terça-feira, novembro 11, 2008

Fantástico trabalho publicado no NEJM sobre a influência das preocupações com o sistema de saúde no resultado das eleições americanas. Quando em Portugal se fizer algo sequer minimamente comparável voltaremos a conversar (a discussão sobre o modelo de SNS que queremos é um tema tabu e lamentavelmente sempre negligenciado nos momentos eleitorais)...

The New England Journal of Medicine
Special Report
Volume 359:2050-2061 November 6, 2008 Number 19

Voters and Health Reform in the 2008 Presidential Election
Robert J. Blendon, Sc.D., Drew E. Altman, Ph.D., John M. Benson, M.A., Mollyann Brodie, Ph.D., Tami Buhr, A.M., Claudia Deane, M.A., and Sasha Buscho, B.A.

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The 2008 presidential election season has been unique in a number of ways. What insights about future health policy will the election give us? This is the second in a series of reports published in the Journal that examines this question.

The first report focused on health care's role in each party's presidential primaries. Its central conclusion was that the adherents to the two major political parties had substantially different visions of the future of health policy in America.1 These findings have been reinforced by subsequent surveys of each party's convention delegates. In these surveys, a random sample of attendees was asked what was more important: to provide health care coverage for all Americans or to hold down taxes. As compared with 7% of Republican delegates, 94% of Democratic delegates selected expanding coverage; 77% of Republican delegates and 3% of Democratic delegates said holding down taxes was more important.2

This second article looks at health care's role in the general election along several dimensions. First, we examine the public's perceptions of the state of health care. Second, we look at the role of health care in this election and compare its relative importance with that in previous elections. Third, we report and contrast the health policy views of registered voters who say they intend to vote for Senator John McCain with those of supporters of Senator Barack Obama. In analyzing these views, we will focus on the issues that have been raised by the presidential candidates during the campaign. Finally, we will discuss our view of the implications of our findings for the prospects of health reform in the next administration.


Sources of Data

The data presented were drawn from 11 national opinion surveys, including 1 main survey designed and analyzed for this article by public opinion researchers at the Kaiser Family Foundation and the Harvard School of Public Health.3 Field work for this study was conducted by International Communications Research from September 10 through September 21, 2008, as a telephone survey of a nationwide sample of 1622 self-described registered voters.

We have also drawn on the results of five surveys conducted with representative samples of the general public from February through September 2008 (selecting the most recent data on each topic covered).4,5,6,7,8 These polls involved telephone interviews with 1007 to 1207 randomly selected adults and were conducted with the use of methods typically used by national media organizations so the results could be compared with those from media surveys conducted during the same period or earlier.

The remaining five surveys were national election-day exit polls of randomly selected voters conducted on presidential election day in 1988, 1992, 1996, 2000, and 2004 by media organizations.9,10,11,12,13 Self-administered interviews with the use of paper questionnaires were conducted with 6990 to 87,946 voters. The results of these surveys were compiled by the Roper Center for Public Opinion Research in Storrs, Connecticut, or from data provided by the organizations that conducted the surveys.

Survey Questions

See the Supplementary Appendix, available with the full text of this article at www.nejm.org, for a description of the survey questions.

Statistical Analysis

The surveys reported in this article, like all surveys, were subject to sampling error. The results may therefore differ from those that would have been obtained if the whole population had been interviewed. For example, an analysis of a sample of 1000 to 1200 persons will, with a 95% degree of confidence, have a statistical precision of approximately ±3 percentage points; for a sample of 10,000, the comparable precision would be ±1 percentage point.

In general, national polling organizations that engage in media surveys or surveys with the use of similar methods do not release their rates of response. According to the most recently published research, the typical response rate for polls of this kind is 25%.14 The response rate for the survey of registered voters was 39%, and the cooperation rate was 50%.3,15

Independent studies have shown that statistically adjusting — or weighting — the data obtained from random-digit–dialed telephone surveys to known population variables ameliorates the effects of a lower response rate.14,16,17,18,19,20 The results of the surveys presented here were statistically weighted to reflect the actual composition of the population of the United States, calculated on the basis of data from the Census Bureau, according to age, sex, education level, region, race or ethnic background, and household size.21 In the main survey, demographic data were collected even for respondents who did not identify themselves as registered voters, enabling a similar weighting process.

None of the surveys described in this article involved interviews with adults who used cell phones only; this is a possible source of noncoverage bias. However, several recent studies have shown that when data are weighted demographically, the results from samples that include only land-line respondents are nearly identical to those that include both cell-only and land-line respondents.22,23,24,25

To examine differences between "McCain voters" and "Obama voters," we compared responses by conducting z-tests for differences in proportions, taking into account the effect of the design of the study.26 "McCain voters" or "Obama voters" are defined as registered voters who said that if the presidential election were being held today, they would vote for or lean toward voting for John McCain and Sarah Palin or for Barack Obama and Joe Biden.

