Is Ideology Bad For Health? Why Political Partisanship Should Be Asked On Population Health Surveys

Political party identification is rapidly becoming the strongest and most consistent predictor of compliance with COVID-19 mitigation strategies, surpassing income, education, and other demographic characteristics. For instance, a recent study of COVID-19-related health behaviors and policy preferences found that partisanship was the most consistently predictive indicator across the 38 COVID-19-related behaviors and attitudes. More recently, vaccine hesitancy has taken on a partisan hue with nearly 60 percent of White Republicans in March 2021 saying that they will either not take the vaccine at all or are unsure compared with just 7 percent of White Democrats. Counties with a higher vote share for Trump have seen lower vaccine uptake, contributing to low-vaccination clusters and continued hospital overcrowding.

That public health policies are political is not news to the many scholars that have studied the politics of public health for decades. While it is less surprising that politics influences policy making, the substantial influence that politics has on individual health behaviors is more striking. Many public health actors continue to maintain that public health should not be political; yet, it is quite clear that it is already politicized. One reason that the magnitude of influence of partisanship on health behaviors has been difficult to see is that, until recently, public health scholars, including those working on the political determinants of health, have been hindered in their ability to empirically document the extent of influence of partisanship on health behaviors. Party identification and ideology are not routinely included on population health surveys.

Of the following major, nationally representative health surveys, none contain questions on political party identification nor ideology/vote choice: the Behavioral Risk Factor Surveillance System (BRFSS), National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), National Survey on Drug Use and Health (NSDUH) and Medical Expenditure Panel Survey. The major vaccination survey, the National Immunization Survey, also does not include questions on political ideology, even though a long literature has documented growing vaccine hesitancy linked to mistrust in government and value orientations. Newer surveys such as the Understanding America Survey have provided valuable insights on COVID-19 behaviors but ask only about trust in different government actors and have no questions on party identification. A new Household Pulse Survey was implemented by the Census Bureau during COVID-19 and contains rich questions on COVID-19 vaccination but does not ask about party identification. Routine public opinion polls such as Gallup and the American National Election Studies that do ask about party affiliation are increasingly adding questions about COVID-19, but these surveys do not have other robust measures of health.

Consequently, studies examining the relationship between partisanship and health typically rely on ecological data. For instance, studies have examined the relationship between opioid use and vote share for Trump and have found strong positive associations, even after adjusting for covariates. News media reports have highlighted the positive relationship between county vote share for Trump and COVID-19 vaccination rates. A recent study found higher levels of vaccine hesitancy among those living in Republican states than Democratic states but could not assess this association at the individual level. The few studies in the US that have examined the relationship between party identification and health outcomes at the individual level have relied primarily on surveys in which health is not the major focus, such as the General Social Survey (GSS). Using data from the GSS, SV Subramanian and Jessica M. Perkins find that Republicans have better self-rated health compared with Democrats and Independents, even adjusting for income and other confounders. Republicans were less likely to be smokers compared with Democrats after accounting for several factors including race, ethnicity, and socioeconomic status. Using data from the National Longitudinal Study of Adolescent Health and GSS, Julianna Pacheco and Jason Fletcher find that people who report excellent health are more likely to identify with the Republican Party. By contrast, an analysis of the European Social Survey found that identifying on the political right was associated with poorer self-rated health across 29 European countries. Self-rated health is generally considered to be a fairly weak, subjective measure of health status. To better understand the direction of associations and mechanisms leading from partisan support or political ideology to health, nationally representative population health surveys should add one or more questions about political affiliation.

The Political And Partisan Determinants Of Health: A Research Agenda

By adding political variables to population health surveys, we could better understand which health-related attitudes, behaviors, and outcomes are influenced by partisanship/ideology and which are not. Research has shown that while some health issues become hotly politicized, such as the HPV vaccination or emergency contraception, others, such as whether cell phones cause cancer or the health consequence of harmful algal blooms, remain largely within the scientific domain and are usually unquestioningly accepted by the public unless a controversy arises that draws scientific consensus into question.

To the extent that partisanship is associated with certain health outcomes and risk behaviors, if routine questions on respondents’ political attitudes and ideology were added to population health surveys, we could begin to untangle the mechanisms. For instance, party identification may influence health through the spread of partisan mis/dis-information by trusted politicians or information sources. These effects may be amplified as people are increasingly locked in their own social media echo-chambers with algorithms that target content supporting their preexisting beliefs. This would suggest a direct pathway from statements of specific political leaders or partisan information sources to attitudes and behaviors of supporters. Trump’s downplaying of the pandemic’s severity and engagement with unproven medical treatments likely sent a signal to his supporters contributing to their lower risk perceptions. 

