Health Representation Bias Revisited: Views, Issue Salience and the Structure of Inequalities

Health is increasingly in the focus of politics due to the recent pandemic and the current demographic trends. This brings attention to the question how people with poorer health status are represented. Past studies established a negative relationship between poor health and the participation in elections (Mattila et al., 2013, Pacheco and Fletcher, 2015). Health needs are becoming more critical in the contemporary societies, but the affected individuals' voices could be marginalized by the participatory institutions. However, do individuals with poor health actually hold different views or support different parties than the healthier? Studies touched upon this topic (Robert and Booske 2011, Pabayo et al., 2015, Reher 2021), however the evidence is still fragmented: they focused on specific views or attitudes, on specific health conditions, and in limited scopes. I aim to strengthen this evidence in two ways. First, I offer a comprehensive treatment of the views of the health groups from general values to attitudes, and policy preferences. I use the newest wave of the World Value Survey (Wave 6, 2018) to access a wide range of relevant variables in a cross-country setting which allow us to map the health attitudes extensively. Second, I also address current problems with the identification of how salient these distinct values and attitudes are in the stated preferences of the poorer health group. I approach this by showing the relationship between poorer health individuals' values and preferences, and their preferred parties, where I categorize parties based on economic and cultural left-right, and their favored amount of social spending using the Global Party Survey data (GPS, 2018). Party preference is a good indicator of issue salience and ordered, culminated preferences. I propose that the views of the poorer health group are more egalitarian and they prefer more redistribution, and these issues are salient for their political behavior (party choice) as well. The substantive consequences of participation inequalities could strengthen the argument for the existence of a health representation bias. As a second contribution, I specify the structure of health representation inequalities. I focus on the interactions of income, education and health status, and argue that the health inequalities are inter-sectional. There is not only a general representation inequality between health groups, but these are further amplified by other socio-economic factors within the health groups. First, I test whether more affluent people in the poor health groups are closer to the healthy group in their views. Second, I also test whether the more affluent poorer health individuals are more likely to participate than their less well-off peers. I build multi-level models, and will rely again on the WVS data. I offer a complex analysis of representation inequalities combining views and participation, in the intersection of health and other socio-economic factors. This provides a comprehensive and nuanced treatment of the inequalities both regarding the substantive effects, and the underlying structure of these effects. Findings could show how and what inequalities are (re-)produced with implications for electoral institutions and policy responsiveness.