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Previous research has shown that in primaries and caucuses, as in the general election, voters select their candidate on the basis of a number of factors such as stands on issues, perceived leadership ability, experience, character, and likability.2 A candidate's chances of winning the nomination and subsequently the general election in November are also important.3,4 With regard to issues, not only are the candidate's specific policy stands important, but the impression the candidate gives that he or she shares the voters' views, values, and beliefs on issues of importance to them is important as well.
Since the primary elections this year are highly competitive, both parties' candidates have been focusing on the issues that concern their own, narrow group of primary voters. This process has important ramifications for the way in which the debate over possible changes to the health care system is unfolding.
This article examines the role of health care in the 2008 presidential primary elections in two ways. First, it draws on data from multiple opinion surveys to better understand how Republicans and Democrats differ in their values, beliefs, and attitudes with regard to health care and health care policy. Second, it focuses particularly on voters who say they are going to participate in the early Democratic and Republican primaries and caucuses, looking at differences in their health care preferences and the extent to which the health care issue is affecting their vote.
Finally, we explore how the differences in views and desires concerning health care among Republicans and Democrats are reflected in the kinds of proposals being put forward by the major candidates, and we assess the ways in which these divisions might affect the general-election campaign.
Methods
Sources of Data
The data presented here were drawn from 11 national opinion surveys, including 1 main survey designed and analyzed for this article by public opinion researchers at the Kaiser Family Foundation and the Harvard School of Public Health.5 Field work for this study was conducted by International Communications Research from November 1 through November 11, 2007, as a telephone survey in the District of Columbia and in 35 states where either a Republican or Democratic presidential primary or caucus was scheduled for January or February 2008.
The states included in the survey were Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Iowa, Kansas, Louisiana, Maine, Maryland, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Oklahoma, South Carolina, Tennessee, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. This list of states was determined according to the primary and caucus schedule as of November 1, 2007; after that date, any states that moved their primaries to January or February 2008 were not included.
The sample consisted of randomly selected, self-described registered voters. A total of 508 of these voters said they were absolutely certain to vote or would probably vote in the Republican primary or caucus in their state, and 674 of these voters said they were absolutely certain to vote or would probably vote in the Democratic primary or caucus in their state. Since party primaries in many states allow voters who are not members of their party to vote, and since some voters change party identification in the weeks preceding a primary, we did not restrict the respective samples of likely voters to a particular party. In the survey, among persons who were likely to vote in a Republican primary or caucus, 71% self-identified as Republicans, 23% as Independents, and 2% as Democrats; the other 4% identified with other parties or did not give an identification. Among the likely voters in a Democratic primary or caucus, 75% self-identified as Democrats, 20% as Independents, 3% as Republicans, and 2% as "other" or "none."
Other sources of data include results obtained from telephone surveys conducted by national media polling organizations. These surveys were conducted between November 2006 and September 2007.
Survey Questions
In order to compare the values, beliefs, and attitudes concerning health care and health care policy among Republicans and Democrats, we first examined responses to a variety of survey items. These items ranged from views of President George W. Bush's handling of health care,6 to ratings of the nation's health care system,7 to worries about losing health insurance8 (Table 1 and Table 2).
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Statistical Analysis
In general, national media polling organizations do not release their rates of response. According to the most recently published research, the typical response rate for polls of this kind is 25%.15 With the use of the fourth method of response-rate calculation of the American Association of Public Opinion Research, the response rate for the survey of likely voters in a primary or caucus was 38%, and the cooperation rate was 47%.5,16
Independent studies have shown that statistically adjusting — or weighting — the data obtained from random-digit–dialed telephone surveys to known population parameters ameliorates the effects of a survey conducted over a short period.15,17,18,19,20,21 The results of the surveys presented here were statistically weighted to reflect the actual composition of the population of the United States, calculated on the basis of data from the Census Bureau, according to age, sex, education level, region, race or ethnic background, and household size.22 In the survey of the voters in primaries, demographic data were collected even from respondents who did not qualify as likely voters, enabling a similar weighting process to ensure representativeness.
