Fairness, Equality, and Public Opinion about Health Care

Conventional wisdom suggests that the best way to persuade Americans to support changes in health care policy is to appeal to their self-interest — particularly to concerns about their economic and health security. An alternative strategy, framing problems in the health care system to emphasize inequalities, could also, however, mobilize public support for policy change by activating underlying attitudes about the unfairness or injustice of these inequalities. In this article, we draw on original data from a nationally representative survey to describe Americans’ beliefs about fairness in the health domain, including their perceptions of the fairness of particular inequalities in health and health care. We then assess the influence of these fairness considerations on opinions about the appropriate role of private actors versus government in providing health insurance. Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes. Even after taking into account self-interest considerations and the other usual suspects driving policy opinions, perceptions of the unfairness of inequalities in health care strongly influence respondents’ preferences for government provision of health insurance.

That is from a recently published paper (gated; ungated) by Julia Lynch and Sarah Gollust.  There is a lot of rich detail about public opinion in this piece, so I’ll begin by briefly noting a few initial findings:

  • Large majorities find inequalities in quality of care and access to care to be unfair, but not inequalities in life expectancies.

  • When randomly assigned to read vignettes describing inequalities as based on income, education, race, or gender, respondents found inequalities based on income most unfair, followed by education and race (essentially tied), and then gender.

  • Perceptions of unfairness are accentuated when they are believed to derive from structural factors (such as prejudice or failures in the health care system), but not when they are believed to derive from individual factors (unhealthy behaviors or genetics).

The centerpiece of the analysis is a model of support for “a government insurance plan that would cover all medical and hospital expenses for everyone.”  Naturally, Democratic partisanship, liberalism, and egalitarianism are strongly associated with support for such a plan.   But people’s evaluations of their own health, whether they were uninsured, whether they have a serious medical condition, and their income are generally not associated with support for government health care.  What does matter is fairness: people who believe that inequalities in health care are unfair are more likely to support this plan.

This article comports with an intuition I’ve had about the Affordable Care Act.  I’ve heard commentators opine on whether people’s attitudes toward the ACA will grow more favorable with time, once they see that it helps them in various ways.  This presupposes that people’s attitudes about health care reform are predicated on self-interest.  I’ve been dubious, and Lynch and Gollusk provide some confirmation.  Health care opinions are really based on things that don’t change very much: partisanship, ideology, values.

If support for the ACA or “Obamacare” or whatever does increase—note that I said “if”; I’m not making a prediction here—it will be because organized opposition to the ACA has died down, and the information that this opposition provided to the public has become less available.  And without exposure to arguments about problems of Obamacare, public opinion will become less polarized and some independents and maybe a few Republicans will become more supportive.  This comports with an argument I’ve made previously: public opinion about health care reform derives from cues provided by political elites.  Thus, the sharp division between Democratic and Republican leaders produced polarized attitudes among Democrats and Republicans in the public.  Leaving aside the possibility of a Supreme Court ruling on the individual mandate, the question is whether, five years from now, Republicans and others are still criticizing the ACA as strongly as they do today.

3 Responses to Fairness, Equality, and Public Opinion about Health Care

  1. roseonpolitics June 10, 2011 at 10:57 am #

    Unfortunately I think the answer to the question you propose is yes. Our politics seem to be more polarized then ever, and I don’t see that changing any time soon.

