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Frerichs, R.R. HIV and health insurance.

SEA-AIDS Network, September 22, 1996

Posted in response to:

SEA-AIDS, September 21, 1996

From Tamar, Bangkok, Thailand

In response to requests for comments and information relating to human rights issues in Asia, here are a few human rights abuses that currently take place in Thailand

  • All applicants for health insurance must be HIV tested, if they are positive, they are denied health, life, and accident insurance.

  • Men who want to become monks must be HIV tested. If they are positive they may not enter the monastery.

  • Kindergartens in certain villages are still refusing children whose parents are HIV positive. The new solution that some districts have come up with is to test the children and see if they are positive. Only negative children would be allowed to attend.

  • An AIDS hospice in central Thailand was forced to close down a few months ago following severe community violence. No civil action was taken against the perpetrators.

  • Pre and post test counseling is still an exception.

  • Certain occupations require routine HIV tests.

  • When an HIV positive person is in a hospital bed a large sign indicating their status is placed above their head for all to see.

There is good news though. There are over 30 groups of HIV positive persons in the Chiang Mai area alone, creating support networks, going on home visits, holding workshops on meditation, yoga, and herbal medicine.

There are also great centers with herbal medicine research and distribution.


Thai Youth AIDS Prevention Project

R.R. Frerichs Posting

In a list of alleged HIV-related human rights abuses recently posted to SEA-AIDS, Tamar from the Thai Youth AIDS Prevention Project mentioned the practice of mandating HIV testing as a prerequisite for obtaining privately-funded health insurance. While I found many other items in the list to be abhorrent, including private health insurance restrictions seems ill conceived.

Let me explain why. Health insurance is nothing more than prepayment of future health services by a group of persons. The annual insurance fee is set so that on average there is sufficient money to pay for all claims, with additional money set aside for administrative overhead.

To keep fees down, many people sign up with insurance companies that limit policies to healthy persons at entry. Stipulations may included being non-smokers, having normal blood pressure, and having no pre-existing medical condition such as diabetes, cancer, or HIV infection. Companies that enforce such entry provisions have lower fees, and likely sell more health insurance policies.

In the United States, the average life time cost of treating an HIV infected person is about $100,000. The cost seems to be much lower in Thailand, likely due to later diagnosis of AIDS cases (HIV testing is limited so there is less early detection), and lower labor and facilities costs.

At a recent workshop my colleagues and I conducted in Bangkok, one of the participants from the MOPH estimated that the lifetime cost of HIV/AIDS in Thailand likely is in the $5,000-8,000 range, well below the US cost. Either way, when an HIV infected person is included in a health insurance pool, this cost must be absorbed by the other members of the health insurance plan. It clearly is unethical to deny payment to someone who becomes HIV infected after they have enrolled in a health insurance plan. Such risk should be calculated in the price of the insurance. Yet denying health insurance to those who already are HIV positive saves the other policy holders the automatic increase of $5,000-8,000 that comes with that person.

Unfortunately when this "free market" logic is applied to everyone, there are many people with pre-existing conditions who can never get health insurance. When they require care, many are forced to seek public assistance, relying on the government to offer such services. In a sense, the government is the largest insurer of all, since it collects taxes (rather than insurance fees) and provides medical care to those who have no other options.

The government cannot legally or morally discriminate against HIV infected persons or those with other ailments, and thus cannot turn away persons who harbor the virus. Yet many people want to avoid having government agencies care for high numbers of HIV infected persons since it places an additional tax burden on everyone. To keep taxes low, they try to discourage private health insurance groups from doing entry-level HIV testing so that they will accept HIV infected persons in their health plans.

HIV infected people have the right to care, the same as others. The fundamental question, however, is who will pay -- the purchaser of a private health plan with out-of-pocket money, or the collective society via government imposed taxes. By listing private health insurance restrictions as a violation of human rights, Tamar implies that people wanting low-cost health insurance are bad while saying nothing about the collective responsibility of the general society to provide care.

Such a one-sided view detracts from the other more appropriate items in Tamar's list of human rights abuses.