Health Care Voters May Surprise Us

Health Care Voters May Surprise Us
AP Photo/Mark Humphrey
Health Care Voters May Surprise Us
AP Photo/Mark Humphrey
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In the heated tribalism of modern American politics, one issue transcends entrenched political divides: health care.

A new public opinion survey by RealClear Opinion Research measured voter attitudes about this pivotal issue. Respondents identified health care as a top issue, with 62% rating it the most or second most important issue facing the future of America. Health costs burden nearly half the survey’s respondents, hitting Republicans and Democrats alike. Although 72% of people in the poll feel they get excellent or good care, almost as many feel the system is broken or not working well.

But voter attitudes towards sweeping reform proposals like “Medicare for All” do not reveal the whole story when it comes to health care priorities. Because all voters eventually become health care consumers, it's worth looking beyond their opinions on health care issues to determine how they feel and behave as individual health care consumers. How do those individual feelings and behaviors relate to voting patterns and political engagement? The answers may shed new light on how to reach voters on health care issues.

As it turns out, what kind of health care consumer you are may have more to do with your age, education, and overall outlook, than with who you vote for or your political ideology.

Delving into the RealClear Opinion Research polls results, four distinct health care consumer types emerge, based on a combination of factors relating to levels of health care satisfaction, engagement, and propensity to research costs and options. The four groups can be plotted along two axes: satisfaction with health care and propensity to shop in a health care context (or engage with health care decisions).

Although there are nuanced demographic differences within the groups, for the most part political affiliation is consistent. That is, these groupings had little to do with party breakdown. The real differences emerge along dimensions of empowerment and engagement with the health care system, and ideological priorities for the future of health care, such as lowering costs versus ensuring universal access to care or protecting vulnerable people in the health care context.

Satisfied and Savvy (24%)

Satisfied and Savvy are contented shoppers. As health care consumers, they are generally happy with the quality and value of health care they receive. They make sure they get what they need by engaging in their health care decisions, paying close attention to their health care costs, comparing options and checking prices before getting health care services, and researching their doctors online. This group was least likely to prioritize lowering health care costs as the most pressing issue facing health care, though almost half of them reported feeling burdened by health care costs. They are the most likely to assume others get good health care (55%), mirroring their own satisfaction.

This group was also the most educated and wealthiest, and nearly two-thirds (64%) white. Millennials comprise 32%, whereas people 65 and over were just 13% of this group.

Satisfied and Savvy consumers are not just engaged with their health care, they are also the most politically engaged of all segments – almost twice as likely to be engaged as the least-engaged group, and most likely to feel the country is on the right track. Politically, they are more likely to be affiliated with one of the two major parties: 43% identifies as Democrats, 31% as Republican, and only 14% as Independents. Looking ahead to 2020, this political engagement translates into stronger support for leading Democratic contenders. For example, 48% of this group is certain or likely to vote for Joe Biden, double the support from his weakest segment.

Despite relative health care satisfaction, this group was least likely to oppose Medicare for All reforms, and most likely to feel people should not lose health insurance when they leave a job. Reform proposals that protect or enhance health insurance portability may especially resonate.

This group actively and effectively navigates the health care system, generally to their benefit. They are engaged politically, and open to changes to the system. They are likely to be open-minded to new health care models, having mastered their way in the current one.

Skeptical and Searching (19%)

Like the Satisfied and Savvy group, the Skeptical and Searching group is highly engaged in their health care decisions. They are also active and cost-conscious health care shoppers, researching options and paying close attention to their health costs. But, unlike the first group of shoppers, they are not particularly satisfied with the status quo. They are most likely (68%) to report feeling burdened by health care costs, and are more than twice as likely to feel burdened than the least burdened group. Not surprisingly, lowering health care costs was this group’s most pressing concern for the future of health care. They were also most likely to be concerned with making sure all Americans have access to health care. They were the least likely to assume others’ care is good (21%); if their own health care is bad, perhaps they assume no one else’s could be better.

Demographically, this group has the largest concentration of millennials (33%), and the lowest representation of older Americans (7%). Nearly three-quarters of this group was white, and they were least likely (11%) to report annual income over $100,000.

More than half of Skeptical and Searching group members are politically engaged. They have as many Independents (23%) as Republicans, the largest concentration of Independent voters of our segments. More than a third identify as Democrats. They are least likely (27%) to feel the country is on the right track; more than half (53%) feel it is on the wrong track. This group had the lowest proportion of 2016 Trump voters, and are least likely to report plans to vote for Trump in 2020.

