Sources of the Emotional Explosion in the Health Care Debate

The extremely heated and emotional debate that erupted in the summer of 2009 over President Obama’s attempts to formulate and pass major reforms in the U.S. health care system might seem more than a little surprising. It was probably inevitable that such far-reaching change would generate considerable controversy and even fear. However, the virulence of the emotions and the linkage of health care to such seemingly unrelated “hot button” issues such as gun control certainly does not represent “politics as usual.” This

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paper seeks to trace the roots of this explosion by examining public opinion about health care reform at the time of the 2008 presidential election. While the American public appeared supportive of universal health care, one of the central reforms, the differences in opinion among various groups of citizens held the potential for the sharp cleavages that exploded in the following year.

The data for our analysis comes from the 2008 American National Election Study (ANES) conducted by the Survey Research Center of the University of Michigan. One major advantage of using this data set is that the respondents are polled on a very wide array of political topics, which allows us to examine how attitudes about health care reform are related to many other important issues. In this paper, we examine the attitudes about universal health care of the 1,442 white Americans in the ANES sample.

Whites were fairly supportive of providing universal health care at the time of the 2008 elections. Exactly half (50%) approved of extending the system to provide universal care in contrast to the 37% who opposed this reform, with another 13% neutral. While this fell short of a strong majority, it did suggest that President Obama could have found a very significant core of support for the major reforms that he was contemplating. Alternatively though, if a significant segment of these supporters were susceptible to persuasion, the opposition to health care reform could have become quite daunting, as it did in fact.

One method to assess the potential for the health care debate becoming emotional and even nasty is to break support for universal health care down by a variety of demographic characteristics and political attitudes. If attitudes about health care are correlated with sharp cleavages in American politics, the potential for the debate about the issue becoming strongly politicized would be much greater than if views about universal health care formed a separate dimen-

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sion. Our analysis found that partisanship was highly correlated with support for universal health care in 2008. There was a huge difference of 45 percentage points in support for health care reform (69% to 24%) between the supporters of Barack Obama and John McCain. Likewise, people who did not like Rush Limbaugh were much more supportive of universal health care than those who did by the strong margin of 52% to 29%. That this difference, 23 percentage points, was significantly less than the one for presidential vote, moreover, suggests a potential for Limbaugh to rally his supporters even more sharply against health care reform, which certainly seems to have happened in the spring and summer of 2009.

People’s need for health insurance would also be expected to shape their support for health care reform. This indeed turns out to be the case. Those without current insurance were considerably more supportive of universal health care by the margin of 63% to 47%; and those with family incomes under $40,000 were much more supportive of universal care than the more affluent; 64% to 43%. Yet, the difference between Americans younger and older than 65 (51% to 40%) was not that pronounced, despite the fact that seniors have Medicare. In retrospect, this limited age difference created another potential for increased opposition to health care reform when seniors became receptive to Republican claims that the Democratic plans threatened their Medicare benefits.

We also related attitudes about health care reform to several issues tapping two central issue dimensions in American politics: the role of government in helping the disadvantaged and cultural values. Health care represents an important issue in the debate over whether government should take a proactive role in promoting the social welfare of American citizens. Consequently, it should not be surprising that there were strong correlations between indicators of desiring a proactive government and support for universal

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health care. For example, support for universal health care varied greatly between those who wanted government to do more and those who advocated a smaller public sector (63% to 30%). Likewise, 68% of people who were not concerned about the size of the federal deficit wanted universal health care compared to only 45% of those who demanded deficit reduction. Significantly, public opinion shifted considerably in a conservative direction on both these attitudes about the role of government in response to strident Republican criticisms of President Obama’s economic policies. Consequently, support for health care reform was almost certainly undercut by growing public perceptions that government was “doing too much.” The relationship between cultural issues and support for health care reform is more problematic because, a priori, there would not appear to be any logical linkage between them. Yet, conservatives on abortion, immigration, guns, and gay marriage were less likely to favor universal health care than those who were liberal by approximately 10 to 20 percentage points: (40% to 61% for guns, 43% to 60% for gay marriage, 42% to 51% for abortion, and 42% to 55% for immigration. Taken together, these findings suggest a very significant potential for health care reform to become enmeshed in the culture war divisions that have become the most emotional divisions in contemporary American politics.

The roots of the intense and even vicious debate over health care reform in 2009, then, can be found in public opinion at the time of the 2008 elections well before the issue became highly salient. Superficially, the general public appeared to be at least mildly supportive of reform. Yet, it is also easy to discern the launching pad for the bitter battle that soon erupted. First, even as the issue lay quiescent, attitudes about health care were fairly strongly correlated with partisanship. Consequently, the eruption of a strident partisan battle over health care in the Spring of 2009 almost certainly activated latent partisan feelings. Second, the association

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between attitudes about health care reform and polarizing cultural divisions (surprising as it may be) provided more tinder for an escalating and expanding conflict. Third, the growing conservatism of Americans about the general role of government in 2009 undoubtedly contributed to the growing polarization on health care. Finally, the sharp growth in the opposition of senior citizens probably reflected growing hostility on cultural issues (e.g., fear of political and social change) as much as self-interest over perceived threats to Medicare.

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