Psychology
2011. Vol.2, No.9, 948-952
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.29143
Belief Structures, Common Policy Space and Health Care
Reform: A Q Methodology Study
Charles Wilf
School of Business, Duquesne University, Pittsburgh, USA.
Received
Debate on the merits of health care reform continues even after passage of the Affordable Care Act of 2010. Poll
results confirm a split along political party and associated ideological lines with democrats more supportive and
republicans generally opposed to the law. As parts of the law are now subject to increasing scrutiny, it may be
instructive to question whether a party-centered or surrogate liberal/conservative dichotomy is the best repre-
sentation of positions in the health care debate. Q Methodology reveals a more complex set of belief structures,
suggesting that a simple dichotomy is misleading in terms of the values that underlie the role of health care in
society. Five distinct belief structures were found, each with different concerns as to the purpose and potential
benefits of various health care initiatives. In addition, Q Methodology allows for the formation of a common
policy space within which all belief structures are independently in agreement in four specific areas. It is argued
that this empirically derived consensus can serve as a basis for effective political engagement and policy imple-
mentation.
Keywords: Belief Structures, Common Policy Space, Q Factor Analysis, Obamacare, Subjectivity
Introduction
Designed to increase health care coverage for much of the
United States population, improve accountability of insurance
providers and decrease costs, the Affordable Care Act became
law in March, 2010. Some provisions of the law were imple-
mented immediately, and provisions to be implemented through-
out the next decade are intended to save more than $500 billion
in Medicare beneficiary savings alone (Medicare Beneficiary
Savings and the Affordable Care A ct, 2011)1.
Yet the debate over the law’s anticipated effectiveness con-
tinues, and parts of the law, often referred to as Obamacare,
have been challenged by states and are subject to review and
possible invalidation. The political landscape that drives these
challenges is usually framed as a conflict between liberal and
conservative points of view for which we usually substitute the
democratic and republican political parties respectively. Recent
poll results show the democrats in principle remain in favor the
law which expands health care coverage, while the republicans
continue to believe that the law will neither improve health care
delivery nor reduce costs (Kaiser Health Tracking Poll, 2011).
The seemingly intractable conflict between opposing ideolo-
gies as reflected in the polls presupposes a categorization of
beliefs that may not reflect more complex differences in the
political continuum. Rather than assume that health care beliefs
are solely defined and limited to the positions espoused by the
major political parties, a systematic investigation of subjective
health care priorities may reveal more meaningful points of
view. The ability to identify alternative conceptualizations of
the health care debate may in turn lead to more appropriate
service delivery and cost solutions.
This paper argues that a liberal/conservative dichotomy is
overly simplistic and masks a more complex system of belief
structures. Through a subjectivity-based analysis of health care
opinions that uses Q Methodology, a more incisive array of
belief structures can not only pinpoint important differences
between these structures, but also suggest a common policy
space within which useful and politically feasible health care
solutions might occur.
Q Methodology
Q Methodology uses a specific experimental design to create
rank orderings of opinion statements, whereupon factor analysis
is performed to ascertain belief structures (Stephenson, 1953;
Brown, 1986, 1980; McKeown & Thomas, 1988). The theory
and technique of Q Methodology may be considered to fall
within the more general framework of social cognition (Fiske &
Taylor, 1984). In social cognition and particularly in Q Meth-
odology, a belief structure i s a subjective point of view that is 1)
communicable, 2) always advanced from a position of self-
reference, and 3) amenable to objective analysis since they do
have structure and form. Moreover, individuals have a struc-
tured set of beliefs that remain stable over time (Cook, Scioli,
& Brown, 1975).
Policy analysis consists of the identification of narratives
which describe policy dilemmas (Hampton, 2009; Dryzek,
1990). Durning (1999) and Durning & Osuna (1994) hold that
Q Methodology adds specific value by going beyond a strictly
positivist orientation so that analysts can derive deeper under-
standings. Among these is the creation of a policy space to
uncover areas of agreement in the policy debate (Hurd &
Brown, 2004). Wolf (2004), in addition to identifying unique
belief structures as a guide to pinpointing policy issues, like-
wise emphasizes similarities among belief structures as a pre-
ferred way to create a more comprehensive understanding of
potential common policy options.
1Medicare is the United States government provided health insurance pro-
gram which covers 1) persons over age 65; 2) persons under age 65 with
certain disabilities; and 3) individuals of any age with specific transplant
needs (Med icare Ben efit s, 2011). As the US p opulat ion ages and ev en unde
r
the new law, Medicare will become increasingly important in the provision
of health care services.

