Public Health Across Partisan Lines: What Has Changed Since the Onset of COVID-19

Abstract

Two polls were conducted by an independent polling firm in September 2018 and July 2020 to assess public perceptions of public health departments and services among voters in the United States. The poll also sought to uncover changes in perception before and after the onset of COVID-19. A random sample was drawn from state voter files proportional to the national registered voter population by state, with quotas set by specific demographics to ensure representativeness. Overall, 1800 individuals participated between the 2 polls and weights were used in the analysis to adjust for nonresponse. From 2018 to 2020, respondents' familiarity with local public health departments rose 11% and their perception of the importance of the public health department to community health increased by 16%. In addition, support for public health departments and services differed significantly by political affiliation. In 2020, 85% of Democrats perceived the public health department to be very important while only 62% of their Republican counterparts felt similarly. Public health advocates have a unique opportunity to demand sustained funding for public health as American voters are more familiar and supportive of public health departments now than they were before the pandemic. In addition, policy makers, elected officials, and political candidates have the opportunity to leverage these data to fight for the health of their communities.

As the United States contends with COVID-19, there is a renewed understanding of the importance of robust, well-funded public health systems. Historically, Americans support public health and public health agencies but express dissatisfaction toward specific functions of public health systems and have mixed feelings about their own public health system.^1,2 Specifically, the public has long viewed the Centers for Disease Control and Prevention (CDC) favorably and has continued to do so throughout the pandemic.³ However, in the last decade, the CDC's budget has fallen by nearly 10%, which is closely tied to the funding of state and local public health systems, hindering the effectiveness of those systems.⁴

Studies suggest the public has some ambivalence about public health—indicating that an assessment of public support for public health must ask about public health systems generally as well as support for specific agencies, functions, and policy tools that collectively comprise the public health enterprise.^1,2,5 Support for these different aspects of the public health system likely vary, and this variation may be particularly pronounced between Democrats and Republicans, as past research demonstrated.¹ The large and persistent partisan gap documented over the last decade in support of the Affordable Care Act suggests that partisan differences in evaluating other public health policy issues may also have grown.^5,6

These patterns are exemplified by the partisan response to COVID-19, as numerous polls have shown partisan differences in attitudes about the threat of and response to COVID-19. While Democrats and Republicans express similar concern about the effect of COVID-19 on the economy, Democrats are far more likely to see COVID-19 as a major threat to the health of the US population and more likely to see the importance of social distancing and testing in responding to COVID-19.^7,8 President Trump's handling of COVID-19, as well as politicized responses by Republican and Democratic leaders across the United States, has created diverging narratives and may have signaled to the public that they should interpret public health and health policy issues in partisan ways.⁹ Understanding how the public perceives public health services, especially during a divisive and dangerous pandemic, is critical to determine how to mobilize the broad support that is needed for a robust public health infrastructure to protect and promote the health of the public.

Methods

Analysis in this article is drawn from national opinion poll data. Two polls were conducted by an independent firm, Public Opinion Strategies, in the first week of September 2018 and the second week of July 2020. The sample was drawn randomly from state voter files, with state-specific sample size determined on the basis of individual votersʼ selection probability proportional to size (PPS) of the state voter population, relative to the national population of registered voters. Quotas were set by specific demographics such as state, region, age, gender, and ethnicity based on data from the US Census and voter files in order to ensure the sample was representative of the US registered voter population nationally. Interviews were conducted by phone using CATI software with trained live interviewers. Nonresponse weights were used in the analysis to adjust the resulting estimates to be nationally representative. Overall, 1800 individuals participated in the 2 polls—1000 in 2018 and 800 in 2020.

