The scope and limits of equality as a normative guide to federal health care policy.

In American political culture, as in much of Western political thought, the proposition that men are and ought to be treated as equal in the eyes of polity, law, and society is highly valued. Whether traditional arguments for equality can be properly extrapolated from the political and social spheres to a third sphere--the distribution of resources and services under public welfare state policies--is another question, rarely explored with care. In one of these policy areas, health care, the notion that each citizen is entitled by right to equal access to medical care has grown very popular. Federal programs that equalize access among groups by means of biomedical research, hospital construction and renovation, and financial aid for the elderly and poor have dominated federal health care policy since the end of the Second World War. Empirical consideration of the nature of medical care services, the structure of the health care system, and the consequences of programs to equalize access suggests, however, that public expectations and federal policy may have placed more weight on the principle of equality than it can properly bear. In recent years policy analysts have begun to insist that the equal access issue be viewed in the context of the national cost of medical services relative to that of other social goods, the cost effectiveness of medical services, and the degree to which health and illness result from behavior in an individual's power to pursue or avoid. Attracted by the new revisionist thinking, but unwilling to follow its arguments to their logical policy implications, federal policy makers have institutionalized their ambivalence. The mainstream equalizing programs continue to receive strong support, but they are now challenged by another set of federal programs based largely on revisionist premises. This seemingly inconsistent policy solution is probably the most rational approach to preserving the claims of equality of medical care services, while assigning the principle of equality an appropriately delimited scope.