As a result of the 2020 election, Democrats now have control of 3 bodies of national government: the presidency and both houses of Congress. But their margins in the Senate and House of Representatives are slim, which likely means very close votes on major legislation. Over time, the voting patterns of elected officials have tipped more closely to the views of people who identify with their own political party than those of the public as a whole, emphasizing the importance of analyzing policy preferences by party. Since the mid-1990s, those who identify with the 2 political parties have grown further apart in their policy preferences. In 2019, average Democrats differed from average Republicans in their views across 30 policy-related issues about what government should do in the future by 39 percentage points, more than double the gap in 1994.1 What is not often recognized is how profoundly divided those who identify as Democrats and Republicans are on key issues of health care policy today, such as Medicaid spending and abortion.
While initiatives of the majority party, in the current case Democrats, are likely to align largely with their own constituents’ views, the close balance of power within both houses of Congress makes the views of the minority party, in this case Republicans, important to consider.
Using recent probability-based national polls, with sample sizes ranging between 1007 and 15 590, this Viewpoint describes the views on 4 issues among those who identify with the majority and minority parties.
Among these 4 issues, action to deal with the COVID-19 pandemic shows the least partisan differences. Individuals in the US overall, as well as both Democrats and Republicans, want to address the destructive effects of COVID-19. In a survey conducted after the 2020 election in which 1007 participants were asked to describe how important each of 23 potential priorities mentioned in the media should be for the new president and Congress, 4 of the public’s top 5 priorities were related to coping with the effects of COVID-19 on lives and the US economy. These included enacting a major COVID-19 relief bill; substantially expanding federal support for COVID-19 testing, vaccination, and personal protective equipment; passing a major economic stimulus bill; and increasing eligibility for food stamps during the COVID-19 pandemic.2 These were among the top 5 priorities for both Democrats (n = 328) and Republicans (n = 272).2
However, these shared priorities do not mean the parties will support the same policies to deal with the COVID-19 crisis. Democrats and Republicans differ sharply about whether federal or state governments should be mainly responsible for developing and executing plans to limit the spread of the SARS-CoV-2 virus. In a survey conducted in July to August 2020 in which 5501 participants were asked the question, 68% of Republicans (n = 2475 surveyed) preferred state/local governments, whereas 64% of Democrats (n = 2751 surveyed) preferred the federal government.3
Democrats and Republicans also differed on whether they will pay attention to the views of medical scientists. In a survey from April 2020 that included 5047 participants, a majority (53%) of Democrats (n = 2574 surveyed) expressed “a great deal” of confidence in medical scientists to act in the best interests of the public compared with 31% of Republicans (n = 2271 surveyed).4 This difference in confidence may shape the nation’s capacity to respond to future disease outbreaks and needs to be addressed. Another survey from November to December 2020 that involved 2150 participants found that 90% of Democrats (n = 361 surveyed) reported that they believe that federal government spending to prevent the spread of infectious diseases should be increased compared with 44% of Republicans (n = 273 surveyed) (only 1073 were asked this split-sampled question).5 Polls suggest that both parties support some sort of emergency aid bill to respond to COVID-19, but Republicans want a smaller, more constrained bill and will not support President Biden’s proposed $1.9 trillion legislation.
