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The European Journal of Health Economics

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01-05-2016 | Original Paper

Attitudes of Germans towards distributive issues in the German health system

Authors: Marlies Ahlert, Christian Pfarr

Published in: The European Journal of Health Economics | Issue 4/2016

Abstract

Social health care systems are inevitably confronted with the scarcity of resources and the resulting distributional challenges. Since prioritization implies distributional effects, decisions regarding respective rules should take citizens’ preferences into account. In this study we concentrate on two distributive issues in the German health system: firstly, we analyze the acceptance of prioritizing decisions concerning the treatment of certain patient groups, in this case patients who all need a heart operation. We focus on the patient criteria smoking behavior, age and whether the patient has or does not have young children. Secondly, we investigate Germans’ opinions towards income-dependent health services. The results reveal the strong effects of individuals’ attitudes regarding general aspects of the health system on priorities, e.g. that individuals with an unhealthy lifestyle should not be prioritized. In addition, experience of limited access to health services is found to have a strong influence on citizens’ attitudes, too. Finally, decisions on different prioritization criteria are found to be not independent.

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The translation of the respective German questions into English can be found in Appendix 2.

The translation of the German question into English can be found in Appendix 2.

The issue is discussed by the German public under the term “two-tier medicine”. For a reflection on arguments related to this issue, cf. Breyer and Kliemt [11].

We do not take further aspects of the respondent’s situation into account that may influence her egoistic view, like e.g. experiences with illnesses or the impact of some reference point. We focus solely on a similarity to one of the characteristics of the patients described in the questionnaire.

The exact wording in the questionnaire of the ISSP survey is: “Is it fair or unfair that people with higher incomes can afford better health care than people with lower incomes? (1) very fair, (2) somewhat fair, (3) neither fair nor unfair, (4) somewhat unfair and (5) very unfair”, with “can’t choose” also admissible (about 57 observations). However, the latter are disregarded from the regression.

Although variables within this group seem to be highly correlated with each other, the correlation matrix as well as the variance inflation factor (VIF) does not indicate any problems of multicollinearity in the estimations. The correlation matrix and the VIF statistics are available upon request. We have also tested whether the inclusion or deletion of one or more variables affect our results. However, the results prove robust.

We have also tested whether these variables affect prioritizing decisions but found no significant effects.

The correlation between the variables no access health care and reason: unhealthy behavior is 0.08. Though both variables seem to measure nearly the same, they are distinctly different. Whereas no access health care covers attitudes about who should receive publicly funded health services, the variable reason: unhealthy behavior reflects individuals’ conviction of the causes of severe health problems.

Although the number of households with three or more children is very low, results of the empirical analysis do not change if alternative specifications are used. Results are available upon request.

This reduces the sample by 36 observations.

We do not expect a potential endogeneity of either of the dependent variables. Thus, we refrain from estimating a recursive multivariate probit model [29] as this would require some theoretical advice on the dependency of the prioritizing decision questions.

We also tested whether the parallel lines assumption of the standard ordered probit model holds or whether to apply a generalized ordered probit model. However, results of a likelihood-ratio test and a Brant test were not able to reject the hypothesis of equal coefficients. Thus, we proceed with the standard ordered probit model.

Results of the restricted model as well as the full estimation results of the full specified model can be found in the Appendix.

We have also run separate binary probit models of the three dependent variables. Results of these models can be found in the Appendix. Comparing the results of the multivariate probit models to the estimation of single probit models shows some differences regarding the level of significance of the coefficients while the magnitude of the coefficients are almost unchanging. This figure supports the use of multivariate probit models to estimate the underlying prioritizing decisions.

We have also tested whether a specification with the original 5-item Likert scale (without combining categories one and two) changes the findings. However, the results prove very robust whether we use a 4-item or 5-item scale of the dependent variable inequality reduction. Results are available upon request.

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Title: Attitudes of Germans towards distributive issues in the German health system
Authors: Marlies Ahlert
Christian Pfarr
Publication date: 01-05-2016
Publisher: Springer Berlin Heidelberg
Published in: The European Journal of Health Economics / Issue 4/2016
Print ISSN: 1618-7598
Electronic ISSN: 1618-7601
DOI: https://doi.org/10.1007/s10198-015-0693-x

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Attitudes of Germans towards distributive issues in the German health system

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