Market Justice and US Health Care

IN THE UNITED STATES, HEALTH CARE COMPETES FOR CONsumers with other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, selfinterest, personal effort, and voluntary behavior. The contrasting approach, social justice, allocates goods and services according to the individual’s needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity. Social justice in health care requires universal coverage and ensured access to care, whether through social insurance, private insurance, or some combination. Market justice runs deeply in health care in the United States. Well into the 20th century, both buyers and sellers participated in a fully functioning market. Patients predominantly used personal funds to purchase health care until the rise of employment-linked health insurance. Allopathic physicians competed openly with other healing arts practitioners before state licensure laws erected barriers to market entry and limited the scope of practice of nonphysician practitioners beginning in the late 19th century. What dominated health care from the late 20th century to the present was not some sudden introduction of market principles and forces but tension among the differing perspectives of key medical care stakeholders on the appropriate role and strength of market forces. This Commentary traces 4 developments during that period: the rise and fall of health care coverage; the commoditization of medical care; the transformation of the medical profession; and the medicalization of health—discussing these developments in the context of the diverse and conflicting perspectives on market justice of consumers, employers, physicians, hospitals, suppliers, insurers, public officials, and theoreticians.