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D A T A W A T C H : 
B L A C K S  &  H E A L T H  P O L I C Y
W E B  E X C L U S I V E  

03  D E C E M B E R  2003  



African Americans’ Views On Health Policy: 
Implications For The 2004 Elections

Health care is a more important voting issue for African Americans than for whites

by Kalahn Taylor-Clark, Robert J. Blendon, and John M. Benson

ABSTRACT:

In the competition for African American voters in the 2004 elections, health policy is likely to be an important issue. Blacks are about twice as likely as whites to say that health care issues are important in their vote choice. Using national survey data, this paper shows that candidates will have to have well-developed proposals on the uninsured, protecting Medicaid, aiding neighborhood health centers, and expanding funding for AIDS, to appeal to black voters. However, in responding to black voters, candidates will have to be careful not to alienate white voters by proposing health policies that involve sizable increases in taxes or government regulation.

Political leaders are predicting that there will be more competition for African American voters in 2004 than in previous elections.¹ On one side, Democratic leaders are trying to mobilize this traditionally Democratic group to turn out in support of their candidates.² On the other side, some Republican Party leaders have recently made commitments to act on issues of concern to African Americans.³

African Americans are about twice as likely as whites to view health care as one of the most important issues in deciding their vote.⁴ On nearly every specific health policy measure, African Americans are significantly more likely than white Americans to feel that such issues are very important in determining for whom they will vote (Exhibit 1).

It will be important for candidates trying to appeal to African American voters to know where those voters stand on health care issues and how their views differ from those of majority white voters. Earlier studies have examined the similarities and differences between blacks and whites in various social policy areas and on specific health and health care issues.⁵ However, none has taken a comprehensive look at today’s health policy issues.

This paper explores similarities and differences in views between blacks and whites about several health policy areas that could be important in the 2004 elections. We focus on three main issues: views about the U.S. health care system generally; attitudes about government’s role in dealing with health care broadly; and views about government’s role in five major health policy areas: covering the uninsured, health care regulation, reducing racial and ethnic disparities in health, dealing with HIV/AIDS domestically and abroad, and reforming Medicare.

Data Sources And Methods

The data reported in this paper are derived from twenty-six nationwide surveys of the general public. The surveys were of two types. (1) Sixteen were conducted by telephone with randomly selected, representative samples of 1,007–3,884 adults between 1999 and 2003. Much of these data come from a series of Henry J. Kaiser Family Foundation surveys on health and social policy. (2) Ten were conducted in person as part of the University of Michigan’s National Election Studies between 1970 and 2000, with sample sizes ranging from 1,281 to 2,705 adults.⁶

Responses were compared by testing differences between proportions using Fisher’s Exact Test. Throughout the results, when the responses of African Americans and whites are said to differ, the differences are statistically significant when p £ .05. Such differences are also indicated on the exhibits themselves.

Study Results

System- and individual-level views. Politicians seeking to reach out to black voters will want to gauge how African Americans view both the U.S. health care system in aggregate and their personal experiences within the system. African Americans have a more negative view of the health care system as a whole and are more likely than whites to perceive that African Americans have individual or systemic problems in health care (Exhibit 2). They are also more likely to believe that racism is a major problem in health care and to be worried about things going wrong with their own medical care or insurance coverage.

Blacks (34 percent) are nearly twice as likely as whites (19 percent) to say that the U.S. health care system has so much wrong that it needs to be completely rebuilt.⁷ Blacks are also significantly more likely than whites to be very dissatisfied with the U.S. health care system, not at all satisfied with the nation’s system for improving and protecting the public’s health, and not at all satisfied with the availability and affordability of health care in the United States.⁸

African Americans are more likely than whites to believe that blacks have major problems in and with the health care system. Blacks are significantly more likely than whites to believe that being able to afford medical care, not having enough doctors in their neighborhoods, and having difficulty getting care because of their racial or ethnic background are major problems for African Americans. Interestingly, although blacks are significantly more likely than whites to believe that racism in health care is a major problem, they are less inclined to believe that racism is as major a problem in health care as it is in other policy areas.⁹

