Health in citizen‐state interactions: How physical and mental health problems shape experiences of administrative burden and reduce take‐up
Published date | 01 March 2023 |
Author | Elizabeth Bell,Julian Christensen,Pamela Herd,Donald Moynihan |
Date | 01 March 2023 |
DOI | http://doi.org/10.1111/puar.13568 |
RESEARCH ARTICLE
Health in citizen-state interactions: How physical and mental
health problems shape experiences of administrative burden
and reduce take-up
Elizabeth Bell
1
| Julian Christensen
2
| Pamela Herd
3
| Donald Moynihan
3
1
Askew School of Public Administration and
Policy, Florida State University, Tallahassee,
Florida, USA
2
VIVE –The Danish Center for Social Science
Research, Åbyhøj, Denmark
3
McCourt School of Public Policy, Georgetown
University, Washington, DC, USA
Correspondence
Julian Christensen, VIVE –The Danish Center for
Social Science, Søren Frichs Vej 36 G, 8230
Åbyhøj, Denmark.
Email: juch@vive.dk
Funding information
European Research Council, Grant/Award
Number: 802244
Abstract
Public services represent a key means by which societies seek to reduce inequal-
ities. However, some people may experience administrative procedures as more
burdensome than others, creating inequality within programs intended to be
equity-enhancing. Prior work has found human capital (e.g., education and condi-
tions like scarcity) to affect burden and take-up. We build on this by examining the
role of health in the form of attention disorders, pain, anxiety, and depression in
the context of tax reporting in Denmark and college financial aid in Oklahoma,
USA. Across cases, attention disorders and pain are associated with more burden-
some experiences and in the financial aid case, they are associated with reduced
take-up as well. Individuals suffering from multiple health problems have the most
negative experiences and lowest take-up. The results suggest that extra support
may be needed for people suffering from health problems in order to reduce ineq-
uities in experiences and outcomes.
Evidence for Practice
•Physical and mental health—including attention disorders and pain—matters to
people’s experience of the state, and their ability to access government benefits.
•Administrative arrangements that are nominally equal in their design and imple-
mentation can result in unequal outcomes because of health differences.
•Compared to people without health issues, those struggling with attention dis-
orders, pain, and anxiety report more burdensome experiences with specific
government programs.
•The effects of ill-health are cumulative: those with multiple health problems
have the most burdensome experiences and lower levels of benefit take-up.
•Reducing administrative burdens or making extra help available would offer
more equal access to public services.
Citizen interactions with the state raise fundamental
questions for public administration, including how such
encounters become venues for inequality.
1
One source
of unequal experiences and outcomes is state actions in
the form of policy designs and implementation prac-
tices. Some, such as groups relying on means-tested
programs, tend to face more onerous experiences than
others, such as middle and upper-middle class
individuals, or those with access to universal, less
administratively burdensome social insurance programs
(Herd & Moynihan, 2018). These differences in policy
designs matter for people’s well-being (Baekgaard et al.
2021) and shape future encounters with government
(Soss, 1999). Marginalized groups are especially vulnera-
ble to state-imposed burdens, as documented, for
example, in research on the experiences of immigrants
Received: 15 January 2022 Revised: 19 October 2022 Accepted: 21 October 2022
DOI: 10.1111/puar.13568
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribu tion and reproduction in any medium, provided the
original work is properly cited.
© 2022 The Authors. Public Administration Review published by Wiley Periodicals LLC on behalf of American Society for Public Administration.
Public Admin Rev. 2023;83:385–400. wileyonlinelibrary.com/journal/puar 385
(Chudnovsky and Peeters 2021; Heinrich, 2018), indige-
nous people (Carey, Malbon, & Blackwell, 2021), low-
income students applying for college financial aid
(Dynarski & Scott-Clayton, 2006), individuals with non-
conforming gender identity (Nisar, 2018), and women
seeking an abortion (Herd & Moynihan, 2018). In addition
to burdensome policy designs, such marginalized groups
may more often face street-level bureaucrats who impose
burdens on them (Olsen, Kyhse-Andersen, & Moynihan,
2020) and who lack the administrative capacity to cut
through red tape and reduce burdens, even if they want
to (Bell & Smith, 2021).
