A/67/302 However, premiums may be regressive, and thus inequitable, if they are not based on an individual’s ability to pay, but rather linked solely to individual health risks. Risk-rating premiums in this way also results in adverse selection, wherein insurers screen applicants in order to exclude high-risk individuals from coverage. 41 Adverse selection leads to the exclusion of the poor and individuals with pre-existing illnesses from insurance pools, including the poor, and results in smaller, less diverse pools, which weakens the effects of cross-subsidization. 42 Regressive premiums and practices leading to adverse selection infringe upon the right to health to the extent that they discriminate against vulnerable or marginalized groups and reduce overall access to good quality health facilities, goods and services. 39. In order to reduce the negative effects of regressive premiums and adverse selection within a multiple payer system, participation in a health insurance pool should be compulsory. Compulsory participation ensures universal insurance coverage and allows for the use of equalization mechanisms, or risk adjusters, to facilitate cross-subsidization between different pools. For instance, a percentage of the funds of low-risk pools may be required by law to be transferred to high-risk pools under particular circumstances. 43 States may also directly regulate private insurers by, among other measures, limiting the information they are permitted to collect about potential pool members, restricting the manner in which premiums are calculated, and prohibiting the exclusion of individuals with pre-existing health conditions from insurance pools. Government insurance programmes should also provide coverage for the poor or other vulnerable or marginalized groups who are excluded from private pools owing to their inability to pay, because of pre-existing health conditions or because they are high-risk of poor health. For example, individuals employed in dangerous work may be denied health insurance because of increased health risks and workers in low-paying jobs may be unable to afford high premiums charged by private insurers. Under the right to health, States have an obligation to ensure that these individuals have access to health services through health insurance. This obligation may be met through appropriate regulation of private health insurers, the subsidization of private insurance premiums or the availability of government-run insurance programmes. 40. At a more targeted level, community-based health insurance pools funds collected from members of small communities and includes a variety of financing mechanisms, such as community health funds, mutual health organizations and rural health insurance. Community-based health insurance programmes may operate in complement or supplement to single or multiple payer systems. These programmes generally exist in poor and other vulnerable or marginalized communities and may increase access to health facilities, goods and services for vulnerable or marginalized groups and facilitate the participation of communities in decisionmaking processes affecting their health. 44 __________________ 41 42 43 44 12-46101 Elias Mossialos and Sarah Thomson, Voluntary health insurance in the European Union, European Observatory on Health Systems and Policies (Belgium, WHO, 2004), pp. 107, 108. Robert Carroll and Phillip Swagel, “The Intersection of Tax and Health Care Policy”, National Tax Journal, vol. LXII, No. 3 (Washington, D.C., 2009), p. 568. Naoki Ikegami and John Campbell, “Medical Care in Japan”, The New England Journal of Medicine, vol. 333, No. 19 (1995), pp. 1295-1299. See Werner Soors et al., “Community Health Insurance and Universal Coverage: Multiple paths many rivers to cross”, World Health Report (2010), Background Paper No. 48 (Geneva, 2010). 15