Social Solidarity vs Actuarial Fairness in Health Reform

Health reform proposals, from the “Massachusetts model” to federal initiatives, vacillate between a social solidarity model, with the goal of universal access to care, and an actuarial fairness model, which matches insurance coverage and price to individual health risks. On the one hand, most U.S. proposals purport to provide insurance coverage (not necessarily health care) to almost everyone, without regard to individual health status, reflecting the social solidarity model. On the other hand, many current proposals condition access to care or the price of insurance benefits on indicators of health status, such as age or compliance with wellness programs, consistent with models of actuarial fairness. Since each model rests on fundamentally different premises, the presence of both in any health reform initiative may invite irreconcilable conflicts in cost and coverage. This presentation evaluates the use of both models in current health reform laws and initiatives, including Massachusetts Chapter 58 and Senator Wyden's Healthy Americans Act. It suggests a method for identifying the elements of each model in health reform proposals and for determining the extent to which each serves specific goals of health reform, from universal access to care to assigning personal responsibility for health risks.