The outcome of hot-button health issues from Medicare reform to the uninsured hangs on who gains control of Congress and the White House this fall. Health care policy in the United States is a partisan minefield, with Democrats and Republicans disagreeing on everything from Medicare changes to malpractice reform to strategies for covering the nation's 43 million uninsured. While the economy, terrorism, and the Iraq war rank high on everyone's priority list, health care is not far behind. According to HSPH polling expert Robert Blendon, head of the Harvard Opinion Research Program, there is little middle ground between Democrats and Republicans when it comes to the nation's health.

Blendon's surveys drill down through Americans' surface preferences to reveal their core beliefs and values. Since 1988, his group has been doing election studies in collaboration with researchers at the Kaiser Family Foundation. These studies, in addition to surveys conducted with the Robert Wood Johnson Foundation and news organizations such as National Public Radio, ABC News, and the Washington Post, explore not only what Americans want, but their underlying political philosophies as well. For example, 61 percent of Democrats say government should make a major effort to provide insurance to the uninsured, even if it means raising taxes. In contrast, only 37 percent of Republicans feel this way. Forty-one percent of Republicans say the government should make only a limited effort to extend coverage for the uninsured if a tax hike is required, and another 18 percent like things just the way they are (chart 2).

Going to extremes

In the last 20 years, the political landscape has become dramatically more polarized, with elected Republicans more conservative, and their Democratic counterparts more liberal, than the parties' memberships overall. Why? One factor, Blendon says, is the way Congressional boundaries have been redrawn, creating districts that are fiercely Democratic or dominantly Republican. Candidates face their stiffest opposition in party primaries and must sharpen their positions to appeal to the party's most faithful. Election victors are, on average, 10 percentage points more liberal than average Democrats when polled on the issues, or 10 percent more conservative than average Republicans.

Another reason for the growing polarization between elected Democrats and Republicans is voter apathy. People who turn out to cast their ballots tend to feel more strongly about election-year issues than nonvoters. These forces can make compromise between the parties on key issues nearly impossible, Blendon observes. "It may actually be easier for legislators to compromise on health care if the issue drops out of the top tier of voter concerns," he says.

The two parties are especially far apart on the so-called "pocketbook" issues--ones that impact people's bottom line (chart 3). "Republicans care more about tax cuts," Blendon says. Meanwhile, a large majority of Democrats say government spends too little to protect the nation's health. Small wonder: their party includes many wage-earners of $50,000 or less, whose health is at greatest risk.

"Ill health is higher among poorer people, immigrants, the elderly, and other economically disadvantaged groups," Blendon says. "Unfortunately, many of them don't vote," a reality that exacerbates the gap between legislators and those they try to represent.

Yet another cause for disagreement between the two parties is the country's public health system. Asked to rate their level of satisfaction, a whopping 32-point difference emerges, with many Dems none too pleased (chart 4).

Americans are also at odds over health-related issues with a strong moral component, Blendon says. "We're all against viruses and diseases like AIDS, but we don't share common values on abortion and teaching the use of condoms, or taxation to pay for treatments in other countries."

Are there any points of consensus? Blendon says yes: Both parties agree that the health care system is broken, and that costs--now 14 percent of gross national product--are out of hand. But there is no agreement on what to do.

Beyond partisanship

While many Americans claim to vote for the man (or woman), or to vote on the issues, statistics suggest otherwise. "Eighty percent of Democrats and 80 percent of Republicans go with candidates from their party," Blendon says. While Democrats are slightly more numerous than Republicans, he notes, Republicans are slightly more effective than Democrats in "getting out the vote."

These facts being equal, November's election will turn on the 20 percent of Americans in each party who don't always vote the party line. "They'll vote instead for a particular person or issue," says Blendon. Candidates should focus on luring independents and their swing votes.

In the end, elections are won or lost based on how swing voters feel about the incumbent. Says Blendon: "Are they mad about things he or she has or hasn't done? Or do they feel he or she has done a good job overall? If the answer to the last question is 'no,' the next is: 'Does the challenger look to be up to the job?' "

The war in Iraq, the economy, and terrorism will weigh heavily on swing voters this November. Some health care issues have the potential to help or hurt incumbents, Blendon predicts, if voters' attitudes shift from neutral to dissatisfied … to angry. Take the Medicare prescription drug benefit: Polls show that seniors are unhappy, both with how the benefit is constructed and with its failure to empower government to negotiate lower drug prices (charts 6 and 8).

"Seniors vote, which is why we saw a push to pass this legislation," says Blendon. "People are angry with Bush about Medicare. He can't point to this as an accomplishment of his administration, as he had hoped." As fears about health insurance coverage and premiums intensify (charts 5, 7), look for Democratic Presidential candidate John Kerry and Congressional candidates to use these issues to woo uncommitted voters.

Post-election forecast

So what do Blendon's polls forecast for health policy after the elections?

If Bush is re-elected, tinkering with health insurance by Republicans could expand coverage to perhaps 3 million more uninsured, Blendon says. If Kerry gets into the White House and the Democrats control Congress, many millions more may receive coverage. But the problem of the uninsured won't disappear, no matter who wins.

Instead, Blendon foresees a mix of state-run programs to expand access to Medicaid, new incentives for employers to insure low-wage workers, and tax breaks that encourage people to buy coverage. While universal health care has strong moral appeal for many, no more than 20 percent of Americans can agree on any one health reform proposal. And too few are willing to pay the price.

Julie Fitzpatrick Rafferty is director of Development Communications at HSPH.