Who should receive government-financed health care? Who should pay? These are critical questions in modern democracies, not least because they represent an enduring political problem. Namely, should the government place an emphasis on means or on equity? Different health care systems with different methods of addressing this fundamental question have developed around the world.
In Canada, where a universal health care system is seemingly part of our national identity, questions abound regarding the sustainability of the current system and how to reform it for the future. In our neighbour to the south, health care remains a divisive political issue, with political parties in the United States still debating over what the fundamental nature of their health care system should look like. Clearly, individual-level opinion is important in these debates over key health reform issues.
Yet research in the area of individual attitudes has been misguided. Up to this point, research on preferences towards health care systems has focused on traditional self-interest (including demographics, socioeconomic status, and age), sociological, and political-ideological explanations for individual attitudes. Macro-level, top-down approaches towards the topic have been the norm, often with little to no emphasis on cross-national micro-level analysis. What is missing is an understanding of the important differences between people which contribute to how they think about health care. I’ve been exploring this concept along with Peter Loewen in the Department of Political Science. Applying innovative behavioural-economic theories to political behaviour, we argue that there are fundamental pre-political differences in the areas of risk, altruism, trust in the government, and trust in the market that all exert an effect on preferences for different health care system types independent of the aforementioned traditionally considered factors.
Behavioural economic games operate off of the assumption that individuals vary by types and behaviours. By deciding to engage in a given behaviour, we can identify an individual’s type. We use behavioural games, which involve monitoring the decisions involved with the transfer of money between a subject and another party, to categorize individuals based on their risk tolerance, trust in government and private market actors, and altruistic tendencies using a sample of more than 4000 subjects in Canada, the United States, the United Kingdom, Australia, and New Zealand.
We then relate these individual types to support for three styles of health care system derived from real world examples: a market-based system which provides a baseline of care for the poor and elderly but requires others to purchase coverage on their own such as in the US; a mixed system with a minimum level of care for all, with the option of accessing better care like the Australian model; and a universal system that provides the same level of care to all citizens regardless of means, as is the case in Canada.
Our results show that individual’s preferences across these five democratic countries are influenced by the system types that they are familiar with. Higher levels of altruism and trust in government actors are correlated with support for more universal systems and higher levels of government involvement. Likewise, risk-loving types and those with higher trust in markets support more market-based systems. These results hold even when we account for the influence of partisanship and political ideology in different versions of our models.
Why does this matter? Public opinion is an essential part of any reform initiative. These findings can help policymakers craft reforms that align with individual preferences in a way that engenders systemic support. This in turn can strengthen citizen support for systems, which they can view as a reflection of their values. What’s more, it highlights the constraints that current arrangements exert on the formation of individual attitudes.
For too long, the macro perspective of political ideology, demographics, and other traditional self-interest based explanations has limited the discourse on health care. It is time now to refocus on the distinguishing differences that precede political experiences for the fundamental building blocks of every health care system: the individual. It is only with this focus that nations around the world can succeed in providing a high level of health care at a reasonable cost for their citizens.
Alex Kamath is a visiting Fulbright Scholar from New York University ’13 conducting research through the department of political science with Professor Peter Loewen.