An examination of recent public opinion data, as well as historical trends, can give some insight into the potential role health care might play as an issue in the upcoming presidential election in November 2004.
Setting the context: issues are only one part of what determines vote. In examining how health care as an issue might play out in any given election, it is important to point out that candidates’ stands on the issues are only one part of what determines how people vote. In a survey following the presidential election in 2000, nearly four in ten voters (37%) said the candidates’ stands on issues were the most important factor when they decided who to vote for, while others said character and moral values (27%), leadership abilities (14%), and the candidates’ experience (12%) were the most important factor 1
Health care as a voting issue in past elections. When it comes to the relative importance of different issues in deciding their vote, health care has been one of the top five issues chosen by voters in four of the last six elections, and it was the second most frequently chosen issue in the presidential election in 2000 and the congressional election in 2002 (Table 1). The economy has been the number one issue in each of the last three presidential elections, and was also the top issue in the congressional election in 2002.
Table 1. Top 5 issues in deciding vote for president/U.S. House (percentages) -
Exit polls of voters2 |
| | 1992 | 1994 | 1996 | 1998 | 2000 | 2002 |
| 1 | Economy/jobs (42) | Crime (35) | Economy/jobs (26) | Education (23) | Economy/jobs (18) | Economy (34) |
| 2 | Federal deficit (21) | Economy/jobs (27) | Medicare/Soc. Security (18) | Moral standards (21) | Health care/ Medicare/Rx (15) | Health care (16) |
| 3 | Health care (20) | Taxes (23) | Education (15) | Economy/jobs (16) | Education (15) | Education (15) |
| 4 | Family values (15) | Health care (21) | Federal deficit (15) | Taxes (15) | Taxes (14) | Terrorism (14) |
| 5 | Taxes (14) | Family values (21) | Taxes (14) | Soc. Security (13) | Soc. Security (14) | Soc. Security (13) |
Where health care is likely to rank as a voting issue in November 2004. Although a lot could change in the weeks leading up to the November election, polls conducted in recent months indicate that health care may again play an important role as an issue in the 2004 election, though secondary to the war in Iraq and the economy. In a June 2004 survey, when asked in an open-ended question about the most important issue deciding their vote for president, just over one in ten adults (11%) said that health care would be most important, ranking behind the war in Iraq (40%), and the economy (32%) (Chart 1). In an ABC News/Washington Post Poll conducted September 6-8, when asked to choose the single most important issue in their presidential vote from a list of issues, 13% of registered voters chose health care, ranking behind the economy and jobs (27%), the U.S. campaign against terrorism (25%), and the war in Iraq (18%), but ranking ahead of education (6%).
Health care is an issue closely related to the economy. Although the economy/jobs almost always outranks health care as a voting issue, it is important to note that these issues are very closely tied, since most people get their health insurance through an employer, and many are concerned about being able to afford health care for themselves and their families. When asked in a 2003 survey which is their biggest source of personal concern about how the economy might affect them, about a quarter (24%) said not being able to pay for health care, ranking just behind losing a job (26%), and ahead of many other economic concerns (Chart 2). While the importance of health care and the economy are almost always measured separately in polls, it is important to consider health care as one dimension of economic concerns.
In addition to concerns about affording health care, many people report real experiences with increasing costs. In the August 2004 Kaiser Health Poll Report survey, nearly two-thirds (65%) of people with health insurance said the amount of money they pay in premiums has gone up in the past three years, including three in ten (30%) who say it has gone up a lot. Among those who report increasing premiums, a quarter (25%) report that the increase was a major problem for their family, nearly half (46%) say it was minor problem, and about three in ten (28%) say it was not a problem.
Which specific health care issues will matter most? While it’s important to know where health care ranks as a voting issue, it’s also important to realize that there are various specific health care issues that people refer to when they say that health care will have an impact on their vote. When asked in an open-ended question in June 2004 to name the most important health care issue influencing their vote for president, about a quarter of people (24%) named issues related to health care costs, and nearly as many (22%) named health care issues affecting seniors, such as Medicare. About one in eight (13%) named issues related to access to care and insurance, 6% named insurance company-related issues such as problems with HMOs, and 3% named specific medical conditions such as HIV and cancer. Again, it is important to realize that cost is an underlying factor in many people’s health care concerns – for instance, those who say that Medicare is the most important issue to their vote may be concerned about the cost of prescription drugs for seniors. When the question is asked about the most important health care problem for the government to address (rather than most important issue to your vote), a much larger share name health care costs
(46% in an August 2004 survey said health care costs were the most important health care problem for the government to address
3).
