Health care is always important for voters, but this year, it is at the top of everyone's mind.
The health needs and economic costs of COVID-19 and protections for people with preexisting health conditions tied for first place in a recent Commonwealth Fund poll on which health care issue matters most to U.S. voters in the 2020 election.
Voters are also worried about health care costs, the safety of voting in person, and whether or not their vote would be counted if they vote by mail.
Then there’s the question of which candidate is most likely to address voters’ health care concerns. To learn what voters said, and unpack some of the poll’s key findings, listen to the latest episode of The Dose with the Commonwealth Fund’s Sara Collins.
Illustration by Rose Wong
Bio: Sara R. Collins
SARA COLLINS: The biggest fear that people have is not only to get sick, but what happens if you don’t have insurance to cover the cost of that illness or make sure that you can get health care when you need it?
SHANOOR SEERVAI: Health care has always mattered to voters. But this year, it is at the top of everyone’s mind because the pandemic is continuing to disrupt our lives. So on today’s episode of The Dose, we’re going to talk about health care and the 2020 election. The Commonwealth Fund recently polled voters across the U.S. asking which of three health care issues matter most in their vote for president. And likely voters were pretty much split between two issues. Forty percent said addressing the public health needs and economic costs of the COVID-19 pandemic was most important. Thirty-nine percent said protecting insurance coverage for people with preexisting conditions was most important. And about 20 percent said lowering health care costs was most important. Then for each of these, the Fund asked voters which candidate, former Vice President Biden or President Trump, would be most likely to address the issue.
What we find is that nationally, a majority said Biden. On COVID, it’s about 56 percent; on preexisting conditions, about 58 percent; and then on lowering health care costs, it was 53 percent of voters who said Biden would be most likely to address the issue. Even in 10 battleground states — and those are the ones that the political pundits are watching most closely to predict the outcome of the election — likely voters tended to favor Biden. In nine out of 10, every state but Ohio, likely voters said Biden would be more likely to address the health needs and economic costs of COVID-19, as well as to lower health care costs. And in all 10 of the battleground states we looked at, likely voters said Biden is most likely to protect health coverage for people with preexisting conditions.
One note: We recorded this episode before President Trump issued an executive order pledging to protect people with preexisting conditions, but he didn’t outline a plan for how he would ensure these people would get the health care they need. Anyway, the results of the poll are most interesting when we start to think about how the three issues — the pandemic, preexisting conditions, and health care costs — are connected. So I asked Sara Collins, vice president for Health Care Coverage and Access at the Commonwealth Fund, to help me understand what this survey means, especially now that the election is just a few weeks away.
Sara, I was surprised to see that voters were split between the pandemic and preexisting conditions. Why do you think that’s the case?
SARA COLLINS: That’s where these issues are very intertwined — the COVID pandemic is about health and people’s concerns about getting sick and preexisting condition production is intrinsically about health, and people worry about not having insurance if they or a loved one were going to get sick. So it’s not terribly surprising, even in states with high case rates right now in terms of COVID, to see the issue of preexisting conditions as being nearly as important, and if not more important in their vote, than the candidate’s ability to address COVID.
SHANOOR SEERVAI: And if we think about the issue of preexisting conditions and protecting people with preexisting health conditions, why is it that voters think former Vice President Biden is more likely to uphold these health protections?
SARA COLLINS: It’s hard to know. I mean, just in terms of the policy that both candidates are promoting, Vice President Biden is proposing to support the Affordable Care Act, which includes protections for people with preexisting health conditions and even build on that, where President Trump has pledged to repeal the law and is supporting the case now before the Supreme Court that would actually declare the whole law unconstitutional. So to the extent that people understand that difference, it could drive these big differences we’re seeing in people’s confidence that Biden would be more likely of the two to protect preexisting health conditions. Voting is complicated, and people have lots of different reasons for siding with one candidate over another, but just on the basis of policy, it seems to be consistent with both candidates’ stances right now. President Trump has pledged to protect people with preexisting conditions, but he hasn’t articulated yet exactly how he would do that.
SHANOOR SEERVAI: And as you mentioned, the Supreme Court and the Affordable Care Act, I wanted to ask you about the future of the ACA now in the context of Justice Ruth Bader Ginsburg’s recent death.
SARA COLLINS: So the case before the Supreme Court is about whether or not the individual mandate is constitutional or not. And a lower court decided that the mandate is not constitutional and that, because it’s intrinsic to the function of the overall law, that actually the whole law should therefore be declared unconstitutional. The Trump administration is supporting that case. That case is now before the Supreme Court. With the loss of Justice Ginsburg, who would have voted to uphold the Affordable Care Act, the law is more at risk than it was a couple of weeks ago.
If it were declared unconstitutional and inseverable from the rest of the law, then even people who have COVID, even if they didn’t become sick, would probably be considered to be having a preexisting health condition, which means it would be very difficult for them to get insured in an individual market that did not have preexisting conditions and protections anymore, which was what that would look like. It would look like the world looked like pre-ACA, when people who had health problems could not get coverage, no matter how minor the health problem, you could have acne and be considered at risk in terms of having higher health care costs.
