This paper critically analyses how overarching policy goals and practices surrounding access and entitlement to health care (HC) have been dominated by a conflicting system of libertarian and equity-based principles. We examine how this mixed-motives system originated and the importance of policy legacies inherited from the Poor Laws era in shaping modern conceptions of access and entitlement to HC. We also considered how these determined the scope of state intervention in this policy domain. Drawing on empirical evidence and interviews with key stakeholders in Irish health policy, we explored the appetite to engage in meaningful HC reforms that address the growing gaps of inequity between higher and lower socio-economic groups in society. Rather than emulating European counterparts' emphasis on universal coverage within an egalitarian paradigm, Irish policy actors have sought to instill a spirit of fairness in HC delivery. Under the guise of equality of opportunity and equity, the policy focus has centred on directing publicly funded HC towards lower-income groups and the most vulnerable in Irish society. However, we argue that the operation of the mixed-motives structure has also created conflict and policy ambiguity surrounding overarching goals which frame the governance and consumption of HC in Ireland. This is evidenced by the dysfunction and complexity of the two-tier system of public-versus-private access to HC services. Ultimately, we argue that the policy aspirations of equality that underpin the HC structures surrounding access and entitlement should be revisited to achieve greater health outcomes and create a more equal society.