Health insurance coverage for incarcerated citizens is generally acceptable by Western standards. However, it creates internal tensions with the prevailing justifications for public healthcare. In particular, a conceptualization of medical care as a source of autonomy enhancement does not align with the decreased autonomy of incarceration and the needs-based conceptualization of medical care in cases of imprisonment; and rejecting responsibility as a criterion for assigning medical care conflicts with the use of responsibility as a criterion for assigning punishment. The recent (...) introduction of sofosbuvir in Germany provides a particularly instructive illustration of such tensions. It requires searching for a refined reflective equilibrium regarding the scope, limits, and justifications of publicly guaranteed care. (shrink)