The rules of the game: Healthcare systems and cross-national attitudes about healthcare provision

Abstract

In recent years, healthcare typologies are increasingly scrutinized. Prevailing healthcare system categorizations draw on comparative–institutional welfare state arrangements that constitute the “rules of the game” for healthcare provision. Challenging these perspectives, health policy perspectives suggest that ongoing policy changes shifted the “rules of the game” in ways that are not adequately captured by traditional comparative–institutional typologies. As a result, new questions arise about which categorization is most salient for understanding public attitudes about healthcare. We adjudicate between these two perspectives by examining the association between healthcare system typology and two different and important types of attitudes about healthcare provision: government responsibility and spending. Using hierarchical linear models, we find that traditional welfare state conceptions of healthcare systems are more closely associated with public opinions about healthcare provision. In general, respondents in countries with healthcare systems that have greater state involvement and rely more on public financing, which are traditional, institutional–comparative factors, report greater support for government responsibility in and spending on healthcare. We highlight how rallying broad public support for changes to healthcare systems in the wake of the COVID-19 pandemic will require that researchers and policy makers understand what the public has come to expect about healthcare, as well as the institutional arrangements around healthcare that set the “rules of the game.”