Solidarity, equity, fairness and reciprocity in health care
Prainsack and Buyx (2011; 2017) argue that solidarity is the acceptance by a person or by a group to carry financial, practical and/or emotional costs to support others with whom they recognise similarity in a relevant aspect. This similarity can be a common goal, shared risk or an objective, as well as subjective, characteristic. Particularly, in health care such solidarity comes in three tiers: It can be interpersonal, communal on the group level or contractually incorporated into institutions. Solidarity in public health care systems with SHI is a prime example of institutionalised solidarity because citizens contribute based on their wages and salaries and receive medical treatment and care that correspond to their needs. Solidarity in an ideal state can be seen as the outcome of a ‘social contract’, in which personal and ethical allocation preferences of a collective are reconciled through impartial consideration, i.e. under the veil of ignorance (cf. Dolan et al. 2003).
Olsen (2011) provides an account of equity in health care. He suggests that in countries with publicly funded health care two principles are paramount: Equal access for equal need and reduction of health inequalities. While the former represents the ideal of universalist welfare, the latter recognises that some health inequalities are perceived to be inherently unfair. Daniels (2001) argues that there is a social obligation to guarantee the existence of institutions, such as social insurance or subsidies for PHI, that protect equal opportunity in a rebuke to efficiency maximisation, aggregate welfare maximisation and utilitarian objectives. Yet, equity and inequity in health care remain to be normative concepts. First, as Anand (2002) argues, inequality aversion differs between different domains in health care and such an aversion ought to be higher across some population groups than others. Second, equity and equality are not the same, even though health equity incorporates the idea of equal opportunity to be healthy. Third, health equity cannot be directly measured but merely be grasped “... as the absence of disparities in health (and in its key social determinants) that are systematically associated with social advantage/disadvantage” (Braveman and Gruskin 2003, p. 256).
Fairness denotes the “... view that some important types of health inequalities are considered unfair” (Olsen 2011, p. 815). Therein, fairness also remains normative. Brock (2002) points out that ‘fair’ treatment priority can be given to the worst off, according to benefits aggregation or so that fair chances can be pinned against best possible outcomes. All of these, and more, may seem fair to certain people in certain circumstances. Daniels (2007) advocates three core concerns for fairness in health that are equity, efficiency, and accountability, that should be fulfilled to meet central criteria of fairness in health policy.
Reciprocity can be direct, generalised (indirect), strong, weak, conditional, unconditional, negative, and/or positive. Generally, “... a reciprocal action is modeled as the behavioral response to an action that is perceived as either kind or unkind” (Falk and Fischbacher 2006, p. 294). Framed differently, “Reciprocity demands proportionate balancing of the benefits and burdens of social cooperation between participants…” (Viens 2008, p. 1). I argue that in its essence reciprocity should be evaluated insofar it can or cannot alleviate the ‘tragedy of the commons’ and whether it can establish a social norm in a given context. A scenario with identical individual incentives but absent cooperation is known as the tragedy of the commons (e.g. Gächter et al. 2017). Gross and De Dreu (2019) demonstrate that attenuation of said tragedy depends on the costs of individual solutions. If they are low, cooperation deteriorates, even if individual negative reciprocity (punishment) is available. However, centralised punishment institutions or establishment of social norms of cooperation and of generalised reciprocity can solve the dilemma. Thus, when individualism is reasonably cheap, cooperation depends on a type of governmental enforcement and/or on the establishment of a social norm that facilitates cooperation.
Solidarity is a collectivised practice in public health care systems with SHI. Equity in health care encompasses an ideal to aspire to and to work towards and fairness involves the individual and normative attitudes on redistribution dilemmas and decisions about allocation of scarce medical resources. In theory reciprocity, in its generalised form, can amplify or replace continuous state monitoring of and intervention in health insurance markets. However, the state often may be a required institution to generate and stabilise such generalised reciprocity through governmental constraints on resource consumption (cf. Hardin 1968; Frischmann et al. 2019).
