Justice and public participation in universal health coverage: when is tiered coverage unfair and who should decide?

Abstract

Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be determined by assessing whether differences in coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior re..