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Rachel Elliott, clinical senior director at Harvard Medical School,
Boston, Massachusetts
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The 2004 presidential election in the US between George W. Bush and John
Kerry has achieved a higher level of interest than probably any other.
Recent world events, the US’s role abroad and economic and social
issues at home mean that Americans are paying more attention to discussions
and issues than ever before. Outside the US, the world is watching closely
as the identity of the next leader of the world’s most powerful
nation cannot fail to affect us all.
On 24 October, polls suggest Bush had 49 per cent of the vote and Kerry
had 48 per cent. Eighty-six per cent of Republicans think Bush has done
a good job during his past four years in office, but only 20 per cent
of Democrats believe this, the widest difference ever. Most states favour
one party over the other. If you live in Alabama, everyone on the bus
wants Bush to win, whereas everyone on the bus in Massachusetts wants
Kerry to win. There are only 15 states that are realistically undecided
(swing states), representing 12 per cent of the population (8 per cent
of voters).
What is clear from previous presidential elections is that the challenger
only wins if people are unhappy with the performance of the incumbent
and start looking for an alternative. No president other than Harry Truman
has been elected with an approval rating of below 45 per cent and all
presidents with an approval rating of 55 per cent or more have been re-elected.
Bush’s approval rating has dropped from 83 per cent in January
2002 to 49 per cent in September 2004, so we have a close race.
This means that both parties need to concentrate on convincing undecided
voters. To win swing states, each party must focus on factors most likely
to influence voting. The key factors that affect voting in general are
the candidate (leadership ability, character, experience), political
party loyalty and policy issues. Policy issues crystallise ideological
views of the government’s role.
This is exemplified in health care. Republicans continue to promote a
reduced federal role for the government through policies that empower
individuals, such as the introduction of health tax credits. Democrats
promote an increased federal role (by American, but not European, standards)
through the introduction of a scheme to cover a large proportion of the
currently uninsured. The Republicans accuse Kerry of wanting to introduce
a single payer system (the UK NHS is such a system), which they attest
will lead to governmental control, rationing, loss of choice and poorer
quality.
Although many people vote on the basis of party loyalty and policy issues,
it is clear that, in this election, the candidate’s characteristics
are as important as issues such as health care. First, the fitness of
each as a commander-in-chief during a war is extremely important and
51 per cent of Americans prefer Bush in this role, perceiving him, at
a time of threat, as a strong, autocratic leader.
Bush is also the first president for a long time to use his religious
faith explicitly in policy decision-making. Twenty-six per cent of the
US population is evangelical Christian. Bush’s views on abortion
laws and homosexuality as a lifestyle choice make this involvement of
faith highly relevant to health policy, especially because for this election
abortion is the seventh biggest issue for voters.
So what issues are people voting on? In October 2004, the main issue
for voters is jobs and the US economy (27 per cent), followed by US policy
in Iraq (26 per cent) and terrorism (19 per cent). Health care is fourth
most important (9 per cent) so gets some air time, but not as much as
that devoted to homeland security.
The problem with health care as an election issue is that it is a chronic
problem. Everyone knows costs are going up and there are 48 million uninsured
people, but acute issues like Iraq influence voting more strongly. However,
among the 8 per cent of undecided voters, main issues are the economy
and health care. So, lobbying in swing states focuses more on health
care.
Where does health care fit into the presidential election? Polling shows
that the most important health issues to voters are rising costs (24
per cent: insurance premiums 14 per cent and prescription costs 10 per
cent), Medicare (24 per cent), and the uninsured (14 per cent. Bush’s
approval rating is low in health: there are 5.1 million more uninsured
people since he came to power, health insurance premiums have risen by
50 per cent since he started his term and Americans are becoming more
uneasy about pharmaceutical companies.
The Medicare Bill was passed in December 2003 to provide prescription
drugs for older people and the Republicans have focused on the success
of this in their campaign. However, only 26 per cent of older people
are happy with this bill, as a result of its complexities, loopholes
and deductible charges. This bill has not proved the vote-winner it was
expected to be.
The Republican focus has now changed to reducing malpractice suits, which,
they say, account for much of the increases in health insurance premiums.
Malpractice costs, for example, are currently being mooted by the Republicans
as the cause of the lack of vaccine manufacturers in the US.
The Democrat focus has been on reducing the numbers of people uninsured.
Kerry proposes expanding coverage to about 27 million more Americans
by broadening access to private plans and by expanding Medicaid and the
State Children’s Health Insurance Programme. However, the uninsured
tend to come from poor and minority groups, who tend not to vote and
have a weak political voice. Fifty per cent of Americans (mostly Republicans)
believe that limited, or no, provision should be made for the uninsured,
and 47 per cent (mostly Democrats) agree with major changes that would
lead to increased taxes. In reality, both campaigns have been caught
off guard by the dominance of insurance costs and the levels of discontent
with the Medicare Bill.
In summary, health care policies and other smaller galvanising issues
like education may only swing the vote if the race is close. Also swing
voters are volatile. Uncertain events such as increases in casualties
in Iraq can alter voting by five percentage points. Recent high profile
events, including the deaths of Ronald Reagan and Christopher Reeve,
and the campaigning of Michael J. Fox, support the case for stem cell
research for Alzheimer’s disease, Parkinson’s disease and
spinal cord injuries. This has split the anti-abortion group vote.
A final word: on 2 November, watch what Tennessee does! Its people have
voted with the winner in the past 10 presidential elections.
ACKNOWLEDGEMENT The content of this article has benefited significantly
by my attendance at a seminar by Robert Blendon, professor of public
health policy and management, Harvard School of Public Health. |
The
Pharmaceutical Journal