PHI & redistribution preferences
There is a debate of whether the state should retrench from health care or should rather guarantee its provision to the public (cf. Taghizadeh and Lindbom 2013; Del Pino and Ramos 2018). While people can be found on a continuum between those two positions, public opinion on health care is shaped by welfare regime type, type of health care system and individual characteristics (Gevers et al. 2000).
While PHI can add benefits to society (cf. Colombo, and Tapay 2004), it also can manipulate health care systems’ pursuits for equity by circumventing guiding principles, rules and regulations. Additionally, PHI is regressive, whereas social insurance is progressive in high-income countries (Hsiao and Liu 2001). PHI is not equally accessible to all social strata, minorities and vulnerable groups alike (e.g. King and Mossialos 2005; Kiil 2012; Jin et al. 2016).
People who possess PHI might cut short waiting times and lists, get different drugs or have access to private health care providers, thus distorting medical priority setting and aggravating health inequities (e.g. Borrell et al. 2001; Blendon et al. 2002; Schoen and Doty 2004; Van Doorslaer et al. 2008; Allin and Hurley 2009; Grignon et al. 2010; Lapidus 2017). For Austria Czypionka et al. (2018, p. 13) note: “Although illegal to prioritize patients with VHI, empirical evidence shows that VHI policy holders can obtain faster access to elective care in public hospitals”. Similar observations can be made for instance in Germany (Lungen et al. 2008; Ramos et al. 2018) and in Ireland (Whyte et al. 2020).
British evidence shows that longer waiting lists result in more frequent purchases of PHI (Besley et al. 1999). Research also indicates that people with PHI use health care services and prescription medicines more frequently and intensely than people without PHI, for example in France (Buchmueller et al. 2004) and in Denmark (Kiil and Arendt 2017). Summarising, those who contribute to PHI do so expecting a benefit from their premium payments, be it shorter waiting lists, more advanced drugs or more frequent use of health care overall. Thus, people with PHI exhibit a higher and perhaps exacting demand for health care. Supporting this, Olsen et al. (2004) find that Danes who were subjected to taxation contribution framing more often use altruistic arguments for being willing to pay, while respondents who encountered insurance premium framing are more likely to name selfish reasons.
Now addressing the supply side, doctors have a competing interest to provide sound treatment to their patients (Tollison and Wagner 1991). This manifests as doctors seem to be driven by both self-interest and ideology in their attitudes towards private welfare services (Martinussen 2008), where doctors’ self-interest can be furthered by financial incentives (e.g. Rodwin 2004). In fact, doctors nowadays frequently promote and prescribe novel drugs albeit there may be no evidence of those drugs’ superior efficacy. Even medical professionals follow market forces and self-interest (Light 2010) and such self-interest for private practice can increase inequity for patients and medical professionals alike (Oliver 2018). As patients follow doctors’ advice they might also utilise private health care services provided by some doctors (cf. Wiles and Higgins 1996; Waring and Bishop 2013). Summarising, when health care providers receive payments from public and private sources “... doctors and hospitals will have incentives to prioritize VHI-financed patients” (Sagan and Thomson 2016, p. 99; cf. Oxholm et al. 2021).
H1: People with PHI disfavour redistribution in health care, whereas people without PHI favour redistribution.
Perceived fairness: Beyond self-interest
“Few individuals in the developed world will be able to afford the health care they will need in their lifetimes” (Latham 2012, p. 130). Thus some kind of health insurance is necessary to guarantee basic treatment and minimum standard of equity in health care. The fairness of possible health insurance schemes is closely tied to issues of distributive justice and consequently also relates to how health care is financed (cf. Clark and Weale 2012).
Context has been shown to significantly affect which distributive justice principles people apply, i.e. people exhibit different justice attitudes in different situations (Liebig and Sauer 2016). Van Hootegem et al. (2020) show that in health, equality is the most popular justice principle in a Belgian sample, but not when it comes to unemployment benefits or pensions. People have different justice attitudes within the health care domain as well, when high resource scarcity is pinned against medium or low resource scarcity in health-health trade-offs (cf. Scott and Bornstein 2009).