Respondents were asked how important it was for their health department to perform certain activities, on a scale of 1 (“not at all important”) through 10 (“very important”). The full list of items can be found in Appendix Table 1. For the purposes of analysis, particular emphasis was placed on identifying which respondents felt items were “very important” (ie, responded as 8-10) and so results were dichotomized as done in a previous study asking about the importance of various determinants of health.¹⁰ Similarly, respondents were asked to what extent a number of social services were important for creating a healthy community, including public health departments (see Appendix Table 1). Similarly, responses were dichotomized at 0-7/8-10.

One item has changed between 2018 and 2020. The exact wording for the “Communicable Disease” item in 2018 was as follows: Using a scale of 1 to 10, with 1 meaning it is NOT AT ALL important your local health department does this and 10 meaning it is VERY important that your local public health department does this. The (first/next) one is ... Help stop the spread of communicable diseases, such as meningitis (men-en-jigh-tus), Salmonella, and the flu. In 2020, half of the sample received this same language, with the other half receiving the following: Help stop the spread of communicable diseases, such as coronavirus (kuh-roe-nuh-virus), meningitis (men-en-jigh-tus), Salmonella, and the flu. The primary covariate of interest is political affiliation, which was categorized into Democrat (“lean” through “strongly”), Independent, and Republican (“lean” through “strongly“). Bivariate comparisons were conducted using a Rao-Scott adjusted chi-square. Data were analyzed and visualized in Stata 16.1 (StataCorp LLC, College Station, Texas).

Results

In 2018, 36% of respondents identified as Republican and 42% as Democrat; this shifted to 40% and 44%, respectively, in the 2020 sample. Fifty-three percent of respondents were women in 2018 and 2020. Thirty-four percent of respondents were people of color in 2018 and 36% in 2020.

When asked how familiar they were with public health departments, 49% of respondents (95% CI, 46-52) said “somewhat” or “very familiar” in 2018 and 60% in 2020 (95% CI, 57-64, P < .001). When asked, on a scale of 1 to 10, how important public health departments were to community health, 57% (95% CI, 53-60) responded 8 or higher (“very important”) in 2018 and 73% did so in 2020 (95% CI, 70-76, P < .001). Perceptions of public health department importance differed significantly by political affiliation. In 2018, 71% (95% CI, 67-75) of Democrats rated public health departments very important compared with 42% of Republicans (95% CI, 37-48). In 2020, 85% of Democrats (95% CI, 81-88) and 62% of Republicans (95% CI, 56-68) rated public health agencies very important (Figure 1). This represents an upward shift of 14% for Democrats (95% CI, 8-19, P < .001) and 20% for Republicans (95% CI, 12-28, P < .001).

FIGURE 1: Perception That Health Departments Are Very Important to Community Health^{a a}Bars represent 95% confidence intervals. The y-axis represents the percentage of respondents who rated a public health department as 8-10 (“very important” to community health). D indicates Democrat; I, Independent; R, Republican.

Respondents were also asked how important it was for a public health department to provide a particular service. Responses of 8 or higher on a scale of 1 to 10 are grouped as “very important.” Differences were observed between respondents identifying as Republican versus Democrat for every item except “Disaster Response” in 2020 (Figure 2). Eighty-four percent of Democrats rated this item very important in 2018 compared with 80% in 2020 (P = .219). Seventy-one percent of Republicans rated this item very important in 2018 and 75% in 2020 (P = .8126). The interparty difference between Democrats and Republicans in 2020 was not statistically significant (5%; P = .0925). In 2020, ratings increased for all items except “Communicable Disease.” The only service for which the increase was significantly different by political party was the “Prevention” item, where Democrats increased by 4.7% and Republicans increased by 14.2% (P = .0489).

FIGURE 2: Respondent Perceptions of the Importance of Public Health Departments Providing Specific Services in Their Communities, 2018 and 2020, by Political Affiliation^{a a}Bars represent 95% confidence intervals. The y-axis represents the percentage of respondents who rated a given item as 8-10 (“very important” to provide). D indicates Democrat; I, Independent; R, Republican. Full-item descriptions are available in Appendix Table 1. The “Communicable Disease” item shows only respondents receiving the 2018 version of the question (n = 758 in 2018; n = 399 in 2020), whereas the “Comm. Disease (COVID)” item shows respondents who received the original version in 2018 (n = 758) and the modified version in 2020 (n = 398).

