Public preferences for reducing health inequality in the US: a national survey

There are sometimes trade-offs between improving total health and reducing health inequality among social groups. When faced with such trade-offs, decision makers need information about public values. However, although evidence of this kind has been collected in a limited number of countries, there is little or no evidence of this kind available for the United States. We used a national online survey of the US general population (aged 18–69) and applied a modified version of a standard benefit trade-off questionnaire used in several other countries, involving pairwise policy choices with different levels of health benefit and inequality. Proportions in qualitative health inequality categories were calculated, along with a simple index based on healthy years foregone and health inequality aversion parameters based on Atkinson and Kolm indices. Multivariable regression analyses were conducted to explore within-country heterogeneity by age, gender, income, education and geographic region. Around two thirds (65.9%) of respondents in the analytic sample (n = 440) had positive health inequality aversion, of which 20.7% were classified as “Weighted Prioritarian”, 4.3% as “Maximin” and 40.9% as “Strict Egalitarian”. The remaining respondents were mostly “Pro-Rich” (32.7%) rather than “Health Maximisers” (1.4%). The median respondent was “Weighted Prioritarian” and weighed health gains to the poorest fifth of people six to seven times more highly than health gains to the richest fifth (Atkinson 9.1; Kolm 0.1). Health inequality aversion was lower in the Midwest region of the US compared to the Northeast region, but otherwise was not closely correlated with observed respondent characteristics. Median views about health inequality aversion in the US were similar to those in Japan and the UK, but there was a greater degree of polarisation with higher proportions of respondents at both extremes of the distribution (“Pro-Rich” and “Strict Egalitarian”).