To alleviate the dilemma of scarcity between health and wealth and within health people need to form some kind of bond. They need to find an equilibrium where they can cooperate, without levying health-related costs on any individual that this individual could not afford and without causing unfair costs for all other group members, while also not reducing the health of these other group members. I now provide two rationales for distinguishing SHI and PHI on grounds of fairness in order to address such a dilemma.
First, both PHI and SHI require the reciprocity and shared interest of its members that are in an interdependent state with possibility of sanctions. Also, both kinds of health insurance require a level of chance solidarity (Lehtonen and Liukko 2011). But while PHI relies on voluntary contribution, SHI is solidaristic in terms of generalised reciprocity (cf. Koos and Sachweh 2019). Reciprocity also plays a crucial role in PHI (cf. Leitner and Lessenich 2003), where PHI rather follows a market-logic of reciprocal exchange with risk-adjusted premiums. I suggest that PHI constitutes direct reciprocal exchange as ‘risk reciprocity’ and SHI is a form of generalised indirect exchange with a long-term outlook (cf. Molm et al. 2007; Ullrich 2002). Thus, PHI and SHI are distinguishable on the basis of their modes of reciprocity. Some duties are conditional on reciprocity, such as the duty to share fairly. These duties result from someone's status as a moral person or are binding and conditional on mutual exchange. Thus, even non-contribution on the part of a person, who is unable to contribute, does not imply that they are exempt from distributive justice (Lister 2011). It is important to note, that SHI does not discriminate on the basis of factors that can cause inability to contribute, while PHI discriminates through exclusion and through setting high risk premiums. Hence, SHI is de-facto luck-egalitarian, i.e. does not differentiate between bad brute luck and bad option luck (cf. Vallentyne 2002; Segall 2007; Cavallero 2011; Björk et al. 2020).
Second, I share the view that health care constitutes a public good in its fundamental properties (e.g. Karsten 1995; Abdalla et al. 2020; and more broadly cf. Kallhoff 2014; Sunstein and Ullmann-Margalit 2001). Kohn (2020) presents solidarism as a way out of the public-private dilemma, where “Reallocation can take the form of universal insurance that secures the individual against misfortune or collective benefits such as hospitals and infrastructure” (Kohn 2020, p. 1109). Further, there needs to be compensation for negative externalities produced by commodification. The solidarist position includes “… that the positive achievements are produced collectively and a critique of modes of allocation that reflect power and luck rather than justice”. (Kohn 2020, p. 1113). Therefore, SHI and the public provision of health care address redistribution, which functions as a protection against misfortune. In addition, it is argued that gains are achieved collectively and should be fairly allocated, rather than according to luck and power.
By contrast, PHI concerns the voluntary and private provision of a public good. Evidence for cooperation in such a scenario points towards inequity and individualistic-opportunistic behaviour (e.g. Chan et al. 1996; Heap et al. 2016; De Geest and Kingsley 2019; Gross et al. 2020). PHI faces two fundamental issues: the free rider problem and the assurance problem. Both can be solved via contracts and centralised punishments. “Overall, public provision tends to produce less efficient outcomes than private provision by allowing the possibility of severe underprovision of the public good. On the other hand, if a society dislikes income inequality and prefers progressive taxation, then public provision may deliver more desirable outcomes” (Slavov 2014, pp. 253-254). Thus, (economic) efficiency is positioned in a trade-off with equity, which further indicates that PHI is associated with a market-logic of direct reciprocity, i.e. tit-for-tat, and a sense of solidarity that is limited to the interpersonal tier but that does not extend to collective or contractual tiers.
Seeing health care as a (global) public (solidarity) good versus through the lens of private provision has some serious and differing ethical implications. If we accept the latter, then “There are clear indications that in a market-driven medical system with poor regulation, the poor are not getting appropriate services for what they are paying” (Das 1999, p.118). And if we trust in market mechanisms for resource allocation in health care and health insurance, then we also accept the cost-effectiveness-equity trade-off and the trust in private firms to provide healthcare more efficiently than public entities. In this case market justice is preferred over social justice in health care (cf. Budetti 2008). To sum up, SHI and PHI are distinguishable on grounds of them being different reciprocal exchange types and on grounds of the division over fairness in public good provision that the two exhibit. In short, the different reciprocal exchanges and the division over fairness in public good provision ought to generate fairness differences between those, who only hold statutory insurance, and those, who possess PHI.
