Understanding Health Care in the 2012 Election

The outcome of the 2012 election will have far-reaching ramifications for the future of U.S. health care. Rarely in a national election have the two major candidates' views about health care been so diametrically opposed. The views of President Barack Obama and Republican presidential nominee Mitt Romney differ on whether the 2010 Affordable Care Act (ACA) should be implemented or repealed, whether Medicare and Medicaid should remain in their current forms with their current level of commitments, and whether the availability of abortion services should be further restricted. In addition, the candidates differ on whether the historically high federal budget deficit¹ should be addressed with spending cuts alone or whether the solution should include some tax increases and whether more of the spending cuts should come from defense or from the domestic arena. This last decision will probably affect the level of future federal health care spending in areas such as the National Institutes of Health, the Centers for Disease Control and Prevention, and community health centers, among others.

Here, we examine the role of health care in the 2012 election by drawing on the results of 37 independent telephone polls (with both land-line and cell-phone respondents) in a project supported by the Robert Wood Johnson Foundation. Examination of these polls as a group provides insight into the evolution of the public's thinking. Our analysis focuses on public perceptions of the current political environment surrounding health care, the role of health care as a voting issue, and the importance of specific health policy issues to individual voters' choices.

Table 1. Table 1. Most Important Issues for Voters in Presidential Elections, 2008 and 2012.

Polls show that health care is the second most important issue for likely voters in deciding their 2012 presidential vote (CBS–NYT, September 2012; HSPH–SSRS, 2012; see Opinion Polls on Health Care in the 2012 Election). This is the highest that health care has been ranked as a presidential election issue since 1992 (CNN–NEP, 2008).² When likely voters were asked to choose from a list of issues, an approach similar to that used in election-day exit polls, one in five (20%) named “health care and Medicare” as the most important issue in their 2012 voting choice, far behind “the economy and jobs” (cited by 51%) (HSPH–SSRS, 2012) (Table 1).

One factor that influences election outcomes for incumbent presidents is the public's assessment of their record — in this case, the President's record on health care — during their first term.³ Obama's approval rating on handling health care is 41%, with 52% disapproving (ABC–WP, July 2012). In terms of perceptions of progress, the majority of Americans believe the problem of health care costs in the United States has worsened during the past 5 years (65%). Only 27% see quality of care as having improved, although about equally few (25%) think it has worsened (NPR–RWJF–HSPH, 2012).

Figure 1. Figure 1. Public Attitudes about the Affordable Care Act.

Data are the averages from available polls for each period. For 2010, polls included KFF (April), AP–GfK (March), Gallup–USA Today (March), WP (March), Pew (April), and CBS (March–April). For 2011, polls included KFF (April), AP-GfK (March), Gallup (March), ABC–WP (January), Pew (January), and CBS (February). For early 2012, polls included KFF (April), AP–GfK (February), Gallup–USA Today (February), ABC–WP (March), Pew (March), and CBS–NYT (March). Current polls included KFF (September), ABC–WP (July), Pew (June–July), Reuters–Ipsos (July), NBC–WSJ (July), NPR (July), and CBS–NYT (September).

To date, the Obama and Romney campaigns have highlighted four major health care issues. The first is the ACA, which is seen as one of the President's major domestic-policy accomplishments. Despite 2¹∕₂ years of contentious debate, the public has not changed its view. Americans' assessment of the ACA remains mixed. Although several elements of the law are popular (CBS–NYT, March 2012; KFF, April 2012), since passage of the law in March 2010, the majority of Americans (in an average of polls) have not approved of the ACA. As shown in Figure 1, Americans have been relatively evenly divided in their opinions, even after the favorable Supreme Court decision on June 28, 2012, which upheld the constitutionality of the law. An average of current polls shows that 44% approve of the ACA and 45% disapprove.

This division occurs in part because the public anticipates varying effects of the ACA on the economy and on specific groups of people. More Americans believe that the ACA will hurt the economy (46%) than believe it will help it (37%) (Gallup, July 2–3, 2012). A majority believe that the ACA will make things better for the poor (60%), people who currently do not have health insurance (59%), and people who get sick (55%). However, only about one third believe that the ACA will make things better for people who are currently insured (36%), businesses (33%), and taxpayers (30%) (Nat J–UT, 2012; Gallup, July 9–12, 2012).