C. WILF 949
In the current Q Methodology study, a set of 36 health care
opinion statements, selected from newspaper articles and
magazine articles and letters to the editor, was evaluated by 40
subjects2 according to a specific criterion of instruction. Ac-
cording to Nunnally (1978), comparative responses only make
sense if the stimuli are from some common domain. Since pol-
icy analysts view reasoned debate as the legitimizing basis of
the democratic process (Albaek, 1995), published statements in
widely available sources are deemed to be representative of this
domain. The sample of statements was selected over a period of
several weeks from online and print versions of national and
local publications.3
The selection of sample statements is based on two theoreti-
cal criteria. The first is theoretical completeness. The model
requires that a comprehensive and representative selection of a
particular statement population be included such that the range
of possibilities is accounted for (McKeown & Thomas 1988).
The study uses three statement types which are given the labels:
“free market”-oriented statements, “socialist” or more collec-
tivist-oriented statements; and more “complex” statements that
relate health care issues to larger societal concerns. The free
market statements as they appear in the sources are generally
less favorable to a proactive health care stance, while the so-
cialist statement subset is more favorably inclined to health care
reform. The complex statement subset was included to ac-
knowledge that the public debate about health care is not al-
ways independent of other short and long term social, economic
and political concerns.
The second theoretical criterion in experiments of this type is
the degree of definiteness of the sample statements. Thompson
(1966 and discussed in Brown, 1980, and Coke & Brown, 1976)
studied the concept of definiteness in public opinion research.
He postulated a hierarchy of definiteness, consisting of three
levels-bias, wish and policy—that indicate the intensity of feel-
ing regarding opinion. A bias is a particular interpretation of
facts. A wish is a desire for a specified end or course of action.
A policy is a belief as to the best means for achieving valued
outcomes. In terms of intensity, a wish, or desired end state,
implies a bias, or a given state of affairs. Yet the reverse is not
true. Likewise, a policy implies a wish, but it represents a more
thought-out position; it is more intense, and hence more defi-
nite.
Table 1 presents the 3 × 3 factorial design indicating the nine
statement types to be included.
The model includes the nine opinion statement types each
replicated four times for a total of 36 statements in a balanced
factorial design. Four statements of each type are included as to
facilitate reliability (Brown, 1980). Three examples of state-
ment types are:
This is not about health care. It’s about government control.
(free market bias statement—fb)
The American health care system is in bad need of reforms
that will eliminate the tragedy of 46 million uninsured people.
(socialist wish statement—sw)
If we can enac t tort reform that protects p atients fr om reckless
Table 1.
Q Method opinion statement a r r a y .
Statement Type
Free-Market Socialistic Complex
Intensity Bias FB SB CB
Level Wish FW SW CW
Policy FP SP CP
doctors and doctors from reckless lawyers and juries, we reduce
the cost of healthcare tremendously. (complex policy statement—
cp)
In a 9-point “Most Agree-to—Most Disagree” continuum,
the methodology requires subjects to place two statements un-
der the Most Agree (value +4), and Most Disagree marker (–4),
three statements each under the +3 and –3 markers, four state-
ments each under the +2 and –2 markers, and six statements
each under the +1, 0, and –1 markers. Advantages of the forced
normal distribution are twofold. First, the same rating scale is
used by all respondents, and facilitates intersubjective com-
parisons. Secondly, the format forces frequent statement com-
parisons, especially at the extremes (Tetlock et al., 1992). And,
it is the extreme cases that most determine the belief structures
(Brown, 1980).
It is hypothesized that Q factor analysis of preference order-
ings will reveal otherwise nonverbalized belief structures.
Moreover, specification of the main effects (free market, so-
cialist and co mpl ex statem ent t ypes) in a m odel of this type do es
not guarantee that a set of conclusions will be revealed (Ste-
phenson, 1963). The interest lies in the interpretation of factors
(Stephenson, 19 64). There are no m eanings externall y imposed a
priori. Rather, the explanation of factors reaches into latent
belief systems (Stephenson, 1965), which, in the present case
concerns health care belief structures as subjectively construed.
Each statement has a factor score (a unique value on a scale
of –4 to +4, paralleling the original response scale) which indi-
cates the strength of belief of the officials who collectively load
on the respective factor. Defining statements for each belief
structure (factor) are those whose factor scores differ signifi-
cantly from the scores of the other belief structures on the same
statement. This indicates which statements are not only most
important to those within a given factor, but simultaneously
whether these statements are unique in importance (either in a
positive, negative, or neutral way) to that factor group. A factor
score wh ich differs fro m all other s by 2 is significa nt at the .05
level, and a factor score which differs by three is significant at
the .01 level (Brown , 1980) .