None of the surveys described in this article involved interviews with adults who used cell phones only; this might be a possible source of noncoverage bias. However, a recent study has shown that when data are weighted demographically, as described above, "the absence of this group from traditional telephone surveys has only minimal impact on the results."23
To examine differences between Republicans and Democrats, we compared responses by conducting t-tests for differences in proportions, taking into account the effect of the design of the study.24 Confidence intervals were also calculated.
In the tables, "don't know," "not sure," "no opinion," "refused" (declined to answer), and "no answer" are not shown unless they sum to 10% or more for any group whose responses to a question are included. However, the data from persons who give such responses are included in the base used to calculate percentages.
Results
Attitudes Concerning Health Care
The attitudes of Republicans and Democrats differ substantially with regard to four issues that could affect future health policy: President Bush's handling of health care, the health care system generally, their own care, and possible solutions to health care problems (Table 1).
Republicans are almost evenly divided in the assessment of President Bush's handling of health care, whereas a large majority of Democrats express disapproval, suggesting a desire for a different policy direction in the next administration.6
Although members of both parties are generally dissatisfied with many aspects of health care in America, Democrats are significantly more likely to give the system poor reviews. Only one of five Democrats rates the nation's health care system as "excellent" or "good,"7 and nearly half say there is so much wrong that the system needs to be completely rebuilt.9 Large majorities are dissatisfied with the cost and quality of health care in the United States, and they say the fact that many Americans do not have health insurance is a "very serious problem."10 Although Republicans do not give the system high marks, they are generally far less critical than Democrats are.
As to their own health care, Republicans are more likely than Democrats to report being satisfied with the cost and quality of care that they receive,6 and they are less likely to be worried about losing their coverage, receiving service of worsening quality, or having to pay more for care.8
These marked differences in satisfaction — both national and personal — coexist with real differences in terms of where Republicans and Democrats turn to look for solutions to the problems of high costs and the uninsured. Although a plurality of Democrats say that government should have primary responsibility for making sure that Americans have health care, and the majority say they are willing to pay higher taxes for increased coverage, the plurality of Republicans say health care coverage should be an individual responsibility.6,11 Republicans are also more likely than Democrats to view the private health insurance industry as being more effective than government in providing coverage and controlling costs.6
In addition, Democrats are considerably more likely than Republicans to favor requiring that everyone have health insurance, with the government helping to pay for insurance for those who cannot afford it.12 This is currently a prominent provision in the Massachusetts Health Care Reform Law and part of the proposals of several presidential candidates.25,26
With regard to two key health-related social issues, Republicans are significantly more likely than Democrats to believe abortion should be illegal in all or most cases13 and to oppose the loosening of federal government restrictions on the funding of embryonic stem-cell research (Table 2).14
Views of Likely Voters in Primaries
We designed and analyzed the results of a new survey of voters in early state primaries. The results of this survey suggest that health care ranks as a high-profile issue in the Democratic nominating contests and is one of a handful of domestic issues that is also at stake in the Republican contests. Echoing the findings above, these results also suggest that what Democratic voters want to see with regard to health care reform is quite different from what Republican voters want (Table 3).
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Democrats and Republicans also differed with respect to the specific health care issues they said would be most important in their selection of a candidate. Voters in Democratic primaries were divided between a focus on expanding insurance coverage and controlling costs. In contrast, the top issue for voters in Republican primaries was health care costs; substantially fewer cited improving the quality of medical care and reducing medical errors or expanding health insurance coverage. Only a small share of likely voters in primaries for either party identified reducing spending on Medicare and Medicaid as the most important health care issue.
About two thirds of Democrats also said that they want to see their presidential candidates propose "a major effort to provide health insurance for all or nearly all of the uninsured," even if it "would involve a substantial increase in spending." In contrast, only a minority of Republicans said they want to hear about this kind of major effort, with about the same proportion saying they would prefer no action on this front. A plurality of Republican voters said they would prefer a more limited, less costly expansion. This difference was not driven by the distribution of the uninsured between the two parties' likely voters in primaries. Similar proportions of likely Democratic (9%; 95% confidence interval [CI], 7 to 11%) and Republican (6%; 95% CI, 4 to 8%) voters in primaries reported being uninsured.
