The Symbolic Manipulation of Health Issues in Elections

Why don’t data and facts and policy plans and lists of accomplishments connect with many voters? It’s an old problem I have written about before. This time, here’s a deeper dive into some of the reasons why and what might be done about it.

There is a vast and very old literature in my field, political science, called symbolic politics. It began with a classic written by Murray Edelman at the University of Wisconsin called “The Symbolic Uses of Politics” way back in 1964, and then was refined by many others after that and used to explain voting, domestic politics, even war. It’s just one school of political science, but it’s useful for explaining a lot of what we see today in the politics of health, as well as our failures to communicate effectively with the public.

To grossly oversimplify symbolic political analysis for current purposes, what it says is that what you see on the surface in politics—elections and voting, the substance we analyze and debate, and journalists report on—is part but not all that is really going on. We see substantive debates about issues we try to inform with facts and evidence. Candidates try to win over voters with policy plans and long lists of accomplishments (think Bidenomics). But, what often really matters is how issues and elections trigger deeper emotions and beliefs that divide us and motivate voters, sometimes ugly ones like racism and xenophobia. Edelman explained how what he called elites (think former president Trump) manipulate voters and the public through the use of symbolic issues, often reduced to slogans, to gain support, spur outrage, or compel action (like voting).

The phenomenon is likely more pronounced now than in Edelman’s day. He and his disciples did not live in a world with the fragmented media and powerful conservative outlets that are constantly hammering away today about immigration and race and the culture wars to add their power to symbolic politics.

A classic case from long ago in health care was fluoridation. On the surface, the debate was about whether putting fluoride in the water was safe. The pros and cons of fluoridation were widely debated, but what fluoridation symbolized to its opponents in conservative and rural America was big government, a violation of their personal freedom, and the imposition of norms by urban elites and experts on their way of life. At the time, it was even seen as communism. The factors that were really motivating people had little to do with fluoride at all, it was a symbol. Sound familiar?

This is often why 10-point-policy plans and long recitations by candidates of their accomplishments don’t work with everyone. They assume rational calculus when issues are symbolic—about other and deeper motivations for many voters.

Three current examples are immigration, the Affordable Care Act (ACA), and Covid. None are as extreme an example of symbolic politics as fluoridation, but all three have elements of it.

Republican voters in New Hampshire and South Carolina named immigration as their top issue in the primaries there, even ahead of the economy. But 6% of the population of New Hampshire and 5% of the population of South Carolina are immigrants. There are obviously consequential substantive disagreements about immigration policy between Democrats and Republicans that block compromise. But the Southern border is thousands of miles away from both South Carolina and New Hampshire, and it’s highly doubtful that either the policy debate or the actual impact of immigration on their states was motivating those voters. Rather, a larger sense that they are falling behind and losing their country and way of life and that somehow immigrants are to blame, impressed on them by conservative media, former President Trump, and others, has made immigration a powerful “symbolic” issue for them. It’s a strategy perfected first by Victor Orban in Hungary, who made immigration a rallying cry when Hungary did not have an immigration problem.

California, my home state, has the highest share of immigrants in the U.S., and New Jersey, where I was Human Services Commissioner, the third highest; however, urbanization and integration into the economy in those states have muted or neutralized similar views almost entirely. In fact, immigration is mostly welcomed, if not popular, in California.

Covid has been almost a mirror image of fluoridation but on steroids. The debate the country had was variously about masks or vaccines or schools, among other issues, and as with immigration, there are real substantive differences between Democrats and Republicans on these topics. But those debates were also used to trigger deeper fears among Republicans that their personal freedom was threatened by experts, government agencies like the Centers for Disease Control, and Washington. As a result, in all of our polling about Covid, only one variable explained people’s positions on almost every issue—whether someone was a Republican or not. The country split far more over the symbolic politics of the issues than the substantive differences over them. Just as Edelman observed in his time, political leaders, including former president Trump and Governor DeSantis, made Covid a symbolic issue in the culture wars, dividing the country and fragmenting the national response. (For more on this, read my piece “Understanding the US failure on coronavirus.”)

The ACA is far more popular now than it used to be with strong majorities of the public supporting it. But even larger majorities of Republicans (67%) still oppose the ACA even though enrollment has been strong in red states and millions of Republicans benefit from it. That’s because it was made into a symbol for them of President Obama and of the federal government that has lingered for the Republican base. Because they react to the symbol, ACA repeal remains a talking point that continues to get applause at Trump campaign stops, even as they like the ACA’s benefits, such as protections for pre-existing conditions. There are substantive differences mixed in with the symbolic politics; many Republican experts and elected officials favor a different approach to health reform. But that’s not what drives the applause lines at Trump rallies. In polling many years ago when the ACA was more hotly debated, more people who opposed the ACA flat out told us their views reflected “the general direction of the country” than the health care law itself.

Understanding the symbolic dimensions of politics and issues is critical for experts. We can reach a share of the public with facts and data but need additional strategies to reach everyone, including storytelling and trusted messengers. But none of our strategies have proven sufficient. No one has all the answers to the political divide in America or how to communicate across it.

For their part, elected officials can reach many with their record of accomplishments and with policy plans. But for the large share of the public who are disaffected, distrusting of experts and evidence, and ripe for populist appeal, policy may sound just like another argument from elites for fluoride, or masks, or the ACA.

One partial answer to the populist symbols used to reach disaffected America may be to counter them with values every American would agree with, not facts and complex policy plans they don’t trust. A good example is standing up for the right to choose and for personal freedom as a way to respond to efforts to restrict abortion and reproductive rights. Persuadable opponents may oppose abortion on moral or religious grounds, but they also may see personal liberty and the right to choose as a deeply held American value. Over the years, Senator Bernie Sanders has been adept at appealing to working class voters who overlap with the Trump base based on values but from the left rather than the populist right.

Another approach is to appeal to everyone on the basis of nearly universal nonpartisan kitchen table worries, such as their out-of-pocket health care costs. Ideas like capping the cost of insulin or negotiating drug prices may impact fairly narrow groups of the population, but politically, they have the great virtue of being understandable to voters and tapping into universal concerns. President Biden featured this approach in the several health proposals he made in the State of the Union address to lower people’s out-of-pocket costs. The two approaches—emphasizing commonly held values and addressing universal kitchen table concerns—are not mutually exclusive.

The political right and its supporting media have excelled at meeting disaffected working and rural Americans where they are, enlarging their ranks and forming them into a political base. Experts, centrists, and the left, less so. That’s why Democrats are regularly criticized for having great policy plans but a far less effective “message.” For their part, experts generally think very little about communication, although more so today than in the past. Among many other things, what’s needed is recognizing that the policy debates do not always connect with what is really motivating many people when issues and elections have deeper symbolic meaning triggered by both the media they consume and by candidates.

View all of Drew’s Beyond the Data Columns

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