Diseases related to COVID, long-term health problems like heart problems or kidney problems, those could be things that you might get a plan, but you might not get coverage for those kinds of health issues that insurers would view as high risk to them in terms of costs.
SHANOOR SEERVAI: So I guess when I initially looked at the finding, I was surprised that preexisting conditions and COVID basically tied for the issue that voters are most concerned about. But as you’re explaining this case and the possibility that people with preexisting conditions could lose coverage if the ACA is overturned, I’m realizing that COVID and preexisting conditions are actually very closely tied to each other. They can’t be separated from each other, and this is something that is weighing very heavily on people’s minds.
SARA COLLINS: That’s right. Health is always a major issue for people and cost is always an issue and we asked about cost, but people mostly worried about maintaining their own health and maintaining the health of their families. And COVID is a major threat to that and people are very worried about it. And the biggest fear that people have is not only to get sick, but what happens if you don’t have insurance to cover the cost of that illness? Or make sure that you can get health care when you need it? So that insecurity, I think, is really resonant in these findings. Both the insecurity about the pandemic and its trajectory over the next few months, particularly as we enter this fall period where people are headed indoors and are afraid that infection rates are going to go up, kids are going back to school, and the specter of not having the protection of preexisting conditions or having the ability to get health care when they need it, just because they got this illness, I think is very frightening to people.
SHANOOR SEERVAI: I want to back up a little bit to what you said about the fear people have around cost, especially if they don’t have insurance coverage. And in the survey, costs actually came up as number three, it was only 20 percent of voters who said that this was the most important health issue to them. Was this surprising?
SARA COLLINS: We asked people how important these three issues were first, before we asked them to basically rank them. And about more than half of people said that COVID and preexisting health conditions were very important in their vote. About two of five, just under that, said that lowering the cost of the health care was the most important factor in their vote. It was when we asked people to choose that that number dropped, that share of people who said that that was the most important factor, dropped down. So it was an important factor to many voters, but it wasn’t the most important factor of those three.
But I think these issues are all linkable. And then the issue of cost, we asked in another part of the survey that we didn’t publish, we asked people how worried they were about their health care costs, being able to pay for different kinds of health services over the next 12 months and getting treated for COVID. A majority of people said they were very or somewhat worried about how much it would cost them to pay to get treated for COVID if they or a family member was to become sick. So that of all the things we asked about, COVID and the cost of COVID, the highest percentage of people expressing a lot of concern about how much they might have to pay.
SHANOOR SEERVAI: Right. So what you’re saying is that, even though COVID and preexisting conditions came out as the top issues that voters are concerned about, you can’t isolate those from cost? It comes up again and again in these other ways and especially with the pandemic.
SARA COLLINS: That’s right, and lacking protection in insurance plan for preexisting conditions means that you are, by definition, exposed to the cost of that care. And if preexisting conditions protections weren’t present in health plans, you might face the very real potential of not having any of those costs covered anymore under your insurance policy. So, the preexisting condition issue is about health, but it’s also about cost, because if you’re not protected, then you will face the full cost of whatever kind of treatment that you need that isn’t covered.
SHANOOR SEERVAI: Can we dig deeper into how different demographic groups feel about the health care issues on the candidates?
SARA COLLINS: Sure.
SHANOOR SEERVAI: I mean, for example, did you notice women more likely to place their faith in Vice President Biden or President Trump when it came to COVID and preexisting conditions?
SARA COLLINS: So on the issue of COVID, I’ll address that first. Women, black likely voters, Hispanic likely voters, Democrats, people with incomes under $50,000 were much more likely to say that Vice President Biden was most likely to address the issue. There were narrower differences on this issue between men and whites and people with the higher incomes, but Biden was still viewed even in those groups as more likely to address the issue of COVID. Between Democrats and Republicans, and this is where people’s voting becomes complex and you see it in the partisan differences, but there are polar opposites between Democrats and Republicans about which candidate was more likely to address the issue of COVID. With Democrats majorities indicating Biden and Republicans majorities indicating Trump.
On the issue of preexisting health conditions, the differences that we saw between women, black likely voters, Hispanics, people with lower incomes, were actually wider. So on that issue in particular, there was even more support for Biden, the expectation that he would actually protect people than there was for Trump. And among groups where the difference had been rather narrow on COVID, men, whites, and people with incomes over $50,000, those differences widened on the issue of preexisting conditions. So men, whites, and people with higher incomes were more likely to see Vice President Biden as protecting their preexisting conditions than Trump, by a wider margin than they were on the issue of COVID.
SHANOOR SEERVAI: Can you tell me more about the margin between people of color when they said which candidate they think would be likely to address the issue of COVID? I’m thinking specifically how badly Black and Latinx populations have been hit by the pandemic.
SARA COLLINS: Blacks and Hispanics, the demographic groups that place COVID, were more likely to say that COVID was their top concern relative to preexisting health conditions. And on that issue, strong majorities, large majorities among blacks by a margin of seven to one, Hispanics by more than two to one, said that Biden would be the more likely of the two candidates to be able to address both COVID, public health needs of COVID and its economic costs. Obviously these demographic groups that had been very hard hit by COVID and also the economic ramifications of it in terms of job loss and people being on the front lines and as essential workers. So that’s a major concern among people in those two demographic groups and they decisively view Biden as more likely to address it.
