In her classic 1993 article, “The Struggle for the Soul of Health Insurance,” Deborah Stone contrasted the principle of mutual aid—“the essence of community” in the face of sickness—and the principle of actuarial fairness, under which “each person should pay for his own risk.” Stone claimed that “in most societies sickness is widely accepted as a condition that should trigger mutual aid,” while in the United States, a competitive insurance industry fosters in people “a sense of their difference, rather than their commonalities, and their responsibility for themselves only, rather than their interdependence,” leading to the fragmentation of “communities into ever-smaller, more homogeneous groups” and “the destruction of mutual aid.”

The United States has, as Stone observes, long been an outlier in its approach to financing care for sickness. Over the past half century, we have developed mutual aid-based programs to care for some, but most Americans have had to pay the “actuarially fair” cost of their care, either as individuals or as employee groups. Mutual aid has existed only on a limited scale. The Affordable Care Act is the most comprehensive attempt to date to remedy this situation.