Generally open to Medicare for All proposals, their support actually rises when the premise of the question explicitly eliminates private health insurers. This group is most focused on health care costs and puts in the effort to manage those costs as well as they can. Yet based on their own experience bearing financial burdens, the system is not working for them. Candidates and proposals aimed at this group need to speak to reducing the crushing weight of health care financial burdens.

Unhappy and Unplugged (25%)

Unhappy and Unplugged health care consumers are dissatisfied with health care today, but also disengaged. Unlike Skeptical and Searching consumers, this group does not shop or engage actively in their health care decisions. When identifying the most pressing issues facing health care, they are three times (22%) more likely than the Skeptical and Searching group (7%) to prioritize making sure people with alcohol and drug problems can access care. They are also most likely to report caring about health care cost transparency (25%). They are least likely to prioritize making sure all Americans have access to health care (42%), that people with pre-existing conditions are not charged more than others (35%), or that health care decisions are made by doctors rather than insurance plans (35%). This group has a clear hierarchy of needs, focusing on access to treatment for drug and alcohol abuse above general health care access.

This group has proportional representation among millennials (31%), but is just 8% of people 65 and over. Unhappy and Unplugged consumers are less educated, and lower income than other segments. They are half as likely as their counterparts in the Satisfied and Savvy group to have a college degree, and more than half (56%) report annual income less than $50,000.

This is also the least politically engaged segment (39%). Political affiliations in this group were distributed on par with other groups, though this group has slightly fewer (30%) Democrats, but essentially the same proportion of Republicans (23%) and Independents (21%). They were the least likely to have voted in 2016, with almost one-fifth sitting out the election. Of those that voted, this group was most likely to have cast their ballot for Donald Trump (46%) and least likely to have done so for Hilary Clinton (41%).

Looking ahead, only 35% of Unhappy and Unplugged are certain or likely to vote for Donald Trump in 2020, and they are least likely to support Joe Biden (24%) or Bernie Sanders (24%). This group reported the highest opposition (17%) to Medicare for All, yet showed greater support for plans that eliminate private health insurers. It may be hard to reach these voters, and proposals focused on protections for others are unlikely to resonate. Addressing access to alcohol and drug treatments is the most likely way to appeal to this group.

Coasting and Contented (31%)

Coasting and Contented health care consumers are satisfied non-shoppers. They do not tend to actively engage in their health care decisions. They are least likely to report feeling burdened by health care costs (34%); they report feeling burdened half as often as the most-burdened group (Skeptical and Searching). That said, they are most likely to prioritize lowering the cost of prescription drugs (44%). They also focus more than other groups on protecting people with pre-existing conditions (42%) and making sure health care decisions are made by doctors not insurers (41%). Conversely, they are less concerned than other groups with cost transparency (18%).

This group is disproportionately older, with the lowest proportion of millennials (20%) and the highest proportion of people 65 and older (23%). Party affiliations in this group were consistent with the others; 35% identify as Democrats, 28% as Republicans, and 21% as Independents. Compared with other segments, they object most (18%) to Medicare for All proposals that eliminate private health insurance.

This cohort does not have to work that hard to get what they need from their health care. Likely over-representative of Medicare enrollees, it is unlikely they will support sweeping changes that jeopardize their health care happiness. Medicare for All may be seen as a threat to Medicare for them.

In the end, health care is more than a political issue; it is also deeply personal. Health problems can make anyone physically vulnerable, and many people financially so. For Americans with less education and financial means, navigating the system to get what they need is challenging, and many do not even bother to try. Apathy or lack of engagement in health care decision-making parallels their political disengagement.

The politics of health care reform, therefore, requires understanding differences in consumer priorities and designing policies to meet their most pressing needs. The Democrats pursuing the 2020 nomination -- and the GOP alike -- would do well to look beyond their core supporters when staking out their health care territories and get to know voters as distinct types of health care consumers. More nuanced solutions, targeted to distinct health care segments, may be the key to transcending party lines and addressing voters’ top priorities.

Deb Gordon, a senior fellow at Harvard Kennedy School’s Center for Business and Government and a former health plan executive, researches health care consumerism and writes about consumers at the intersection of policy and practice. Follow her on Twitter @gordondeb.

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