The Role of Health Care in the 2022 Midterm Elections
-Jarrett Lewis and Brian Stryker
(This commentary originally appeared in JAMA Health Forum on 1/18/23).
Before 2022, health care was a central issue in the first midterm elections of 3 of the last 4 U.S. presidents. Exit polls showed that health care ranked as the most important issue in the 2018 midterm, the second most important issue in the 2010 midterm, and the third most important issue in the 1994 midterm. Presidents Clinton and Obama spent a portion of their first two years in office working to pass a signature health care bill. President Trump spent a portion of his first two years in office working to overturn a signature health care bill. In each case, health care had a sizable role in those midterm elections. Many campaign television advertisements featured nurses, physicians, and patients. In the case of each midterm, voters reacted against the efforts of those presidents and delivered a congressional majority to the opposite party.
In 2022, campaign television advertisements were again full of nurses, physicians, and patients. However, the focus was very different than past midterms, as the Supreme Court’s Dobbs v Jackson Women’s Health abortion decision overturning Roe v Wade took the place of health care more broadly as a vote-driving issue.
Health Care in the Midterm Elections
Health care was not a major factor in the 2022 midterm elections. In fact, it was not even offered as a choice for “most important issue” to the 18,571 voters who completed the Edison Research exit poll (the exit poll used by ABC, CBS, CNN, and NBC).
Two surveys of actual midterm voters showed where health care ranked on the issues list. In a Harvard T.H. Chan School of Public Health survey, 34% of voters said health care was extremely important to their vote, ranking 12th of 19 issues tested. Further, in a Public Opinion Strategies survey, 9% said health care was one of the top 2 issues that factored into their vote, ranking the issue seventh of 10 issues tested.
Health care was not a central issue in 2022 in part because it was not a core focus of President Biden’s first 2 years. Further, few campaigns substantially featured the issue. A few Democrats touted the prescription drug relief that was included in the US Inflation Reduction Act, and some talked about individual Republicans’ support of cutting Medicare.
Abortion in the Midterm Elections
While health care as a systemic issue was not central to these midterm elections, a health care issue was pivotal to the outcome: abortion. We may look back at 2022 as “The Dobbs Election.” Democrats spent more than $300 million in campaign advertising on the issue of abortion, which was more than 50 times the amount they spent on abortion as an issue during the 2018 midterm elections. An extraordinary proportion of Democrats’ attack advertisements on abortion framed it as a health care issue and one that affected health care workers. They talked about current or potential laws that could imprison nurses and physicians for performing abortions.
The issue, and Democrats’ framing of it, was associated with voting outcomes. Exit polls showed abortion was the second most important issue to voters, closely trailing inflation. Democrats won 76% of voters who said abortion was their top issue. The Dobbs decision was also associated with increased Democratic turnout. In a Kaiser Family Foundation survey of midterm voters, 38% said the Supreme Court’s decision to overturn Roe v Wade was strongly associated with their decision about whether to vote in the election. Those voters broke heavily for Democrats.
We should expect abortion to again have a large role in the 2024 election. Given Democratic success on the issue, it will again be a focal point in many campaigns. It may also appear as a ballot issue in several states. Democrats are likely to raise it as a campaign issue, and Republicans could be caught between a staunchly pro-life primary electorate and a general electorate that sided with Democrats on the issue in 2022.
Looking Ahead to the 118th Congress
With Republicans winning control of the U.S. House of Representatives, any significant health care legislation introduced in the 118th Congress faces the near-insurmountable hurdle of a divided Washington DC. There is an ideological chasm between Republicans and Democrats when it comes to foundational health care policy. One need not look further for evidence of this than Democratic voter attitudes toward Medicare for All and Republican voter attitudes toward the Affordable Care Act. Most 2020 Democratic Presidential primary voters in every state except South Carolina expressed support for a single government-run health insurance plan. Conversely, nearly two-thirds of Republican voters prefer to repeal the Affordable Care Act.
However, bipartisan voter support exists in several areas. Most Democrats and Republicans support expanding access to telehealth, believe mental health is in a state of crisis in the U.S., and have favorable attitudes toward the Medicare program. At the state level, the midterm elections illustrated the continued popularity of Medicaid expansion, as South Dakota became the seventh Republican-led state to pass Medicaid expansion through a ballot initiative since 2017.
Looking Ahead to the 2024 Election
It might be easy to interpret health care’s minimal role in the 2022 midterm elections as a sign that it will have a minimal role in the 2024 election. But while health care was not at the top of the mind for voters in November 2022, we believe it will again resurface as a key campaign issue. Health care accounts for nearly one-fifth of the U.S. economy, is the largest employer, and touches nearly every voter in some fashion. Considering the two major political party’s disparate views on the structure of the U.S. health care system, a spirited debate will likely ensue.
Both parties have an opportunity to win on the issue, in part because Americans are pessimistic about the state of the system. In a recent Gallup survey, 44% of Americans gave the U.S. health care system a D or F grade. Additionally, a recent Associated Press–NORC survey found that 56% of Americans believe that the U.S. does not handle health care well. Voters are looking for improvements to the U.S. health care system.
What may elevate health care back to the top of the issue set are widespread concerns regarding health care costs. A Kaiser Family Foundation survey from March found that more than 40% of Americans live in a household where someone has postponed receiving medical care during the past year due to cost. Further, two-thirds of Americans express concern that an illness or medical emergency in their family would be followed by bankruptcy.
Although health care was not the major factor in the 2022 midterm elections that it has been in other recent midterm elections, abortion did play a critical role in the outcome. While we may not see much in the way of sizable health policy legislation in the 118th Congress, health care is likely to reemerge as a top campaign issue in 2024 and beyond.