Another source of inequality is individual-level differ-
ences in human capital affecting citizens’ability to man-
age state-encounters (Christensen, Aarøe, Baekgaard,
Herd, & Moynihan, 2020). People vary in their ability to
cope with administrative burden, and some are better
able to identify and access benefits they are eligible for,
even within programs where all target group members
are subject to the same administrative rules and proce-
dures (Chudnovsky & Peeters, 2020; Döring, 2021;
Masood & Nisar, 2021). In this paper, we focus on a spe-
cific kind of individual-level factor that might shape citi-
zens’interactions with the state, one which has received
minimal attention in public administration research
despite playing a huge role in people’s lives: physical and
mental health. Health problems increase people’s need
for assistance. At the same time, health problems may
exacerbate burdensome experiences of the state and
make it more difficult to access government assistance.
Throughout the paper, we focus on four specific health
problems: physical pain, anxiety, depression, and attention
disorders in the form of Attention Deficit/Hyperactivity Dis-
order (ADHD) and Attention Deficit Disorder (ADD). These
health conditions are relatively common forms of poor
health. Just two forms of pain disorders (headache disorders
and lower back pain) and depression have been the leading
causes of disability across the globe for the last three
decades. Across the globe, an estimated 264 million people
experience depression, while another 284 million experience
anxiety disorders, 366 million experience persistent adult
ADHD, and 73 million experience ADD (James et al., 2018;
Song et al., 2021). Moreover, pain, anxiety, depression, and
attention disorders are all known to be associated with
reduced cognitive resources, including but not limited to
executive functions like working memory, attention, and
planning abilities (Bell et al., 2018;Dotsonetal.,2020;Lin-
dert, Paul, Lachman, Ritz, & Seeman, 2021;Mazza,Frot,&
Rey, 2018; McDermott & Ebmeier, 2009; Moriarty, McGuire, &
Finn, 2011; Phelps, Navratilova, & Porreca, 2021;Shields,
Moons, Tewell, & Yonelinas, 2016;Suchy,2009;Whitlock
et al., 2017).
Because of their impact on people’s cognitive
resources (as well as other mechanisms such as physical
mobility), we expect that pain, anxiety, depression, and
attention disorders will be associated with a lower ability
to cope with administrative procedures, leading, in turn,
to more administratively burdensome experiences as well
as reduced access to benefits. We investigate the role of
these four health conditions in the context of two cases
that represent very different kinds of state-encounters
(tax reporting and a means-tested financial benefit pro-
gram targeted at low-income students). Our cases are set
in different countries (USA and Denmark) and vary both
in terms of the burdens they impose and the benefits
they promise, thereby increasing our ability to assess the
external validity of our results.
Our results show that health does shape peoples’
experiences of government, but in ways that are more
complex than expected. Attention disorders and pain are
consistently associated with more intense experiences of
administrative burden as well as lower take-up of bene-
fits. However, the evidence regarding depression and
anxiety is more mixed depending on model specification.
Importantly, we find that the effects of health problems
are cumulative: the most burdensome experiences and
the lowest levels of benefit take-up are found among
individuals who suffer from multiple health problems at
once. The implication is that examining the effect of a sin-
gle heath issue in isolation offers an incomplete picture.
Instead, understanding the impact of health on the pub-
lics’ability to negotiate state processes requires attention
to comorbidities.
The findings illustrate how attention to administrative
burdens in citizen-state interactions creates an area of
overlapping interest for researchers and practitioners in
the fields of public health and public administration
(Christensen et al., 2020; Herd & Moynihan, 2020). For
example, previous work has documented how burdens
can limit people’s access to health insurance (Carey
et al., 2021; Fox, Stazyk, & Feng, 2020), health care
(Kyle, 2021), and disability supports (Deshpande &
Li, 2019), and how burdens can trigger physiological as
well as mental health responses among target group
members (Baekgaard et al., 2021; Hattke, Hensel, &
Kalucza, 2020). We contribute to this work by providing
evidence that individual differences in both physical and
mental health matter to people’s experiences of burden,
as well as to take-up of services and benefits. In turn, we
advance current explanations of why administrative bur-
dens are unequally distributed by highlighting and empir-
ically demonstrating the role of physical and mental
health in citizen-state interactions. Additionally, while
public health scholars have demonstrated the challenges
faced by people suffering from physical and mental
health issues in completing everyday tasks (Whalen
et al., 2006), we take this research a step further by exam-
ining the consequences of physical and mental health for
citizens’interactions with the state, including their ability
to access financial benefits. Our findings have important
practical implications for public managers in the pursuit
of equity and reducing administrative burden, which is a
growing priority issue (U.S. OMB 2021). Ultimately, policies
seeking to advance equity will be hampered if they fail
386 HEALTH IN CITIZEN-STATE INTERACTIONS
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