Who Pays? Who Benefits? Unfairness in American Health Care

TLDR: The Patient Protection and Affordable Care Act (PPACA) as mentioned in this paper was the major reform legislation of 2010, which has not been sufficiently recognized as the fundamental issue of social justice that it is.

Abstract: U.S.-style health insurance greatly amplifies price-gouging opportunities for health care providers, who inflate prices both to enrich themselves and to subsidize and expand the nation’s health care enterprise. To the extent that lowerand middleincome Americans with private health coverage pay premiums that go to support and expand the system, they are subject to an unfair (regressive) “head tax” levied by unaccountable entities for ostensibly public but also private purposes. Lower-income premium payers also often pay for costly health coverage designed to suit the economic interests and values of professional and other elites rather than their own. They also appear to get less as a group out of their employers’ health plans than their higher-income coworkers. Even after the Patient Protection and Affordable Care Act (PPACA), the major reform legislation of 2010, the distribution of cost burdens and benefits of the American health care system has not been sufficiently recognized as the fundamental issue of social justice that it is. PPACA, which failed to seriously address the sources of injustice identified in this Article, appears to have been a missed opportunity to redress systematic unfairness in American health care. * William Neal Reynolds Professor Emeritus of Law, Duke University School of Law. ** Professor of Law and Business Administration, Duke University; for much of the time this Article was written, he was Scholar-in-Residence and Senior Fellow, Center for Economic and Contract Organization at Columbia University Law School. The authors are especially grateful to Thomas P. Miller of the American Enterprise Institute for thoughtful and informed guidance through the complexities of the 2010 reform legislation; they accept sole responsibility, however, for any errors, imprecision, or ambiguity that inevitably remain. Additional thanks for to Jennifer Behrens and Jane Bahnson for excellent research assistance.