Universal Coverage and National Health Insurance Reform
On the issue of universal health insurance coverage, the 2 parties’ constituents appear to be sharply divided. Nearly 9 in 10 Democrats (87%) (n = 703 surveyed) reported that they believe it is the responsibility of the government to ensure all individuals in the US have health insurance coverage, a view shared by fewer than 1 in 4 Republicans (23%) (n = 580 surveyed). Among Democrats, 75% reported that they prefer a health insurance system mostly run by the government, whereas 79% of Republicans reported that they prefer a system based mostly on private health insurance.5
The same survey of 2150 individuals also addressed specific coverage proposals and found majorities of Democrats (n = 703 surveyed) expressed support for each of 3 options: building on the Affordable Care Act (ACA) (93%), Medicare-for-All (85%), and a Medicare buy-in to the ACA sometimes called “the public option” (82%). In contrast, only 30% of Republicans (n = 580 surveyed) expressed support for building on the ACA and 28% supported Medicare-for-All. While 62% of Republicans (n = 580 surveyed) reported that they support a Medicare buy-in to the ACA, that support does not represent an endorsement of the notion that government should ensure universal coverage. In addition, 64% of Republicans reported that they support replacing the ACA with a state-based private health insurance alternative compared with 36% of Democrats (n = 703 surveyed).5
US Health Care System Reform
Currently, enthusiasm for broad reform of the US health care system is limited among both parties’ constituents. In a Gallup poll from June to July 2020, 55% of Democrats (n = 407 surveyed) and 53% of Republicans (n = 323 surveyed) indicated that they have a great deal or quite a lot of confidence in the current US medical system.6
Any debate about making substantial changes to the US health care system will encounter the deep division between the 2 parties’ constituents over future federal government involvement in health care. About two-thirds of Democrats (68%) (n = 703 surveyed) indicated that they believe the federal government should be more involved in health care, a view held by only 17% of Republicans (n = 580 surveyed).5
Members of both parties view one issue as a high priority for federal government intervention. In a December 2020 poll that included 328 Democrats and 272 Republicans, taking action to reduce high prescription drug prices was listed by both Democrats and Republicans as among their top 6 priorities (from a list of 23) for the new president and Congress.2 However, Democrats and Republicans in Congress currently disagree on how best to achieve that goal.
Race and Disparities in Health Care
At the time of the election, Democrats were far more likely than Republicans to express concern about racism and disparities. In a CNN exit poll involving 15 590 individuals, racial inequality was one of the top issues for Joseph Biden voters in the 2020 election (38% of 7951 surveyed said it was the most important issue in their vote), but not for Donald Trump voters (only 3% of 7405 surveyed expressed a similar view).7
Views of racism and unequal treatment also show a sharp partisan divide. A Kaiser Family Foundation survey conducted in August to September 2020 found that substantially more Democrats than Republicans believe racism is an important problem in the US today (84% of 371 surveyed compared with 33% of 309 surveyed, respectively).8 Another survey found that the partisan split on unequal treatment encompasses both criminal justice and health care. More Democrats (76% of 2448 surveyed) than Republicans (20% of 2072 surveyed) reported that they view the way racial and ethnic minorities are treated by the criminal justice system as a very big problem.9 In a separate survey, 65% of Democrats (5147 surveyed) reported that they believe Black people are treated less fairly than White people when seeking medical treatment compared with 11% of Republicans (4542 surveyed).10
Potential Direction of US Health Care Policy
What do these findings indicate about the likely direction of US health care policy in the near future? Democrats and Republicans are unified about the need to resolve the COVID-19 outbreak, with the expectation that after vaccinations become widely available, people will be able to return to their normal lives. For individuals, this will be a personal issue, not just a policy issue. Failure to meet the public’s expectations could substantially influence future US politics.
With a new administration and the Democratic majority in Congress, support for moving toward universal coverage will be very strong. Because of the closeness of the party distribution in Congress, the Biden administration may find it difficult to pass a single comprehensive bill. More likely, as already embedded in the proposed $1.9 trillion bill that President Biden has submitted to Congress, there are likely to be a number of administrative changes to increase the number of people enrolled in the ACA, as well as efforts in Congress to pass sections of expanded coverage using special budgetary rules that do not require as large a number of votes to be enacted. Efforts to reorganize the health system are unlikely to be a high priority for the new administration and Congress, but there may still be interest in addressing high drug prices.
The Biden administration is likely to place a high priority on addressing the problem of racism in general and specifically racial disparities in health and unequal treatment in health care. Because of partisan divisions in Congress, the administration will probably rely more on executive orders and administrative actions than legislative solutions to address these problems. However, not well recognized is that a more conservative Supreme Court may be concerned about the expansion of executive authority without approval of Congress.
Corresponding Author: Robert J. Blendon, ScD, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (rblendon@hsph.harvard.edu).
Published Online: March 5, 2021. doi:10.1001/jama.2021.1147
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was supported by a grant from The Commonwealth Fund.
Role of the Funder/Sponsor: The funder had a role in the preparation, review, or approval of the manuscript, and decision to submit the manuscript for publication.