Findings
Five unique belief structures were found from the Q factor
analysis, consisting of 30 of the 40 respondents and represent-
ing 63% of the explained variance.4 The emergence of these
unique structures underscores the difficulty in formulating and
implementing acceptable health care policy.
2Since the interest of Q methodology is in the nature of the segments and the
extent to which they are similar or dissimilar, the issue of large numbers, so
fundamental to most social research, is rendered relatively unimportant. In
p
rinciple as well as practice, single cases can be the focus of significant
research (Brown, 1993).
3Main national sources for statements were the Wall Street Journal, The
N
ew York Times and Business Week magazine. As the study was con-
ducted in the Pittsburgh region, some statements were extracted from the
Pittsburgh Post-Gazette and the Pittsburgh Tribune-Review, the areas two
main newspapers.
4The remaining 10 respondents were spread over 5 additional factors. How-
ever, they contribute no unique factor scores and were they included they
would remove significant factor scores from belief structures 2 and 4. De-
mographically there are no dominant characteristics. As such their elimina-
tion fr om the model d oes n ot af fect t he f undament al 5- facto r bel ief st ructu re
derivation.

C. WILF 950
Belief Structure 1—Welfare State Activists
Ten respondents loaded on this factor which is defined by
four statements. Two significant factor scores are positive and
two are negative:
Statement 18.
Society should guarantee health care like we guarantee the
right to think and pray as you like (sw).
Factor scores: 3 –1 –2 0 –2
Statement 23.
A public option is the only option for people who have lost
jobs due to the economy and do not have affordable health
insurance (sp).
Factor scores: 1 –2 –3 –1 –1
Positive factor scores here indicate an entitlement position,
implying that government should take a proactive role in health
care. Even though the public option was only mildly supported,
all other belief structures viewed it negatively, suggesting that
even a program that was not well delineated still had support as
a matter of principle from this group.
Statement 12.
It is the responsibility of each person to pay for theirs and
their families own health care (fp).
Factor scores: –4 –1 1 –2 1
Statement 11.
The answer to the health care crisis is for people to take re-
sponsibility for their own health (fp).
Factor scores: –1 1 1 2 3
Statement 12 strongly reinforces the collectivist approach to
health care costs, and even the mild rejection of personal re-
sponsibility suggests that only activist government intervention
can provide adequate protection for the population. Note that
three of the four defining statements for the Welfare State Ac-
tivists are higher order policy level statements, representing
well-thought out positions. There are no republicans in this
group, and all educational levels are represented (high school
graduate through graduate degree).5
Belief Structure 2—Future Cost Alarmists
Eight respondents loaded on this factor, defined by three
statements.
Statement 7.
If we don’t reduce the growth in health care costs, we’ll
leave our children with a crushing tax burden (fw).
Factor scores: 0 3 0 –1 0
Statement 16.
Forty seven million Americans without health care is a fail-
ure of our society. (sb)
Factor scores: 3 1 –2 3 –1
Statement 25.
As things stand, the health care industry finds it more prof-
itable to treat chronic diseases than to prevent them (cb).
Factor scores: 2 0 2 3 –3
Statement 7 largely defines the Future Cost Alarmists. Yet
Statements 16 and 25 reinforce this belief structure. They are
concerned with the present state of affairs and the factor scores
for the Alarmists are significant in their neutrality with factor
scores of 1 and 0 compared to the more definitive positions of
the other belief structures. The Alarmists are singularly focused
on financial hardships to come. While all categories of state-
ments are represented, two of the three statements are bias-type,
or the most basic reactive class of expression. No political party
dominates this group and they are older.
Belief Structure 3—Status Quo Advocates
Seven respondents comprise this factor, defined by five
statements, two positive and three negative.
Statement 8.
Because a government-run health insurance company doesn’t
need to make a profit, privately run companies will be squeezed
out of business, and the government would have a monopoly
(fw).
Factor scores: –2 –3 3 –2 0
Statement 6.
Universal coverage undercuts the whole notion of cost con-
tainment (fw).
Factor scores: –2 –3 2 –2 –2
Statement 21.
To compete and win in a global world, no one needs the
burden of health insurance shifted from business to government
more than American business (sp).
Factor scores: 0 –2 –4 –1 0
Statement 29.
We need to address the economic inequity that underlies our
ability to achieve health care outcomes that other societies
have achieved (cw).
Factor scores: 1 1 –4 2 2
Statement 17.
The American health care system is in bad need of reforms
that will eliminate the tragedy of 46 million uninsured people
(sw).