  2. C.D.Warner January 21, 2012 at 1:39 pm #

    It is wrong what the state does to small privately owned nursing facilities!
    I’m not in the nursing business but know people who are. At the state level all Nursing facilities were shut down for the states inability to provide appropriate care. Residents were treated like Jews in a concentration camp. To all the families whose loved ones were treated in such a deplorable manner… They were never compensated for the abuse their loved ones suffered. The only compensation was the state closed the doors of their facilities. In retaliation the state decided that all skilled nursing facilities must be inspected. Regardless of how ridiculous an accusation is the state swoops in like a vulture to suck funds from these establishments. Supposedly they do this because of the high amount of abuse that occurs in nursing facilities. This is in most cases is not true. Group Homes are not looked at in the same manner but should be. It is imperative for a regulation committee to examine nursing homes for a variety of reasons including quality, this is good because God forbid a privately owned and operated home treat residents as the states once did or larger organization does. The bigger the nursing homes organization is the less likely they are inspected. It is obvious why… contributions and donations and the same reason why Hospitals are not more closely looked at and ridiculed and fined by the state. Those are the types of facilities where the true abuses occur and where the state should appropriate their funds from. There is an established protocol used by the inspection teams that really is never followed. There primary goal is not a residents care or mistreatment, they inspect primarily to suck funds from these establishments. During inspections the teams interview residents, family members, administrative and care staff digging for any reason at all to appropriate funds from these facilities. Clinical records are usually reviewed and often records from years past supposedly to determine if quality care is being provided to residents even though those records have no bearing on why they are there to begin with. The inspection is just an easy way for the state to get a free check if what they ask for is not found. If an employee fails to document something the owners are held responsible for the employees mistake even though that is not even the reason the inspectors are there to begin with. The truth is when abuse occurs it is usually at the hands of an employee not the owner of these facilities. Something should be done to protect these owners from employee abuse and the employee should be the one fined. Of course that will never happen because the funds are not there for the taking. Often resident’s family members will file a complaint simply because they are a devious human being because someone said something to them about their rude behavior or something they did. Thanks to some resident’s family member or a disgruntled x-employees vengeful and spiteful nature these facilities lose millions if not billions of dollars a year to the state based off of false accusations. The State Inspectors act like bullies who abuse their authority as a means to suck funds for the state they operate in. I am truly disgusted with our state and federal government. Everything in life revolves around money which only hurts the people of our country who reside in these facilities whose sole purpose is to provide care for them because there family won’t. All government agencies act as Kings of the past who live high on the hog off the labor and sacrifices of us all. This goes the same for BWC. Americans are crippled and not compensated by the organizations that were created for them. Any time there are profits and or funds the Government will profit off those funds at the expense and suffering of the people the funds were created for. We will always be peasants beneath those who have power that they get by stealing from us all. If we attempt or try to take from them what they take from us it is called blackmail, fraud or theft and we go to jail. They will never be held accountable for their lies, theft, and deceit of The American People and the truth is we can’t do anything about it. This is why we say life sucks, shit happens, life’s a bitch and then we die, it is the gospel truth. This is why we blog.

  3. C.D.Warner January 21, 2012 at 5:19 pm #

    By http://www.etsy.com/shop/ZombieFriedTees

    The best way to persuade Americans to support changes in health care policy is to make health care more affordable period. It should be an issue to reform expenses with in the industry. It should not cost what they charge. No one should make $50-$100’s an hour for anything.
    New technologies and procedures should be adopted across the board and not just offered only to the wealthy or private insurance. People gripe about equality all the time but the truth is no one is equal on any level to someone else. We are different on many levels accept for under the skin. We are the same medically speaking. The underlying attitude about the unfairness or injustice of these inequalities is Americans’ belief about fairness in that we all have a right to be treated as equals. When has that every truly happened in American history or any nation’s history. Everyone has been a peasant, a slave, or treated unequally at some point in your heritage line. Unless of course you come from a long line of incestuous royalty; then you would just be genetically inferior to all.
    Our perception of fairness is blind to the role of private insurance versus government providing health insurance. Go to any VA or free Health clinic in America and see firsthand the inequalities of health care and the unequal healthcare outcomes of those clinics/ Hospitals. Health care should not be free. The problem is People in the health care industry make too much damn money. THE RENT IS TO DAMN HIGH! Reform needs to level wage gaps in the job market and that would resolve many social issues of inequality and people being able to afford things. Everyone can’t make more but some could still live better than those individuals by making a little less. I think a $40.00 cap on all jobs in America would resolve our nation’s problems. The profits of course would still go to the business owner who provide us all with jobs.
    Inequality in Health Care has always been based on income/ insurance, not education, race, or gender. You get what you can afford. Old procedures should be banned by the industry when new and better procedures are invented or discovered. This is the unfairness in healthcare.
    The government insurance plan would cover all medical and hospital expenses for everyone. Sounds great for Democratic partisanship, liberalism, and egalitarianism that strongly support such a plan. I sure don’t want a VA doctor using barbaric procedures on myself or anyone else for that matter. And that is what you would get. Blind to reality and fixated on an Idea that is not obtainable. Nothing is free and our government is broke. They can’t afford to do this! They can’t do anything without messing it up worse than it was to begin with.
    The Affordable Care Act should be called The Substandard Treatment Act. I believe it will grow more favorable with time, as more and more jobs disappear and more and more debt accumulates. Health care opinions are really based on things that don’t change very much such as partisanship, ideology, and values, which really are nonexistent in politics so it is a doomed idea from the get-go.
    Obama care should say it all to the American Public. Nothing he has done so far has improved anything but increase our nation’s debt. The Government should leave health care alone or that Industry will be broke also. If it passes we will have more job losses and debt due more failures of the Obama Administration. We are not a Welfare Nation at least not at the moment but in four more years we just might be.
    -Chad David Warner