Conventional wisdom suggests that the best way to persuade Americansto support changes in health care policy is to appeal to theirself-interest — particularly to concerns about their economicand health security. An alternative strategy, framing problemsin the health care system to emphasize inequalities, could also,however, mobilize public support for policy change by activatingunderlying attitudes about the unfairness or injustice of theseinequalities. In this article, we draw on original data froma nationally representative survey to describe Americans’ beliefsabout fairness in the health domain, including their perceptionsof the fairness of particular inequalities in health and healthcare. We then assess the influence of these fairness considerationson opinions about the appropriate role of private actors versusgovernment in providing health insurance. Respondents believeinequalities in access to and quality of health care are moreunfair than unequal health outcomes. Even after taking intoaccount self-interest considerations and the other usual suspectsdriving policy opinions, perceptions of the unfairness of inequalitiesin health care strongly influence respondents’ preferences forgovernment 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.

[Cross-posted at the Monkey Cage]

John Sides

John Sides is an associate professor of political science at George Washington University.