Impact of Political Party and Ideology on Perceptions of Health Disparities

1. Impact of Political Party and Ideology on Perceptions of Health Disparities Harry Perlstadt, PhD, MPH Michigan State University East Lansing, MI 48824-1111 American Public Health Association Session 4111.0 Ethnic & Racial Disparities Denver, Colorado November 9, 2010

2. Presenter Disclosure Harry Perlstadt (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. Premise • While researchers, government agencies and public health workers know about the social determinants of health and their relationship to health disparities, the perceptions of the general population have not been fully explored. • Studies have found such perceptions vary by race, ethnicity and socioeconomic status. • But political ideology and party affiliation may also play a role.

4. What is a Health Disparity? • Little consensus on what constitutes a health disparity. • Objective: Any differences among populations that are statistically significant and differ from the reference group by at least 10 percent AHRQ, 2006 • Subjective: Differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust. WHO in Whitehead, 1991

5. Politics and Health Disparities • Bush Administration belittled the conclusions of 2004 National Healthcare Disparities Report linking race and SES to health inequalities. Kaiser, 2004 • Given the current stormy debates over race, genetics, and health disparities, it is critical to be conscious of continual conservative efforts to promote a political climate that favors individualistic explanations of population health and discounts concerns about social determinants of health disparities.Krieger (2005)

6. Political Ideology and Health • Political parties with egalitarian ideologies in wealthy OECD countries tend to implement redistributive policies aimed at reducing social and health inequalities. Navarro et al (2006) • Political conservatives in 29 European countries are less likely to report poor health, controlling for age, gender, and socio-economic status. Subramanian, Huijts, and Perkins (2009)

7. Research and Political Will • Social problems do not become policy issues even if research has documented that they are problems  Gamble and Stone (2006) • Until now most research has focused on the causes and outcomes of health disparities and improving treatments. • Very little research has looked at framing and messaging disparities for a broad audience, specifically the nature of public opinion on health disparities. Prevention Institute (2007)

8. Political Will and Health Inequalities • The public may choose not to address health inequalities if they perceive it to endanger the quality or accessibility of their own health care services or if the means are unacceptable. • If health and health care are viewed as a political issue rather than as a moral philosophical right then ‘doing the right thing’ for health may not be the same as ‘doing the right thing’ politically.  Lewis, Saulnier, and Renaud (2000)

9. Other Findings • A 2007 Wisconsin survey found support for government intervention to decrease health disparities was greater among Democrats and those not believing in limited government. Rigby and Soss et al, 2009 • A 2009 poll found liberals and Democrats in Massachusetts claimed the state’s health care reform was a success while conservatives and Republicans considered it a failure. Rasmussen Reports, 2009

10. Public Perceptions 1999 Kaiser Survey • Majority of white and African Americans were uninformed about health care disparities • Those with less than a college education were more likely to be unaware of documented racial and ethnic differences • Most minority Americans perceive that they got lower quality care than whites, but most whites assumed otherwise.  Lillie-Blanton, Brodie, Rowland et al (2000)

11. Hypothesis • Political party and ideology affect perceptions of discrimination in health care delivery and differences in health quality for minority groups.

12. Methods  Sampling • A random digit dialed telephone survey of 1,036 Michigan residents. Reached only persons who lived in households that had landline telephones. • The State of the State Survey [SOSS] is administered quarterly by the Institute for Public Policy and Social Research of Michigan State University. • Sample was stratified into six regions of contiguous counties plus the City of Detroit • Interview Dates: 5/26/09 - 6/30/09 • Error: ±3.0% Completion Rate: 46%

13. Methods  Questions (Dependent) • Respondents were asked four questions from Race, Ethnicity and Medical Care: A Survey of Public Perceptions and Experiences (Kaiser Foundation, 1999) • How often do you think the health care system treats people unfairly based on • Whether or not they have health insurance • How well they speak English • How often does a person's race or ethnic background affect whether they can get routine medical care when they need it. • Quality of care minorities receive compared to whites.

14. Methods  Independent Variables VariableCategories • Ideology (7) Very Conservative to Very Liberal • Political Party (7) Strong GOP to Strong Democrat • Race (3) White, African American, Other • Sex (2) Male Female • Income (11) LT $10,000 to GT $150,000 • Age (79) 18 to 96 • Community (4) Rural, Small Town, Suburban, Urban • Education (19) 0 years 18+ years

15. Methods  Correlations with Dep Vars • Ideology high correlation with insurance (+), quality (-) • Political party with insurance, language and ethnicity • Income with quality (-)

16. Methods  Inter-correlations • High Moderate Low • Highest inter-correlations for party and ideology; education and income. • Moderate inter-correlations for race and party, income, community.

17. Methods  Stepwise Regression—1 • Each case was weighted so that the proportion of cases in the total sample matched the proportion of adults in the state’s 2000 census from the sampling regions on key variables (sex, race, age and multiple phone lines). • A regression equation was created for each of the four dependent variables: unfair treatment health insurance, unfair treatment language, unable to get care when needed, and quality of care for minorities. • Eight variables were entered in a step-wise regression: political ideology, political party, sex, race, age, community type, income, and education achieved.

18. Methods  Stepwise Regression—2 • Analysis did not rest on an established theory or extensive research on perceptions of health disparities. • A pragmatic exploratory approach in which a key set of variables with some degree of multicollinearity could be tested on each dependent variable. • The final results indicate changes in the relative contributions of variables given the order in which they were originally entered and their final rank when the model was terminated by the program. • Can be tested by subsequent surveys.

