(SLATE) — At the end of 2011, the remarkable innovator Donald Berwick was forced to resign as the recess-appointed head of Medicare and Medicaid, a casualty of Republican-led opposition to his confirmation. An outspoken fan of the United Kingdom’s single-payer system, Berwick was portrayed by critics as a socialist who once commented that “excellent health care is by definition redistributional.” In 2010, for example, Republican leaders of the Senate Finance Committee grilled him about whether he “still distrusted the free market” and made it his goal to “make health care rationing the new normal.”

The furor over Berwick reflects a broader, fundamental disagreement over the nature of health insurance. Should it be “social” insurance, with which financial risk is leveled between those who are ill and healthy, so the carefree twentysomething and diabetic elderly man pay equally into the system? Or would it be better structured as “actuarial” insurance, where those expected to consume more shell out more, just as those who drive flashy, expensive cars or rack up speeding tickets pay higher auto insurance rates? If your view is the former, you generally support the notion of a single-payer system, as Berwick and many Democrats do. On the other hand, if you see health insurance as actuarial, you favor tiered premiums depending on age and pre-existing conditions, and tend to like health savings accounts, as many Republicans do. This dispute is central to continuing political wrangling over the 2010 health reform legislation, the main provisions of which are scheduled to take effect in a few years.

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