Factor scores: 2 2 –3 2 2
Taken together, these statements suggest a distrust of sys-
temic changes in the health care system. Significant factor
scores for statements 8 and 16 reflect cost concerns, not unlike
those of the Alarmists. However, the negative factor scores for
statements 21, 29 and 17 reveal a more universal rejection of
change. If costs were the only concern of this group, it is
unlikely that statement 21 would be rated so negatively. With
one exception, the defining statements are wish, or desired end
state type of statements. Status Quo Advocates know what they
want and they do not want change. No political party dominates
this group, and all respondents have at least a college degree.
Belief Structure 4—Uncertain Interventionists
Three respondents load on this belief structure which is de-
fined by three statements.
Statement 20.
Health care should not be regarded primarily as a business,
with a main goal of increasing shareholder value (sw).
Factor scores: –1 0 1 4 –3
Statement 34.
We are going to have to invest in some kind of a system that
is walled off from politics (cp).
Factor scores: –1 2 1 –3 1
Statement 2.
This is not about health care. It’s about government control
(fb).
Factor scores: 3 –3 4 0 4
This group acknowledges the potential conflict between
business interests and the political process, but is decidedly
noncommittal regarding the role of government. While other
belief structures maintain extreme positions regarding govern-
ment and its place in health care, the Uncertain Interventionists
have yet to reconcile politics and government. And while they
5For all belief structures, males and females are almost equally represented.

C. WILF 951
reject the notion of health care as strictly a business, any alter-
native vision remains undefined. All categories and all levels of
statements are represented, reflecting this comprehensive yet
unfocused belief structure. This group has the youngest mean
age.
Belief Structure 5—Anti-Government Libertarians
While only two respondents are represented in this belief
structure, three statements with significant positive/non-nega-
tive factor scores, and six with significant negative factor scores
render it instructive in defining the health care reform parame-
ters. Especially as the debate over rescinding many provisions
of the Affordable Care Act intensifies, the quantity of defining
statements suggests that this belief structure should not be ig-
nored.
Statement 32.
What the public wants in universal health CARE, not uni-
versal health INSURANCE (cw).
Factor scores: 0 0 1 0 3
Statement 4.
Medicine is a commodity to be bought and sold (fb).
Factor scores: –2 –2 –1 –3 1
Statement 8.
Because a government-run health insurance company
doesn’t need to make a profit, privately run companies will be
squeezed out of business, and the government would have a
monopoly (fw).
Factor scores: –2 –3 3 –2 0
Statement 24.
The public option is the answer for middle class people who
are denied affordable coverage due to pre-existing conditions
(sp).
Factor scores: 1 0 –1 –1 –4
Statement 35.
Nobody should have to pay more than a fixed percentage of
their income for health insurance premiums (cp).
Factor scores: 2 2 –1 –2 –4
Statement 20.
Health care should not be regarded primarily as a business,
with a main goal of increasing shareholder value (sw).
Factor scores: –1 0 1 4 –3
Statement 22.
The federal government should provide assistance to states
to make their own plans cheaper and cover more people (sp).
Factor scores: –1 –1 0 1 –3
Statement 25.
As things stand, the health care industry finds it more prof-
itable to treat chronic diseases than to prevent them (sp).
Factor scores: 2 0 2 3 –3
Statement 9.
In healthcare what needs to happen is an emphasis on
healthy living (fp).
Factor scores: 2 3 2 1 –1
Taken together, this set of defining statements points to dis-
trust and even hostility toward government intervention in gen-
eral and health care in particular. The two statements with sig-
nificant positive factor scores suggest a muted if basic skepti-
cism, and there are no policy level statements here. Conversely,
two of the six negative statements are at the scale extreme, and
three are at the next highest. Additionally, five of the six are
policy-level statements, indicating a well-developed belief
structure. Anti-government Libertarians are more certain in
their rejection of interventionist ideas; even the seemingly non-
controversial statement 9 cannot be supported by this group, as
it suggests a course of action that in principle could be seen to
inhibit personal freedom.
Creating the Common Policy Space
The emergence of discrete belief structures via Q Methodol-
ogy highlights the breadth of diverse and often competing posi-
tions in the health care debate. This is particularly at issue when
different belief structures have significant factor scores on the
same statement. Three such statements are found here:
Statement 8.
Because a go ver nment-run health ins urance compa ny doesn’t
need to make a profit, privately run companies will be squeezed
out of business, and the government would have a monopoly
(fw).
Factor scores: –2 –3 3 –2 0
Statement 20.
Health care should not be regarded primarily as a business,
with a main goal of increasing shareholder value (sw).
