The injustice of the proposed private healthcare insurance scheme
George Cautherley, Convenor, Healthcare Policy Forum
In the recently-released healthcare financing consultation document, the government says it has listened carefully to society's views: that people value "voluntary choice for public or private healthcare" and that they want "more choices and better protection in private healthcare". In the government's perception, citizens are all classical utility maximizers - they all want to maximize their own healthcare choices and protection through being able to switch between the public and private healthcare sectors at wish. How far this understanding of citizens' preference on healthcare is accurate we do not know. There must however be not a few people who treasure the public healthcare system and its underlying principle of equal access to healthcare, and as many who do not wish to count on the private sector.
Be that as it may, the government says it can play an "active role" in helping maximize citizens' choices and protection. The proposed private healthcare insurance (PHI) scheme is said to gear towards providing us with "better choices for lifelong protection". The government claims that it will be our "lifelong health partner" and will consider providing financial subsidies to assist us to uptake PHI so that we will have more choices and better life-long protection.
Nominally, the scheme and the subsidies are for every citizen. But the truth is that not every citizen can afford PHI. The "we" in the PHI scheme does not really include everyone. The government knows well that the PHI scheme and the subsidies are in fact for those who are able to pay for PHI only. Specifically, according to a consultancy report commissioned by the government, the scheme actually targets individuals with monthly incomes over $10,000 and those who currently have PHI. Official statistics have shown that the higher one's income, the more likely one can afford and will purchase PHI. Under the proposed scheme therefore, it becomes that the higher one's income, the more likely one can enjoy better healthcare choice and protection, the privilege being supported by taxpayers' money. In short, the PHI scheme provides disproportionate benefits to those on higher incomes. This raises the issue of justice in using public money.
Justice demands that everyone be treated equally unless there are good reasons for doing otherwise. Applying this principle to our context means that the better healthcare choice and protection supported by government subsidies should be made available to every citizen unless there are justifiable reasons for conferring the benefit on high-income people only. In theories of justice, two common arguments for differential treatments are needs and merits. But neither needs nor merits justify giving more publicly-supported benefits to high-income people in our case. There is no reason why the need of those on high incomes for quality healthcare protection should or could trump the same need of others and can have greater claims on public money. Likewise, it is counter- intuitive that people on higher incomes deserve better healthcare protection and more government subsidies simply because they earn more.
Quite the contrary, our moral intuition enjoins that given the same healthcare need, no individual's need should have higher priority or a greater claim on public money over the need of others. In this connection, it is worth recalling that equal access to healthcare - healthcare distributed on the ground of healthcare need only - is the fundamental value of public healthcare systems in many advanced countries. In our view, instead of supporting high-income people to purchase PHI, a just use of public money should be on improving the public healthcare system so that better protection can be enjoyed by every citizen.
Even if the government thinks it has good reasons for giving PHI subsidies to the relatively well-off, there is little explanation for such a position in the consultation document. The only guiding value for using public money is "cost-benefits" - that public money should be used to achieve the objectives of the PHI scheme in the most cost-effective way. The government is however totally silent on the justice of the objectives now proposed. As it stands, the PHI scheme will only move our healthcare system in the direction of greater inequality. Those on higher incomes will have improved access to healthcare - they will be able to access both private and public healthcare as suits their needs. Such inequality is now being advocated and proposed for institutionalization by our government, using public money!! The government may reply that the relatively less well-off will also benefit as the PHI scheme relieves pressures on the public system. Even if this projection is correct, which we have ground to doubt very much, the problem of inequality in the access to healthcare supported by taxpayers' money remains. We await the government's engagement on the fairness of its proposed scheme.
The Chinese version of this article was published in Hong Kong Economic Journal Daily on 6 January 2011.
