Understanding Variation in the Correlates of Health Care Satisfaction and Beliefs

Abstract

Public satisfaction is an important component of determining the performance, stability, and legitimacy of health systems. Meeting public expectations in health care should be an essential goal for any society, but reaching this goal is not straightforward and can require careful navigation of political values and social priorities that may vary from country to country. This dissertation uses population surveys to study the dynamics of public views of health care and health systems. Chapter one investigates ways in which drivers of health system satisfaction in the United States may differ from those in seventeen other high-income nations. Using variance decomposition methods, I find evidence that access-related concerns outweigh satisfaction with recent health care interactions in the United States, while the reverse tends to be true in other countries. Sociodemographic patterns indicate that the high salience of access-related concerns in the United States may be related to its wide gaps in insurance coverage and generosity relative to other countries. In chapter two, I compare health and health care disparities in the United States with other nations. I compare self-assessments of personal health and health care between high-income and low-income individuals in 32 countries and find that the United States has among the largest income-related differences across a variety of measures. Prevalent public awareness of unmet need and attitudes regarding the fairness of income-based health inequalities suggest a degree of public tolerance for health inequalities in the United States compared to most other wealthy countries, though amid strong political divisions. Chapter three probes deeper into the determinants of health system satisfaction in the United States by integrating and comparing the influences of personal health care experiences, health system performance, and political context on state health care system approval. By exploiting state variation in political context and health system performance, I find that standard differences among the states in these measures are associated with major shifts in population-level state health care system approval. The strong association of health system approval to state performance and political environment signals a degree of accountability and responsiveness to public preferences at the state level.