Fairness of health inequalities and public preferences for health care reform in the United States

Conventional wisdom suggests that the most promising strategy to persuade Americans to support health care reform is to appeal to Americans' self-interest: their economic security and concerns about their personal health. Given increasing attention to disparities in health and health care, an alternative strategy might be to frame the problem as a moral one, thus activating the public's underlying attitudes about fairness to mobilize their support for reform. We designed an Internet-based survey of a nationally-representative sample of U.S. adults (N=1300) to assess the associations between the public's perceptions of health inequalities and their support for health care reform. Respondents were provided with vignettes about health and health care inequalities and then asked to what extent they perceived these inequalities as unfair. We find that a majority of respondents evaluate health care inequalities as unfair, and that these evaluations in turn significantly predict support for government provision of health insurance. Even after taking into account respondents' self-interest (such as their health and insurance status), political orientations, membership in a disadvantaged group, and egalitarian and humanitarian values, perceptions of the unfairness of health care inequalities strongly influence their preferences for provision of health insurance. These findings suggest that if advocates or politicians framed problems in the health care system to emphasize the moral aspects of inequalities, this strategy could promote more support for health reform. We will discuss this study's contribution to the growing field of public health ethics by illuminating the importance of the public's values in health policy opinion.