Specifically, the issue of how the ACA will affect people 65 years of age or older has been raised in connection with the $716 billion in cuts or savings from Medicare in the ACA and the question of whether seniors would be worse off under Medicare as a result. Currently, more people believe the ACA will make things better for people who are 65 or older (48%) than think it will make things worse for them (35%) (Nat J–UT, 2012).

The second issue is that of changing Medicare in the future to a system in which the government provides seniors with a fixed sum of money that they could use to purchase either private health insurance or Medicare coverage. An average of current polls shows that 27% favor such a proposed change, whereas a majority (66%) are opposed (ABC–WP, August 2012; Nat J–UT, 2012; CBS–NYT, September 2012; KFF, September 2012).

The third health care issue is a proposal to change Medicaid from the current system to one in which the federal government gives states a fixed amount of money and each state decides whom to cover and what services to pay for. An average of 57% of Americans oppose such a change, whereas 37% are in favor (Quinnipiac, 2011; KFF, May 2011).

The fourth issue is that of placing substantial new limits on the availability of abortion services. Here, the public is divided, with more people favoring restrictions on abortion. About half believe either that abortion should be illegal in all circumstances (15%) or that it should be legal in only a few circumstances (37%). About 4 in 10 believe that abortion should be legal under any circumstances (35%) or most circumstances (9%). However, a large majority (83%) of the public believes that abortion should be legal when the pregnancy was caused by rape or incest (CNN–ORC, 2012).

An average of polls shows that 81% indicate that health care is a very important issue in their vote for president (ABC–WP, July 2012; CBS–NYT, July 2012; Fox, 2012). However, relatively few people choose it as their top issue.

We examined poll results for likely voters, the subgroup of the public who say they have registered and are absolutely certain to vote in November. When we look at the views of likely voters who say that “health care and Medicare” (20%) or abortion (4%) will be the most important issue in deciding their presidential vote, the picture of the effect of the four issues on the election differs from what we see in overall public opinion polls (HSPH–SSRS, 2012).

A majority of likely voters who say that “health care and Medicare” is the most important issue in their vote self-identify as Democrats (59%) rather than as independents (25%) or Republicans (14%). Meanwhile, a majority of likely voters who say that abortion is the most important issue identify as Republicans (56%) rather than as independents (20%) or Democrats (20%).

Table 2. Table 2. Effect of the Presidential Candidate's Positions on the Voting Preferences of Likely Voters Who Rank Health Care and Medicare or Abortion as the Most Important Issue in Determining Their Vote.

We looked at these voters' views on the four main health care issues, presented in terms of the Republican presidential candidate's positions on those issues (Table 2). Among likely voters who said “health care and Medicare” was the most important issue in their choice, 41% said they were much less likely to vote for a candidate who supported repealing all or part of the ACA; 14% said they were much more likely to vote for such a candidate. Thirty-nine percent of these “health care and Medicare” voters said they were much less likely to vote for a candidate who favored changing Medicare to a system in which the government provides seniors with a fixed sum of money that they could use to purchase either private health insurance or Medicare coverage; 11% said they were much more likely to vote for such a candidate. Thirty-five percent said they were much less likely to vote for a candidate who favored changing Medicaid from the current system to one in which the federal government gives states a fixed amount of money and each state decides whom to cover and what services to pay for; 8% said they were much more likely to do so.

Among likely voters who said abortion was the most important issue in their choice, 61% said they were much more likely to vote for a candidate who favored placing substantial new limits on the availability of abortion services; 24% said they were much less likely to vote for such a candidate.

It should be noted that many likely voters who are opposed to the ACA or who favor major changes in Medicare and Medicaid may not rank “health care and Medicare” as the top issue in their voting choice. They may see “the economy and jobs” (51%) or “the federal budget deficit and taxes” (14%) as most important.

In summary, health care is playing a greater role in this presidential election than in many other recent ones. However, the economy dominates most voters' thinking in terms of their priorities for choosing a candidate. But in a close election, the two candidates' stands on health care issues could help swing the balance among some voters. Debates about the future role of government in health care are likely to figure prominently in the remainder of this presidential campaign. At this point in the election cycle, with the exception of voters focused on abortion, those who select health care as their top voting issue are much more likely to support the policy positions of Obama than those of Romney.