We Should Embrace Inequity

Unequal Healthcare Outcomes Are OK

“Human beings are born with different capacities. If they are free, they are not equal. And if they are equal, they are not free.”
— Aleksandr Solzhenitsyn

That is an uncomfortable sentence, especially in healthcare, where we desperately want to believe equality and abundance can coexist.

All doctors have stories about ultra-wealthy patients. Imagine a hypothetical ultra wealthy brain injured patient. The family is able to build a private rehabilitation hospital inside the home, pay for around-the-clock nursing, multiple therapists, home modifications, continuous oversight, and state of the art equipment. All without waiting lists or prior authorization.

Many people see this and instinctively conclude that something has gone wrong. I look at it differently.

The real question is not whether this is unequal. Of course it is. And no system in the world would be able to provide that level of abundance to every patient. But Solzhenitsyn’s point was that equality and freedom are often competing values, and pretending otherwise usually ends with less of both.

This is the central tension that healthcare policy tries desperately to avoid admitting. We want freedom and equality simultaneously. We want every patient to have identical access to every possible treatment while also preserving choice, innovation, physician autonomy, and incentives for people to invest enormous amounts of time and capital into healthcare. But these goals conflict.

Healthcare is made of scarce things. There are only so many operating rooms to go around. Physicians cannot spend adequate time with too many patients. No slogan changes this, and calling healthcare a “human right” does not magically produce an infinite supply of neurosurgeons, nurses, or rehabilitation specialists.

In a free system, wealthy patients fly for second opinions, take time off work to dedicate to their treatment, and have all the resources available to them. In some systems, those freedoms are severely curtailed. You cannot simply bypass the queue by paying for more care inside the system. Equality is preserved by restricting freedom. You can pay out of pocket for things that are not covered by insurance, but if it is covered, the ability to pay out of pocket is restricted.

This is what many advocates of healthcare equality refuse to confront. A system that forbids private augmentation does not create abundance. It simply limits everyone to the same constrained baseline.

If a wealthy family wants to hire additional therapists, bring rehabilitation into the home, pay nurses directly, or create a better recovery environment for a loved one, what exactly is accomplished by forbidding it? Does the poor patient receive more therapy because the rich patient received less? Does the nurse suddenly appear elsewhere? Does the rehabilitation facility become less crowded? Usually not. More often, everyone is simply flattened downward toward the same bureaucratically managed average.

This flattening impulse is increasingly common in healthcare policy. We see it in attacks on concierge medicine. We see it in hostility toward physician-owned hospitals. We see it in attempts to prevent physicians from opting out of government payment systems. We see it in the moral outrage anytime someone purchases faster or more customized care.

But medicine has never been equal, and pretending otherwise simply obscures where the inequality actually exists.

A politically connected hospital executive has advantages over an ordinary patient. A professor at an elite academic center has advantages over a rural laborer. A physician’s family member often gets informal access and guidance that others do not. A patient who speaks the native language fluently and understands the healthcare system navigates it differently than someone who does not. Even in fully socialized systems, influential people quietly obtain better access, faster referrals, and private options.

The wealthy also create demand signals. When affluent patients spend enormous amounts of money on rehabilitation, diagnostics, devices, or personalized care, they signal that these things have value. Capital and labor then flow toward providing them. You get more doctors, therapists, technology. You’ve used price signals to solve access problems. Over time, what began as elite and expensive often becomes more common and more affordable.

The rich do not merely consume innovation. In many cases, they subsidize its early development and this private augmentation often creates experimentation and innovation that centralized systems cannot.

The first versions of almost everything are expensive. New technologies, new devices, new delivery models, and new organizational structures rarely emerge fully formed as cheap universal public goods. They begin inefficiently. They are adopted first by people willing and able to spend more. Over time, competition, iteration, and scale drive costs down and spread access outward.

This is true far beyond healthcare. Air travel, automobiles, smartphones, MRI scanners, laparoscopic surgery, and biologic drugs were all once accessible only to elites or major institutions. The wealthy and the ambitious effectively subsidized early adoption.

Healthcare reformers often speak as if private spending is inherently parasitic. In reality, private spending is often part of the discovery process. It allows physicians and patients to experiment outside rigid centralized structures. Some experiments fail. Some are wasteful. But others become the standard of care years later.

Central planning struggles with this because centralized systems are inherently conservative. Bureaucracies are designed to standardize, not discover. A public payer cannot easily individualize around every patient preference, every family circumstance, or every novel therapeutic idea. It must create categories, rules, payment schedules, and eligibility criteria. It must compress reality into billing codes and coverage determinations.

This is one reason modern healthcare increasingly feels inhuman. Patients become units moving through administrative pathways rather than individuals with different values, resources, and priorities.

The irony is that many of the same people demanding equality in healthcare are also demanding “personalized medicine.” But personalized medicine is, by definition, unequal. A truly personalized system allows different people to pursue different levels and styles of care based on their preferences and resources. It allows families to say, “We want more rehabilitation.” “We want more home nursing.” “We want direct physician access.” “We want a second opinion immediately.” “We are willing to spend our own money for these things.”

On the other hand, the bureaucratic state decides what level of care is “appropriate,” and everyone is expected to accept it regardless of personal priorities or willingness to spend more.

None of this means society should abandon vulnerable patients. A civilized society should guarantee a credible safety-net. But there is a profound difference between guaranteeing a floor and enforcing a ceiling.

None of this is emotionally satisfying. Watching money buy opportunity in moments of human vulnerability will always feel uncomfortable. But discomfort is not the same thing as evidence that freedom should be prohibited.

Modern healthcare policy increasingly attempts to enforce ceilings in the name of fairness. The logic is seductive: if some people can buy better care, and some people die because they can not, then the system must be unjust. But this assumes the only morally acceptable outcome is equal consumption. That is neither achievable nor desirable in a free society.

The wealthy will always find ways to improve their healthcare. They will travel. They will pay cash. They will hire private physicians. They will leverage personal networks. They will purchase additional nursing, rehabilitation, nutrition support, exercise facilities, and personalized recovery services. And because of these advantages, they will die at a lower rate than those who cannot afford these luxuries. The only real question is whether these activities happen openly within legal markets or quietly through informal privilege.

I would rather be honest about it and allow physicians and patients to contract freely. I would rather permit direct-pay arrangements, physician-owned facilities, concierge models, home-based recovery systems, and alternative care structures than trap everyone inside the same increasingly bureaucratic machine.

Because the real danger to healthcare is stagnation, not inequality.

It is a system so obsessed with equalizing access to mediocrity that it gradually destroys excellence, experimentation, physician autonomy, and innovation altogether. A system where no one is allowed to buy more care, but everyone waits longer. A system where independent practice disappears, bureaucracies grow endlessly, and physicians become employees executing protocols inside massive administrative systems.

Healthcare policy should begin with acknowledging tradeoffs. Freedom creates inequality because human beings are unequal in talent, priorities, risk tolerance, family structure, and resources. Attempts to erase those differences inevitably require coercion, bureaucracy, and centralized control.

Solzhenitsyn understood this because he lived under a regime that promised equality while crushing freedom.

A humane society should ensure that no one is abandoned. But it should also recognize that freedom means allowing people to pursue more, spend more, build more, and experiment more with their own resources.

Some inequity is the price of that freedom.