By Golly, a Two-Tier System!

An anesthesiologist slash right-wing crank who happens to share the name Ronald Dworkin with an important legal and political theorist has taken the august op-ed pages of the The Wall Street Journal to (a) whine about the fact that he, personally, might earn a lower income under a national health care system, and also that we should (b) “Expect a two-tier medical system and needless ER deaths if Congress and the White House have their way.”

It’s probably true that universal health care systems have a tendency to lead in a two-tier direction, as people with the means necessary to purchase additional services above the publicly provided “floor” wind up with somewhat more lavish care, though not necessarily better basic treatment for illness. That said, from this complaint you’d think that we were currently living in some Communist utopia in which health care is provided “to each according to his needs.” Even among Medicare recipients we have a two-tiered system according to whether or not you’re prosperous enough to afford “Medigap” coverage. Then there’s the tier separating people with really generous health care plans from those stuck in lower tiers that severely constrain your choice of doctor and access to specialists. And of course there’s the tier for people with catastrophic-only coverage and the tier for poor people on Medicaid and the tier for people with no insurance whatsoever. Probably more tiers than that, too. Our current system is clearly, obviously, and by design less egalitarian than all the major alternatives. That’s the whole point.


One question is why, with income inequality reaching unprecedented levels, we shouldn’t act to redress that inequity in our health care system? Dworkin appears to concede that inequity is bad, describing the residual inequity of a universal health care system as a great evil. But surely it’s progress relative to where we are.