19. Findings  Unfair Treatment Insurance • Respondents with less education, women, political liberals, whites and high incomes were more likely to think that the health care system often treats people unfairly based on having health insurance. • Ideology was entered first, but it slipped to fourth after education, race, and sex were entered. • Not entered: political party, community type, age

20. Findings  Unfair Treatment Language • Democrats, men, living in an urban area, political conservatives, older adults and minorities were more likely to state that the health care system often treats people unfairly based on how well they speak English. • Political party entered fourth, but had highest beta weight. • Not entered: education, income

21. Findings  Not Get Care When Needed • Liberals, men, minorities, low income, in an urban area and older adults were more likely to state that a person's race or ethnic background often affects if they can get routine medical care when they need it. • Ideology entered fourth but had highest beta weight. • Not entered: political party, education

22. Findings  Quality of Care • Low income, in urban area, conservatives, republicans, and younger people were more likely to state that when going to a doctor or health clinic for health care services, minority groups receive high quality care. • Both ideology and party appear in the equation, but were lower than income and community. • Not entered: race, education, sex

23. Ideology and Party (r = . 447) • Political ideology entered all four regressions while political party affiliation only entered two: use of English and perceived quality of care. • Party affiliation entered before ideology. Party ranked higher than ideology for use of English but would finally be ranked lower than ideology on perceived quality. • Although entered fourth on race/ ethnicity affects whether people get routine medical care when needed, ideology became the highest ranked and party affiliation never was entered.

24. Ideology and Party—2 • As expected political liberals perceived unfairness often resulting from lack of health insurance and inability of racial/ ethnic minorities to get routine care when needed. • Ideology and party affiliation were congruent for perceived quality of care: democrats and liberals claimed that minorities received lower quality of care than white. • But democrats and conservatives thought that unfairness resulted from problems speaking English.

25. Community and Race (r = .275) • Community entered three of four regressions. It entered first on unfairness resulting from speaking English and getting routine medical care when needed. It entered second for quality of care. • Race entered three regressions: unfairness insurance, language and getting routine care. • When both were entered, community was entered before race. • Results were congruent—both said unfair treatment if problem speaking English and minorities often do not get care when needed.

26. Education and Income (r = .480) • Income entered two regressions: unfairness due to health insurance and minorities receiving lower quality care. Education appeared in only unfairness due to health insurance. • Education entered ahead of income for unfairness due to health insurance. • Result non congruent, with higher educated perceiving unfairness due to health insurance seldom occurring while higher income respondents saw it as often occurring.

27. Conclusions • Political ideology and community of residence influence how people perceive health disparities. • Changing the health care system to reduce health disparities involves political will. • Future research should include political ideology and party, community of residence and public perceptions of health disparities in relation to willingness to improve the health care delivery system and treatment of minority groups.

28. References • AHRQ Agency for Healthcare Research and Quality, (2006) National Healthcare Disparities Report (Rockville, Md.). • Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M (2000) Race, Ethnicity, and the Health Care System: Public Perceptions and Experiences Medical Care Research and Review, 57 Supplement 1, 218-235 • Gamble, V. N., Stone, D. (2006). U.S. Policy on Health Inequities: The Interplay of Politics and Research. Journal of Health Politics, Policy andLaw 31: 93-126 • Kaiser Foundation (1999) Race, Ethnicity & Medical Care: A Survey of Public Perceptions and Experiences http://www.kff.org/minorityhealth/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13294 • Kaiser, J (2004) Democrats Blast a Sunny-Side Look at U.S. Health Disparities. Science 303: 451 • Krieger Nancy. (2005) Stormy weather: race, gene expression, and the science of health disparities. Am J Public Health 95:2155-2160.

29. References • Lewis, S, Saulnier, Ml and Renaud, M (2000) Reconfiguring Health Policy Simple Truths, Complex Solutions pp509-524 in Handbook of Social Sudies in Health and Medicine , Albrecht, GL. Fitzpatrick, R, Scrimshaw, SC. (eds) Thousand Oaks, CA Sage Publications. • Navarro, V, Muntaner, C, Borrell, C, Benach, J, Quiroga, Á Rodríguez-Sanz, M , Vergés, N and Pasarín, MI (2006) Politics and Health Outcomes. The Lancet, 368:1033-1037 • Prevention Institute (2007) Laying the Groundwork for a Movement to Reduce Health Disparities. REPORT 07-01 http://www.preventioninstitute.org/documents/DRA_LayingtheGroundWork_PIPrint_061207.pdf , April 2007. • Rasmussen Reports (2009) Massachusetts: 26% Consider State’s Health Care Reform a Success June 29, 2009 http://www.rasmussenreports.com/public_content/politics/general_state_surveys/massachusetts/massachusetts_26_consider_state_s_health_care_reform_a_success • .

30. References • Rigby E, Soss, J, Booske BC, Rohan AM, Robert, SA (2009) Public Responses to Health Disparities: How Group Cues Influence Support for Government Intervention. Social Science Quarterly 90: 1321-1340. • Subramanian SV, Huijts, T and Perkins, JM (2009) Association Between Political Ideology and Health in Europe. The European Journal of Public Health 19:455-457 • Whitehead, Margaret (1991) "The Concepts and Principles of Equity and Health," Health Promotion International 6: 217–228.