Health care access in the United States. Conflicting concepts of justice and little solidarity.

Health policy in the United States is not presently based on the solidarity principle. Public insurance reaches only the elderly, disabled, and poor. Most non-elderly Americans are privately insured, and about 17.5 percent of the population is uninsured. Many Americans who are privately insured lack adequate insurance and suffer financial distress when they need medical care. A recent move toward "consumer-driven" health care, i.e., insurance with higher cost-sharing, is likely to aggravate this problem. The fundamental problem is that Americans are caught between two sharply conflicting visions of justice. For many Americans, "just" health insurance means actuarially fair insurance-everyone pays a premium based on his or her own risk profile. Those who believe in this vision of justice have been in the political ascendancy for the past decade. For other Americans, however, justice looks very much like solidarity--the healthy help those in poor health, the wealthy help those who lack wealth. Everyone should receive at least a basic minimum of health care, which should be publicly funded if necessary. This vision may be moving toward the political ascendancy.