The Politics of Health Care and the Psychology of Issue Differences

The article “The Deservingness Heuristic and the Politics of Health Care” (AJPS 61:1 –  January 2017) by Carsten Jensen and Michael Bang Petersen is summarized here:

Political scientists have always known it: issues differ. Position issues are issues that spur political conflict and where citizens hold opposing views on what constitute the right policies. Valence issues, in contrast, stand out because everyone agrees about their importance and the basic gist of the needed policies.

One pair of issues that differ sharply along the position-valence dimension is unemployment protection and health care. Both issues are at the core of the welfare state, the policies affect the lives of millions and both issues are concerned with risks that are heavily influenced by socio-economic status: people with low socio-economic status are much more likely to become unemployed and ill. Unemployment is a clear-cut position issue: people are divided on whether the unemployed deserves government help. Health care is, in contrast, a valence issue and people across socio-economic strata and across countries stand united in a demand for higher levels of public spending on health care. While this might seem surprising for American political scientists, given the high levels of political conflict associated with not least Obamacare, the data in Figure 1 paints a crystal-clear picture: across the Globe, everyone wants more health care. The only thing that is debated is the means to that end.


Note: Figure 1 is reproduced from Jensen & Petersen (2016). The figure combines data from the 2008 European Social Survey (ESS, Panel A) with data from the 2006 International Social Survey Programme (ISSP, Panel B) and covers 105,393 subjects from 41 countries. Dark grey bars represent percentage of a population strongly supporting public health care; light grey bars represent the percentage of a population strongly supporting unemployment protection.


The question that we wanted to answer is: Why? How do two so similar issues emerge as so different? More to the point: Why is there such unanimous support for health care spending?

The traditional approach to understanding issue differences in political science is to look at how elite discussions constraint people’s thinking about issues, what Phillip Converse termed social sources of constraint. We have instead turned toward another source of constraint: psychological ones and, in particular, the deeper processes of biological evolution that have shaped these constraints.

In a broad, historical perspective, unemployment is a novel issue which first emerged during the industrial revolution. In contrast, as is evidenced by the existence of some form of immune systems in all organisms, the need to defend against infections and injuries is evolutionarily ancient. Importantly, for humans at least, parts of the defense against the consequences of health problems are social and take the form of care from others. Archaeologists have thus found suggestive evidence of health care in the Pleistocene fossil record and anthropologists have observed both the spread and importance of health care practices in forager societies.

Evolutionary biologists and anthropologists have accordingly argued that health care is an evolved feature of human life history and that our psychology has been designed to respond to health problems with a motivation to provide care. One key reason for the evolution of health care is that evolutionarily recurrent health problems were very different from the health problems of today. Today, the major causes of health problems are lifestyle related and highly predicted by socio-economic status. According to anthropological research, the major causes of ancestral health problems were, in contrast, accidental infections and injuries – something that could and did affect everyone.

We argue that when people think about modern health care, their minds are constrained by assumptions that were ancestrally valid, that sick people are unfortunate and deserving of care. When thinking about the recent issue of unemployment, in contrast, psychological constraints are fewer and political disagreements more easily occur. As consequence, health care itself emerges as a valence issue and unemployment as a position issue.

We have tested a number of observable implications of this argument with regards to differences between opinions about health care and unemployment, respectively. Using so-called implicit association tests, we show that already at the level of preconscious, implicit processing people are unified in a view of sick individuals as victims of circumstances beyond their control. This is not the case for unemployed individuals. We have shown repeatedly that these implicit associations constrain health care attitudes even in the face of countervailing factors. When people are exposed to explicit arguments suggesting that sick individuals are themselves at fault for their plight, they still hold on to their belief of deservingness. Even if people’s self-interest should prompt them to reduce support for public health care, they continue to view sick individuals as deserving. In line with the argument that fewer psychological constraints fixate attitudes and beliefs about unemployed people, people are, in contrast, much more moved by self-interest and available information on this issue. In a final cross-cultural test, we show that this difference in the degree of psychological constraint cause attitudes towards the unemployed to be highly correlated with political ideology in three, otherwise highly different countries: United States, Japan and Denmark. Attitudes towards the sick, in contrast, are uncorrelated with political ideology. Everyone across these countries and across the political spectrum believe that sick people are deserving.

In this way, by knowing the evolutionary trajectories of different political issues and by analyzing the psychological constraints that these trajectories have selected for, we as political scientists can build testable theories of the psychologies of issue differences.

About the Authors: Carsten Jensen and Michael Bang Petersen are Professors in the Department of Political Science at Aarhus University. Their forthcoming article “The Deservingness Heuristic and the Politics of Health Care” was published in volume 61, issue 1 of the American Journal of Political Science.


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The American Journal of Political Science (AJPS) is the flagship journal of the Midwest Political Science Association and is published by Wiley.