (95% confidence interval (CI): 1.05-5.04), and patients with Type III insurance had a hazard ratio of 3.30 (95% CI 1.52-7.17) compared with the reference group of Type I insured patients. Health insurance status was an independent predictor of survival in ovarian cancer. Research is needed to devise strategies to improve the medical care of patients with basic insurance.

Adult↗
PubMed1993

Employment and insurance for young adults with congenital heart disease.

OBJECTIVE: To determine the life and health insurability and employability of young adults with congenital heart disease. DESIGN: Questionnaire study. SETTING: Cardiac department of a tertiary referral hospital for children. PATIENTS: Young adults 18-30 years old with a variety of congenital heart defects, both simple and complex, including postoperative patients. MAIN OUTCOME MEASURES: Availability of insurance at normal or high rates, with or without special conditions or exclusions. Prospects for employment. RESULTS: Questionnaires were sent to eight large life insurance companies, five health insurance companies and, 15 employers, and 26 replies were received (93%). The consensus for life insurability was that young adults with mitral valve prolapse without regurgitation, postoperative ductus arteriosus, and aortic coarctation were insurable at standard rates. Those with any of the other heart defects listed were either insurable at high rates, or in the case of many lesions, not insurable at all. The consensus for health insurance was that insurance was available, but with complete exclusion of benefit for the cardiac disorder. Employment prospects were good for those with simple defects, but poorer for those with complex lesions. CONCLUSIONS: Prospects for insurance and employment for young adults with complex congenital heart lesions are poor. Inconsistencies found in insurance and job policies may be due to lack of appropriate guidelines for the outcome of young adults with corrected and uncorrected congenital heart disease.

Adolescent↗
PubMed2001

Life and health insurance behaviour of individuals having undergone a predictive genetic testing programme for hereditary non-polyposis colorectal cancer.

OBJECTIVE AND METHODS: We describe the insurance behaviour of subjects (n=271) who had previously taken a predictive genetic test for hereditary non-polyposis colorectal cancer (HNPCC); 31% of them were mutation positive, indicating a high risk of cancer. One year after testing, subjects were sent a questionnaire including questions about their present life and health insurance before participation in the study, and their actual and planned purchase of the insurance policies during the testing programme which compromised a pre-test counseling session, a period for reflection, the testing, and a test disclosure session. RESULTS: Thirty percent reported that they already had a life insurance and 14% a health insurance before participating in the study. The mutation-positive subjects possessed a health insurance significantly more often than the mutation-negative individuals (21 vs. 11%, p=0.02) and similar trend was observed for life insurance (36 vs. 28%, p=0.12). Life and health insurance policies purchased just before testing was reported by 3 and 2% of the subjects, respectively. Life and health insurance policies purchased after testing were reported by 3 and <1% respectively, and planned purchase by 3 and 2%, respectively. No statistically significant differences were found between the groups defined by mutation status in reports of life or health insurance behaviour during or after the programme. CONCLUSION: According to self-reported data, the mutation-positive subjects did not differ from the others in the purchase of life or health insurance policies. However, the mutation-positive individuals reported that they possessed health insurance policies before entering the study more often than their counterparts.

Colorectal Neoplasms, Hereditary Nonpolyposis↗
PubMed1993

Statutory caps: an involuntary contribution to the medical malpractice insurance crisis or a reasonable mechanism for obtaining affordable health care?

