Original ResearchIncome, egalitarianism and attitudes towards healthcare policy: a study on public attitudes in 29 countries
Introduction
Healthcare systems constitute one of the central areas of modern welfare regimes that have grown rapidly over most of the last half century.1 Currently, a major challenge is how to sustain these systems in a context of growing fiscal constraints,2 raising concerns regarding health provision, and the legitimacy of the reforms in many countries.3, 4
At this juncture of institutional change, understanding citizens' preferences about how healthcare policies should be financed becomes crucial, as these attitudes are critical for supporting or impeding policy reforms. Several studies have examined attitudes regarding healthcare policy, finding that government involvement in the provision of healthcare is widely supported in Western democracies.4, 5, 6, 7, 8 Nevertheless, this literature has usually considered single measures of support for health policies, which vary across studies, restricting the validity of the results. Furthermore, although most of the studies have considered income and values as two main sources of support for healthcare policies, most of the time they have been studied separately, leaving the contrasts and potential interactions between these two factors unveiled.9, 10, 11 The present study aimed at filling some of these gaps by contrasting the effects of income and egalitarian values on three different measures of support for healthcare policies: a general attitude towards government involvement in healthcare provision and two attitudes regarding specific policy instruments (taxes and funding for particular programs). This was performed on a comparative framework using the International Social Survey Programme (ISSP) 2011 health module for 29 developed and developing countries, accounting for national contexts beyond those of traditional studies that only consider industrialised societies.5, 11, 12, 13
The remaining of this introduction begins addressing the main perspectives that account for the association of income with healthcare policy attitudes, and continues to then focus on the role of egalitarianism.
The income of voters has been traditionally recognised as a main determinant of policy attitudes.14, 15 In the setting of healthcare literature, scholars have suggested several explanatory mechanisms for the income effect, summarised into three main perspectives: self-interest, insurance, and deservingness. The first perspective explains preferences in terms of material self-interest bearing on current consumption.16, 17 By assuming the dependence of healthcare system's finance on progressive taxes, those with high income will oppose support for state responsibility in healthcare because this means higher levels of taxation that they will have to pay, leaving them as net payers who contribute more than they consume. On the contrary, low income groups will support healthcare policy, insofar as they are net beneficiaries. Thus, we would expect a negative income effect on support for this kind of policy.
Although the self-interest view about the income effect dominates in the studies of policy attitudes,11, 12, 13 we can identify at least two theoretical alternatives. The insurance view also depends on self-interest as motivational basis but assumes that individuals care more about future consumption. This perspective has pointed out that preferences for protection against unexpected shocks—such as being ill—tend to be higher for those with higher shock's exposure.16, 17, 18 When risk aversion of individuals is high, this theory predicts that the demand for insurance against future income shocks increases for those with larger income, as those who are better off have more to lose than the most disadvantaged. Within this view, we would expect the opposite income effect than the prognosis of the self-interest perspective: the association between income and support for health policy is positive. Finally, the deservingness view has gone beyond self-interest by focussing on the so-called deservingness heuristic, which is an implicit cognitive bias of human nature generated over human evolutionary history.19 The deservingness heuristic has tagged sickness-based needs as random events and has prompted individuals to support benefits when the need is caused by this kind of randomness.20, 21 Furthermore, this implicit bias crowds out other more cognitively demanding factors that fuel disagreement about healthcare, such as self-interest and values. Following this theory, it is expected for citizens to hold views in favour of government intervention in healthcare across all income levels and, thus, income would not be associated with health policy attitudes.
The empirical evidence related to the effect of income on attitudes about healthcare policies—mostly from industrialised nations—has been so far ambiguous. Gevers et al.12 showed a positive association between income and support for public healthcare. By contrast, Missine et al.13 and Wendt et al.11 found greater support among low-income individuals, whereas Naumann5 did not detect a significant impact of income. Sun et al.22 put forward this research by examining attitudes towards access for non-citizens to publicly funded healthcare in advanced and developing countries, not finding a significant effect of income.
