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
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.