On the individual level, we looked at underlying factors that might influence how blacks perceive the U.S. health care system. We found that African Americans are significantly more likely than whites to report that they are very worried about being unable to afford needed health care or prescription drugs during the next year. Even among those who have health insurance, African Americans are more likely than whites to be very worried about being able to afford insurance in the future and about losing their benefits or having them cut.¹⁰

Role of government. One area in which African Americans and whites generally differ is in their views about the role of government on domestic policy issues. African Americans are more supportive than whites of an activist government that seeks to improve Americans’ standard of living (75 percent versus 52 percent).¹¹ Likewise, 77 percent of blacks but only 39 percent of whites believe that the government should be larger with more services.¹² Blacks (58 percent) and whites (57 percent) generally agree that governmental regulation of business is necessary to protect the public interest.¹³ However, they disagree about the extent to which government should regulate in the private sector. For example, 38 percent of blacks and 64 percent of whites believe that the government has gone too far in regulating business and interfering with the free-enterprise system.¹⁴

Views on health policy. In health policy specifically, African Americans and whites are most divergent in their views regarding governmental policies that prioritize covering the uninsured, increase regulation in health care, expand governmental efforts to reduce racial and ethnic disparities in health, and increase spending on HIV/AIDS. However, there are also areas where blacks’ and whites’ opinions about policy are congruent. These include approaches to reforming Medicare policy and support of incremental approaches to covering the uninsured.

What should government do about the uninsured? Perhaps the most important health policy issue as viewed by African Americans is the problem of the uninsured. African Americans (93 percent) are significantly more likely than whites (69 percent) to believe that it is extremely or very important that the government pass a law in the next year to provide health insurance for most uninsured Americans.¹⁵ Moreover, a majority of African Americans (61 percent) would be willing to see government make a major effort to provide health insurance for most uninsured people, even if it means that such efforts would require a tax increase; a significantly smaller proportion of whites (42 percent) share this view.¹⁶

A substantial majority of black and white Americans support many of the incremental approaches to covering the uninsured that are being discussed today, including expanding state government programs and neighborhood clinics, requiring businesses to offer private health insurance for employees, and offering income tax deductions (Exhibit 3). In contrast, both blacks and whites express a lower level of support for a single-payer government plan. In 2003 55 percent of blacks and 44 percent of whites favored a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan.¹⁷ In 2000 a majority of neither group favored a government insurance plan that would cover all medical and hospital expenses for everyone (Exhibit 4). Support among African Americans for this latter plan has dropped from about two-thirds thirty years ago to less than half in 2000.

One area where African Americans and whites disagree is on the importance of Medicaid. Blacks (55 percent) are more than twice as likely as whites (21 percent) to feel that Medicaid is extremely important for them or their families.¹⁸ Ninety-four percent of African Americans support expansion of state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program (SCHIP), to provide coverage for people without insurance.¹⁹ Thus, maintaining and indeed enhancing the benefit structure of the Medicaid program will prove to be of much greater importance to blacks than to whites.

Regulation. African Americans are more likely than whites to feel that there is not enough governmental regulation in health care (70 percent versus 54 percent).²⁰ On nearly every measure of the need for more federal regulation in health care policy, blacks are significantly more likely than whites to believe that there is not enough governmental regulation today (Exhibit 5). The only area in which there is not a significant difference between blacks and whites regarding health care regulation is in the area of regulating the cost of prescription drugs.

Even though blacks and whites differ, it is important to note that African Americans are not monolithic in their views on health care regulation. A substantial minority of African Americans agree with the majority of whites that additional regulation is not needed in most of these health care areas.

Reducing racial and ethnic disparities. African Americans tend to view federal efforts as important to improving their relative standing in American society, even if it means that they will have to pay more in taxes. This is true in education and employment policy and the criminal justice system, as well as in health care policy.²¹ A large majority of African Americans believe that the federal government should be responsible for ensuring that minorities have equality with whites in health care services. Political conflict occurs because far fewer white Americans share this view: There is a thirty-five-percentage-point gap. While equal-quality health care is near the top of African Americans’ list of government responsibilities in the realm of reducing racial disparities, whites rate it above only equal-quality jobs (Exhibit 5).