A medical malpractice insurance crisis occurred in the mid-1970s and mid-1980s evidenced by escalating malpractice insurance rates and increasing numbers of malpractice claims. Insurance companies maintained that the increase in insurance rates was necessary because of the sharp rise in the number of malpractice lawsuits, astronomical damage awards, and ineffective mechanisms to prevent and to eliminate nonmeritorious claims. Physicians responded by forming their own insurance companies, cancelling high-risk procedures, and orchestrating intensive legislative lobbying for tort reform. Insurance companies, physicians, and the legislature collaborated efforts to resolve this medical malpractice crisis. A national debate erupted regarding the proper way to address the medical malpractice insurance crisis. Insurance companies and physicians pressured state legislatures to reform liability laws that, in their opinion, permitted recovery of excessive damage awards by plaintiffs. Consumer groups and lawyers suggested tighter regulation of the insurance industry. State legislatures, in an attempt to remedy the perception that injured plaintiffs were overcompensated for their injuries, enacted "tort reform legislation," which included statutory caps on damages recoverable in medical malpractice actions. As a result of the extensive lobbying effort by physicians and insurance companies, twenty-seven states enacted statutes limiting recovery of damages in medical malpractice lawsuits. Lawyers responded by challenging state malpractice legislation on constitutional grounds, alleging violations of federal and state equal protection and due process clauses and the Seventh Amendment right to a jury trial. Opponents of the cap also asserted violations of state constitution provisions such as the "open courts" provision or the "special legislation" clause. To date, the state courts have held that statutory caps are unconstitutional. Statutory caps and other tort reform measures are extremely important in light of proposed health care legislation entitled the Health Care Liability Reform and Quality of Care Improvement Act of 1992 [the "Health Care Bill"]. This Comment critically examines the constitutionality of statutory caps on damages in medical malpractice actions. It focuses on the public policy behind the caps and the constitutional issues embodied in limiting an individual's recovery. It also analyzes the impact of the Health Care Bill on statutory caps. Part I outlines the medical malpractice insurance crisis, describes the statutory reforms and discusses the public policy behind tort reform. Part II examines the constitutionality of statutory caps and summarizes the arguments of the proponents and the opponents of these caps. Part III discusses the Health Care Bill and its impact on medical malpractice legislation with respect to statutory caps. This Comment concludes that a compromise must be reached that addresses both the growing health care insurance crisis and the protection of individual rights. The Health Care Liability Reform and Quality of Care Improvement Act of 1992 attempts to achieve this compromise.

Civil Rights↗
PubMed2001

Sources of health insurance and characteristics of the uninsured: analysis of the March 2001 Current Population Survey.

This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to an individual's health insurance status. Based on EBRI estimates from the March 2001 Current Population Survey (CPS), it represents 2000 data--the most recent available. Between 1999 and 2000, the percentage of Americans with health insurance increased: 84.1 percent of nonelderly Americans were covered by some form of health insurance in 2000, up from 83.8 percent in 1999. The percentage of nonelderly Americans without health insurance coverage declined from 16.2 percent in 1999 to 15.9 percent in 2000, continuing a trend that started between 1998 and 1999. The main reason for the decline in the number of uninsured Americans was the strong economy and low unemployment. Between 1999 and 2000, the percentage of nonelderly Americans covered by employment-based health insurance increased from 66.6 percent to 67.3 percent, continuing a longer-term trend that started between 1993 and 1994. In 2000, 34.3 million Americans received health insurance from public programs, and an additional 16.1 million purchased it directly from an insurer. More than 25 million Americans participated in Medicaid or the State Children's Health Insurance Program, and 6.1 million received their health insurance through the Tricare and CHAMPVA programs and other government programs designed to provide coverage for retired military members and their families. Even though the number and percentage of uninsured declined substantially between 1998 and 2000, more than 38 million Americans remain uninsured. While an increasing percentage of Americans were being covered by employment-based health plans, this trend may not continue because of the combined re-emergence of health care cost inflation and the weak economy. As long as the economy is strong and unemployment is low, employment-based health insurance coverage will expand and the uninsured will decline gradually. However, the combination of the current weak economy and the rising cost of providing health benefits will likely result in more Americans without health insurance coverage. Should the uninsured remain unchanged and continue to represent 15.9 percent of the nonelderly population, 40 million would be uninsured by 2005. If the uninsured represented 25 percent of the population, 63 million would be uninsured in 2005 and 65 million nonelderly Americans would be uninsured by 2010.

Adolescent↗
PubMed2003

How dental utilisation in The Netherlands was affected by a radical reform of the dental insurance system.

OBJECTIVES: To establish the effects of the 1995 insurance system reform on dental utilisation. STUDY DESIGN: Four categories of patients experiencing homogeneous insurance changes - public/private insurance with and without additional private dental insurance--were analysed. The reform was hypothesised to increase dental expenditure for the Sickfund with (S+), and privately insured with (P+) and without (P-) additional dental insurance. Sickfund insured without additional dental insurance (S-) were not expected to change dental expenditure. Volume effects were also hypothesised per insurance group. These eight hypotheses were tested using longitudinal dental utilisation data of regularly attending adult dental patients: 91 general dental practitioners provided 803 utilisation records. RESULTS: The expected increase by S+ of dental expenditure was corroborated by the results. The three other hypotheses regarding dental expenditure were not supported by the results. The hypotheses regarding volume of dental services were partially supported. The S+ significantly increased their uptake of crowns. The S- showed constant uptake of crowns, endodontics and extractions as expected. The results for P+ and P- showed the constant uptake of restorations. The P+ group also showed the hypothesised significant increase in endodontics. CONCLUSIONS: Having additional dental insurance did not seem to influence the use of dental care in this population of regular attending adult patients. The basic health insurance (Sickfund or private) seemed to have an effect on dental utilisation. The results indicate an association of (expected) treatment need and the application for additional dental insurance.

