What's Fair in Health Care?
Julia Lynch
Cohort X, Harvard
Life in any collectivity, no matter how egalitarian, generates social, economic,
and political inequalities. Some of these inequalities garner little attention, appearing as
natural or at least justified. Other inequalities seem unfair, even deeply unjust.
Normative theories of justice offer guidance about what kinds of inequalities we should
view as fair or unfair. But we have only the broadest notions of how citizens of countries
like the United States actually evaluate inequalities in various domains of social life, or
why they evaluate them in the way that they do. In the language of health policy studies,
what kinds of underlying beliefs help people to distinguish between inequalities,
disparities and inequities?
My research seeks to discover what criteria ordinary Americans use to evaluate
the fairness of inequalities in access to health care, the quality of care, and health
outcomes. Through comparison with attitudes towards inequality in other domains
(income, education, pensions, and political influence) and, eventually, across countries,
this research will generate a mapping of the conceptual terrain underlying beliefs about
fairness in health care, and a deeper understanding of whether health care provokes
distinctive responses to questions about fairness. The design of the survey will also allow
for inferences about the causes of interpersonal variability in beliefs about fairness, and,
with the addition of a cross-national component, for tests of hypotheses about the causes
of societal-level differences in justice beliefs.
Survey research has been used to tap views about inequalities in income, the
distribution of jobs, educational opportunity, political access, and, to a lesser extent,
health care. The inequalities examined have been across various groups, including the
population as a whole, whites versus blacks, men versus women, and, less frequently, the
old versus the young. In the research that seems to me of most value, respondents are
asked separately if they perceive an inequality to exist, why they think the inequality
exists, and whether they think the inequality is fair or not. More frequently, one or more
of these steps is missing or elided, and in particular, beliefs about fairness are often
inferred from beliefs about the prevalence or causes of inequality rather than measured
directly. I am currently developing a survey instrument that combines questions adapted
from existing research on inequality in non-health-related domains with a parallel, largely
de novo health inequality battery.