Unmanaged Care: Towards Moral Fairness in Health Care Coverage


Sharona Hoffman


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 42 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 about 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. The 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.


Health Care Coverage, Health Insurance, Uninsured, Moral fairness in health, distributional justice, health care reform, universal health care

Publication Date


Document Type


Place of Original Publication

Indiana Law Journal

Publication Information

78 Indiana Law Journal 659 (2003)

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COinS Sharona Hoffman Faculty Bio