Introduction

All of us potentially face exclusion from health insurance because of risk, loss of insurance coverage with job loss or job change, maldistribution or appropriate providers, and inadequate coverage for home care, mental health care, and other services, including drugs. A system that corrected these and other problems we all risk having to confront would go a long way toward ensuring fair treatment. The most effective way to do so would be to enact a comprehensive national health care reform that met key criteria for justice or fairness.

But what does a just or fair system require? What criteria of fairness should it be judged by? Specifically, in this climate of widespread determination to reform the system, what criteria should we use to assess the fairness of health care reform proposals?

Access to appropriate, willing physicians and other providers is a requirement for justice. Society has the obligation to ensure that there are adequate practitioners to meet the health care needs of patients, and that professional and individual practitioner obligations and prerogatives are compatible with the requirements of justice. Ordinary exclusionary practices of health care insurers employing standard underwriting procedures violate considerations of justice. Health care insurance must be governed by different criteria of fairness than some other forms of insurance against risk, because its primary goal is to ensure access to services that play a central role in ensuring fair equality of opportunity. Charging significantly higher premiums to those at higher risk violates requirements about the fair sharing of the burdens of meeting health care needs. Fair treatment involves careful consideration of the kinds of services that should be included in an insurance benefit package. We should not deny access to a new technology simply because it has a high cost or because it falls into a particular category of services, such as long-term care rather than acute care. Rather, we should limit access to a beneficial service only if we can show it is less important to offer it—because of its “opportunity cost”—than other services we should be offering. If we are to impose fair limits on services, we must develop reasonable criteria and fair procedures for making such decisions.