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