Dissertation Title: "Understanding Variation in the Correlates of Health Care Satisfaction and Beliefs"
Public satisfaction and approval are important components 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 international and domestic surveys to explore the dynamics of public views of health care and health systems in the United States.
Paper one explores 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 in the United States outweigh satisfaction with recent health care interactions, while the reverse tends to be true in other countries. Socio-demographic variation in access experiences and concerns in the United States suggest that wide disparities in insurance coverage and generosity may play a role in elevating their importance relative to other countries where access to health care is more uniform and minimum standards guarantee that most people receive health care of a certain quality.
In paper two, I examine how health care disparities in the United States compare with other nations, focusing on how self-assessments of personal health and health care differ between high-income and low-income individuals in 32 countries. I find that the United States has among the largest income-related differences across a variety of measures, standing in contrast to other wealthy countries. Analysis of American awareness of unmet need and their attitudes regarding the fairness of income-based health inequalities suggests more public tolerance for health inequalities in the United States than elsewhere, though amid strong political divisions.
Paper three probes deeper into the determinants of health system approval 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 system approval, signaling a large degree of democratic accountability. The strong responsiveness of health system approval to state characteristics argues strongly in favor of incorporating the role of states in future research on this topic.