Causal Attributions and the Politics of Health Inequality: Public Support for Policies to Reduce Health Inequality in Four OECD Countries

Despite steady increases in life expectancy over recent decades, health inequalities remain remarkably persistent. While the socioeconomic gradient in health is well-documented, we know less about the politics of health inequality: specifically, whether the lack of effective policy intervention stems from a deficit in public demand or from other structural barriers. We argue that attitudes toward policies aimed at reducing health inequality depend on “causal attributions”, i.e. the extent to which citizens perceive health outcomes as the result of individual agency (dispositional) or structural causes (situational). By focusing on whether people attribute health inequality to factors within or outside an individual’s control, we build on a growing literature on the psychological foundations for understanding the variation in public support for the welfare state. We contribute to this field by addressing the lack of empirical research on attitudes toward different types of policies designed to reduce health inequality. To our knowledge, this is the first comparative study to examine the impact of causal attributions on health inequality attitudes across different health systems and welfare regimes. Using data from an original, nationally representative survey in four countries representing different health systems and welfare regimes (Germany, Switzerland, the United Kingdom, and Canada) fielded in 2024 (n=2,000 per country), we examine the role of dispositional attributions (internal causes under individuals’ control) and situational attributions (external causes outside individuals’ control) in shaping responses to health inequality. We analyze how these attributional patterns relate to support for three policies aimed at reducing health inequality: 1) government measures to reduce differences in life expectancy, 2) government measures to reduce income differences (addressing the social determinants of health), and 3) equal provision of health care by the government. We find, across all four countries, that individuals who emphasize situational attributions show greater support for all three policies that promote more equal health outcomes, whereas those who emphasize dispositional attributions, such as the belief that individuals are in control of their own health, are less supportive. There is some cross-national variation: in Switzerland and Canada, dispositional attributions are strongly associated with decreased support for equitable health care provision, but attributing health differences to factors within individuals’ control does not reduce support for policies targeting income or life expectancy inequalities. However, overall, the findings are remarkably similar across different health and welfare state contexts. Crucially, the effects also persist independently of political ideology and party affiliation, reinforcing the importance of psychological mechanisms in understanding the political acceptance of health inequality. Overall, our findings deepen the understanding of the psychological foundations of public attitudes toward health inequality and clarify the conditions under which people are more likely to support efforts to reduce it. These findings suggest that public support for welfare-state interventions in the health domain depends on how citizens interpret the causes of unequal health outcomes and underscore the value of integrating psychological attribution theories into political economy and welfare-state research to better explain variation in public support for inequality-reducing policies.