Fairness in Health Care: Who Pays? Who Benefits?

Clark C. Havighurst, Duke Law School
Barak D. Richman, Duke Law School

Available in the Faculty Scholarship collection.


Lower- and middle-income Americans with private health coverage pay not only to protect their own families’ health but also to support a vast health care enterprise that primarily benefits others. The system is able to finance itself in part because U.S.-style health insurance greatly amplifies price-gouging opportunities for health care firms with true market power; even though the resulting excess profits often cross-subsidize seemingly desirable activities, the substantial cost burden falls ultimately on premium payers like a severely regressive (i.e., unfair) “head tax.” Lower-income premium payers also bear excessive costs for their own health care. For one thing, they appear to get less out of their employers’ health plans than their higher-income coworkers, despite paying similar premiums. Most importantly, however, the coverage they enjoy is designed according to the economic interests and values of others, not their own. Because of the tax subsidy for health insurance, consumers do not see with any clarity the costs they bear for the coverage they enjoy. Employers, industry interests, and politicians therefore can (and do) make choices on their behalf that systematically neglect economizing possibilities. The distribution of the cost burden and benefits of Americans’ health care has not been sufficiently recognized as the fundamental issue of social justice it undeniably is.