Unhealthy Democracy: How Partisan Politics is Killing Rural America

Abstract

The urban-rural divide is one of the central conflicts in US politics. This divide has become increasingly important as the health care and socioeconomic realities and patterns of partisan political support of urban and rural communities have increasingly diverged. This dissertation explores how rural people politically respond to and develop public policy attitudes as a function of health experiences. The first part of this dissertation explores how the influence of social group attachments—namely partisanship and racial attitudes—have evolved over time in their influence on rural support for government health insurance. This section demonstrates that partisan group attachments explain the vast majority of variation in rural health care attitudes and behaviors, both historically and now. Moreover, differences in support for government health insurance between Republicans and Democrats have grown larger over time—even amongst individuals personally receiving government health care. The second part of this project further explores why the least healthy rural communities and people are less supportive of government health insurance than other less-needy communities. I show that rural people living in communities with worse health conditions develop more resentful attitudes toward government and cities. In turn, rural people blame the government for their problems and want less and not more government health care. The third and fourth sections of the dissertation explore the electoral effects of negative health experiences on rural voters. Section three shows that voters blamed the federal government under President Barack Obama and the Affordable Care Act for more severe experiences with the opioid epidemic, even though these more painful experiences were largely the product of Republican state politician inaction. Section four similarly shows that rural voters blamed President Obama, and not state Republican politicians, for local hospital closures that occurred between 2012 and 2016, even though the vast majority of these closure happened in states that did not expand Medicaid under Republican leadership.