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income distribution, medical resources


Those in the richest countries have far more income and wealth than those in poor countries. Moreover, the most fortunate in the richest countries – particularly those in the top centile of the income distribution – are far richer than those around them. Most dramatically, even within that top centile, the richest of the rich have far more resources than even their elite peers. Like fractals, the patterns of distribution repeat at various levels.

This pattern of fractal inequality ensures that spending that seems trivial to those at the top of an income distribution can overwhelm the purchasing power of those in the middle, which in turn can dwarf the purchasing power of those at the bottom. The reallocative effects of higher spending on health care by the wealthiest can cascade down the distributive ladder.

This paper describes some of these effects in the U.S. health care sector, modeling the rise of concierge medicine, single specialty hospitals, and cosmetic surgery as epiphenomenal of the expansion of the purchasing power of wealthier Americans between 1975 and 2005. Each of these developments is part of a larger trend toward allocating medical resources in accordance with ability to pay as opposed to medical need.

This reallocation of medical resources has in turn provoked several stopgap measures to promote access to care for the underserved in the U.S., ranging from medical tourism to physician and nurse immigration. These measures may, in turn, divert medical attention away from the global poor.

Zero-sum contests for influence and power remain prevalent within our social world, and cause particular concern in the health care sector. A relatively fixed supply of doctors can mean that any group that uses its buying power to purchase disproportionately time-consuming (and often unnecessary) medical attention threatens to divert care from those with less purchasing power. Fractal inequality of income and wealth forces us to reconsider the relationship between markets and health care. If high levels of inequality persist, policymakers will need to reinforce the redistributive aspects of health care law.

Publication Citation

19 Annals of Health Law 269 (2010).


Health Law and Policy