The politics of increasing healthcare costs: A conjoint experiment on deservingness of co-payment exemptions

Over the last decades, life expectancy has steadily increased, contributing to the aging of populations worldwide. This demographic shift poses significant challenges for welfare states, particularly in managing rising healthcare costs. Many countries struggle with financing their comprehensive benefits packages, prompting policy responses that include increasing co-payments for healthcare services. These cost-sharing measures regulate access to healthcare by shifting part of the financial burden onto patients. However, to prevent exacerbating health inequalities, governments may exempt certain groups from these increased charges. Against this backdrop, it remains unclear to what extent citizens support such healthcare reforms and which groups are seen as deserving of exemptions. This study addresses this gap by examining public perceptions of deservingness for healthcare co-payment exemptions. Drawing on an original conjoint experiment conducted in 2024 (embedded in the PRIOHEALTH survey) across four countries - Germany, Switzerland, Denmark and Canada - the study investigates what factors shape these perceptions. Specifically, the conjoint experiment focuses on the role of age, migration background, income, health status, diet and exposure to environmental risks. Additionally, the study tests for heterogeneous treatment effects to assess whether individual differences in support for exemptions to increasing co-payments exist by social-structural variables (age, gender, education, income) as well as political ideology, health beliefs, and subjective health. The findings reveal clear patterns: individuals are perceived as more deserving of exemptions to rising co-payments when they are older, do not have a migration background, possess low income, suffer from chronic illness, maintain a healthy diet, and live in a neighborhood with poor air quality. While the magnitude of these effects varies by political orientation, the overall patterns are remarkably consistent across the four countries in the sample. This research makes a significant contribution to the existing literature by identifying the groups seen as most deserving of preferential treatment in the face of rising healthcare costs. It also offers insights into broader debates about the legitimacy and fairness of healthcare funding, particularly in times of increasing financial strain in advanced welfare states.