In the tables, "don't know," "not sure," "no opinion," "refused" (declined to answer), and "no answer" are not shown unless they sum to 10% or more for any group whose responses to a question are included. Data from persons who give such responses are, however, included in the base used to calculate percentages.


The General Public's Perceptions of Health Care

Table 1 presents the general public's assessment of the state of health care overall and for individuals during the 2008 election campaign period. The majority of respondents rate the state of the U.S. health care system at the time of the election as "fair" or "poor," and although most respondents do not see the health system as being in a crisis situation today, they do see it as facing major problems.4 Similarly, a substantial minority believes that the health systems in some other countries are better than the current U.S. system.5 More than two thirds say they do not approve of President George W. Bush's handling of health care policy.6 A majority of Americans believe that wounded veterans of the war in Iraq do not receive high-quality medical care when they return to the United States.7

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Table 1. Americans' Views about the Health Care System and Their Health Care.

With regard to their own recent health care, about one of five Americans reports problems with the quality of care they receive. One of five also reports problems paying their medical bills in the past year, and a similar proportion say there were times in the past year when they needed care but did not receive it.4 In addition, about one of four reports being "very worried" that they will not be able to afford the cost of health care services they need, and similar proportions are very worried that the quality of health care they receive will worsen. Among persons with health insurance coverage, about one of four is very worried that they could lose it in the future.8

As to personal financial pressures in the wake of recent changes in the economy, 3 of 10 Americans say their family is having "serious problems" paying for health care and health insurance, the third most common of a list of seven serious financial challenges facing the public this fall.8

The Role of Health Care in Presidential Elections

Since 1988, health care has been one of the six most important issues to voters in each presidential election (Table 2).9,10,11,12,13 In only one election did health care rank as one of the top two issues. That was 1992, the election that preceded a national debate over health reform. In 2008, registered voters ranked health care third as an election issue. The differences between the issues ranked second through fourth were not statistically significant.3 Health care has ranked higher as a presidential voting issue for Democrats than for Republicans and Independents in every presidential election from 1988 through 2008.3,9,10,11,12,13

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Table 2. Most Important Issues for Voters in the Presidential Elections of 1988, 1992, 1996, 2000, 2004, and 2008, According to Political Party.

Our analysis shows that some demographic groups are more likely than others to name health care as a top voting issue in nearly every presidential election. Women (except in 1992), low- and moderate-income voters, voters 65 years of age or older (except in 2008), and blacks (except in 1996) have been more likely than men, higher-income, younger, and white voters, respectively, to cite health care as an important voting issue (Table 3).3,9,10,11,12,13

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Table 3. "Health Care Voters" in Presidential Elections, According to Demographic Characteristics.

Views of Registered Voters

Health Care as a Priority in the 2008 Election

Views of registered voters about their health care priorities and policy preferences for the next president are shown in Table 4.3 When registered voters were asked to choose the most important issue affecting their vote among a list of issues, health care ranked second among those who said they intended to vote for Senator Obama and tied for fourth (with the war in Iraq) among those intending to vote for Senator McCain. The majority of registered voters indicated that the presidential candidates' stands on issues were more important than the candidates' characteristics in making their voting decision. However, the majority of McCain voters said candidate characteristics were more important, whereas the majority of Obama voters said that issues were more important in their voting decision.

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Table 4. Registered Voters' Attitudes about Health Care Priorities and Health Policy, According to Presidential Voting Intention.

Health Care Priorities

When asked to choose their top health care priority for the new administration from a list of five problem areas, registered voters overall, McCain voters, and Obama voters ranked affordability as the top priority. Second among voters overall was expanding health insurance coverage for the uninsured. Obama voters were significantly more likely than McCain voters to indicate that expanding health insurance coverage for the uninsured was a priority issue (Table 4).

Health System Reform

Registered voters were presented with a series of health policy choices. The majority of registered voters favored either an overhaul of the system or major changes. Obama voters were more likely than McCain voters to say that the health care system needed to be overhauled and less likely to see the system as needing no change or minor changes (Table 4).

Health Care Coverage

The majority of Obama voters said the federal government should be most responsible for helping ensure that Americans receive health insurance coverage. McCain voters were significantly more likely than Obama voters to say that the responsibility lies with individual persons. Asked to choose among three approaches to increase insurance coverage, voters were equally divided between support for a large, nearly universal plan and more limited approaches. However, Obama voters were more than twice as likely as McCain voters to favor the large plan, whereas the majority of McCain voters selected the two more limited options for coverage expansion (Table 4).

