Differences in welfare attitudes of Eastern and Western Europeans have often been explained in terms of legacies of communism. In this article, we explore evaluations of healthcare systems across European countries and argue that East-West differences in these evaluations are explained by differences in current institutional design of healthcare systems in the two regions. The empirical analysis is based on the fourth round of the European Social Survey, applying multilevel and multilevel mediation analysis. Our results support the institutional explanation. Regional differences in healthcare evaluations are explained by institutional characteristics of the healthcare system, i.e. lower financial resources, higher out-of-pocket payments and less supply of primary healthcare services in Eastern compared to Western European countries. We conclude that specific aspects of the current institutional design of healthcare systems are crucial for understanding East-West differences in healthcare evaluations and encourage research to further explore the relevance of institutions for differences in welfare state attitudes across socio-political contexts.

Knowing the public opinion of healthcare is essential when assessing healthcare system performance; but little research has focussed on the links between the public's general attitude to the healthcare system and its perceptions and expectations of specific healthcare-related aspects. Using data from the fourth round of the European Social Survey 2008/09, we explore the cognitive determinants of global evaluations of the healthcare system in 12 Eastern and 16 Western European countries. We find that healthcare evaluations follow a coherent cognitive reasoning. They are associated with (i) perceptions of the performance of healthcare systems (i.e. efficiency, equality of treatment, health outcomes), (ii) expectations of the government's role in providing healthcare, and (iii) reflections on demographic pressures (i.e. aging populations). Contrary to the general assumption that normative expectations are responsible for differences in healthcare evaluations between Eastern and Western Europe, our results suggest that regional differences are largely due to a more negative perception of the performance of healthcare systems within Eastern Europe. To enhance the public opinion of healthcare, policy makers should improve the efficiency of healthcare systems and take measures to assure equality in health treatment.

This article investigates to what extent austerity-oriented measures introduced in the Portuguese health sector during the recent economic crisis were associated with changes in the public opinion on healthcare. We conducted multivariate regression analyses of cross-sectional, biannual data from the European Social Survey (2002–2015) for 13,271 individuals living in private households in Portugal. In line with our expectations, healthcare evaluations of the general population improved until 2010 but declined with the implementation of comprehensive austerity measures introduced under the Memorandum of Understanding after 2011. Healthcare evaluations of vulnerable social groups – older and retired individuals, individuals with poor health, low income and education – declined particularly strongly. In addition, differences in healthcare evaluations between more and less vulnerable social groups were more pronounced after 2011. Interestingly, healthcare evaluations of the general population and of some of the most vulnerable groups ‘recovered’ in 2015, when most of the Memorandum measures were implemented. Our findings contribute to the literature on the effects of austerity measures on welfare attitudes and stress the need to analyse the differential impact of crisis-induced welfare state reforms across social groups.