European University Institute, Italy & Humboldt-Universität zu Berlin, Germany.
Max Planck Institute for Social Law and Social Policy, Germany.
Soc Sci Med. 2020 Dec;267:113146. doi: 10.1016/j.socscimed.2020.113146. Epub 2020 Jun 30.
Existing research has found that individuals often perceive healthcare inequalities as unfair; yet, there is high variation in unfairness perceptions between countries. This raises the question of whether the institutional context of the healthcare system is associated with what people perceive as unfair. Using data from the ISSP study and OECD health expenditure data from 2011/13, we explore whether individual attitudes about the unfairness of healthcare inequality - the ability to purchase "better" healthcare for the affluent - vary systematically with a country's institutional environment: namely, with the prevalence of cost barriers to healthcare access, and with the degree and type of public healthcare financing. Three general findings emerge from the analysis: (1) Higher cost barriers correlate with lower levels of perceived unfairness in healthcare inequality, suggesting those exposed to greater levels of inequality tend to be more accepting of inequality. This finding is consistent with empirical justice theory and the expected relevance of an 'existential' standard of justice, stemming from individuals' proclivities to accept the status quo as just. (2) Further, greater public financing of healthcare correlates with higher perceived unfairness. Drawing on neo-institutionalist theory, this may suggest that greater public financing enshrines access to healthcare as a universal right, and hence provides an ideational framing that delegitimizes unequal opportunities for purchasing better healthcare. (3) Further, higher unfairness perceptions of lower income and educational groups are more strongly associated with greater public financing than those of their respective comparison groups. This may indicate that the normative right to healthcare is of particular importance to the disadvantaged, which could potentially explain the political quiescence on healthcare of lower income and educated persons in societies that lack universal health systems. In sum, this study contributes to the larger debate on the interrelatedness of healthcare institutions and public opinion, and specifically on perceptions of unfairness.
现有研究发现，个体通常认为医疗保健不平等是不公平的；然而，不同国家之间对不公平的看法存在很大差异。这就提出了一个问题，即医疗保健系统的制度环境是否与人们认为不公平的内容有关。本文利用国际社会调查项目（ISSP）研究和经合组织（OECD）2011-13 年卫生支出数据，探讨了人们对医疗保健不平等不公平程度的态度——即富人获得“更好”医疗保健的能力——是否会随着国家制度环境的变化而发生系统性变化：即是否与医疗保健获取的成本障碍的普遍性，以及公共卫生融资的程度和类型有关。分析得出了三个总体结论：（1）较高的成本障碍与较低的医疗保健不平等感知不公平程度相关，这表明那些面临更大不平等程度的人更容易接受不平等。这一发现与实证正义理论以及源于个人接受现状为正义的“存在主义”正义标准的预期相关性一致。（2）此外，更多的公共卫生融资与更高的感知不公平相关。借鉴新制度主义理论，这可能表明更多的公共卫生融资将获得卫生保健的机会视为普遍权利，并因此提供了一种思想框架，使购买更好的医疗保健的不平等机会失去合法性。（3）此外，与收入和教育程度较高的群体相比，收入和教育程度较低的群体对不公平的看法与更多的公共融资更为相关。这可能表明，对医疗保健的规范性权利对弱势群体尤为重要，这可能解释了在缺乏全民健康保险体系的社会中，低收入和受教育程度较低的人对医疗保健的政治冷漠。总之，本研究为医疗保健制度与公众意见之间的相互关系，特别是对不公平的看法的更广泛辩论做出了贡献。
