Many consider inequality in health unfair if it is caused by inequality within the healthcare system but less unfair when caused by individuals’ health behaviour. However, healthcare systems are challenged when it comes to ensuring equal care for equal need.
In Roemer’s equality of opportunity theory, people have equal opportunity for obtaining something if obtaining it reflects their effort instead of their circumstances. Very little is known about how responsibility exerted by patients prior to illness affects the healthcare they are provided by the healthcare system.
We aimed to apply Roemer’s theory to an acute care setting where healthcare is most directly in the hands of the healthcare system in order to study the role of patient-exerted responsibility for their opportunities in the healthcare system. We operationalised the responsibility patients exert as Body Mass Index (BMI), smoking and alcohol habits, and their circumstances as demographics, socioeconomics, prognostic factors and year of discharge. Opportunity in healthcare was defined as patients’ attainment of clinical guideline-recommended acute hospital care.
In Roemer’s theory, we detected inequality of opportunity as restricted attainment of healthcare was mainly associated with patients’ circumstances, such as lower education, old age or living alone. We also identified a strong association with BMI; being underweight negatively affected patients’ opportunities as it led to suboptimal healthcare, while the opposite was found for being overweight and, in particular, obese.
Hence, patient-exerted responsibility affected patients’ opportunities in healthcare, though perhaps in an unexpected way. This improved understanding of inequality may help to focus future research and, in the long term, support clinical and political efforts to achieve equal care for equal needs.