SHANOOR SEERVAI: Was this what you expected to find Sara? Or are you surprised by these results?
SARA COLLINS: I think that the results are very consistent with the experience that we’ve seen over the course of the last six months, that people of color have been disproportionately affected by the pandemic and its economic costs. And so it’s not so surprising that it is the top concern of theirs, relative to these three that we’ve asked about. And it is, again, hard to know why people side with one candidate over another, but these groups are viewing Biden as the more likely of the two candidates to deal with this issue.
SHANOOR SEERVAI: And finally, there was one more set of questions that you asked about voting, voting in person and voting in mail, and I was really surprised to see how people responded to these questions.
SARA COLLINS: I was, too. And generally, when we report survey findings or when we ask about people’s concerns about things, and I’ll use the issue of the first question about whether people felt very safe voting in person if the election were to be held today. And about 48 percent of people nationally said they would feel very safe. An additional 30 percent said they would feel somewhat safe. But, and normally we would report out and we do report them, but we would highlight the net of that. So we would look at how many people felt very or somewhat safe. But in this case, because voting is so fundamental to the functioning of our democracy, we felt that it was striking that when in order for the country to function well, people should feel very comfortable going to vote in person, and how much COVID has changed that for people and that less than half of people now tell us that they’re very safe voting in person.
We also asked people about voting by mail and obviously now in most states, because of the pandemic, people are able to cast their vote by mail. And we asked people how much confidence they would have that votes would be counted if people voted by mail, and what’s so surprising and striking, but reflective of really the conversation around the postal service over the last few months and they information about voting by mail, is that only a third of likely voters said that they would be very confident that people who cast their votes by mail would have their votes counted. And again, we just looked at people who were very confident, because in terms of the ability for our country and government to function, people should feel very confident that the vote they cast should be counted. And so it’s very concerning that so few people felt confident. In the battleground states, it ranged from a low of 23 percent in North Carolina to just under half in Arizona, so about 47 percent of likely voters in Arizona.
SHANOOR SEERVAI: I think it’s very concerning that less than half of all Americans feel very safe going to the polls to do that.
SARA COLLINS: And the policy response by states, in states that didn’t allow voting by mail or required people to have a valid excuse, has been in response to that. So here is a safe way of voting, but the messaging around that, the information that’s been in the public, the public hears lots of competing information about the validity of people voting by mail, has clearly reduced people’s confidence in whether that’s an effective way of casting a ballot. So it is one thing to have your world changed, which the pandemic has done fundamentally in so many ways as you mention, and including our ability to vote safely without getting infected.
And a policy response is to come up with ways to address that. And we have proven ways of doing it by allowing people to vote by mail and some states do their entire election by mail, so we have a track record of doing this. And there’s no evidence that there’s any fraud associated with that. We have ways of doing this effectively, but in order for it to work, people need to feel confident, need to know that their votes are going to be counted when they do it this way.
SHANOOR SEERVAI: And did you see a variance in demographic groups when it came to this question of feeling safe to go vote today?
SARA COLLINS: We did. There was significant variation between women and men. Women are less likely to feel safe going to vote in person. Blacks were significantly less likely to feel safe than were whites. Young people, people ages 18 to 34, were significantly less likely than older people to feel safe. And then between Democrats and Republicans, a very wide difference: Democrats only 28 percent said they would feel very safe about an in-person compared to three-quarters of Republicans, so 74 percent of Republicans. So that’s a very significant gap by party.
SHANOOR SEERVAI: And what are the implications of this as we get closer to November and the time that people will be going to the polls?
SARA COLLINS: States have provided people options and there are patterns across these data among likely voters who view Vice President Biden as more likely to address the issue of COVID, they were also the most likely to say that they didn’t feel comfortable voting in person.
SHANOOR SEERVAI: So we’re in this situation where people are really worried about their health, they’re really worried about the pandemic and about protection for people with preexisting health conditions. They’re also concerned about the safety of voting and whether or not their votes will even be counted. What are you most worried about, Sara, as we’re getting closer to the election?
SARA COLLINS: Well, first and foremost, we want to make sure that people are able to get the health care that they need. And right now, we have policies in place that allow that, and they can be improved. There are aspects of the Affordable Care Act that need to be improved, the protections for people with preexisting conditions is solid and it’s there and it has made a big difference for people. But I also think it’s very important that people understand, have full sets of information about how to vote and how to participate effectively in democracy so they can voice their opinions about health care. That is, the elected officials need to know what their fears are about health care, what their desires are, and what they care most about. And that’s what voting is all about. And so everybody should feel very confident about voting by whatever mechanism is made available to them.
SHANOOR SEERVAI: All right. Well, thanks so much for joining me today.
SARA COLLINS: Thank you so much, Shanoor.
SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, Oona Palumbo for mixing and editing, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.