H2: Finding the prioritisation of privately insured persons fair increases the effect in H1.
The auxiliary variables employed in this study are located on the micro-level. However, they are attitudes and preferences directed towards institutions, i.e. the public health care system, the government, political parties, and the Austrian population’s public health.
There is ample research on the role of trust in institutions and redistribution preferences in general welfare. Overall, higher trust is associated with higher demand for redistribution (e.g. Hetherington and Husser 2011; Yamamura 2014; Silva et al. 2016). Busemeyer (2021) finds that higher trust in the performance of the health care system and higher political trust increase support for additional health care spending in Germany. It is reasonable to expect that higher trust in relevant institutions corresponds to a stronger support of redistribution in health care as well.
H3: The higher the trust in the government and in the public health care system, the more a person favours redistribution in health care.
Some partisan theory suggests that left-wing voters tend to be people on low incomes, whereas right-wing voters are more likely high income earners (cf. Borck 2007). Additionally, left-wing parties spend more on public health care than right-wing parties when long enough in power (Herwartz and Theilen 2014). In line with this Koos and Leuffen (2020) find that Germans with party preferences for left-wing parties are slightly more financially solidary than supporters of mainstream parties and potential voters of right-wing parties are considerably less financially solidary in context of the COVID-19 pandemic. However, when it comes to medical solidarity Koos’ and Leuffen’s (2020) results suggest that party preferences become less distinct factors when compared to financial solidarity. So, it seems people exhibit both partisan differences overall and differences in solidarity in differential domains, where solidarity in health-related areas may be higher than in others. Hence, there may be notable differences between voters of different parties in their redistribution preferences in health care, as they might not share fundamental beliefs and expectations in the welfare state and the role of government in health care.
H4: People who would vote for a conservative, liberal or right-wing party disfavour redistribution in health care while left-leaning party voters are in favour of it.
Generally health care can be seen as a vital part of the welfare state (e.g. Moran 2000). Yet, the provision of high-quality health care can be located with the state, with private entities or with both as the private-public mix . Missinne et al. (2013) investigate 24 European countries and find that support for state responsibility to provide universal health care is high, setting significant self-interest and ideological disposition aside. It seems plausible that people who think the state should provide high-quality health care also support redistribution in health care.
H5: The more a person supports state-provision of health care, the more they favour redistribution in health care.
The Meltzer-Richard Theorem (Meltzer and Richard 1981) suggests that the relatively poor want more government and the relatively rich want less government. The median voter, i.e. the person(s) with median income, will get the decisive vote on the size of government. Andreoli and Olivera (2020) lend support for this in finding that receiving social net benefits results in supportive preferences for redistribution and Armingeon and Weisstanner (2021) find that political ideology and self-interest interact when predicting redistribution preferences. Therein lies a trade-off between taxation and social spending or social benefits. High taxes can guarantee generous social benefits, while low social benefits can make low tax rates feasible. I propose that from preferences about said trade-off, which concerns the role of the state and welfare more broadly, one can also derive preferences for redistribution in health care more specifically.
H6: The more people favour social redistribution, the more they are also in favour of redistribution in health care.
Last, the COVID-19 pandemic poses a risk to public health and risk perception has for instance been linked to protective health behaviour (e.g. de Bruin and Bennett 2020). As health care systems, particularly ICUs, are in danger of being overburdened (e.g. Moghadas et al. 2020), there should be more support for redistribution in health care when perception of COVID-19 induced risk to the population is high.
H7: The higher the population-level COVID-19 risk perception of a person, the more they support redistribution in health care.