Adult↗
PubMedDate not supplied

How to complete a medical insurance form.

The information submitted is knowledge accumulated over years of experience teaching dentists how to bill medical insurance. This is supplemented with a good number of personal expert witness testimonies in criminal and malpractice insurance cases. The objective is to prevent problems before they start with the prudent use of information. My experience in court testimony on these issues has shown me that there is an army of lawyers, insurance company fraud examiners, and dentists working for the aforementioned, just waiting for you to improperly use this method of insurance reimbursement. Use this only if you understand the nuances of what it is you are doing! For example, any procedure you bill to dental insurance using CDT-2 codes can be billed to medical insurance using medical insurance CPT-95 codes. The difference is that if the procedure is not a covered medical expense, it will not be paid by the medical insurance carrier. I strongly suggest that you do not fall into the trap of obfuscating these codes. There are a number of so-called insurance "gurus" teaching dentists how to write confusing and misleading operative reports so as to obtain reimbursement for procedures that normally would not be covered. I beseech you--please do not do it! The penalties are severe. You will experience a significant increase in payments from the medical insurance when procedures are submitted in the proper manner. More and more computerized dental insurance management programs are offering their clients the ability to automatically cross-code and submit dental/medical insurance claims. It is a recognized ability of dentists to do such. Billing responsibly is of the utmost importance.

Forms and Records Control↗
PubMed1994

Notes from the insurance underground: how the chronically ill cope.

This report from the field is an account of the experience of individuals with multiple sclerosis (MS) in Indiana in getting and keeping private health insurance. The report presents the findings of a telephone survey of individuals with MS in Indiana. While survey respondents were generally able to obtain health insurance through the Medicare program or employer-based private health insurance plans, many experienced formidable barriers to adequate and affordable health insurance, such as preexisting exclusions, cancellations, high premiums, and coinsurance. Respondents adopted a variety of strategies to keep private health insurance, including selectivity in submitting claims, which worked to reduce their health insurance coverage. Our findings raise two crucial questions: (1) to what extent are the chronically ill forced to take extraordinary measures to get and keep health insurance? and (2) to what extent do insurer practices in pricing insurance and determining coverage of benefits actually make health insurance even more inadequate and unaffordable for the chronically ill? These two questions are critical in understanding the full dimensions of the health insurance crisis in the United States today.

Actuarial Analysis↗
PubMed2005

Private health insurance: implications for developing countries.

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.

Developing Countries↗
PubMed2002

Insurance and quality of care for adults with acute asthma.

OBJECTIVE: The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma. DESIGN: Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured. SETTING AND PARTICIPANTS: Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma. RESULTS: Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied. CONCLUSIONS: Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.

Acute Disease↗
PubMed1996

Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care.

OBJECTIVES: Individuals without health insurance in general receive fewer health services and are more likely than insured patients to experience poor outcomes. The main goal of this research was to study whether physicians' clinical recommendations vary for insured and uninsured patients, implying that physicians' choices of care may mediate insurance-related differences in health care use. METHODS: The authors designed clinical scenarios that describe routine decisions encountered by primary care physicians in ambulatory settings. Scenarios were designed to include discretionary, nondiscretionary, preventive, and diagnostic/therapeutic services. Insurance status of patients was indicated as either insured or uninsured for the service under consideration. Scenarios were presented to a nationally representative sample of primary care physicians (n = 1182) as part of the American Medical Association 1992 Socio-economic Monitoring System Survey. Physicians were assigned randomly to receive eight scenarios in which patients were either insured or uninsured. For each scenario, physicians were asked to indicate the percentage of patients for whom they would recommend a given service. RESULTS: After controlling for variables associated with nonresponse, we found that physicians who were presented scenarios with insured patients recommended service for 72% of patients, and physicians who were presented scenarios with uninsured patients recommended the same services for 67% of patients (P < 0.001). Physicians recommended both discretionary services (50% versus 42%; P < 0.001) and nondiscretionary services more often for insured than uninsured patients (93% versus 91%; P < 0.05). CONCLUSIONS: In self-reports, physicians are more likely to recommend services for insured than for uninsured patients, and more so when services are discretionary. This provides evidence that physicians' recommendations may be important mediators of insurance-related variation in the use of health-care services. Higher rates of use among the insured may not always reflect higher quality of care, particularly when the service is discretionary in nature.