自願醫療保險計劃的不公義
高德禮（George Cautherley），醫療政策論壇召集人
在醫療改革第二階段諮詢文件中，政府稱已經用心聆聽社會意見，看到市民「重視可以自由選擇公營或私營醫療服務」及「希望在私營醫療服務方面有更多的選擇和更佳的保障」。似乎在政府的認知中，市民都是典型的追求最大利益的人，每個市民都只著意能否根據喜好，自由地在公私營醫療部門中追求最大的醫療選擇和保障。
當然，我們無法知曉這個認知有多正確，但我們相信，不少市民極之珍惜現時的公營醫療系統及其背後「平等享有醫療」的社會價值，亦有不少市民不願或不能倚賴私營醫療服務。
無論如何，政府聲稱會擔當「積極角色」幫助市民得到最大的選擇和保障，又說自願私人醫療保險計劃的目標是為市民「獲取終身醫療保障提供更佳的選擇」。
政府更承諾會做市民的「終身醫療夥伴」，並會考慮津貼市民購買私人醫保。
愈需保障愈加無助
表面上，醫保計劃及津貼是每個市民都可以參加和申請的；事實上，並非每個市民都有能力購買私人醫保，醫保計劃的對象實際上並非包括每個市民。政府清楚知道醫保計劃及津貼，只是為那些有能力購買私人醫保的人而設。準確點說，根據政府的顧問報告，計劃只是因應那些月入高於1 萬元及現時有購買私人醫保的市民而設。因此，以醫保計劃的設計來看，收入愈高的市民，就愈有可能享有更多的醫療選擇和保障，而這些高收入市民的優厚待遇，則會由納稅人支付。
簡言之，醫保計劃給予高收入市民不成比例的利益。
這便引起了使用公帑的公義問題。公義，是要求每一個人都應受到平等的待遇，除非不同的待遇是建基於合理的基礎上。將這原則引用到醫保問題上，意味每一個市民都應同等地享有受政府資助的較佳醫療選擇和保障，除非政府能合理解釋為何這些較佳選擇和保障只應給予高收入的市民。
在公義理論裏，兩個普遍用作合理化不同待遇的理據是「需要」（needs）和「應得的」（merits）。可是，這兩個理據都不能合理解釋為何只有高收入的市民才應享有由政府資助的較佳醫療選擇和保障。我們看不出為何高收入市民的醫療「需要」，會比低收入市民的醫療「需要」更重要，以致他們可優先使用公帑。同樣地，我們的「道德直覺」（moral intuition）也不能接受，高收入的市民較低收入市民更「應該得到」由公帑資助的較佳醫療選擇和保障。
公帑應投公營醫療
我們的「道德直覺」認為，就相同的醫療需要，沒有一個人的需要比其他人的更重要，以致有優先使用公帑的權利。不少先進國家醫療體制的「平等享有醫療」（equal access to healthcare）原則，即醫療分配應只以醫療需要為基礎的原則，正正反映這道德價值。
我們認為將資助私人醫保的公帑投放在公營醫療系統上，讓每一個市民都享有較佳的醫療保障，才是符合公義的做法。
政府真有合理原因，要為高收入市民提供私人醫保津貼？諮詢文件對這些原因卻沒有任何?墨。「成本效益」卻是諮詢文件唯一提到使用公帑的指導價值，諮詢文件只關心醫保津貼能否符合「成本效益」地達到計劃預期的目標。至於這個目標是否符合公義、手段是否符合公義，諮詢文件完全隻字不提。
就?醫保計劃本身，計劃只會令香港醫療系統更趨不平等。高收入的市民將有較佳的選擇和保障，可根據需要選擇公營或私營醫療服務，而低收入市民則只可以繼續倚靠公營部門。這樣的不平等，竟然由納稅人的稅款資助，並由政府倡議和制度化！
政府可能會辯稱，資助私人醫保可減輕公營部門的負擔，低收入市民會因而受惠。就這一說法，我們已撰文提出質疑。根據現有的研究，私人醫保不單不能減輕公營系統的負擔，相反，它更有可能增加後者的負擔。退一步說，即使私人醫保真能減輕公營系統的負擔，但由公帑支持的就醫不平等的公義問題卻依然存在。
在貧富懸殊嚴重的香港，不公義之事還不夠多嗎？我們期待與政府辯論私人醫保計劃的不公義問題。
文章刋登於2011年1月6日信報
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