The Austrian health care & insurance system
The Austrian health care system is solidaristic in the sense that people contribute on the basis of their ability (e.g. a specific percentage of people’s salaries that is taken off automatically) and receive services based on need (Ter Meulen 2017; Spahl and Prainsack 2021). Austria has a Bismarckian public health system. Its core funding mechanism is compulsory social security contributions that are directly or indirectly tied to employment and to occupational status. Insured persons can include children or other family members without separate insurance. In addition, there is a growing sector of PHI for those who want services beyond the services covered by the statutory health insurance. PHI covers ‘extras’, such as access to private doctors, a single-occupancy room during hospital stay et cetera. Austria has very high health insurance coverage (about 99%) and its population reports few unmet medical needs (Toth 2019).
In a previous analysis Austrians exhibited the highest satisfaction with their health care system out of 14 investigated Western European countries, but Austrians also had the third lowest rank in wanting extensive state involvement in health care (Wendt et al. 2010).
McAlister and Helton (2021) describe Austria as a publicly funded health care model with equality of care by the providence of universal healthcare for all citizens. Income-related inequalities in health care in Austria are on comparatively (OECD and EU) low levels (Devaux 2015; Ásgeirsdóttir and Ragnarsdóttir 2013). According to Bambra (2005) Austria has a medium level of decommodification in health care. Further, Reibling et al. (2019) put Austria in a health care cluster that includes high supply-and choice-oriented public systems, which means Austria has a publicly financed health care system that is personnel-intensive and offers relatively free choices to patients. However, there seems to be potential for ‘institutional corruption’ that undermines the principles of good health, equity and efficiency in the Austrian health care system (Sommersguter-Reichmann and Stepan 2017), as it does in Europe and the USA more broadly (Sommersguter-Reichmann et al. 2018).
Private health insurance in Austria. Thomson and Mossialos (2009, p. 16)
Examples of benefits covered
% of population covered (2006)
% of total expenditure on health (2006)
Occupations opting out of the
statutory scheme (some self employed),
eligible for statutory cover
Dental and eye care, physiotherapy, home visits, psychotherapy,
health resorts, rehabilitation, drugs, CAM
Private wards/hospitals and doctors, choice of hospital doctor, faster
access (elective care), per diem cash benefits for inpatient care
Similar to statutory cover
Data & Variables
The data analysed in this paper stem from the Austrian Corona Panel Project (ACPP), an online panel survey conducted among the Austrian resident population, which started in late March 2020 and is ongoing to date (cf. Kittel et al. 2020). The ACPP respondents have a minimum age of 14 and the age range is not restricted towards old age. Respondents were quota sampled based on the key demographics of age, gender, region, municipality size, and educational level based on official statistics, with the quota sample being structured to closely mirror the Austrian resident population. For the subsequent analysis data of ACPP wave 22 is used, which was fielded mid-April 2021. The full data paper is available in Kittel et al. (2021).
The dependent variable is an additive index of eight variables of preferences for redistribution in health care. These were developed for the ACPP and answers are on 5-point Likert scales. Three preferences directly grasp the relationship between public and private medicine. The other five preferences encompass equality of treatment, public spending increase on health care, personal willingness to pay higher contributions, higher contributions for cost-intensive patients, and handling of medical excess payments (user charges). More information on these preferences and the index is located in the Appendix (Fig. A1-A5).
Private health insurance, fairness and auxiliary variables
The main predictor variables are possession of PHI (dichotomous) and attitudes on fairness of prioritising privately insured persons, where the latter is on a 5-point Likert scale. Auxiliary variables are trust in government and in the public health care system. Further, party preferences are considered, wherein conservative, liberal and right wing parties are pooled, as well as left-wing parties, and also other parties and non-voters with those who would cast a void ballot and ‘do not know’ responses. Government responsibility to provide high-quality health care grasps the concept of state welfarism versus retrenchment. Redistribution preferences in distributive welfare are considered where high taxes and high social benefits are pinned versus low taxes and low social benefits. Perceived health risk is the personally assessed threat of COVID-19 to the Austrian population’s public health.
All predictor and auxiliary variables are standardised. Multiple imputation is applied for all auxiliary variables and consequent listwise deletion of missings yields a final sample size (N) of 1027 respondents.