Lockman A, Blendon RJ. Rural US Voters’ Views on Health Policy and COVID-19 Before the 2020 Election. JAMA Health Forum. Published online September 21, 2020. doi:10.1001/jamahealthforum.2020.1123
Rural US residents played a key role in the 2016 election. Despite media portrayals as an ideological monolith,1 rural views on issues—including health policy—are nuanced. Ahead of the upcoming elections, it is important to examine rural US residents’ opinions on major health issues and how their strong and divergent political values influence their view of the government’s role in addressing these challenges. We reviewed multiple public opinion surveys conducted from 2018 to 2020 by the Harvard T.H. Chan School of Public Health in partnership with Robert Wood Johnson Foundation and NPR,2 the Commonwealth Fund and the New York Times,3 and POLITICO4 on rural US residents by partisan affiliation (ie, Democrat, independent, or Republican) and found that despite numerous serious problems shared across party lines, rural US residents’ views on the coronavirus disease 2019 (COVID-19) response, health reform, and the role of government are largely shaped by their political values. Even in the midst of a major public health crisis such as COVID-19, rural US residents are deeply divided in their views of how policy makers should respond. Much like their nonrural counterparts, rural Republicans largely favor opening the economy during the COVID-19 outbreak and having less government involvement in health care. Rural Democrats largely favor keeping nonessential businesses closed until COVID-19 spread is contained, and they support greater government involvement in health care. In comparison, rural independent voters are largely split on both issues.
Rural US residents have been widely affected by the economic fallout from the COVID-19 pandemic, an experience shared across party lines. More than 1 in 3 rural US residents (36%) have reported job losses or lost wages since the COVID-19 outbreak. In 2018—before the COVID-19 pandemic and approximately a decade after the Great Recession of 2007 to 2009—more than half of rural US residents (54%) reported negative ratings of their local economies. However, despite widespread economic problems, deep political divisions exist in rural US residents’ preferences on the government response to the COVID-19 crisis. Approximately two-thirds of rural Republicans (65%) believe that nonessential businesses should be open to reduce financial difficulties for businesses and people compared with 33% of rural Democrats. These divisions on views of the COVID-19 pandemic are notable because they lie in stark contrast to public opinion on the opioid crisis, which has bipartisan consensus among most rural Americans, who view it as a serious problem in their communities.5
In addition to economic problems due to COVID-19, sizeable shares of rural US residents across the political spectrum reported problems with health care access and costs; 27% reported being unable to get health care when needed at some point in the past few years, and half (50%) reported that health costs have been a serious problem for family finances. Despite this, relatively few rural US residents (30%) believe that the federal government should be more involved in health care. However, there are strong partisan divisions in these beliefs: rural Democrats (61%) are substantially more likely than rural Republicans (6%) or independents (28%) to support greater government involvement. Similarly, less than half of rural voters (46%) believe the government has a responsibility to ensure all US residents have health insurance coverage, with substantial differences between rural Republicans (18%), rural Democrats (78%), and rural independents (48%).
When it comes to health care reform, rural US residents are divided on paths to reform, including Medicare for All (48% support, 49% oppose). Few rural Republicans (24%) support Medicare for All compared with rural Democrats (80%) and independents (47%). Most rural US residents view the Patient Protection and Affordable Care Act unfavorably (56%), with rural Republicans (84%) being substantially more likely than rural Democrats (23%) and independents (54%) to have a negative opinion of the law.
Rural US residents’ preferences for a limited role for federal governmental in their lives appears even beyond health issues. Most rural US residents (59%) believe that when something is run by the federal government, it is not run too well or not run well at all, with partisan splits in rural opinions similar to those regarding federal involvement in health care: 61% of rural Republicans, 41% of rural Democrats, and 72% of rural independents share this view.
The 2016 election highlighted the importance of uniquely challenging problems in the rural United States,6 including slow economic recovery from the Great Recession of 2007 to 2009, health care shortages, and widespread opioid addiction. However, narratives suggesting that rural US residents are ideologically homogenous fail to account for the strength of partisan identity in individuals’ views as well as the cross-pressures of economic changes, challenges to health care access, and personal values surrounding social issues and religious beliefs.1,7
Partisan divisions among rural US residents’ responses suggest the strength of partisan identity and value-driven reasoning in assessing the challenges they face.8 As individuals increasingly hold strong political views, policy opinions are largely reflective of individuals’ political values, not necessarily problems themselves.9
These findings have important implications for how political candidates appeal to rural Americans during future elections. On issues with wide differences—such as Medicare for All and COVID-19 restrictions—candidates seeking rural votes will likely either need to embrace the extreme sides of health issues or appeal to independent voters, who remain largely divided on numerous issues. Rural Republicans generally lack confidence in the government’s ability to run programs and are deeply opposed to greater government involvement in health care. Meanwhile, most rural Democrats have greater confidence in government and support a stronger role for the federal government. The role of government is a major issue that influences how rural voters perceive challenges at hand and where they believe help should come from.
These partisan divisions may become increasingly polarized given today’s economic and public health challenges. The direction of policy solutions will largely be driven by whichever party secures power following the 2020 federal election, making it clear that these highly salient issues will likely be front and center leading up to election day. The outcome of the 2020 election will in turn influence which health policies are placed on the national agenda and how those policies are pursued.
Corresponding Author: Alee Lockman, MPH, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, 14 Story St, Cambridge, MA 02138 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Ms Lockman reported receiving grants from the National Institute of Mental Health of the National Institutes of Health during the conduct of the study. No other disclosures reported.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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