Adult↗
PubMed2002

Loss of health insurance and the risk for a decline in self-reported health and physical functioning.

BACKGROUND: Millions of Americans are intermittently uninsured. The health consequences of this are not known. SETTING: National survey. PARTICIPANTS: Six thousand seventy-two participants in the Health and Retirement Study (HRS) age 51 to 61 years old with private insurance in 1992. MEASUREMENTS: Loss of insurance coverage between 1992 and 1992 and development of a major decline in overall health or a new physical difficulty between 1994 and 1996. RESULTS: In 1994, 5768 (95.0%) people continued to have private insurance, 229 (3.8%) reported having lost all insurance, and 75 (1.2%) converted to having only public insurance. Over the subsequent 2 years (1994-1996), the risk for a major decline in overall health was 15.6% for those who lost all insurance versus 7.2% for those with continuous private insurance (P <0.001). After adjusting for baseline sociodemographics, health behaviors, and health status, the adjusted relative risk for a major decline in health for those who lost coverage was 1.82 (95% CI, 1.25-2.59) compared with those with continuous private insurance. Those who lost insurance also had a higher risk for developing a new mobility difficulty compared with those with continuous private insurance (28.5% vs. 20.4%, respectively; P= 0.02), but this was not significant in multivariate analysis (adjusted RR, 1.26; 95% CI, 0.90-1.68). CONCLUSIONS: Loss of insurance has adverse health consequences even within 2 years after becoming uninsured. Studies of insurance coverage should routinely measure the number of Americans uninsured at any time over the preceding 2 years as a more accurate measure of the population at risk from being uninsured.

Female↗
PubMed1997

Genetic information and insurance: some ethical issues.

Life is risky, and insurance provides one of the best developed ways of controlling risks. By pooling, and so transferring risks, those who turn out to suffer antecedently uncertain harms can be assured in advance that they will be helped if those harms arise; they can then plan their lives and activities with confidence that they are less at the mercy of ill fortune. Both publicly organized and commercial insurance can organize the pooling of risk in ways that are beneficial for all concerned. They provide standard ways of securing fundamental ethical values such as solidarity and mutuality. Although policy holders do not know or contract with one another, each benefits from the contribution of others to a shared scheme for pooling and so controlling risk. Although there is a limit to the degree to which commercially-based insurance, where premiums depend on risk level, can go beyond mutuality towards solidarity, in practice it too often achieves a measure of solidarity by taking a broad brush approach to pooling risk. However, the ordinary practices of insurance, and in particular of commercial insurance, also raise ethical questions. These may be put in simple terms by contrasting the way in which an insurance market discriminates between different people, on the basis of characteristics that (supposedly) determine their risk level, and our frequent abhorrence of discrimination, in particular on the basis on religious, racial and gender characteristics. Are the discriminations on which insurance practice relies upon as standard acceptable or not? The increasing availability of genetic information, which testing (of individuals) and screening (of populations) may provide, could lend urgency to these questions. Genetic information may provide a way of obtaining more accurate assessment of individual risks to health and life. This information could be used to discriminate more finely between the risk levels of different individuals, and then to alter the availability and the costs of health, life and unemployment insurance to them. Since all of these forms of insurance bear very directly on the way most people live, it will matter to them how (if at all) insurers take account of genetic information. Will use of this information improve or damage the capacity of insurance to provide confidence in the face of uncertain harms, and help if they happen? Will it discriminate in acceptable or in unacceptable ways? Will it support or damage the sorts of mutuality and solidarity various sorts of insurance schemes have successfully institutionalized?

Ethics, Medical↗
PubMed2004

Subsidies and the demand for individual health insurance in California.

OBJECTIVE: To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population. DATA SOURCE: Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001. STUDY DESIGN: A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage. PRINCIPAL FINDINGS: The elasticity of demand for individual insurance by those without access to group insurance is about -.2 to -.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage. CONCLUSIONS: Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system.

Adult↗