No Fair? Public Opinion and the Fairness of Health Inequalities

Jun 13, 2011, 3:30 PM, Posted by

This post is part of an ongoing series of Voices from the Field by scholars, fellows and alumni of RWJF Human Capital programs. The author, Sarah Gollust, Ph.D., is an alumna of the Robert Wood Johnson Foundation Health & Society Scholars program. Read more about her latest research.


In graduate school in public health, I was taught that health disparities are differences in health that are “avoidable, unfair, and unjust,” using Margaret Whitehead’s 1992 definition. Most readers of this blog would likely agree that health differences across groups defined by race, ethnicity, or social class are unfair. But does the American public agree? Does the public consider such differences across groups to be an injustice, or simply unfortunate? Do members of the public even know about disparities at all? And if they did, how would that knowledge affect their opinions about policy?

Arriving at Penn as a Health & Society Scholar in the summer of 2008, I was delighted to discover that Julie Lynch, Penn faculty member and an alumnus of the Robert Wood Johnson Foundation Scholars in Health Policy Research program and an RWJF Investigators Award recipient, shared my curiosity regarding these questions. And—thrilling for a junior researcher like myself—she actually had the data to begin to address them.

Julie had fielded her “What’s Fair in Health Care” survey on a nationally representative sample in 2007, and the data provide tantalizing glimpses into what Americans think about inequalities across multiple social policy domains.

In the first paper to come out of our productive collaboration, released this spring in the Journal of Health Politics, Policy, and Law, we examine whether the public thinks health disparities are, in fact, unfair. Further, we ask whether—controlling for the usual suspects that we know predict public opinion about health policy matters—these attitudes about the fairness of disparities can explain Americans’ support for government provision of health insurance.

The analyses thus help shed light on a potent political question of ongoing relevance today: Which are more influential predictors of Americans’ support or opposition for health reform? Their pocketbook concerns (which President Obama and advocates of health reform tended to emphasize heavily) or their moral concerns—their thoughts about fairness and justice?

Our data indicate that those Americans who view health care disparities as unfair are more likely to support government provision of health insurance, even after adjusting for characteristics representing their self-interest (i.e., income, insurance status, health status) and political predispositions. Extending beyond our data, we suggest in the paper that strategically framing the goal of changes to the health care system as addressing unfair inequalities could help bolster the public’s support for reform. The moral case for progressive health care policy actions, we argue, is insufficiently presented to the public, but could have a mobilizing effect.

What lessons, as a young scholar, do I draw from this work? First, articulating a moral argument for policy positions is potentially powerful, even—or especially—in the face of divisive opposition (such as what we continue to see in the aftermath of health reform). As an alumnus of the Robert Wood Johnson Foundation Health & Society Scholars Program, a program committed to population health improvement, I hope that my colleagues and I will not shy away from working in that gray area that smacks of politics, morality, or advocacy, and not just delve within seemingly “cleaner” empirical boundaries. And yet, as Julie and I uncovered in our ongoing work to be published later this year, advocates and scholars alike should be cautious when making the case to the public for ameliorating inequalities. In contrast to the select group of health policy professionals reading this blog, ordinary Americans find some inequalities—particularly health status inequalities, as compared to health care inequalities—neutral, that is, neither fair nor unfair. In addition, the presumed cause of the disparity matters, as the public believes some people to be more or less deserving of their lower status plight.

The second lesson I draw from this experience is promoting the value of the RWJF Human Capital network. As my collaboration with Julie—spanning three distinct programs—illuminates, likeminded curious scholars flock into and out of these programs. Making contact across programs could, as it did in my case, yield benefits both tangible and intangible: data sources for answering compelling questions, academic publications, and long-lasting scholarly relationships.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.