Both sets of services relating to policy development saw a substantial partisan divide. For the “Create Health Policy Locally” item (“Work with partners to help create strong local policies that support health, such as smoke-free workplace laws”), 73% of Democrats in 2018 (95% CI, 69-76) and 48% of Republicans in 2018 (95% CI, 44-52, P < .001) indicated the item was very important compared with 75% (95% CI, 70-79) and 47% (95% CI, 42-53, P < .001), respectively, in 2020. Similarly, the “Promote Health Policies” item (“Promote policies that protect people's health such as increasing seatbelt use and encouraging employers to offer paid maternity leave”) saw 74% of Democrats (95% CI, 70-78) and 45% of Republicans in 2018 (95% CI, 41-50, P < .001) rate it as highly important, increasing to 82% of Democrats (95% CI, 77-86) and 49% of Republicans in 2020 (95% CI, 43-55, P < .001).

Responses to the “Communicable Disease” item varied by party and according to which version of the question was used. When asked with the original language about the importance of the “Communicable Disease” item, 71% of Republican respondents (95% CI, 65-76) said it was very important in 2018, which decreased to 68% in 2020 (95% CI, 60-75). Among those asked about the “Communicable Disease” item using the coronavirus language, 74% of Republicans said it was an important service (95% CI, 65-75). For Democrats, the rating increased from 86% in 2018 to 92% for the original language and to 91% for item with the coronavirus language. None of the differences on the “Communicable Disease” item between 2018 and 2020 were statistically significant.

Discussion

The coronavirus pandemic has put governmental public health departments in the spotlight—and in a positive way. Respondents to the 2020 poll indicated increased familiarity with local public health departments than that in 2018. Respondents to the 2020 poll also rated the importance of the public health department to community health higher than their 2018 counterparts.

Consistent with other research, Democrats reported more support for public health departments and services than did Republicans. However, increased support for public health departments was marked, particularly among Republicans (20 percentage points or 47% increase). Given the extreme polarization around certain strategies to mitigate the COVID-19 pandemic (eg, mask wearing and business closures), these findings are noteworthy and reassuring.

These findings counter a prevailing national narrative that would lead us to believe that there is intense opposition to certain public health measures. Despite a vocal minority, most Americans agree that governmental public health is very important to their community's health. Reported support for the work of public health departments also has increased across the board—from environmental health to maternal and child health to multisector collaboration. Certain services are still less popular than others, especially policy development and especially among Republicans. It is clear that among a nationally representative cross-section of the general public, support for public health departments is higher in 2020 than in 2018.

These data should encourage political candidates and elected officials to stand up for public health leaders and denounce the harassment that has contributed to retirement, resignation, or termination of 49 state and local health officials since April.¹¹ Public health departments cannot effectively improve community health when their leaders are targeted, frightened, or undermined for partisan reasons. Policy makers, elected officials, and political candidates should leverage this and share in detail how they plan to support state and local health departments—giving their constituents the best opportunity to live in a healthy and safe community.

Conclusion

Public health advocates have a unique opportunity to advocate for sustained funding for the public health system. American voters are more familiar with and more supportive of public health departments now than they were before the pandemic. Republicans and Democrats alike see the importance of the work of the governmental public health system. While public health's role in encouraging health-promoting policies is critical for protecting and improving health, these results suggest that highlighting that role may not be the best way to solidify bipartisan gains in public support.

Implications for Policy & Practice

• COVID-19 has given the field of public health a unique opportunity to advocate for sustained funding for the public health system.
• Advocates should leverage bipartisan support to secure funding for the public health system.
• When characterizing public health to more conservative audiences, advocates should emphasize areas of practice other than policy development.