Is it unfair for the affluent to be able to purchase "better" healthcare? Existential standards and institutional norms in healthcare attitudes across 28 countries.

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.

Beyond endogeneity in analyses of public opinion: Evaluations of healthcare by the foreign born across 24 European countries.

To address the problem of endogeneity in public opinion research, this study examines the opinions of healthcare held by the foreign born, i.e. those not socialized in the system they are asked to evaluate. It (a) explores the degree to which the healthcare ratings of the foreign born depend on the country's institutional healthcare setting; (b) stresses the importance of referential standards and the significance of knowledge and previous experiences of healthcare services in the country of origin; and (c) investigates differences in healthcare ratings with the length of time foreign born spent in the destination country. This study uses data from the seven rounds of the European Social Survey (2002-2014) and applies multilevel modelling techniques. Results show the institutional characteristics of healthcare services in the country of residence are associated with healthcare evaluations of the foreign born, in particular if these services are compared to those in the country of origin: the better healthcare institutions perform relative to those in the country of origin, the higher the healthcare ratings. Although comparisons with the country of origin seem relevant to all foreign born, they are sometimes more important to recent arrivals. This study suggests knowledge and experience of different healthcare institutions change perspectives and evaluations of healthcare. This finding enriches the discussion of the effects of socialisation and adaptation processes in the formation of public opinion.

Cognitive determinants of healthcare evaluations - A comparison of Eastern and Western European countries.

Knowing the public opinion of healthcare is essential when assessing healthcare system performance; but little research has focussed on the links between the public's general attitude to the healthcare system and its perceptions and expectations of specific healthcare-related aspects. Using data from the fourth round of the European Social Survey 2008/09, we explore the cognitive determinants of global evaluations of the healthcare system in 12 Eastern and 16 Western European countries. We find that healthcare evaluations follow a coherent cognitive reasoning. They are associated with (i) perceptions of the performance of healthcare systems (i.e. efficiency, equality of treatment, health outcomes), (ii) expectations of the government's role in providing healthcare, and (iii) reflections on demographic pressures (i.e. aging populations). Contrary to the general assumption that normative expectations are responsible for differences in healthcare evaluations between Eastern and Western Europe, our results suggest that regional differences are largely due to a more negative perception of the performance of healthcare systems within Eastern Europe. To enhance the public opinion of healthcare, policy makers should improve the efficiency of healthcare systems and take measures to assure equality in health treatment.