Health Care Costs

Broad differences between Obama and McCain voters are also visible on the issue of slowing rising health care costs. The majority of registered voters said the president and Congress could do "a lot" about the cost of health care, but Obama voters were significantly more likely than McCain voters to believe government had such influence.

At the same time, voters are divided as to who should have the principal responsibility for slowing the increase in health care costs. Despite the majority view that the federal government should play more of a role than it does now, most registered voters did not believe that the federal government should have the central role in slowing rising health care costs. Voters who did believe that the federal government should have this role were more likely to be Obama than McCain voters. A plurality of voters said that health insurance companies should be most responsible.

Respondents were given four options for what the next president's top priority should be when it comes to dealing with increasing health care costs. Registered voters overall, as well as supporters of both candidates, chose as their top priority the more personal option, reducing the amount people pay for their health care and insurance, rather than focusing on more national aspects of the problem. In this instance, McCain voters and Obama voters have similar priorities (Table 4).

Elements of Health Reform

Registered voters were asked about seven elements of health reform that were being discussed by the current presidential candidates (Table 5).3 In order to assess which ones were strongly supported, we focused on the elements viewed "very" favorably by a majority of respondents. Overall, only one element was viewed very favorably by a majority of registered voters: requiring health insurance companies to cover anyone who applies, even if they have a previous illness. None of the seven elements were viewed very favorably by the majority of McCain voters. Four elements were viewed very favorably by the majority of Obama voters.

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Table 5. Registered Voters' Attitudes about Elements of Health Reform, According to Presidential Voting Intention.

The majority of registered voters said that health care proposals not raising taxes was the most important or a very important consideration. McCain voters were significantly more likely than Obama voters to express this concern.

Health Care Spending

When respondents were asked to consider the deficit and priorities other than health and to identify what they would like the next president to propose in each of six areas of health spending, the majority of registered voters said that federal spending on medical care for veterans and on programs to prevent disease and improve health should be increased. A lesser proportion favored increased spending in other areas. No more than 12% of registered voters said that federal spending in any of the six areas should be decreased (Table 4).

The only area in which the majority of McCain voters said federal spending should be increased was medical care for veterans, a view shared by Obama voters. McCain voters were significantly more likely than Obama voters to favor increased spending on programs to protect against bioterrorism. Obama voters were significantly more likely than McCain voters to say that federal health spending should be increased in all other areas (Table 4).


The majority of registered voters overall, as well as the majority of Obama voters, said that abortion should be legal in all or most situations. The majority of McCain voters said that abortion should be illegal in all or most cases (Table 4).


What do these results suggest about the future of health reform? Taken together, three factors — widely held negative views of the current health system, concerns about the Bush Administration's policies, and the real health care problems and worries that many Americans report — have made health care an important issue to voters in this election. In addition, health care concerns are clearly part of Americans' broader economic worries.

A large majority of voters favor major changes in health care; however, supporters of the two major candidates differ greatly when it comes to their views on the direction and magnitude of such change. In contrast to Senator Obama's backers, Senator McCain's supporters place a lower priority on reforming health care and favor a less expansive role for the federal government in increasing coverage for the uninsured. They also advocate a lesser role for government regulation of health care costs and more emphasis on the private sector, as well as more restrained federal health spending. Finally, they believe in a more central role for individual responsibility in addressing the nation's health care problems. However, supporters of both candidates have concerns about increasing taxes for health care.

The views of their supporters suggest the possible starting points for health care reform under a President McCain or a President Obama, but of course public views alone do not make health care reform happen. Making any of these desired changes will require a president who decides to invest substantial intellectual and political capital in health care reform. Many strong voices in Congress will be heard, as will health care's powerful interest groups.27 Finding new resources to pay for any expanded coverage will be a major hurdle, particularly in the new economic climate. And all sides will need to face the very real divides in opinion we have shown to exist between supporters of the two candidates and that exist in even starker relief among their policy experts.28

In sum, health care reform legislation is possible under either presidential candidate's administration, but its scope and direction would differ in a McCain presidency versus an Obama presidency. Since health care is likely to be a second-level priority for presidential action as compared with the country's current economic situation, it will take leadership from the White House and the Congress for health care reform to be achieved.

No potential conflict of interest relevant to this article was reported.

Source Information

This article (10.1056/NEJMsr0807717) was published at www.nejm.org on October 30, 2008.

From the Harvard School of Public Health, Boston (R.J.B., J.M.B.); the John F. Kennedy School of Government, Harvard University, Cambridge, MA (R.J.B.); the Kaiser Family Foundation, Menlo Park, CA (D.E.A., M.B., C.D., S.B.); and Opinion Dynamics, Waltham, MA (T.B.).

Address reprint requests to Dr. Blendon at the Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., 4th Fl., Boston, MA 02115, or at rblendon@hsph.harvard.edu.


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