This article sets out the moral failure of single-tier basic healthcare. Single-tier basic healthcare has been advocated on the grounds that the provision of healthcare should be divorced from ability to pay and unequal access to basic healthcare is morally intolerable. However, single-tier basic healthcare encounters a host of catastrophic moral failings. Given the fact of human pluralism it is impossible to objectively define “basic” healthcare. Attempts to provide single-tier healthcare therefore become political processes in which interest groups compete for (...) control of scarce resources with the most privileged possessing an inherent advantage. The focus on outputs in arguments for single-tier provision neglects the question of justice between individuals when some people provide resources for others without reciprocal benefits. The principle that only healthcare that can be provided to everyone should be provided at all leads to a leveling-down problem in which advocates of single-tier provision must prefer a situation where some individuals are made worse-off without any individual being made better-off compared to plausible multi-tier alternatives. Contemporary single-tier systems require the exclusion of noncitizens, meaning that their universalism is a myth. In the light of these pathologies, it is judged that multi-tier healthcare is morally required. (shrink)