HIV/AIDS spending domestically and abroad. Blacks view HIV/AIDS as the most urgent health problem facing the world today, while whites see cancer as being the most urgent. Blacks (47 percent) are significantly more likely than whites (30 percent) to believe that HIV/AIDS is the most urgent. Regarding the United States, both groups view HIV/AIDS and cancer as the top two most urgent U.S. health problems. African Americans are more than twice as likely as whites to name HIV/AIDS as one of the most urgent health problems facing the country today.²²

These divergent views about urgent health problems are reflected in African Americans’ spending priorities. Even after President Bush proposed a $15 billion package to fight AIDS in Africa, nearly half of blacks (49 percent) feel that the United States is not spending enough, while a significantly smaller proportion of whites agree (30 percent) (Exhibit 6).

Medicare policy. Medicare policy is the area in which we find the fewest differences between blacks and whites. The major differences have to do with their opinion about the state of the program. Blacks (41 percent) are significantly more likely than whites (25 percent) to have a very favorable opinion of Medicare.²³ But blacks are also significantly more likely than whites to believe that the program is in financial crisis (32 percent versus 16 percent) and to support rolling back the tax cuts and using the money to help keep the Medicare program financially sound (84 percent versus 69 percent).²⁴

Nonetheless, blacks are divided in the same way as whites are in their preferences about what should be done in the future for the Medicare program. For example, when asked what health insurance should look like for seniors in the future, both blacks and whites were nearly split in their views. About half of blacks and whites (52 percent and 49 percent, respectively) would want seniors to receive benefits through the Medicare program, and nearly half (46 percent and 41 percent) would prefer that seniors receive benefits through private health plans such as preferred provider organizations (PPOs) or health maintenance organizations (HMOs).²⁵ We also found that a majority of both blacks (60 percent) and whites (53 percent) would favor adding a new benefit to Medicare to pay for seniors’ prescriptions rather than using private insurance to do so.²⁶

Concluding Comments

Our findings suggest that if candidates wish to make a concerted effort to court African American voters, they must take a stand on some of the health care issues discussed in this paper. Candidates must understand that African Americans view issues of health care policy as extremely important for themselves and their communities. These findings are also important for politicians, because blacks are twice as likely as whites to vote on issues concerning health policy.

We conclude with several findings. First, we find that the top health policy priority among African American constituents is covering the uninsured. In this area, African Americans will likely favor a major governmental effort. African Americans will be particularly interested in policy agendas that emphasize programs viewed as important sources of care to their communities. Thus, expansion of Medicaid and neighborhood health centers as a means of increasing access to health care will likely gain favor among African American constituents. African Americans are likely to respond to candidates who favor increased governmental regulation of some aspects of the health care system and increased attention and spending on the problem of HIV/AIDS, both domestically and internationally. On the issue of Medicare policy, African Americans are more worried than whites about the future financial problems of Medicare. Thus, blacks are likely to be responsive to candidates who address these problems.

There is a note of caution in these data. Taking stances that appeal to black voters might cause candidates to simultaneously lose some white constituents. Three issues in particular could lead to political conflict. Whites are clearly less supportive than blacks of major tax increases to address health care problems and increased regulation in most areas. Unlike African Americans, whites also appear to be split in their support of government involvement in reducing racial and ethnic disparities in health care if it means increasing taxes. Thus, white support for policies in this area will be contingent upon the specific policy being proposed. Understanding these areas of conflict and agreement will be important to political strategists seeking to garner the support of African American voters.

This work was supported by grants from the Henry J. Kaiser Family Foundation and the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.

