Social Solidarity in Health Care, American-Style

Abstract

The Affordable Care Act (ACA) reflected a significant philosophical shift in the United States from distributing costs associated with sickness based on the principle of actuarial fairness toward a social solidarity principle premised on the “goals of mutual aid and support.”[i] Yet four fixtures of American health care law complicate the translation of the solidarity ethic into real-world outcomes: (1) federalism, (2) fiscal pluralism, (3) reliance on private ordering and private markets for health coverage, and (4) an emphasis on individual rights and personal responsibility. The ACA’s approach to operationalizing solidarity insufficiently accounted for these fixtures. This ultimately limited its success and continues to threaten its durability, in ways laid bare by the 2020 coronavirus pandemic. After tracing the philosophical evolution of health care law in the United States toward the ethic of social solidarity, this article identifies four legal fixtures of the American health care system in tension with it. Assessing the degrees to which the ACA, Medicare-for-All, and public-option proposals confront these fixtures reveals trade-offs in policy design with which reformers hoping to enhance solidarity must grapple. Health reform must navigate through the fixtures to effectuate an American version of social solidarity in health care. Successfully charting this course may demand that reformers set their sights beyond the modest aim of universal coverage and embrace a broader health justice goal.[ii] Social solidarity in health care requires more than just getting everyone covered in fragmented health insurance pools—it requires a commitment to mutual support and a sense that the benefits and burdens of illness and our system for treating and preventing it should be shared by all in a way that is fair and just. Though the four fixtures make the path toward social solidarity in health care more challenging in the U.S., taking seriously the need to accommodate, leverage, or overcome the fixtures can help to build a mutually-funded health care system that is both durable and distinctively American. This article’s exposition of the fixtures of American health care law and the trade-offs they force in pursuit of social solidarity offers a framework for discussion among lawmakers, policy advisers, scholars, researchers, and voters as they take the next steps in health reform.

Keywords: health care, health law, health insurance, Affordable Care Act, universal health insurance, health justice, health equity, health policy

JEL Classification: I13, I18, K32