This paper analyzes the political justifiability of not covering services under national health insurance. Policies are justified by what reasonable, informed, and self-interested persons with limited benevolence would accept. Three basic justifiable purposes of national health insurance are (a) to distribute health care costs over time, (b) to protect against rare but expensive illness, and (c) to provide everyone basic health care. Both cost sharing and maximum limits to coverage to contain costs fails to satisfy all three purposes.
The following principle of noncovered services is proposed: services for specific conditions under medically determined circumstances should not be covered by national health insurance if a substantial number of reasonable persons (more than 50 percent) would not choose them for themselves were they in similar situations, taking into consideration the proportional increase in the cost of insurance. Compulsory payment for coverage of such services appears to require that people have more concern for others' health than for their own. The principle's application to cosmetic, extraordinary, and diagnostic or preventive services is illustrated. It is suggested that the principle should be implemented by regional panels of representative citizens determining what services should be covered in their regions, given a proportional share of health insurance revenues. Other difficulties of implementation are considered.