In addition to health care generally, the results of this survey also suggest that two other health-related issues — abortion and federal funding for stem-cell research — may play a role in the primary contests. In the case of abortion, just more than a quarter of likely voters in both parties said that they could not vote for a candidate who did not share their views. Among these voters, Democrats and Republicans differed significantly in their views. A large majority on the Democratic side believed that abortion should be legal in all or most cases, whereas a large majority on the Republican side believed that abortion should be illegal in all or most cases.
There is a similar pattern with regard to views on federal funding of embryonic stem-cell research. Roughly one of five voters in each party said that they could not vote for a candidate who held a position different from their own. However, among those voters, a large majority on the Democratic side favored loosening of federal funding restrictions on stem-cell research, whereas the large majority on the Republican side opposed it.
Discussion
This season's political primaries are playing an important role in two ways: first, they are elevating the issue of health care generally in terms of public discussion; and second, they are setting up a debate between the two parties about different visions for the future of the American health care system.
Health care's ranking as the top domestic issue among voters in Democratic primaries and one of a handful of important domestic issues among voters in Republican primaries, as of November 2007, has made it a high-profile topic this election season. All the major candidates have addressed health care in their platforms, the issue has been discussed in numerous debates throughout the primary season, and the topic is often mentioned in media analyses of the primaries. However, because the issue has a higher salience for likely voters in primaries among Democrats than among Republicans, the candidates' positions on health care are likely to be discussed more extensively by the Democratic candidates.
The primaries are also serving as the proving ground for two substantially different visions of the future of health care in America. Those differences, as we have shown here, are grounded to some degree in the differing underlying views of each party's constituency. Surveys suggest that Democratic voters are largely dissatisfied with the state of health care in America, are interested in hearing the candidates talk about a major expansion of coverage for the uninsured, and favor the government playing an important role in accomplishing this goal. In contrast, a somewhat less dissatisfied Republican electorate places a higher priority on efforts to reduce the high cost of health care over attempts to achieve universal coverage and is leery of the involvement of the federal government. Republican voters favor more limited expansion of coverage, marketplace solutions, and encouraging persons to make more effective health care decisions for themselves.
These two alternative visions are reflected in the health care proposals that have been put forward by the presidential candidates of the two parties.26 These proposals differ in their goals, mechanisms, and even their preferred type of insurance. In terms of goals, Democratic candidates emphasize universal coverage, whereas Republicans emphasize making coverage more available in the marketplace and providing tax incentives to address affordability issues. With regard to mechanisms for reaching these goals, Democrats emphasize building on the existing system of employer-based coverage and public programs, whereas Republicans want to move toward a system in which more persons purchase their own coverage in the individual health-insurance marketplace. Finally, there is a basic difference in the definition of what health insurance should be, with most Democrats preferring more comprehensive plans in terms of the scope of benefits provided and the level of coverage, and many Republicans embracing high-deductible, catastrophic coverage combined with health care savings accounts that provide tax savings.
Within each party's primaries, the decision by voters about who is best with respect to health care, as with other issues, is likely to be driven by a number of factors. These factors include the differences that voters see between the candidates' plans, the values and beliefs the candidates express about the issue, and voters' perceptions of the candidates' leadership, commitment, and ability to bring about change in this area.
Emerging from the primaries, the two parties' nominees are also likely to put forth differing visions about the role of the federal government in abortion and embryonic stem-cell research. Voters' ranking of issues that are important in determining their vote, as measured in November 2007, could evolve during the course of the primary campaigns.
Looking forward, the ranking of health care as a top issue in the primaries and plans for serious health care reform proposed by both Democrats and Republicans are major steps toward a larger debate in the 2008 general election and beyond. However, the intensity of the debate, and whether it engages the nation the way the last great health care debate did in the early 1990s, remains to be seen. In addition, the prospects for actual health care reform are tempered by two factors: the wide differences in the two parties' views of what health care reform should look like and the current level of satisfaction that majorities of both parties have with their own health care situations.
No potential conflict of interest relevant to this article was reported.
Source Information
From the Harvard School of Public Health, Boston (R.J.B., J.M.B., T.B.); the John F. Kennedy School of Government, Cambridge, MA (R.J.B.); and the Kaiser Family Foundation, Menlo Park, CA (D.E.A., C.D., M.B.).
Address reprint requests to Dr. Blendon at the Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., 4th Fl., Boston, MA 02115, or at rblendon{at}hsph.harvard.edu.
References
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