More on specific health care voting issues. When respondents are given a list of potential health care voting issues, results are somewhat different than when the question is open-ended. When asked about a list of specific issues, more than four in ten say the cost of health care and insurance (44%) and the number of uninsured Americans (41%) will be extremely important to their vote for president. More than a third name the cost of prescription drugs (36%) and drug benefits for seniors (36%) as extremely important, and three in ten patients’ rights (30%) and Medicare (30%) will be extremely important to their vote. Fewer people say they will place as much importance on abortion (24%) and malpractice (19%) (Chart 4). While large numbers say many different health care issues will be extremely important in determining their vote for president, when forced to choose the most important, no single issue dominates. It is also important to note that three in ten (30%) do not say any one of these issues will be extremely important to their vote.
Who are the health care voters? Historically, people in different demographic groups have given different rankings to health care as a voting priority. In recent elections, Democrats, seniors, and people without health insurance have been more likely than their counterparts to say that health care was one of the top issues determining their vote. Importantly, however, those who care about health care as an issue often pay attention to different priorities within health care. For instance, seniors are much more likely to say that Medicare and prescription drug costs are top issues determining their votes, while younger adults are more likely to say they vote based on health care issues such as accessing to health care and insurance.
The role of voter turnout. In addition to understanding which groups are more likely to vote based on health care, it is also important to recognize the variation in voting behaviors of different demographic groups. For instance, seniors are more likely to say health care will be important to their vote, and they are also much more likely to report voting than are younger adults. Seniors will continue to make up a growing share of the electorate as the Baby Boom generation reaches retirement age. In addition, there are more than 40 million people in the United States without health insurance, and it’s possible that such a large group could have a big impact on elections. However, surveys show that the uninsured are less likely than their insured counterparts to report being registered to vote, and to say that they participate in elections. While more than eight in ten (82%) adults under age 65 who have health insurance say they are registered to vote, just over six in ten (63%) of the uninsured under 65 say they are registered, and while seven in ten (71%) of the insured non-elderly say they voted for president in 2000, fewer than half (45%) of the uninsured non-elderly say they voted. Similarly, three-quarters (74%) of people under age 65 with health insurance say they are absolutely certain to vote in the presidential election in 2004, compared with just over half (52%) of the uninsured in this age group (Chart 5).
Evaluation of the parties on health care issues. Differences on the issues between the two major political parties are another factor that many people consider in deciding who to vote for. Since 1993, more people have said they think the Democratic Party would do a better job dealing with health care than the Republican Party. In most years, the Democrats have had between a 10- and 20-percentage point lead over the Republicans (Chart 6). In May 2003, the shares choosing both the Democrats and the Republicans decreased, while the share saying that both parties would do an equal job or neither would do a good job increased. In February 2004, the shares choosing the Democrats and the Republicans increased somewhat, but not to the levels they were at prior to May 2003 (Democrats 32%; Republicans 16%; Both/neither 43%). Historically, the share saying both parties would do an equal job or neither would do a good job increased significantly at two other times since 1993: in April 1994, and in June 1998.
Trust in the candidates on handling health care. More recently, many surveys have asked about the presidential candidates specifically, and who voters trust to do a better job handling health care. In a survey of registered voters by ABC News/Washington Post conducted September 6-8, 2004, 45% said they trusted John Kerry to do a better job handling health care, while 42% said they trusted President Bush. Kerry’s lead on health care was much smaller in this September poll than it had been earlier in the year (Chart 7). The largest gap found by ABC News/Washington Post was in early August, when 55% of registered voters said they trusted Kerry to do a better job handling health care, compared with 36% who said they trusted President Bush.
1 Kaiser Family Foundation/Harvard School of Public Health Post-Election Survey (Nov. 13-Dec. 13, 2000).
2 Exit polls by Voter Research & Surveys (1992), Mitofsky International (1994), Voter News Service (1996-2002).
3 Kaiser Family Foundation Health Poll Report survey (conducted Aug. 5-8, 2004).
4 Kaiser/Harvard Medicare Survey (conducted May 23-27, 2003), and Kaiser Family Foundation Health Poll Report survey (conducted Feb. 5-8, 2004).
