Measuring Preferences in Health Care
Preference measurement has a rich tradition in health economics and in health-related social and behavioural sciences. These frequently concern maximisation of quality-adjusted-life-years (QALYs) and are often designed as discrete-choice-experiments (DCEs). Many such studies further narrow down their target samples to only include patients and/or medical professionals, as well as other health care providers (e.g. Harrison et al. 2017). Nevertheless, research on preferences for resource allocation, efficiency and equity in health exists (e.g. Ubel et al. 2000; Gyrd-Hansen & Slothuus 2002; Luyten et al. 2013; Krucien et al. 2020).
The ViePHEP distinctively looks at public non-clinical preferences for health care and public health schemes. This has two reasons. First, 38.3 % of the Austrian population suffered from a chronic morbidity in 2019. Therefore, there should be a sufficient amount of chronically ill or otherwise injured or disabled persons in a population sample. Second, studies that solely involve patients may have a biased view on the demand side of health care, while only looking at medical personnel or providers might produce biased results on the supply side. Either way, limiting a preference-study to a specific group of stakeholders would not adequately deliver on the objectives and questions formulated in this project. One target is to adequately grasp the status-quo of differences in a heterogenous population, which contains diverse groups in terms of socio-economic positions and of health conditions. Further, an aim of this study is to infer certain patterns of revealed prefences from both the degree of marginalisation and from the perceptions of people in relation to their own fairness attitudes. Third, the ViePHEP will inculde survey items of stated preferences for health policies and health-related resource allocations.
The ViePHEP survey will employ two types of techniques to measure justice-fairness attitudes and stated preferences respectively. The preferences directed towards access, affordability and provision will be revealed by matching status, perceptions and attitudes. The stated preferences for health policies will apply both Likert-scales and willingness-to-pay (WTP), which are both established measurement designs (Whitty et al. 2014; Lehnert et al. 2019). Also, both of these measurement-types are unconstrained and allow for indication of preference-intensity (Mullen 1999).
Preferences for Resource Allocation in Health Care
Preferences for resource allocation in health care, as understood here, centre around four health policy domains. These are funding of and contributions to public health care, willingness-to-pay (WTP) for certain medical interventions and types of care, allocation of scarce resources including the use of health budgets, and redistribution of health-related goods with the objective to foster health equity.
Previous research has shown that possession of private health insurance (PHI) seems to decrease the political support for the public health care systems in nations with private duplicate health insurance systems, yet not in countries with private primary health insurance (Mou 2013). Pfarr and Schmid (2016, p. 624.) find in a German sample that “Persons who benefit from public coverage exhibit a positive willingness to pay for an extension of the coverage beyond the status quo. The others are not willing to contribute to this end”. Jensen and Naumann (2016) find different levels of support for public health care between demographic groups and between people leaning toward the political left or right in 17 European countries. Further research indicates that income affects willingness-to-pay for public health care in 29 countries in the ISSP (Azar et al. 2018) and that perceptions of inequities in health care impact preferences for government provision of health insurance in the USA (Lynch & Gollust 2010). Age also matters for the preferences towards health maximisation and for egalitarian concerns in health care in a Polish study (Kolasa & Lewandowski 2015). Akkazieva et al. (2006) investigate health policy preferences of patients in Hungary. They find that patients primarily have a preference for solidary measures in health care. Read et al. (2021) analyse an English sample and demonstrate that the majority of respondents prefer social care in later life to be paid for by the user and the state in a shared way. Lu et al. (2021) show that the UK public seems to prefer a collective approach to raising additional funds for health and social care by a public organisation. Soroka and Lim (2003) find for the USA and UK that issue framing defines the responsiveness of health care expenditures to public preferences. Wendt et al. (2010) compare 14 European countries and find that higher income is associated with less desire for state involvement in health care in all studied countries, except for the Netherlands. Henderson and Hillygus (2011) show that self-interest and partisan attachments strongly affect health care attitudes in the USA. In an Icelandic sample the majority of respondents favour higher health care expenditure and health provision by the state (Vilhjalmsson 2016). Choma et al. (2018) find that in the USA preferences for the distributive fairness perceptions of equality and need in health care mediate the relationship between political orientation and attitudes on the ACA (Affordable Care Act).
Further, personal experiences with the health care system shape attitudes towards health care policies in many countries (Larsen 2020) and in the USA specifically (Lerman & McCabe 2017). Chavanne (2020) finds for an US sample that support for redistributive health care increases as bad luck becomes more important in causing poverty yet is unaffected as good luck becomes more important in causing wealth. Kullberg et al. (2021) do not find evidence that voluntary health insurance, i.e. PHI, changes the willingness to pay higher taxes for public health care in Sweden. Yet, the authors do not consider redistribution in Swedish health care from a wider angle that would include anything but readiness to contribute more personally. Traina et al. (2019) find that Norwegians demand both personal and public responsibility when it comes to raising co-payments for health care.
Heap et al. (2020) demonstrate that people in the UK and USA highly prefer health over wealth, when being presented with a trade-off between lives lost to COVID-19 and disposable income losses. Barry et al. (2020) show that in the early stage of the COVID-19 pandemic the majority of US adults supported social and health policies, such as paid sick leave, universal health insurance, an increased minimum wage, as well as various unemployment support policies.
Research with Danish survey data shows that respondents exhibit a willingness to improve the quality of the public health care system at the expense of private consumption (Gyrd-Hansen & Slothuus 2002). Empirical evidence suggests that Australians mostly care about outcome egalitarianism and not about cost per life year in their preferences for the allocation of the health budget (Richardson et al. 2012). Research with a Greek sample finds that preferences for public health expenditure allocation have more support among relatively poor citizens (Xesfingi et al. 2015). Foremmy et al. (2020) find that preferences for health care expenditure almost doubled in the COVID-19 pandemic in Spain compared to a 2018 benchmark and that Spanish citizens would on average allocate 22.5% of the public budget to the health sector, which is considerably higher than the 15% of real public spending on health in Spain. Regarding NHS funding and adult social care there is a prevalence for ‘everyone contributes and everyone benefits’ across all population subgroups in the whole UK (Lu et al. 2021). Gollust and Lynch (2011, p. 1085) “[…] investigated the impact of cues about ascriptive (race and class) and behavioral (smoking and diet) characteristics on the formation of health-related opinions”. They find that beliefs about such intertwined characteristics influence health policy preferences.
Finally, preferences can be personal, social or socially inclusive personal. Additionally, each of these three types can be in either an ex-ante or an ex-post context. Thus, preferences in health care depend on normative considerations and the specific policy context (Dolan et al. 2003).
Mullen, P. M. (1999). Public involvement in health care priority setting: an overview of methods for eliciting values. Health expectations, 2(4), 222-234.