Factor scores: –1 0 1 4 –3
Statement 25.
As things stand, the health care industry finds it more prof-
itable to treat chronic diseases than to prevent them (sp).
Factor scores: 2 0 2 3 –3
In each case the Anti-government Libertarians are at odds
with another belief structure. For statement 8, Libertarians dis-
agree with the Status Quo Advocates as the latter resist change
while for the Libertarians this is a non-issue. For statement 20,
the Libertarians and the Uncertain Interventionists have dia-
metrically opposite positions, while for statement 25 the Liber-
tarians and Future Cost Alarmists are most different in their
beliefs. As expected in both cases Libertarians infer that self
interest drives health care and the medical establishment. And,
as these statements are wish or policy level types, the respective
positions are more developed and thus more likely to be de-
fended by those belief structure s holding them .
While it may therefore appear that consensus on health care
reform is unattainable, there is equal empirical support for
agreement by all belief structures among a set of four state-
ments. It is these commonalities that form the basis for a com-
mon policy space and subsequent political engagement. There
are two statements with which all belief structures either agree
or are neutral:
Statement 19.
No American family should be bankrupted by catastrophic
health care bills (sw).
Factor scores: 4 4 1 3 1
Statement 31.
Business cannot keep absorbing soaring health care costs
and keep passing them on to their employees (cw).
Factor scores: 0 1 2 1 1
Statement 19 can be interpreted as a fundamental baseline in
the health care debate, as all five belief structures either
strongly or mildly agree. While statement 31 does not com-
mand the same intensity of support, no belief structure dis-
agrees with this concept. As both statements are wish or desired
end state types, there is genuine concern across the subjectivity
spectrum regarding an outcome that is sensitive to both poten-
tial individual and organizational hardship. A common policy
space begins with an awareness of this fundamental agreed-
upon position.
There are two additional statements with which all belief

C. WILF 952
structures eith er di sagree or are neutral.
Statement 3.
Health care is a luxury, just like living in a nice neighbor-
hood or driving a nice car (fb).
Factor scores: –4 –1 –3 –4 0
Statement 1.
Health care is socialism, and socialism is not an American
value (fb).
Factor scores: –3 –4 0 –4 0
Statement 3 emphasizes the universal prioritization of health
care common to all belief structures, and even the Libertarians
do not reject this position. The statement on socialism, included
so as to make the domain as comprehensive as possible, is also
either strongly rejected or ignored. The health care debate has
often been infused with inflammatory ideology to advance po-
litical agendas. However the analysis reveals an inverse asso-
ciation or indeed no association between health care and an
alternative societal paradigm. It is also significant that both
statements are fact types or lower order statements. All belief
structures show a common position at this most basic level, and
do not involve higher order goals or methods for their attain-
ment.
Conclusion
Q Methodology reveals a set of distinct belief structures that
go beyond differences found in political polls. Five belief
structures were derived from the analysis and indicate that un-
derlying ideas and concerns about health care reform cover a
more complex range than previously indicated. While labels
and hence ideologies such as liberal or conservative have been
repeatedly applied to the health care debate, Q Methodology
shows that these labels are simplistic at best, and potentially
misleading. It may seem, for example, that the conservative
label might equally apply to the Status Quo Advocates and the
Anti-Government Libertarians. But a review of their defining
statements indicates important differences between them. Con-
sider Statement 29:
We need to address the economic inequity that underlies our
ability to achieve health care outcomes that other societies
have achieved (cw).
Factor scores: 1 1 –4 2 2
The Status Quo Advocates are adamantly opposed since this
involves change, while the Libertarians take a position more
like the Welfare State Activists, the Future Cost Alarmists and
the Uncertain Interventionists, who could hardly be considered
conservatives. Yet one could argue that the Libertarians react
positively to this statement because in their belief structure it
represents an imperative for individual self-sufficiency on this
issue, just as self-sufficiency drives their other responses.
Equally important, Q Methodology has shown that despite
deep differences in underlying belief structures, there is a
common policy space that can serve as a practical starting point
for discussing health care service delivery. Protection from
catastrophic financial loss, a concern for accelerating business
health care expenditures, and a belief that access to health care
is a basic necessity are fundamental premises that every belief
structure, from Welfare State Activists to Anti-Government
Libertarians can support. As the health care debate continues
and likely intensifies as challenges to the Affordable Care Act
are presented, policy prescriptions that begin with these few
reliminary yet politically acceptable ideas may have a better
likelihood of generating meaningful and permanent health care
reform than more comprehensive programs that put opposing
belief structures against each other.
p
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