In methodological terms, some studies have used country fixed-effects models that exploit within-country variation at the individual level to establish a plausible causal impact of income, and their findings have provided evidence in favour of the deservingness perspective. Busemeyer et al.23 examined support for government spending on health in Organisation for Economic Co-operation and Development (OECD) countries and found a weak association with income. More recently, Jensen4 did not find a significant effect of income among European citizens.
Besides income, values and ideologies are other important micro sources that capture the actual thinking of citizens about policy issues. Beyond political ideology,12, 24 the literature has also emphasised the role of general values such as egalitarianism.25, 26 This value reflects the general belief that the welfare of all citizens is important and, thus, large economic inequality is undesirable. Egalitarianism is connected to a given policy attitude, insofar as this value reflects the outcomes that people desire from the policy. On the basis of this social-psychological mechanism, Feldman and Steenbergen27 argued that egalitarians see welfare as a social right and support policies that reduce inequalities by promoting universal interventions of the state into the market. Nevertheless, scarce studies have evaluated this prognosis for attitudes regarding health policy. Lynch and Gollust28 examined the role of values on beliefs about health in the US population, suggesting egalitarians are significantly associated with support for government provision of health insurance. Similarly, Lee and Park9 showed that egalitarianism increases the preference for an egalitarian healthcare provision and willingness to contribute to it in Korea.
There are few cross-national studies examining the association between values and health. Among them, the above-cited study by Sun et al.22 did not find a significant association between egalitarianism and attitudes, whereas Missinne et al.13 found a positive effect of egalitarianism on support for state responsibility for organising healthcare among European countries. They also suggested that income and egalitarianism may interact: the positive effect of egalitarianism on state responsibility might be stronger for low-income groups, as they are major users of the health system. Nevertheless, their empirical findings suggested non-significant interaction effects. Still, we lack cross-national evidence that evaluates interactions beyond Europe and the USA.
In sum, the discussion of the literature may be summarised into three main expectations that guided the analysis of the present study. First, following recent evidence in favour of the deservingness view, we expected for income to have no effect on attitudes towards public health policy. Furthermore, the review about values suggested that the greater the commitment to egalitarianism, the stronger the support for healthcare policies. Finally, this positive influence of egalitarianism should have been larger for low-income groups compared with the rich. In the following section, we present the research design to evaluate these prognoses.
Section snippets
Data source and sample
This research relied on data from the third release of the 2011 ISSP module, which focuses on health and covers 32 countries in total.29 ISSP provides representative survey data of adult populations of these nations and applies the same questions among diverse cultural contexts, allowing cross-national comparisons. Our measures of countries' characteristics were collected from the World Development Indicators database.30
The original ISSP 2011 data set included 55,081 observations. Because only
Results
Fig. 1 illustrates the first step of our empirical strategy. Graphs show odds ratios and their 95% confidence intervals from binary logistic regressions without control variables for each country. The panel (b) indicates that egalitarianism has significant and positive associations with attitudes towards government involvement in healthcare in nearly all countries, but the sizes of odds ratios show significant variation. For income (panel [a]), the associations are not significant in most
Discussion
The objective of this study was to evaluate the relationships between income, egalitarianism, and public health attitudes. Analysing data from ISSP 2011, two important conclusions can be drawn. First, as we expected, the effect of income to be very small and non-significant for attitudes towards government involvement and public funding, especially when we controlled for unobserved countries characteristics by using fixed effects. From a theoretical view, these results provide evidence for the
Acknowledgements
Part of this research is a fragment of one of the author's Master thesis focussing on willingness to pay taxes to improve healthcare systems.
Ethical approval
None sought.
Funding
This project was supported by CONICYT/FONDECYT REGULAR/1160921, CONICYT/POSTDOCTORADO/3160705, CONICYT/FONDAP/15130009, and CONICYT-PCHA/MagísterNacional/2015.
Competing interests
None declared.
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