Alternatively, ideology may be more of a marker for underlying value orientations that are actually what is driving observed associations. For instance, political conservativism has been tied to a number of values that tend to undermine trust in government and public health institutions, including individualism, anti-intellectualism, populism, and anti-science attitudes. This would suggest an indirect pathway through which people’s underlying values channel both support for particular parties or candidates and exert influences on their behaviors. Being anti-mask and anti-vaccination comports with values of rugged individualism, a hallmark of conservative ideology, as well as distrust of scientific elites.

This indirect pathway between health and political affiliation is supported by “contextual” theories of risk perception formation including cultural cognition theory and moral foundations theory. Cultural cognition theory suggests that different individuals will process information in predictable ways that accord with behaviors and ideas they and their peers find honorable and socially beneficial, and diverge from behaviors and ideas they find base or socially detrimental. This suggests that there are relatively fixed differences between those with a more hierarchical/individualistic worldview and those with an egalitarian/communitarian worldview, which can shape behaviors toward different health issues. Likewise, moral foundations theory suggests that there are five relatively stable and universal ethical dimensions through which people organize their opinions, judgements, and behaviors: care/harm, fairness/cheating, loyalty/betrayal, authority/subversion, sanctity/degradation. Based on these theories, partisanship can be a stable predictor of health attitudes and behaviors due to the underlying ideological frameworks that shape attitudes toward risk behaviors and health issues.

Better understanding the mechanisms through which partisanship/ideology affects health behaviors and outcomes enables public health practitioners to develop policies and targeted public health messages to appeal to particular political persuasions and ideological objections. Research on health communication and vaccine hesitancy has consistently shown that correcting vaccine misinformation often does not sufficiently change the opinion of those who are already anti-vaccine. Moreover, misinformation can spread rapidly whereas debunking takes a long time, if it happens at all. Rather than debunking the misinformation, counter-narratives that resonate with a person’s core values can be used to redirect attention and attitudes toward more accurate information and health-promoting behaviors. Mass communication campaigns to encourage mask wearing could use targeted messages designed to appeal conservative individualistic values such as “Some people think they’re giving up freedom by wearing a mask. But that’s not true. Wearing a mask is a way of freeing ourselves from the pandemic.” Likewise, messaging targeted at liberals could emphasize communitarian values by demonstrating how mask wearing can protect others.  

Party ID, Ideology Or Value Orientations: What To Measure?

One challenge to future research is deciding which questions to include on population health surveys, as different measures tap into different underlying constructs. At minimum, health surveys can ask about party identification. A typical question wording used in public opinion polls such as Gallup asks, “in politics, as of today, do you consider yourself a Republican, a Democrat, or an Independent?” A follow-up question is then asked of people selecting “independent” to further categorize respondents as potentially leaning in one direction or another since an increasing number of Americans identify as independent.

Political ideology is a bit harder to measure and does not always map directly onto party identification. Ideology remains a difficult-to-define concept. It is different from partisanship in that it implies a commitment to a specific belief system more so than loyalty to a specific party or set of individuals. One way to assess ideology is to ask if people consider themselves to be liberal, moderate, or conservative, such as Gallup’s question wording summarized in exhibit 1.

However, research has found that party identification is a more stable measure of people’s political orientations than ideological identification. In other words, most people consider themselves Republican or Democrat before they consider themselves conservative or liberal. Party identification is also “stickier”: People will stick with a party even when their views on certain issues change, and, in general, people’s views on specific issues do not match consistently with their political ideology.

Consequently, another approach to measuring ideology involves identifying respondents’ underlying values, such as through the Cultural Cognition and Moral Foundations scales described above. The drawback of this approach is that it requires considerably more questions to be added to already long questionnaires, which could also add considerable time and cost. By including at minimum party identification on routine population health surveys such as the BRFSS, NHIS, NHANES, and others, we can begin to develop a more solid evidence base linking partisanship with different health behaviors and outcomes.

Politics Has Always Been With Us: Let’s Try To Understand It, Not Hide From It

Exhortations that public health policy should be based on evidence rather than politics do not change the fact that public health issues can and do become politicized. Simply providing more and better information will not change the fact that the public’s decision making is influenced by a variety of, often partisan, informational cues. To understand how politics affects health decision making, we must study the phenomena. This means including questions that enable us to examine the individual association between political identification and health behaviors, outcomes, and attitudes while adjusting for confounders and other explanatory factors. Embracing the notion that public health policy making involves engaging with politics does not mean rejecting evidence. Rather, rigorously examining the relationship between politics and health can provide an evidence base for informed action to address the political determinants of health.

Exhibit 1: Common survey question wordings to assess political leanings

Source: Data compiled by the authors from Gallup, the General Social Survey, American National Election Studies, Cultural Cognition Worldview Scales, Moral Foundations, and Merkley, 2020.