The government's role in health careIn 1938, 78% of Americans advocated the federal take on responsibility for providing medical care for those unable to pay for it; 75 years later the number fell to 60%.

Public opinion polls reveal that from the late 20th through the early 21st century, the federal government’s role in providing health care services has been a highly salient and contentious issue. However, the divisions so starkly evident in 2013 did not always exist. Public opinion data archived at the Roper Center for Public Opinion research provide a rich history of American perspectives on the subject.

A Health Care Safety Net

The first polls to probe public opinion on the federal government’s role in ensuring access to health care focused on the persons with limited financial means. In 1938, when asked “Do you think the government should be responsible for providing medical care for people who were unable to pay for it?,” 78% of Americans responded yes, 19% responded no, and 3% reported No Opinion (Figure 1). This was during the Great Depression, when the role of the federal government was expanding rapidly. In 1991, during George H. W. Bush’s presidency, Americans were just as, if not more supportive, of the federal government’s providing a health care safety net for the needy. In September 2013, with implementation of the Affordable Care Act underway, a UConn Poll indicates a significant drop off in public support for the federal government providing health care coverage for those who need it.

Public opinion on government provision for health care safety net

Opposition to the ACA’s enactment, the Supreme Court’s ruling against parts of it, repeated attempts to overturn and defund it in Congress, challenges to its implementation and, perhaps most important, a drumbeat of opposition by politicians and advocacy groups probably contributed to this trend.

Not surprisingly, Democrats historically have been the most supportive of providing health care to the needy (Figure 2). However, until recently substantial numbers of Republicans and Independents also favored this position. Between 1991 and 2013, support among Republicans and Independents fell by 42% and 25%, respectively.

Public opinion on government provision for health care safety net by partisanship

In large part, the growth in Republican opposition can be attributed to the tenor of the times. The widespread poverty of the Great Depression and the programmatic responses of an activist federal government lent themselves to widespread support for another government program to support the poor. The skyrocketing costs of health care during the 1980s and 1990s apparently had similar effects.

The increased partisan polarization among policymakers and voters in the 1990s, accompanied by attacks on the provisions of the ACA that proved unpopular, apparently resonated strongly with Republicans and Independents.

Health Care as a Government Responsibility

Moving beyond those of limited means, who should accept responsibility for helping to pay for doctors and hospital bills accrued by the broader public: the federal government, individuals, or some combination of the two?

The devil is in the details. The responses Americans give seem to depend in large part on whether the specific details of a health care reform package are prominently featured on the political agenda.

Polls conducted between 1975 and 2012 demonstrate that most Americans believe there is a role for government to play in providing health care. During this period, between 43% and 57% of all Americans agreed or strongly agreed with the view that the government has a responsibility to help and between 27% and 39% indicated that both the government and the individuals had a role to play. Only 14% and 21% of Americans held the opposite view—agreeing or strongly agreeing that people should take care of themselves.

As Figure 3 demonstrates, support for the federal government’s role waxes and wanes in response to a variety of factors besides those mentioned in connection with health care programs for the poor. These include who occupies the White House and the state of the debate on health care reform.

Government vs. individual responsibility for health care

Public support was fairly high during the Nixon administration, fell somewhat, and then grew during the Reagan and George H.W. Bush administrations. Strong public support for a federal role in providing health care during the late 1980s and early 1990s set the stage for the debate that ensued during the 2000 presidential election. However, the well-publicized and highly partisan debate over health care reform resulted in support for reform declining, in part, as a result of the politicians and advocacy groups’ focus on details of the Clinton plan that proved unpopular.

During the George W. Bush’s presidency support for an increased government role in health care began to again increase. This laid the foundation for the Obama administration’s passage of the Affordable Care Act. As was the case during the Clinton years, a focus on unpopular details of the program led to a decline in public support. The Supreme Court’s ruling against parts of the ACA, repeated attempts to overturn and defund it in Congress, and challenges to its implementation also probably contributed to the decline in support for the federal government’s role. The September 2013 UConn Poll demonstrated that 44% of the public approved of the program and 46% disapproved (the remaining 10% held a neutral view).

Democrats and Republicans have continuously disagreed about the proper role of the federal government in health care. 1975 and 2012, as shown in Figure 4, Democratic support ranged from 55% in 1984 to 68% in 2008; Republican support has ranged from a mere 21% in 2010 to 50% in 1990. The divergence among partisans was relatively modest for most of the 20th Century, and widened during Obama’s first term when the ACA was first proposed and its provisions subjected to substantial scrutiny. Clearly, partisanship had a major impact on Americans’ views of the law and their overall opinions about the federal government’s role in health care more generally.

Government vs. individual responsibility for health care by partisanship