The Singer, Not the Song

In 2010, social psychologist Eric Knowles and two colleagues published a study showing that some of the opposition to health care reform results from prejudice toward African-Americans and dislike of Barack Obama. The research was a panel study in which participants were interviewed several times over the internet.

During the first contact, Knowles measured implicit prejudice against blacks using a variation of the Implicit Association Test. This test measures an automatic tendency to associate white Americans with the concept “good” and black Americans with the concept “bad.” This bias this is unintentional and occurs without our awareness. Knowles found that the people high in implicit prejudice toward African-Americans reported more negative attitudes toward Obama before the 2008 election and were less likely to vote for him. This is one of several studies to show that racial prejudice influenced votes in both the 2008 and 2012 elections.

These negative attitudes toward blacks spilled over onto Obama's policies. People high in implicit prejudice were more opposed to health care reform in 2009, before the Affordable Care Act (ACA) was passed. How do we know their opposition to health care reform was due to prejudice rather than political conservatism, which is highly correlated with prejudice in this country? Knowles did an experiment in which he described a health care plan. For half the participants, it was presented as Bill Clinton's 1993 plan and for the other half, it was presented as Obama's plan. (The actual description was of features that both plans had in common.) Implicit prejudice had no effect on attitudes toward the “Clinton” plan, but when it was attributed to Obama, the more prejudiced participants were more opposed to it. This study was replicated two years later with the same results.

Fast forward to 2014. Aaron Chatterji and colleagues just published a study asking why members of the House of Representatives did or did not vote for the ACA. The study only included Democrats, since only one of 177 Republicans voted for the bill. The researchers looked at whether three variables were related to the legislators' votes: (1) the percentage of their constituents without health insurance, (2) Obama's margin of victory or defeat in the 2008 election in their district, and (3) political contributions from health insurance companies. The statistical analysis also controlled for eight demographic variables, such as the age and racial composition of the district, and five Congressperson characteristics, such as their own 2008 margin of victory. The results were:

• Percentage of constituents without health insurance was unrelated to the legislators' votes.
• Obama's margin of victory made a significant difference. The 219 Democrats who voted for the ACA came from districts in which Obama's average margin of victory was +30%, while the 39 Democrats who voted against it came from districts in which Obama lost by slightly under 10%. Obama's margin of victory accounted for 47% of the variance in these Representatives' votes.
• Political contributions from the health insurance industry also had no relationship to voting.

The authors note that if the Congresspeople had the best interests of their constituents in mind, there should have been greater support for the ACA from Representatives whose districts contained a higher percentage of uninsured people. At different places in the article, they refer to this as either ignoring their constituents' preferences or ignoring their constituents' needs. The latter is more accurate, since they have no measure of voter preference. Maybe some of the people who needed the ACA did not prefer it (or did not know they preferred it). It is primarily the needs of their poorer constituents that these legislators ignored. This is no surprise, since there is a growing body of research showing that politicians votes are consistent with the opinions of their constituents in the top third of the income distribution, but the opinions of the lower and middle thirds are disregarded.

Of course, Obama's margin of victory or defeat is also a salient indicator of constituent preferences, and these Congresspeople were very responsive to it. However, the presidential election was not a referendum on health care reform, which played only a minor role in the campaign, but is more reasonably regarded as a measure of Obama's popularity. It appears that the legislators voted for or against the ACA based on the evidence of Obama's popularity in their district.

The common thread among both studies is that both citizens' and legislators' attitudes toward health care reform seem to be less influenced by the substance of the policy than by attitudes toward the President himself. At the present time, politicians in 24 states (including Pennsylvania) are ignoring the needs of their poorer citizens by refusing to implement the ACA's provision to expand Medicaid. Is this decision also driven by attitudes toward the President?

By the way, the fact that political contributions from insurance companies had no effect on voting doesn't really contradict the hypothesis that politicians are influenced by campaign contributions. The health insurance industry never clearly favored or opposed the ACA, since it has both advantages and disadvantages for them. In fact, the authors never predicted whether health insurance money would make a Congressperson more or less likely to vote for the bill.

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