The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system—some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all available services, creating a multiple-tiered system.
Underlying the repeated failure of attempts to provide universal health care coverage in the United States is the failure to develop a principled mechanism for characterizing basic health services. Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all—or almost all—available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services uncovered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.
On this view, the reason the United States has failed to enact universal health coverage is not primarily political or economic; the real reason is ethical—it is a failure to provide a philosophically defensible and practical mechanism to distinguish basic from discretionary health care services.
(Ezekiel J. Emanuel, "Where Civic Republicanism and Deliberative Democracy Meet," Hastings Center Report 26 [November-December 1996]: 12-4, at 12)
Keith Burgess-Jackson, J.D., Ph.D. 