NOTES

1. Here we use “black” and “African American” interchangeably as a racial category to describe people who have self-identified as black or African American in the surveys.
2. G. Witherspoon, “Democrats Appeal for Black Vote,” Boston Globe, 15 July 2003.
3. L. Clemetson, “G.O.P. Pledges an Effort on Race,” New York Times, 14 January 2003.
4.Washington Post /Henry J. Kaiser Family Foundation/Harvard University poll, 2 August–1 September 2002 (Storrs, Conn.: Roper Center for Public Opinion Research, 2002); and National Public Radio/Kaiser Family Foundation/Kennedy School of Government poll, 23–27 October 2002 (Roper Center, 2002).
5. L. Bobo, “Race, Public Opinion, and the Social Sphere,” Public Opinion Quarterly 61, no. 1 (1997): 1–15; L. Bobo and F. Gilliam, “Race, Sociopolitical Participation, and Black Empowerment,” American Political Science Review 84, no. 2 (1990): 377–393; B. Gerbert and T. Bleecker, “AIDS in the Public Eye: Is the Epidemic Viewed as a Crisis?” Journal of Community Health 18, no. 6 (1993): 335–346; M. Gilens, “Racial Attitudes and Opposition to Welfare,” Journal of Politics 57, no. 4 (1995): 994–1014; M. Harrington Meyer, “Gender, Race, and the Distribution of Social Assistance: Medicaid Use among the Frail Elderly,” Gender and Society 8, no. 1 (1994): 8–28; W. Jacoby, “Core Values and Political Attitudes,” in Understanding Public Opinion, ed. B. Norrander and C. Wilcox (Washington: Congressional Quarterly Press, 2002), 403; and D. Kinder and N. Winter, “Exploring the Racial Divide: Blacks, Whites, and Opinion on National Policy,” American Journal of Political Science 45, no. 2 (2001): 439–456.
6. When interpreting these findings, one must consider that all surveys are subject to sampling error. Size of error varies with the number of people surveyed and the magnitude of differences in their responses to each question. Surveys with sample size of 1,000 will, with a 95 percent degree of confidence, have a statistical precision of plus or minus three percentage points of what would be obtained if the entire population had been interviewed. The number of African Americans responding ranges from 72 to 1,189. The actual sample sizes for whites and African Americans are shown in each exhibit. Statistically significant differences (p £ .05) are also indicated. Other forms of error can arise because of nonresponse bias, coverage bias, question order, and context effects.
7. NPR/Kaiser/Kennedy School poll, 28 March–1 May 2002 (Roper Center, 2002).
8. Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll, 4–8 October 2000 (Roper Center, 2000); and Harvard School of Public Health/RWJF/ICR poll, 11–15 December 2002 (Roper Center, 2002).
9. Kaiser Family Foundation/Princeton Survey Research Associates poll, 7 July–19 September 1999 (Roper Center, 1999).
10. NPR/Kaiser/Kennedy School poll (28 March–1 May 2002).
11. Washington Post /Kaiser/Harvard poll (2 August–1 September 2002).
12. Ibid.
13. Ibid.
14. Washington Post /Kaiser/Harvard poll, 12–19 October 2000 (Roper Center, 2000).
15. Harvard School of Public Health/RWJF/ICR polls, combined 31 May–4 June 2002 and 30 May–3 June 2003 (Roper Center, 2003).
16. Ibid., 6–10 December 2002 (Roper Center, 2002).
17. NPR/Kaiser/Kennedy School poll (28 March–1 May 2002).
18. Harvard School of Public Health/ICR poll, 19–23 February 2003 (Roper Center, 2003).
19. NPR/Kaiser/Kennedy School poll (28 March–1 May 2002).
20. NPR/Kaiser/Kennedy School poll, 26 May–25 June 2000 (Roper Center, 2000).
21. Washington Post /Kaiser Family Foundation/Harvard University Survey Project, The Four Americas: Government and Social Policy through the Eyes of America’s Multi-Racial and Multi- Ethnic Society (Menlo Park, Calif.: Kaiser Family Foundation, 1995).
22. Washington Post /Kaiser/Harvard poll, 13–23 June 2002 (Roper Center, 2002).
23. NPR/Kaiser/Kennedy School poll (26 May–25 June 2003).
24. Kaiser/Harvard School of Public Health/PSRA poll, 25 April–1 June 2003 (Roper Center, 2003).
25. Ibid.
26. Ibid.

Kalahn Taylor-Clark is a W.K. Kellogg Fellow in Health Policy Research at Harvard University. Robert Blendon is a professor of health policy and political analysis at the Harvard School of Public Health and the John F. Kennedy School of Government. John Benson is managing director of the Harvard Opinion Research Program, Harvard School of Public Health.

2003 Project HOPE–The People-to-People Health Foundation, Inc.